CK (S7) TDS Peg

Physics Essentials
Guide
Version 11.2.x
CyberKnife® S7™ System

Date of Revision: 2021-06
1075879-ENG A
Physics Essentials Guide
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 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.
1075879-ENG A |i
Accuray Incorporated Physics Essentials Guide
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.
Trademark Information
Accuray, the stylized Accuray logo, An Ke Rui, CyberKnife, CyberKnife VSI, CyberKnife
M6, CyberKnife S7, TomoTherapy, H Series, Tomo, TomoH, TomoHD, TomoHDA,
TomoEDGE, TomoHelical, TomoDirect, Hi·Art, Onrad, PreciseART, PreciseRTX,
Radixact, ClearRT, Accuray Precision, 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 with Prone with Respiratory, Synchrony Lung Tracking with Respiratory
Modeling, Synchrony Fiducial Tracking with Respiratory Modeling, Synchrony Fiducial
Tracking with InTempo Imaging, TxView, PlanTouch, QuickPlan, CTrue, VoLO, Planned
Adaptive, Autosegmentation, 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
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.
ii | 1075879-ENG A
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.
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.
1075879-ENG A | iii
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 or 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.
iv | 1075879-ENG A
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® Robotic Radiosurgery 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 Robotic Radiosurgery 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 Robotic Radiosurgery 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.
1075879-ENG A |v
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.
vi | 1075879-ENG A
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.
1075879-ENG A | vii
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.
Treatment Delivery Manual

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™, Xsight®
Spine Tracking System, Xsight® Lung Tracking System, Synchrony® Respiratory Tracking
System, and the InTempo® Adaptive Imaging System.

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.
viii | 1075879-ENG A
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.
1075879-ENG A | ix
x| 1075879-ENG A
Table of Contents
Chapter 1: CyberKnife Treatment Delivery System Overview1-1

Introduction ...................................................................................... 1-1
Equipment Locations ....................................................................... 1-2
Treatment Room ......................................................................................... 1-2
Equipment Room ........................................................................................ 1-3
Control Room.............................................................................................. 1-4
Planning Area (Dosimetry or Staff Office)................................................ 1-4
Equipment Components .................................................................. 1-4

Treatment Room ......................................................................................... 1-4
Treatment Robot and Teach Pendant ................................................................ 1-5
Proximity Detection Program.............................................................................. 1-6
Patient Positioning System................................................................................. 1-6
Target Locating System (TLS) ........................................................................... 1-7
Linear Accelerator (LINAC) .............................................................................. 1-10
Iris Variable Aperture Collimator (Optional)...................................................... 1-11
InCise 2 Multileaf Collimator (Optional)........................................................... 1-12
Xchange Robotic Collimator Changer .............................................................. 1-13
Synchrony Respiratory Tracking System (Optional) ........................................ 1-13
Equipment Room ...................................................................................... 1-14
AMM LINAC Rack...................................................................................... 1-15
Mechanical Rack .............................................................................................. 1-20
Computer Rack ................................................................................................ 1-24
Treatment Robot Controller.............................................................................. 1-32
Power Distribution Unit..................................................................................... 1-33
Control Room............................................................................................ 1-34
Planning Area............................................................................................ 1-34
Dosimetry System.......................................................................... 1-35
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Power Modes and Interruptions .....................................................1-35

Local Power ............................................................................................... 1-35
Power-on After Power Interruption ......................................................... 1-35
System Administration....................................................................1-36
CyberKnife System Network Environment ............................................. 1-36
CyberKnife File System, File Editing, and Security ............................... 1-37
Chapter 2: Commissioning......................................................2-1
Introduction.......................................................................................2-1
About Commissioning ......................................................................2-2
Professional Standards of Practice...........................................................2-2
Review of QA Program ...............................................................................2-3
Backing Up Data..........................................................................................2-3
Delivering Data to Accuray ........................................................................2-3
Commissioning and QA Equipment .................................................2-4

CyberKnife System QA Accessories.........................................................2-4
Customer Site QA Equipment....................................................................2-6
Diode Detectors and Diode Test ......................................................2-8

Diode Test.......................................................................................................... 2-9
Laser and Radiation Coincidence Check .......................................2-10

Performing the Laser and Radiation Coincidence Check ..................... 2-11
Using ImageJ to Perform Film Analysis ................................................. 2-13
Film Analysis Using ImageJ and EBT Type Film ............................................. 2-13
Beam Commissioning ....................................................................2-16

Overview of Beam Commissioning ......................................................... 2-16
Beam Commissioning for the Ray-Tracing Dose Calculation Algorithm
for Fixed and Iris Collimators ........................................................................... 2-17
Beam Commissioning for the Monte Carlo Dose Calculation
xii | 1075879-ENG A
Physics Essentials Guide Table of Contents
for Fixed and Iris Collimators............................................................................ 2-19

Beam Commissioning for the Monte Carlo Dose Calculation for the Multileaf Collimator
2-23
Commissioning Requirements for Treatment Planning.................................... 2-23
Beam Data Acquisition for the Ray-Tracing Dose Calculation ............ 2-24
Using the Accessories for the Fixed and Iris Collimators ................................. 2-24
Fixed Collimator Beam Data Acquisition .......................................................... 2-36
Iris Collimator Beam Data Acquisition .............................................................. 2-59
Beam Data Acquisition for the Monte Carlo Dose Calculation
for the Fixed and Iris Collimators............................................................ 2-89
Beam Data Acquisition ..................................................................................... 2-89
Iris Collimator Monte Carlo Beam Data Acquisition ......................................... 2-99
Beam Data Acquisition for the Finite Size
Pencil Beam Dose Calculation .............................................................. 2-100
Multileaf Collimator Beam Data Acquisition ........................................ 2-100
Using the Accessories for the Multileaf Collimator ......................................... 2-101
Coarse Alignment of the LINAC and Water Phantom .................................... 2-111
Beam Alignment Procedure ........................................................................... 2-113
Open Field Profile Measurements for the Multileaf Collimator ....................... 2-116
Tissue Phantom Ratio (TPR) Measurements for the Multileaf Collimator...... 2-121
Off Center Ratio (OCR) Measurements for the Multileaf Collimator .............. 2-126
Output Factor (OF) Measurements for the Multileaf Collimator ..................... 2-129
Importing Beam Data to the Data Server.............................................. 2-132
Accuray Precision Commissioning Tools............................................ 2-134
Monte Carlo Commissioning Workflow
for the Fixed and Iris Collimators.......................................................... 2-134
for the Multileaf Collimator .................................................................... 2-141
Optimization of Source Model Parameters..................................................... 2-143
Decommissioning Beam Data ............................................................... 2-153
Absolute LINAC Dose Calibration................................................ 2-155

General Formalism for the TG-51 Protocol .......................................... 2-155
Beam Quality Conversion Factor .......................................................... 2-156
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Determining the Equivalent Square Field Size............................................... 2-157

Measuring the Beam Quality Conversion Factor ........................................... 2-158
LINAC Calibration Point ................................................................................. 2-159
LINAC Warmup........................................................................................2-160
LINAC Calibration Procedures Using Physics Mode........................... 2-161
Daily LINAC Warmup ..................................................................................... 2-161
LINAC Calibration Check ............................................................................... 2-167
LINAC Calibration Adjustment ....................................................................... 2-170
LINAC Output Constancy Check.................................................................... 2-175
Import Phantom CT Image Studies ..............................................2-178

CT Density Models .......................................................................2-179
Tissue Density Model Selection ............................................................2-179
Water/Air ........................................................................................................ 2-180
Lung Standard................................................................................................ 2-180
Body Standard ............................................................................................... 2-180
Custom CT Density Models ........................................................................... 2-180
CT Geometric Accuracy Check ....................................................2-183

Treatment Delivery Targeting Accuracy .......................................2-185
Single Beam Calculation QA Test ................................................2-186
Performing a Single Beam Calculation QA Test .................................. 2-186
Reading the Exported Dose Data .......................................................... 2-188
Reviewing the Dose Calculation in the Accuray Precision System ... 2-193
Single Beam Calculation QA Test Hints and Tips................................2-195
Dose Box Positioning ..................................................................................... 2-195
Inhomogeneous Phantoms ............................................................................ 2-195
Dose Delivery Verification Check .................................................2-198

DeltaMan Adjustment ...................................................................2-199
Recommissioning the LINAC .......................................................2-199
Sample Beam Characteristics ......................................................2-200
xiv | 1075879-ENG A
References .................................................................................. 2-215
Chapter 3: Quality Assurance Recommendations and

Tests ..........................................................................................3-1
Introduction ...................................................................................... 3-1
QA Program and Documentation..................................................... 3-3
QA Tests and Schedules ................................................................. 3-4
Daily QA Tests................................................................................. 3-5
Safety Interlocks Check ............................................................................. 3-5
System Status Check ................................................................................. 3-7
Laser Alignment Check Application ......................................................... 3-8
Laser Alignment Check Overview ...................................................................... 3-8
Laser Alignment Check Controls........................................................................ 3-9
Laser Alignment Check Procedures................................................................. 3-12
Treatment Robot Perch Position Laser Check ...................................... 3-13
X-ray Tube Warmup.................................................................................. 3-13
LINAC Output Constancy Check............................................................. 3-14
Automated Quality Assurance (AQA) Test............................................. 3-14
Visual Inspection of TG-50 Abutted Rectangular Field Test ................ 3-14
Monthly QA Tests .......................................................................... 3-15

Beam Parameters Check.......................................................................... 3-15
LINAC Laser and Radiation Coincidence Check ................................... 3-16
Dose Delivery Verification Check............................................................ 3-16
Imaging System Alignment Check.......................................................... 3-17
Custom CT Density Model Check ........................................................... 3-17
Treatment Couch Positioning Check...................................................... 3-18
End-to-End (E2E) Test.............................................................................. 3-19
Quality Assurance of the Iris Collimator ................................................ 3-19
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Quality Assurance of the Multileaf Collimator ....................................... 3-19
Quarterly QA Tests.........................................................................3-20
TLS Tracking and Couch Movement Correspondence ......................... 3-20
Annual Testing Requirements ........................................................3-21

MLC Leakage Measurements................................................................... 3-21
Unscheduled Tests.........................................................................3-23
Patient-Specific QA Tests ........................................................................ 3-23
Generating a Single Beam MLC QA Plan ........................................................ 3-23
Robot Targeting Visual Check (BB Test) ................................................3-23
References .....................................................................................3-24
Chapter 4: AQA, E2E, MLC, and Plan QA Tests ....................4-1

Introduction.......................................................................................4-1
General CT Imaging Guidelines for Phantoms.................................4-2
Automated Quality Assurance (AQA) Test.......................................4-3
AQA Overview .............................................................................................4-3
Acquiring a CT Scan of the AQA Phantom...............................................4-4
AQA Treatment Planning for Fixed and Iris Collimators.........................4-5
New Plan............................................................................................................ 4-5
Contour Task > Ball-cube Step .......................................................................... 4-5
Setup Task > Machine Step ............................................................................... 4-6
Setup Task > Fiducials Step .............................................................................. 4-6
Setup Task > Align Step..................................................................................... 4-6
Plan Task > Settings Step.................................................................................. 4-6
Plan Task > Isocentric Step ............................................................................... 4-7
Evaluate Task > Review Step ............................................................................ 4-7
AQA Treatment Planning for the Multileaf Collimator .............................4-7
New Plan............................................................................................................ 4-8
Contour Task > Ball-cube Step .......................................................................... 4-8
Setup Task > Machine Step ............................................................................... 4-8
xvi | 1075879-ENG A
Setup Task > Fiducials Step .............................................................................. 4-9

Plan Task > Settings Step.................................................................................. 4-9
Plan Task > Sequential Step.............................................................................. 4-9
Evaluate Task > Review Step .......................................................................... 4-10
Performing the AQA Test......................................................................... 4-11
Film Analysis for the AQA Test ............................................................... 4-14
Installing AQA Software Package .................................................................... 4-14
Loading Images for AQA Film Analysis............................................................ 4-15
Rotating and Flipping Images........................................................................... 4-17
Setting the Image Resolution ........................................................................... 4-20
Processing the Images..................................................................................... 4-20
Printing and Saving Analysis Results............................................................... 4-21
Equipment and Materials for E2E Tests ........................................ 4-23

E2E Test Procedure Overview................................................................. 4-23
E2E Test for Multileaf Collimator ............................................................ 4-24
Phantoms Used in E2E Tests .................................................................. 4-24
Original Ball-cube Film Cassette ...................................................................... 4-24
Ball-cube II Film Cassette ................................................................................ 4-25
Mini Ball-cube Film Cassette............................................................................ 4-26
Head and Neck Phantom ................................................................................. 4-27
Synchrony Respiratory Motion QA Tool for Respiratory Motion Tracking........ 4-27
Lung Motion Phantom (Optional) ..................................................................... 4-27
Radiochromic or EBT Type Film ............................................................. 4-27
Film Scanner ............................................................................................. 4-27
Film Scanner Calibration .................................................................................. 4-28
E2E Test Film Analysis Software ............................................................ 4-35
Using the Ball-cube in E2E Tests .................................................. 4-36

Precautions When Using EBT Type Film ............................................... 4-36
Using the Original Ball-cube.................................................................... 4-37
Loading Films into the Ball-cube II ......................................................... 4-38
Treatment Plans for E2E Tests...................................................... 4-41
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E2E Planning with Isocentric Sequential Optimization ......................... 4-41

E2E Plans for Stationary Tracking Modes .............................................. 4-41
New Plan.......................................................................................................... 4-42
Contour Task > Ball-cube Step ........................................................................ 4-42
Setup Task > Machine Step ............................................................................. 4-43
Setup Task > Fiducials Step ............................................................................ 4-43
Setup Task > Align Step................................................................................... 4-44
Plan Task > Settings Step................................................................................ 4-44
Plan Task > Isocentric Step for Fixed and Iris Collimators............................... 4-44
Plan Task > Sequential Step for Fixed and Iris Collimators ............................. 4-45
Plan Task > Sequential Step for Multileaf Collimator ....................................... 4-46
Plan Task > Sequential Step for All Collimator Types...................................... 4-46
Utilities Task > Ball-cube Plan Step ................................................................. 4-47
Evaluate Task > Review Step .......................................................................... 4-47
E2E Plans for Respiratory Motion Tracking Modes............................... 4-48
E2E Plan for Synchrony Fiducial Tracking with Respiratory Modeling System 4-48
E2E Plan for Synchrony Lung with Respiratory ............................................... 4-48
Contour Task > Manual Step ........................................................................... 4-48
E2E Dose Delivery for Stationary Tracking Modes ........................4-55

E2E Dose Delivery for Synchrony Respiratory Motion Tracking Modes4-
58
E2E Test for Synchrony Fiducial Tracking with Respiratory Modeling System
4-58
Overview .......................................................................................................... 4-58
Synchrony Respiratory Motion QA Tool Controls ............................................ 4-59
Charging the Synchrony Respiratory Motion QA Tool ..................................... 4-60
Performing a CT Scan for the Synchrony Fiducial Tracking with Respiratory Modeling
E2E Test .......................................................................................................... 4-60
Generating a Synchrony Fiducial Tracking with Respiratory Modeling E2E Treatment
Plan .................................................................................................................. 4-61
Delivering the Synchrony Fiducial with Respiratory Modeling E2E Treatment Plan4-
62
Synchrony Respiratory Motion QA Tool Maintenance ..................................... 4-64
E2E Test for the Synchrony Lung with Respiratory .............................. 4-66
Major Components of the Lung Motion Phantom............................................. 4-66
xviii | 1075879-ENG A
Using the Motion Controller.............................................................................. 4-69

Performing a CT Scan for the Synchrony Lung with Respiratory E2E Test ..... 4-75
......................................................................................................................... 4-77
Treatment Delivery for the Synchrony Lung Tracking with Respiratory Modeling E2E
Test .................................................................................................................. 4-77
Film Analysis.................................................................................. 4-80

End-to-End Film Analysis ....................................................................... 4-80
Film Analysis for E2E Tests..................................................................... 4-81
Calibration Information ..................................................................................... 4-82
Load Images..................................................................................................... 4-82
Process the Films............................................................................................. 4-83
Reorient the Images ......................................................................................... 4-84
Modify Other Information.................................................................................. 4-84
Perform Analysis .............................................................................................. 4-85
Print .................................................................................................................. 4-86
Save Results to a Text File .............................................................................. 4-86
Show DeltaMan Values .................................................................................... 4-87
Export Images .................................................................................................. 4-87
Exit ................................................................................................................... 4-87
Solutions to Common Problems.......................................................................4-87
Film Analysis for the Synchrony Fiducial Tracking with Respiratory Modeling
E2E Test (Optional)................................................................................... 4-88
Film Dosimetry ................................................................................................. 4-88
Film Analysis for the Synchrony Fiducial Tracking with Respiratory Modeling System
4-89
Film Analysis for the Synchrony Lung Tracking with Respiratory Modeling
E2E Test..................................................................................................... 4-91
Uncertainties in the Synchrony Lung with Respiratory E2E Analysis Method.. 4-92
Creating Multileaf Collimator Test Patterns ................................... 4-93

Setting up for the TG-50 and Bayouth Tests.......................................... 4-93
Delivering the TG-50 and Bayouth Tests................................................ 4-95
MLC Live View ............................................................................................... 4-102
Desired MLC Shape ....................................................................................... 4-103
Analyzing Multileaf Collimator Test Patterns....................................... 4-104
1075879-ENG A |xix
TG-50 Picket Fence ....................................................................................... 4-104

Examples of CyberKnife TG-50 Test ............................................................. 4-104
Bayouth MLC QA Method .............................................................................. 4-105
Performing Bayouth Analysis ......................................................................... 4-113
Bayouth Analysis Using RIT........................................................................... 4-114
Bayouth Test Criteria ..................................................................................... 4-126
Plan QA for Treatment Plans .......................................................4-127

Creating a QA Template Plan................................................................. 4-128
Creating a Patient Treatment Plan......................................................... 4-131
Creating a QA Plan.................................................................................. 4-131
Creating a Deliverable QA Plan Fraction ..............................................4-137
Delivering the QA Plan to a Phantom.................................................... 4-138
QA Plan Film Analysis ............................................................................ 4-138
Recording Analysis Results...................................................................4-138
References ...................................................................................4-139
Chapter 5: Algorithms for Dose Calculation and Display ....5-1

Introduction.......................................................................................5-1
Fusion...............................................................................................5-2
Contouring Anatomy.........................................................................5-2
ITTV Generation Algorithm for Simulation Plan.......................................5-2
ITV Generation Algorithm for Lung Optimized Treatment Plan..............5-3
PTV Generation Algorithm for Lung Optimized Treatment Plan ............5-4
AutoSegmentation ......................................................................................5-4
Brain AutoSegmentation .................................................................................... 5-4
Prostate AutoSegmentation ............................................................................... 5-6
VOI Contour to Mask Volume Conversion................................................5-6
VOI Operations Algorithm Description .....................................................5-7
References .......................................................................................5-8
xx | 1075879-ENG A
DRR Generation for Treatment Planning......................................... 5-8

DVH Calculation .............................................................................. 5-8
MLC Secondary Feedback System (SFB)....................................... 5-9
References ..................................................................................... 5-9
Ray-Tracing Dose Calculation Algorithm....................................... 5-10
Contour Correction................................................................................... 5-13
Ray-Tracing Dose Calculation Grid ........................................................ 5-13
Isocontour and DVH Calculation ...................................................................... 5-13
Monte Carlo Dose Calculation Algorithm (Option)......................... 5-15

Required Inputs to the Algorithm............................................................ 5-16
Source Model ................................................................................................... 5-17
Energy Spectrum.............................................................................................. 5-18
Fluence Distribution.......................................................................................... 5-19
Source Distribution ........................................................................................... 5-20
Patient Model ................................................................................................... 5-22
Beam Geometry ............................................................................................... 5-23
User Preferences ............................................................................................. 5-23
History Allocation and Dose Summation ............................................... 5-24
Converting Energy to Absorbed Dose.............................................................. 5-25
Calculating Statistical Uncertainty .................................................................... 5-28
Photon Sampling ...................................................................................... 5-29
Sampling Initial Photon Energy ........................................................................ 5-29
Sampling Source Position ................................................................................ 5-30
Sampling Photon Position ................................................................................ 5-30
Photon Direction............................................................................................... 5-31
Photon Weight.................................................................................................. 5-31
Photon and Particle Transport ................................................................ 5-31
Overview .......................................................................................................... 5-32
Electron History Records and Mean Free Path Data ....................................... 5-32
Random Number Generation ........................................................................... 5-33
Photon Parameter Modification for Multileaf Collimator Transmission............. 5-33
Forced Photon Interaction and Photon Splitting Algorithms............................. 5-35
1075879-ENG A |xxi
Dose Display.............................................................................................. 5-45

Dose Filtering for Artificial Hot Spots ............................................................... 5-45
Smoothing Algorithms ...................................................................................... 5-46
Dose Normalization .......................................................................................... 5-46
Display of Dose and Dose Uncertainty ............................................................ 5-47
Checking Point Dose Calculations Using Independent Algorithms .... 5-48
Checking Total Dose at a Reference Point ............................................. 5-50
Placing the Reference Point............................................................................. 5-50
Additional Dose Check Calculations ................................................................ 5-51
Checking Calculated Dose per Beam at a Reference Point ............................ 5-52
Finite Size Pencil Beam Algorithm .................................................5-57

Finite Size Pencil Beam ............................................................................5-57
Dose Deposition Kernel............................................................................5-60
Field Size Calculation ............................................................................... 5-61
Align Dose Plane with CT Series ............................................................. 5-63
Lateral Scatter Correction ........................................................................ 5-63
Beam Targeting and Optimization Algorithms................................5-65

Resolution of the Dose Calculation Grid ................................................5-65
Dose Cut-Off for Ray-Tracing Dose Calculations ..................................5-65
Total Number of Beams in the Optimization Solution Space ............... 5-66
Special Considerations for Iris Collimator Beams................................. 5-68
Beam Targeting................................................................................................ 5-68
Isocentric Targeting.......................................................................................... 5-68
Segment Generation for the Multileaf Collimator ............................................. 5-69
Isocentric Conformal Targeting ........................................................................ 5-70
Conformal Avoidance Targeting....................................................................... 5-71
Sequential Optimization .................................................................5-74

Mathematical Basis for Sequential Optimization ................................... 5-76
Maximize Minimal Dose ................................................................................... 5-78
Minimize Maximal Dose ................................................................................... 5-79
Maximize Mean Dose....................................................................................... 5-80
xxii | 1075879-ENG A
Minimize Mean Dose........................................................................................ 5-81

Minimize the Dose Volume Objective............................................................... 5-82
Maximize the Dose Volume Objective.............................................................. 5-83
Minimize Monitor Units ..................................................................................... 5-84
Constraints Applied to the Minimization of F(x) .................................... 5-85
MU Limits, VOI Limits, and Objectives ................................................... 5-86
Absolute Constraints ........................................................................................ 5-87
Operation of Optimization Steps ...................................................................... 5-87
Constraints Established by Optimization Steps and Relaxation ......... 5-90
Constraints and Relaxation .............................................................................. 5-91
Relaxed Convergence .............................................................................. 5-92
Ordering the Steps ................................................................................... 5-93
Clinical Examples ..................................................................................... 5-95
Sample Prostate Case ..................................................................................... 5-95
Sample Spine Case.......................................................................................... 5-97
Sample Lung Case........................................................................................... 5-98
Beam Reduction ..................................................................................... 5-100
Time Reduction....................................................................................... 5-101
Time Reduction Annealing Schedule for Fixed and Iris Collimators .............. 5-103
Beam Regeneration for Fixed and Iris Collimators......................................... 5-105
Time Reduction Annealing Schedule for the Multileaf Collimator .................. 5-106
Automatic Collimator Selection ............................................................ 5-107
Special Considerations for Iris Collimator Beams .............................. 5-107
VOLO Algorithms for CyberKnife................................................. 5-108

Introduction............................................................................................. 5-108
Approach ........................................................................................................ 5-108
Limitations ...................................................................................................... 5-109
High-Level Description........................................................................... 5-109
VOI Sampling ................................................................................................. 5-111
Node Selection ............................................................................................... 5-111
MLC Optimization ................................................................................... 5-112
Beamport Selection ........................................................................................ 5-113
1075879-ENG A |xxiii
Beamlet Selection .......................................................................................... 5-115

Beamlet Dose Computation ........................................................................... 5-116
Fluence Map Optimization ............................................................................. 5-116
Mean Dose Objective ..................................................................................... 5-118
Normal Tissue Objective ................................................................................ 5-118
Segment Generation ...................................................................................... 5-120
Segment Dose Computation .......................................................................... 5-121
Segment Weight Optimization........................................................................ 5-121
Segment Shape Adaptation ........................................................................... 5-121
Final Weight Optimization .............................................................................. 5-124
Iris/Fixed Collimator Optimization......................................................... 5-124
Candidate Beam Selection............................................................................. 5-124
Beam Dose Computation ............................................................................... 5-124
Beam Weight Optimization............................................................................. 5-125
References...............................................................................................5-127
Treatment Planning Beam Data for Ray-Tracing and FSPB Dose Calcu-
lations ....................................................................................................5-128
Range of Measurements ................................................................................ 5-128
Construction of Beam Data Stored Tables..................................................... 5-128
Interpolation and Extrapolation of the Stored Beam Data Tables .................. 5-138
Tissue Density and Dose Calculation Accuracy for
Ray-Tracing and FSPB .................................................................................. 5-140
Algorithms Used in Data Fitting...................................................................... 5-141
References ...................................................................................5-146
Appendix 2A: Beam Data Validation Rules......................... 2A-1

Introduction.................................................................................... 2A-1
Beam Data Validation Rules ......................................................... 2A-2
Beam Data Filenames and Collimator Sizes
for Fixed and Iris Collimators....................................................... 2A-12
Beam Data Value Limits for Fixed and Iris Collimators ............... 2A-14
Beam Data Filenames, Field Sizes, and
xxiv | 1075879-ENG A
Value Limits for the Multileaf Collimator ...................................... 2A-16
Appendix 2B: Processing OCR Beam Data (Fixed and

Iris Collimators) ..................................................................... 2B-1
Introduction .................................................................................... 2B-1
Processing OCR Data in PTW MEPHYSTO mc2 (Example) ........ 2B-2
Processing OCR Beam Data in IBA OmniPro
Version 6.4a (Examples) ............................................................... 2B-9
IBA OmniPro with Fixed Collimator OCR Beam Data ........................... 2B-9
IBA OmniPro with Iris Collimator OCR Beam Data ............................. 2B-19
Appendix 2C: Imaging Dose Calculation ............................ 2C-1

Introduction ....................................................................................2C-1
Entrance Skin Dose .......................................................................2C-2
References ....................................................................................2C-3
Appendix 2D: Robot Positioning ......................................... 2D-1

Introduction ...................................................................................... 2-1
Storing the Robot Position ............................................................... 2-1
Initializing Robot Tool Frame ........................................................... 2-5
Monitoring the A5 Joint Angle.......................................................... 2-6
RoboCouch Teach Pendant Sharing ............................................... 2-8
Appendix 3A: Using the Iris QA Tool .................................. 3A-1

Introduction .................................................................................... 3A-1
Overview of the Iris QA Tool.......................................................... 3A-2
Summary of Procedures ................................................................ 3A-3
1075879-ENG A |xxv
Install the Iris QA Software ..................................................................... 3A-3

Initialize Iris QA Software ........................................................................ 3A-3
Acquire Baseline Measurements............................................................ 3A-3
Spot Check ............................................................................................... 3A-4
Prerequisites ................................................................................. 3A-5

Installing the Iris QA Software ....................................................... 3A-6
Using the Iris QA Film Mount ........................................................ 3A-7
Initializing the Iris QA Software ..................................................... 3A-8
Acquiring Baseline Iris QA Measurements.................................. 3A-10
Performing Iris QA Spot Checks ................................................. 3A-12
Iris QA User Interface.................................................................. 3A-13
User Inputs Panel................................................................................... 3A-14
Film Import Panel ................................................................................... 3A-14
Status Panel............................................................................................ 3A-15
Scan Processing Pad Panel .................................................................. 3A-15
Analysis Results Section ...................................................................... 3A-17
Export Results Panel ............................................................................. 3A-20
Troubleshooting........................................................................... 3A-21
Appendix 5A: Electron Transport in the MC Dose

Calculation Algorithm ........................................................... 5A-1
Introduction.................................................................................... 5A-1
Electron Interactions in a General MC Algorithm .......................... 5A-1
Electron Transport in a MC Algorithm ........................................... 5A-3
Pre-generated Electron Histories in Fast MC Algorithms.............. 5A-4
High Energy Inelastic Interaction Modification ..................................... 5A-4
Step Length Scaling................................................................................. 5A-4
xxvi | 1075879-ENG A
Scattering Angle Modification ................................................................. 5A-4
Pre-generated Electron Histories in the Accuray Precision MC Algorithm

5A-5
High Energy Inelastic Interaction Modification...................................... 5A-5
Step Length Scaling ................................................................................. 5A-5
Scattering Angle Modification ................................................................. 5A-5
Validation of the Accuray Precision MC Electron Transport Algorithm5A-

6
High Energy Inelastic Interaction Modification (Soft Tissue, Lung, and Bone)
5A-6
Step Length Scaling in Soft Tissue and Lung ....................................... 5A-6
Step Length Scaling in Bone ................................................................... 5A-7
Scattering Angle Modification in Soft Tissue, Lung, and Bone ........... 5A-8
Application of These Modifications to Non-Biological Materials....... 5A-16
Summary ..................................................................................... 5A-18

References .................................................................................. 5A-19
Appendix 5B: Dose Calculation Results for Typical

CyberKnife Treatments......................................................... 5B-1
Introduction .................................................................................... 5B-1
A Homogeneous Phantom with a Single Beam............................. 5B-2
Iris Collimator Plan ................................................................................... 5B-2
Multileaf Collimator (MLC) Plan............................................................... 5B-2
An Intracranial Case: Vestibular Schwannoma ............................. 5B-9

Iris Collimator Plan ................................................................................... 5B-9
Multileaf Collimator (MLC) Plan............................................................... 5B-9
A Treatment Plan for the Lung..................................................... 5B-15

Iris Collimator Plan ................................................................................. 5B-15
1075879-ENG A |xxvii
Multileaf Collimator (MLC) Plan ............................................................ 5B-15
xxviii | 1075879-ENG A
Chapter 1: CyberKnife
Treatment Delivery System
Overview
Introduction
This chapter describes the subsystems and components of the CyberKnife Treatment Delivery
System. It covers the following topics:
• “Equipment Locations” on page 1-2
• “Equipment Components” on page 1-4
• “Dosimetry System” on page 1-35
• “Power Modes and Interruptions” on page 1-35
• “System Administration” on page 1-36
NOTE: Information on equipment in this chapter may not exactly

match your specific CyberKnife System installation. All figures depict
sample equipment.
The treatment suite is made up of the Treatment Room, the Equipment Room, the Control Room,
and the Planning Area.
1075879-ENG A Introduction |1-1

Equipment Locations
This section gives the locations and example layout of the CyberKnife Robotic Radiosurgery
System subsystems and equipment components.
CyberKnife System equipment is located in the following rooms: Treatment Room, Equipment
Room, Control Room, Planning Area (Dosimetry or Staff Office).
NOTE: Photos and drawings of equipment in this chapter may

not exactly match your specific CyberKnife System installation.
Treatment Room
The Treatment Room contains the treatment robot (also called the treatment manipulator), patient
positioning system, the Target Locating System (TLS), the LINAC, and the Xchange® Robotic
Collimator Changer (Model C).
Figure 1 Example of the CyberKnife System equipment in the Treatment Room
The numbers in the following list correspond to the numbers on Figure 1:

1. Treatment robot. The robot is located at the head of the couch.
2. Patient positioning system (standard treatment couch or optional RoboCouch System,
with either a wall-mounted Hand Controller or couch-mounted Hand Controller.
1-2 | Equipment Locations 1075879-ENG A

Physics Essentials Guide Chapter 1: CyberKnife Treatment Delivery System Overview
3. Target Locating System (TLS). This includes the X-ray sources, the X-ray detectors, and
the X-ray floor panels.
NOTE: X-ray generation power supplies may not always be located in the
Treatment Room.
4. Linear accelerator (LINAC). This is attached to the treatment robot.
5. Xchange® Robotic Collimator Changer (Model C). The Xchange Robotic Collimator
Changer that holds the collimators.
6. X-ray detector and floor panel.
7. Synchrony Respiratory Camera Array (option).
This room also contains the Iris™ Variable Aperture Collimator, the fixed aperture collimator and
the Multileaf Collimator; as well as the Robot Teach Pendant.
Equipment Room
The Equipment Room is intended to contain the bulk of the support equipment needed for planning
and treatment.
• “The Equipment Room is located adjacent to the shielded walls of the Treatment Room.
The Advanced Magnetron Modulator (AMM) LINAC rack, mechanical rack and computer
rack are located in the Equipment Room. Equipment includes the facility power supply to
the PDU, the E-Stop Interlock Control Chassis (ELCC), treatment delivery computer, TLS
computer, and treatment robot controller. The Equipment Room is cooled with a
customer-supplied A/C unit.” on page 1-14
• “Mechanical Rack” on page 1-20
• “Computer Rack” on page 1-24
• “Treatment Robot Controller” on page 1-32
• RoboCouch® Patient Positioning System Controller (Option)
• “Power Distribution Unit” on page 1-33
1075879-ENG A Equipment Locations |1-3

Control Room
The control room contains the following equipment:
• Operator control panel including Emergency Stop (E-Stop) button. This is used to turn on
and off the high beam. It also provides an emergency stop button.
• Dual computer monitor(s). These monitors are used to set up and deliver the treatment
plans. They can also be used to commission and test the equipment.
• System printer. This is used to print out data necessary to check results throughout the
treatment process.
• Closed Circuit TV (CCTV) monitors (supplied by the customer). These are used to
monitor the patient.
Planning Area (Dosimetry or Staff Office)

The Planning Area contains the following CyberKnife System software:
• Accuray Precision Treatment Planning System
• iDMS Data Management System administrative applications. These are used to perform
various functions and are installed on every Accuray Precision Treatment Planning
System workstation.
Equipment Components
This section describes equipment components of the CyberKnife System in the following locations:
• “Treatment Room” on page 1-4
• “Equipment Room” on page 1-14
• “Control Room” on page 1-34
• “Planning Area” on page 1-34
Treatment Room
The following Treatment Room equipment components are described below:
• “Treatment Robot and Teach Pendant” on page 1-5
• “Proximity Detection Program” on page 1-6
• “Patient Positioning System” on page 1-6
• “Target Locating System (TLS)” on page 1-7
• “Linear Accelerator (LINAC)” on page 1-10
• “Iris Variable Aperture Collimator (Optional)” on page 1-11
1-4 | Equipment Components 1075879-ENG A

• “InCise 2 Multileaf Collimator (Optional)” on page 1-12

• “Xchange Robotic Collimator Changer” on page 1-13
• “Synchrony Respiratory Tracking System (Optional)” on page 1-13
Treatment Robot and Teach Pendant

A 6-axis treatment robot is used to position and point the LINAC for patient treatment (see Figure 2
Figure 2 Treatment robot
The treatment robot Teach Pendant (see “Appendix 2D: Robot Positioning” on page 2-1) is a hand-
held computer that can be used to operate the treatment robot manually.
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.
1075879-ENG A Equipment Components |1-5

Proximity Detection Program

The CyberKnife System software includes a Proximity Detection Program (PDP) and a
Supplemental Proximity Detection Program (SPDP) which minimize the risk of collisions with the
patient and CyberKnife System components in the treatment room.
The PDP uses treatment room geometry files and real-time treatment robot position data to prevent
the treatment robot from colliding with the patient or other known objects during treatment delivery.
The PDP software is inactive when treatment robot motion is manually controlled using the Teach
Pendant.
The Supplemental Proximity Detection Program (SPDP) is active outside of treatment when the
treatment robot is manually controlled using the Teach Pendent or when the RoboCouch is
controlled using the RoboCouch Hand Controller. (For more information on the Proximity Detection
Program and the Supplemental Proximity Detection Program see the Treatment Delivery Manual).
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.
For more information on operating the treatment robot manually using the Teach Pendant, and for
information on the Proximity Detection Program and the Supplemental Proximity Detection
Program, see the Treatment Delivery Manual.
Patient Positioning System

The patient positioning system includes the treatment couch (see Figure 1) and is used to position
the patient for treatment. Your configuration may include either the standard treatment couch or
the optional RoboCouch Patient Positioning System.
• The treatment couch uses automatic patient positioning technology.
• The maximum capacity of the standard treatment couch is 350 lb (159 kg). The maximum
capacity of the RoboCouch System is 500 lb (227 kg).
• The standard treatment couch has motorized control with 5 degrees of freedom:
3 translations (Inferior/Superior, Anterior/Posterior, and Right/Left) and 2 rotations (roll
and pitch). With the standard treatment couch, yaw is adjusted manually.
The standard treatment couch includes a table top, head base plate, treatment couch
Hand Controller, and Readout Display Unit.
• The optional RoboCouch System provides 6 degrees of freedom. The RoboCouch
System is available in the RoboCouch Flat Table Top configuration with either a wall-
mounted or couch-mounted Hand Controller.
• Med-Tec™ indexed Computer Tomography (CT) overlay kits (CT overlay and head base
plate) are used on the CT scanners that are used to prepare image data sets for the
CyberKnife System. The kits can be purchased from Accuray.
For more information on the standard treatment couch and the RoboCouch System, see the
Treatment Delivery Manual.

Target Locating System (TLS)

The Target Locating System (TLS) includes the X-ray sources, X-ray generators, and X-ray image
detectors. This section covers the following topics:
• “X-ray Sources” on page 1-7
• “X-ray Generators” on page 1-9“X-ray Image Detectors” on page 1-9
The dual imaging system has several other characteristics:
• The patient couch intersects the path of the imaging X-ray beams between the patient
and the image detectors. The maximum aluminum-equivalent attenuation of the couch
tabletop is 1.1 mm.
• 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.
X-ray Sources
The X-ray sources are attached to the ceiling on each side of the treatment couch and are fitted
with over 2.5 mm of aluminum equivalent filtration (see •). Nominal focal spot size of 0.6 mm for
mA stations up to 160 mA, and 1.2 mm for mA stations of 200 mA and higher.
• X-ray source Dose reproducibility was measured on a representative system using

RaySafe X2 R/F detector in air, at the imaging center. For 120 kV, 100 mA, and 100 ms
the standard deviation was 0.3% with a max deviation of 0.5%, both relative to the
average dose from 10 readings. For 120 kV, 200 mA, and 100 ms the standard deviation
was 0.3% with a max deviation of 0.5%, both relative to the average dose from 10
readings.

• Contrast to noise (CNR) ratio, spatial resolution, and uniformity were measured on a
representative system with Perkin Elmer detectors using a Standard Imaging QCkV-1
phantom, placed at the imaging center at 45 degrees relative to the detector plane.
Phantom imaging obtained at 100 kV, 100 mA, and 40 ms and a flood field image (no
attenuation) was obtained at 40 kV, 20 mA, and 64 ms. Unprocessed images (these are
raw images that only have detector specific corrections applied) were analyzed in
Standard Imaging PIPSpro software version 5.7.1.6 and the following results were
obtained:
 CNR = 404.242 as calculated by:
Contrast-to-Noise Ration (CNR)
The Contrast-to-Noise Ration (CNR) metric quantifies image quality.

µ
light — Mean of the pixel values in the lightest region of an image
µ
dark — Mean of the pixel values in the darkest region of an image
σdark — Standard deviation of the pixel values in the darkest region of an image
 Relative modulation transfer function (RMTF) percentage for F50, F40, and F30
expressed in [lp/cm]
F50 = 14.6 lp/cm
F40 = 16.8 lp/cm
F30 = 19.4 lp/cm
 Uniformity = 94.4% as calculated following NEMA Standards Publication MS 3-2008
for 75% of the useful field of view and sub-regions of interest:
SR01max — Mean pixel value of the subregion with the largest intensity values
SRO1min — Mean pixel value of the subregion with the smallest intensity values
NOTE: The measured values shown in this section were obtained on a representative system and
serve the purpose of demonstration. These values may deviate on each individual installation; refer
to AAPM TG-135 Report on Imaging QA.

X-ray Generators
The X-ray generators, also called High Frequency (HF) Generators, supply high voltage power to
the X-ray sources. The CyberKnife System includes compact generators:
• 50.0 kW X-ray generators: 40 – 150 kV, 10 – 640 mA, 40 – 500 ms.
• Nominal electric power: 50 kW, 100 kV, 500 mA, 100 ms.
Compact X-ray generator specifications:
• Constant potential power rating (kW): 50.0
• Radiographic kVp range: 40-150
• Resolution: 1 kVp
• mA Range and Stations: 10, 12, 16, 20, 25, 32, 40, 50, 64, 80, 100, 126, 160, 200, 250,
320, 400, 500, 640
• Power Output:
 640mA @ 78kVp
 500mA @ 100kVp
 400mA @ 125kVp
 320mA @ 150kVp
The compact generators may be located in either the Treatment Room or the Equipment Room.
X-ray Image Detectors

The X-ray image detectors are used with the X-ray sources to correctly position the patient for
treatment. Depending on your configuration, your CyberKnife System may include one of the
following:
• On-Floor Camera Stands Amorphous Silicon Image Detectors
512 x 512 pixels digital X-ray image detectors
• In-Floor Mounted Flat Amorphous Silicon Image Detectors (see Figure 3.)
1024 x 1024 pixels digital X-ray imagers

Figure 3 In-floor mounted flat image detectors
Linear Accelerator (LINAC)

The linear accelerator (LINAC) is mounted in the X-ray head and delivers radiation to the patient.
LINAC Features
The LINAC is attached to the end of the treatment robot and delivers the radiation treatment to the
patient. The LINAC provides the following:
• Compact 6 MV nominal LINAC at a fixed dose rate of 1000 MU/min, 9.3 GHz X Band
accelerator.
• 12 secondary fixed collimators are included with aperture sizes 5, 7.5, 10, 12.5, 15, 20,
25, 30, 35, 40, 50, and 60 mm.
• Optional Iris Variable Aperture Collimator.
• Optional InCise™ 2 Multileaf Collimator.

The Contact Detection Sensor safety interlock surrounds the collimator housing.
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 operating manually.
• Be familiar with the sequence of operations required to initiate and terminate the
radiation beam (Beam ON and OFF).
• Maintain visual contact with the CyberKnife System at all times during operation.
• Maintain control over the access to the Treatment Room.
• Initiate the radiation beam (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.
Iris Variable Aperture Collimator (Optional)
Figure 4 Iris Collimator
The Iris Variable Aperture Collimator (see Figure 4) is a secondary collimator whose aperture is
adjustable under computer control. Using tungsten segments to rapidly adjust the aperture, the Iris
Collimator can deliver multiple-sized beams from each LINAC position.

The Iris Collimator provides the similar 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). Each bank of tungsten
segments has a height of 6 cm. The reproducibility error of the Iris field size should be less than or
equal to 0.2 mm at 800 mm SAD.
The Iris Collimator mounts on the X-ray head. It requires the Xchange Robotic Collimator Changer
(see “Xchange Robotic Collimator Changer” on page 1-13).
The Iris Collimator includes the following collimator-specific accessories:
• Proximal coupler for use with both the Iris Collimator and fixed collimators.
• Front pointer tool for use with both the Iris Collimator and fixed collimators.
• Pinhole laser collimator for use with both the Iris Collimator and fixed collimators.
For more information on these Iris Collimator accessories, see Chapter 2, “Commissioning”. For
more information on operating the Iris Collimator, see the Treatment Delivery Manual.
InCise 2 Multileaf Collimator (Optional)

The InCise™ 2 Multileaf Collimator (MLC) is a secondary collimator whose aperture is adjustable
under computer control (see Figure 5). Using tungsten leaves to rapidly adjust the aperture, the
MLC can deliver variable shaped beams from each LINAC position.
Multileaf Collimator specifications:
• 2 banks of 26 leaves to create clinical shapes as small as 5 mm between opposed leaf
pairs and as large as 115 mm x 100.1 mm at 800 SAD
• Each leaf is 3.85 mm wide at 800 SAD
• All leaves have full interdigitation and overtravel
• Range of travel from park position to full close on the opposing side of the aperture is
125.4 mm. Adjacent leaves on the same bank can have this separation distance. X1 bank
can move from -63.4 mm to +62 mm. Likewise, X2 bank can move from +63.4 mm to -62
mm. The park position and close position are not configurable by the user.
Secondary Feedback System Camera specifications:
• Imaging frame rate: ≥5 frames per second
• Detection accuracy: ±1.0 mm at 800 mm SAD
• Camera resolution (m per pixel): ≥100 m at the surface of the MLC leaves
• Monitoring of leaf positions: ≥1 Hz
• Enforcement by the Secondary Feedback System Camera in treatment: immediately
before and after each treatment beam
The Multileaf Collimator includes the following collimator-specific accessories:
• Proximal coupler for MLC
• Front pointer

• Pinhole collimator
• MLC Quality Assurance Tool
Xchange Robotic Collimator Changer

The Xchange Robotic Collimator Changer (see Figure 5) is a system for storing collimators both
before and during treatment. The Xchange System supports the standard interchangeable fixed
collimators, the Iris Collimator, and the InCise 2 Multileaf Collimator.
The Xchange System includes the following components:
• Xchange collimator table.
• Xchange calibration isoposts for calibrating the Xchange System.
• 12 fixed secondary collimators.
• Retaining nut to secure a fixed collimator on the X-ray head.
• Optional Iris Collimator.
Figure 5 Optional InCise™ 2 Multileaf Collimator.Xchange
Robotic Collimator Changer Model C
For more information on the Xchange System, see the Treatment Delivery Manual.
Synchrony Respiratory Tracking System (Optional)

The Synchrony Respiratory Tracking System option is used to monitor patient breathing and adjust
the radiation treatment to match patient motion due to respiration.

The Synchrony Respiratory Tracking System includes a camera system consisting of the
Synchrony Respiratory Camera Array, the Synchrony Respiratory Flashpoint camera controller
(see Figure 29 on page 1-30), and the Synchrony Respiratory interface module. In the Treatment
Room, the Synchrony Respiratory Camera Array (see Figure 6) is mounted to the ceiling near the
foot of the treatment couch and used for tracking the Synchrony Respiratory External LED
Markers.
Figure 6 Synchrony Respiratory Camera Array
For more information on the Synchrony Respiratory Tracking System, see the Treatment Delivery
Manual.
Equipment Room
This section covers the following topics:
• “The Equipment Room is located adjacent to the shielded walls of the Treatment Room.
The Advanced Magnetron Modulator (AMM) LINAC rack, mechanical rack and computer
rack are located in the Equipment Room. Equipment includes the facility power supply to
the PDU, the E-Stop Interlock Control Chassis (ELCC), treatment delivery computer, TLS
computer, and treatment robot controller. The Equipment Room is cooled with a
customer-supplied A/C unit.” on page 1-14
• “Mechanical Rack” on page 1-20
• “Computer Rack” on page 1-24
• “Treatment Robot Controller” on page 1-32
• “Power Distribution Unit” on page 1-33
The Equipment Room is located adjacent to the shielded walls of the Treatment Room. The
Advanced Magnetron Modulator (AMM) LINAC rack, mechanical rack and computer rack are
located in the Equipment Room. Equipment includes the facility power supply to the PDU, the E-
Stop Interlock Control Chassis (ELCC), treatment delivery computer, TLS computer, and treatment
robot controller. The Equipment Room is cooled with a customer-supplied A/C unit.

AMM LINAC Rack

NOTE: The configuration of your AMM LINAC rack may be different from the
configuration below.
This section contains the following topics:

• “LINAC Control Computer (LCC)” on page 1-17
• “LINAC Power Distribution Unit (LPDU)” on page 1-17
• “Backup Dose Counter Display” on page 1-18
• “Modulator Control Chassis (MCC)” on page 1-18
• “Gun Driver Chassis” on page 1-19
• “Modulator High Voltage Power Supply” on page 1-19
• “Modulator” on page 1-20
The components in the Advanced Magnetron Modulator (AMM) LINAC rack power, monitor, and
manage the LINAC (see Figure 7).

LCC
LPDU
Back Up Dose
Counter
MCC
Gun Driver
Modulator
High-Voltage
Power Supply
Modulator
Figure 7 AMM LINAC Rack

LINAC Control Computer (LCC)

The LINAC Control Computer (LCC) processes commands to and from the LINAC.
Figure 8 LINAC Control Computer (LCC)
LINAC Power Distribution Unit (LPDU)

The purpose of the LPDU is to centralize the LINAC power distribution, perform mode control, and
perform status monitoring.
Figure 9 LINAC Control Chassis
The LPDU creates a single point for AC and DC power distribution. It also facilitates CyberKnife
safety system integration.

Backup Dose Counter Display

The backup dose counter is located in the AMM Linac rack. The number (value) displayed should
be divided by 10 to calculate the dose in MU. If an expected or unexpected termination of the
radiation beam occurs, the backup dose counter displays the amount of radiation delivered for the
beam. The display is automatically reset to zero immediately before the next beam.
Figure 10 Backup Dose Counter
Modulator Control Chassis (MCC)

The purpose of the MCC is to centralize all electronic boards and improve electrical noise
performance. It contains the modulator and LINAC control circuits, as well as the fault circuitry and
an interface card allowing control by the CyberKnife System.
Figure 11 MCC unit in the AMM LINAC rack

Gun Driver Chassis

The purpose of the Gun Driver is to trigger the radiation beam and monitor the dose that is actually
sent.
Figure 12 Gun Driver Chassis in the AMM LINAC rack
Modulator High Voltage Power Supply

The Modulator High Voltage Power Supply powers the modulator.
Figure 13 Modulator High Voltage Power Supply

Modulator
The purpose of the Modulator is to generate high voltage, high current pulses that are transmitted
to the magnetron for microwave power production.
Figure 14 Modulator unit in the AMM LINAC rack
Mechanical Rack
The mechanical rack contains the following components (see Figure 15):
• “Compressor for Collimator Housings” on page 1-22
• “SF6 Pressure and Water Flow Indicator” on page 1-22
• “Chiller” on page 1-23

Compressor for
Fixed, Iris, and
Multileaf
Collimator
Housings
SF6 Pressure
and Water
Flow Indicator
Chiller
Figure 15 Mechanical rack

Compressor for Collimator Housings

The compressor is included with the fixed collimator, Iris Collimator, and Multileaf Collimator
systems. The compressor is used to provide air pressure for the pneumatic exchange of collimator
housings.
Figure 16 Compressor for optional Iris Collimator
SF6 Pressure and Water Flow Indicator

The SF6 pressure and water flow indicator is located in the mechanical rack.
Figure 17 SF6 pressure and water flow indicator

Chiller
The chiller is a closed loop (distilled water) system that cools the LINAC (see Figure 18. The chiller
is located in the mechanical rack. The chiller is self-contained and does not need any outside water
supply. All heat is dissipated into the Equipment Room.
Figure 18 Chiller

Computer Rack
NOTE: Depending on the hardware version and number of Accuray systems
at your site, the configuration of your computer rack(s) may not match the
configuration below.
A single CyberKnife System includes a single computer rack containing the following components
(see Table 1):
• “Network Switch and Network Firewall” on page 1-26
• “Gateway Controller” on page 1-26
• “Active Temperature Control (ATC) Unit for Iris Collimator” on page 1-27
• “Deadman Switch for the TLS” on page 1-27
• “Keyboard, Monitor, and KVM Switch” on page 1-28
• “E-Stop Interlock Control Chassis (ELCC)” on page 1-28
• “Target Locating System (TLS) Computer” on page 1-29
• “Secondary Feedback System Computer” on page 1-29
• “Treatment Delivery Computer and Optional CyberKnife System Storage Vault” on
page 1-30
• “Synchrony Respiratory Tracking Flashpoint Controller” on page 1-30
• “iDMS Data Server” on page 1-31
• “Uninterruptible Power Supply (UPS)” on page 1-31
NOTE: The Windows-based treatment delivery-related computers, including

the Target Locating System (TLS) computer, LINAC Control Computer (LCC)
located in the AMM LINAC Rack, iDMS data server, and both the treatment
robot and RoboCouch computers, run SE46 whitelisting software.

Table 1 Computer rack
Active Temperature Control (ATC)

Unit for Iris Collimator
Core Network Firewall and Switch
Treatment Delivery System (TDS)

Network Firewall and Switch
E-Stop Interlock Control Chassis

(ELCC)
Keyboard, Monitor, and KVM

switch

Deadman Switch
Synchrony Respiratory Flashpoint

Controller
Gateway Computer
Secondary Feedback System

Computer

Computer
Treatment Delivery Computer

(UCC)
iDMS Server
Uninterruptible Power Supply

Network Switch and Network Firewall

A single CyberKnife System includes two network switch and firewall pairs (see Table 1 on
page 1-25):
• A Treatment Delivery System (TDS) Network switch and firewall.
• A Core Network switch and firewall.
The network switch and network firewall (see Figure 19) pairs are used to manage network access
and protect patient data that is passed through the networks. These units usually sit at the top of
the rack. For more information on these networks, see “CyberKnife System Network Environment”
on page 1-36.
Network Switch Network Firewall
Figure 19 Network switch and network firewall units on the

computer rack
Gateway Controller
The Gateway computer (see Figure 20) is used to transfer log files and data files from the
CyberKnife System to Accuray through the network.
Figure 20 Gateway computer

Active Temperature Control (ATC) Unit for Iris Collimator

The Active Temperature Control (ATC) unit is included with the optional Iris Collimator. The
operating temperature for the Iris sensor system is 30°C. The operating temperature for the Iris
Collimator electronics is 48°C. For more information on active temperature control for the Iris
Collimator, see Chapter 2, “Commissioning”.
Figure 21 ATC unit for optional Iris Collimator
Deadman Switch for the TLS

The deadman switch is a button inside a compartment on the rack that is used for manual imaging
control.
Figure 22 TLS Deadman Switch

Keyboard, Monitor, and KVM Switch

The computer rack includes a keyboard, a fold-out monitor, and a KVM switch (see Figure 23). The
KVM switch allows you to switch between the TLS computer, Synchrony Respiratory Tracking
computer, data server, and KUKA computers on the monitor.
Figure 23 Keyboard, Monitor, and KVM Switch
E-Stop Interlock Control Chassis (ELCC)

The E-Stop Interlock Control Chassis (ELCC) is located in the computer rack. The ELCC performs
a wide variety of hardware functions and also functions as a central point for E-Stop signals:
• Detects E-Stop input (wall switches and other sources).
• Asserts hardware interlock for detected unsafe condition.
• Building circuit control.
• X-ray on/off warning light.
• Treatment Room door interlock.
If the ELCC key switch is set to LOCAL MODE, an interlock is triggered and an error is displayed
on the Error Handling System screen on the treatment delivery computer.
Figure 24 E-Stop Interlock Control Chassis (ELCC)

Target Locating System (TLS) Computer

The Target Locating System (TLS) manages the X-ray sources, the X-ray detectors, and the X-ray
floor panels. See “Target Locating System (TLS)” on page 1-7.
Figure 25 Target Locating System Computer
Secondary Feedback System Computer

The Secondary Feedback System computer provides the treatment delivery software with a
secondary check to verify that Multileaf Collimator leaves are at the required position before the
beam is turned on to deliver dose. This system uses a video camera and image-processing
algorithms to detect the MLC leaf positions.
Figure 26 Secondary Feedback System Computer

Treatment Delivery Computer and Optional CyberKnife

System Storage Vault
The purpose of the treatment delivery computer and the optional CyberKnife System Storage Vault
is to manage user commands that are sent to the system and to hold local data and patient plans.
Figure 27 Treatment Delivery Computer
Figure 28 CyberKnife System Storage Vault
Synchrony Respiratory Tracking Flashpoint Controller

The Synchrony Respiratory Tracking Flashpoint camera controller (see Figure 29) controls the
Synchrony Respiratory Camera Array. A reset button is located behind the front panel on the
Flashpoint chassis.
Figure 29 Synchrony Respiratory Tracking Flash-

point controller

iDMS Data Server

The iDMS data server is the computer that is used to control the iDMS Data Management System.
Figure 30 iDMS Data Server
The data server is located in the computer rack (see Figure 30).
Uninterruptible Power Supply (UPS)

The Uninterruptible Power Supply (UPS) is located in the computer rack. It provides power to the
iDMS Data Management System, networking components, and treatment delivery computer for up
to 5 minutes after system power is lost.
Figure 31 Uninterruptible Power Supply (UPS)

Treatment Robot Controller

The treatment robot controller directs treatment robot positioning (see Figure 32). Reproducibility
is ± 0.2 mm.
Figure 32 Treatment robot controller
NOTE: If your configuration includes the optional RoboCouch System, a

second robot controller (the RoboCouch controller) is installed.

Power Distribution Unit
Emergency
Power Off
Door on the
Front Panel
Main Circuit
Local Power
Breaker
Switches
Figure 33 Power Distribution Unit (PDU)

Control Room
The following equipment is located in the Control Room:
• Treatment delivery computer, monitor(s), mouse, and keyboard.
• Operator control panel.
• Emergency Stop (E-Stop) and Interlock button.
• Closed Circuit TV (CCTV) system. TV monitors should have zoom and pan functions on
each CCTV camera and a large enough screen to easily view all 4 camera views at once.
• System printer.
• Intercom system with Treatment Room.
• Computer with hospital and internet access for billing, scheduling, and email functions.
• Telephones. Must be operational before on-site Accuray Physics Support can provide
training or commissioning support.
Planning Area
• The Accuray Precision System is located in the Planning Area (Dosimetry or Staff Office).
• iDMS Data Management System administrative applications are installed on every
Accuray Precision System workstation.
WARNING: Distractions during treatment planning or delivery can result in errors. To

minimize distractions, keep the Planning Area, Control Room, and location of the Accuray
Precision System separate.

Dosimetry System
Internationally recognized LINAC safety standards require multiple termination methods for the
radiation beam. These methods include primary/secondary dose monitoring systems, backup
timers, and dose rate limits. The Accuray CyberKnife System complies with these requirements
and has submitted test results for each termination method to the appropriate regulating body in
each country of use. However, due to the safety features built into the system, it is not possible for
the end user to test these requirements without assistance from Accuray support. If a site needs
to test one of these backup methods, please contact Accuray Customer Support for assistance.
Power Modes and Interruptions

• “Local Power” on page 1-35
• “Power-on After Power Interruption” on page 1-35
Local Power
Power to the treatment robot and RoboCouch System can be manually controlled through the local
power switches on the PDU (see “LINAC Power Distribution Unit (LPDU)” on page 1-17).
To turn on power without using software, switch the local power switches to "Local" mode. This
may take a few minutes. For a description of the local mode interaction with the CyberKnife System
software power-on, see the Treatment Delivery Manual.
CAUTION: Do not attempt to change the power state of the treatment robot or RoboCouch
System while it is powering up or powering down. Doing so may cause a mastering loss resulting
in an Accuray Customer Support site visit.
Power-on After Power Interruption

If a power interruption or some other disruptive event occurs, the CyberKnife System will need to
be taken from a shutdown state, typical of how the system would be left after a power outage, to a
powered-on condition where it is ready to perform a treatment or be operated in Physics mode.
For more information on ensuring that all subsystems and computers are in the proper condition
for power-up and that communications between various subsystems are working correctly, see
theTreatment Delivery Manual.
1075879-ENG A Dosimetry System |1-35

System Administration
• “CyberKnife System Network Environment” on page 1-36
• “CyberKnife File System, File Editing, and Security” on page 1-37
For information on the following system administration tasks, see the Treatment Delivery Manual:
• Obtaining screen captures
• Transferring system files to Accuray
• Treatment delivery computer tasks, including:
 Logging in to service applications
 Restarting the Treatment Delivery System software
 Rebooting the treatment delivery computer
 Powering off the treatment delivery computer for computer maintenance.
CyberKnife System Network Environment

The CyberKnife System network environment consists of two networks: the Treatment Delivery
System (TDS) Network and the Core Network. Each network has its own firewall. The TDS
Network firewall and Core Network firewall isolate system computers from all traffic not required
for CyberKnife System operation. Firewall rules allow traffic required by the CyberKnife System,
including DICOM transfer, the Log File Transfer Utility (LFTU) used for remote diagnostics, and the
iDMS data server.
WARNING: Do not install unapproved third-party software applications inside the firewall.
The TDS Network consists of CyberKnife System components and computers including:
• Treatment delivery computer
• Target Locating System (TLS)
• LINAC Control Computer (LCC)
• E-Stop Interlock Control Chassis (ELCC)
• Power Distribution Unit (PDU)
• Xchange System (option)
• Secondary Collimator System devices
1-36 | System Administration 1075879-ENG A

• Treatment robot controller

• Collision avoidance system
• Patient positioning system
• Secondary Feedback System computer
The TDS Network switch and firewall control traffic between devices on the local CyberKnife
System network, and between the local CyberKnife System network and the Core Network.
The Core Network consists of the following components:
• Gateway computer
• iDMS data server
• System printer
The Core Network switch and firewall control traffic between the Core Network and the customer
site’s network. They also control traffic between delivery systems in the TDS Network and Core
Network devices such as the iDMS data server and the Gateway computer.
NOTE: If you have a single CyberKnife System, TDS Network computers,

Core Network computers, and networking components are contained in a
single computer rack. If you have additional Accuray systems on your site’s
network, you may have multiple computer racks with different configurations.
Outside the Firewall

Supporting software and workstations such as the Accuray Precision System workstation may be
placed outside the firewall. These systems communicate with the iDMS data server to retrieve,
modify, and save treatment plans. They must be connected to the hospital network. They must also
be able to access the Core Network firewall through the hospital network.
CyberKnife File System, File Editing, and Security

The CyberKnife System uses a file security system that disables the system if certain files are
modified or deleted. This precludes the possibility of treatment planning or delivery errors due to
inadvertent file system changes. If the system is disabled in this manner, an Invalid System
Configuration E-Stop message will be displayed when you attempt to start the Treatment Planning
System. This error is unrecoverable. Contact Accuray Customer Support.
1075879-ENG A System Administration |1-37

1-38 | System Administration 1075879-ENG A

Chapter 2: Commissioning
Introduction
Certain aspects of commissioning of the CyberKnife System are unique. This chapter describes
commissioning procedures that may be unfamiliar to new users of the CyberKnife System.
This chapter covers the following topics:
• “About Commissioning” on page 2-2
• “Commissioning and QA Equipment” on page 2-4
• “Diode Detectors and Diode Test” on page 2-8
• “Laser and Radiation Coincidence Check” on page 2-10
• “Beam Commissioning” on page 2-16
• “Absolute LINAC Dose Calibration” on page 2-155
• “Import Phantom CT Image Studies” on page 2-178
• “CT Density Models” on page 2-179
• “CT Geometric Accuracy Check” on page 2-183
• “Treatment Delivery Targeting Accuracy” on page 2-185
• “Single Beam Calculation QA Test” on page 2-186
• “Dose Delivery Verification Check” on page 2-198
• “DeltaMan Adjustment” on page 2-199
• “Recommissioning the LINAC” on page 2-199
• “Sample Beam Characteristics” on page 2-200
• “References” on page 2-215
The procedures described in this chapter represent the minimum set of activities recommended
for commissioning the CyberKnife System. The owner of the CyberKnife System is responsible
for ensuring that the system is used in accordance with applicable regulations governing the
operation of medical radiation linear accelerator (LINAC) systems.
Typically, a qualified Medical Physicist performs all commissioning of the CyberKnife System, the
LINAC, and the treatment planning system. The Physicist also maintains proper documentation of
that commissioning. For QA scheduling information, see the CyberKnife® Robotic Radiosurgery
System QA Log Book provided by Accuray. For information on the QA tools used to perform the
commissioning procedures described in this chapter, see Chapter 4, “AQA, E2E, and Plan QA
Tests”. For additional information on the CyberKnife System, contact Accuray Customer Support.

About Commissioning
The hospital or equipment owner is legally responsible for performing commissioning and quality
assurance tasks. These tasks are performed by the customer Medical Physicist. The
commissioning tasks described in this manual must be completed before the first patient
treatment. Accuray may send one of its Physicists to the clinic to provide on-site physics support.
Where applicable, instructions for performing specific procedures are contained in this chapter.
Professional Standards of Practice

This section covers the following: AAPM TG-135, AAPM TG-51, and IAEA 398. A number of
documents serve as primary references for the commissioning and on-going quality assurance
(QA) program for radiation therapy treatment planning systems.
In the U.S.A., AAPM’s TG -135 task group was formed by the American Association of Physicists
in Medicine’s Science Council. This publication, Report of AAPM TG 135: Quality assurance for
robotic radiosurgery provides a general functional overview of the CyberKnife® [Ref. 1, Ref. 2].
AAPM’s TG-51 task group is part of the Radiation Therapy Committee of the American
Association of Physicists in Medicine. This publication, called “AAPM's TG-51 protocol for clinical
reference dosimetry of high-energy photon and electron beams,” describes a protocol for clinical
reference dosimetry of external beam radiation therapy using photon beams with nominal
energies between 60Co and 50 MV and electron beams with nominal energies between 4 and 50
MeV [Ref. 3].
The IAEA TRS-398 Absorbed Dose Determination in External Beam Radiotherapy: An
International Code of Practice for Dosimetry based on Standards of Absorbed Dose to Water
publication describes the primary standards of absorbed dose to water for high-energy photon
and electron beams and improvements in radiation dosimetry concepts that offer the possibility of
reducing the uncertainty in the dosimetry of radiotherapy beams [Ref. 4].
The basic information and procedures necessary to conduct most of the recommended
commissioning and QA tests are included in these publications.
Contact a Customer Support Physicist through Accuray Customer Support, if additional
information or assistance is needed.
2-2 | About Commissioning 1075879-ENG A

Physics Essentials Guide Chapter 2: Commissioning
Review of QA Program
Measure and record all aspects of your CyberKnife System at the time of commissioning to create
a set of baseline values. During subsequent QA activities, the baseline values will serve as a
reference for comparison.
Backing Up Data
Make a copy of all the data acquired during commissioning and store the copy in a secure
location.
Delivering Data to Accuray

Accuray establishes an FTP account for each customer site. Use this account to transfer large
data files to and from Accuray Customer Support. For information on using the FTP program
utility to transfer files, contact Accuray Customer Support.
1075879-ENG A About Commissioning |2-3

Commissioning and QA Equipment

It is the responsibility of the hospital to provide the equipment required for beam commissioning
and ongoing QA activities.
CyberKnife System QA Accessories

Table 1 lists equipment provided by Accuray with the CyberKnife System.
Table 1 Equipment provided by Accuray
Equipment Description
Birdcage assembly and detector mount. For holding a diode detector or a Baldwin-Farmer
type ion chamber at a fixed distance from the
radiation source. This includes the birdcage and
couplers for attaching the birdcage to the
collimator housing and for mounting the front
distance pointer in the birdcage. For information
on using these accessories, see “Using the
Accessories for the Fixed and Iris Collimators” on
page 2-24 and “Using the Accessories for the
Multileaf Collimator” on page 2-101. A diode or
detector holder is also included, alone with
hardware to secure the holder to base of the
birdcage.
Front distance pointer. For distance measurement. This includes a

coupler for attaching the front distance pointer to
the collimator housing. See “Accessories for the
Fixed and Iris Collimators” on page 2-25.
Pinhole laser collimator. For path calibration and QA tests. See

“Accessories for the Fixed and Iris Collimators”
on page 2-25 and “Accessories for the Multileaf
Collimator” on page 2-101.
CyberKnife System head and neck phantom For End-to-End (E2E) tests. See Chapter 4,
with Ball-cube film cassettes (includes starter “AQA, E2E, MLC, and Plan QA Tests”.
pack of radiochromic film inserts).
Automated Quality Assurance (AQA) phantom For AQA tests. See Chapter 4, “AQA, E2E, MLC,
(includes starter pack of radiochromic film and Plan QA Tests”.
inserts).
Initial supply of radiochromic films for use with For E2E and AQA tests. See Chapter 4, “AQA,
head and neck phantom and AQA phantom. E2E, MLC, and Plan QA Tests”
2-4 | Commissioning and QA Equipment 1075879-ENG A

Table 1 Equipment provided by Accuray (continued)
Equipment Description
End-to-End (E2E) test film analysis software. For all E2E tests. Provided by Accuray. See
Chapter 4, “AQA, E2E, MLC, and Plan QA
Tests”.
AQA test film analysis software. For AQA tests. Provided by Accuray. See
Tests”.
Synchrony tracking QA tool for motion Provided with Synchrony Tracking System option
tracking. for E2E tests. See Chapter 4, “AQA, E2E, MLC,
and Plan QA Tests”.
Iris QA tool and software. Provided with Iris Collimator. See Appendix 3A,
“Using the Iris QA Tool”.
MLC Quality Assurance Tool and software. Provided with the InCise 2 MLC Collimator. It
includes a template for cutting test films and
software to align and evaluate the films. See
Tests”.
Commissioning spreadsheets For collection of Fixed and IRIS, beam data

(TPR, OCR, and OF). For MLC beam data (TPR,
OCR, OF and Open Field).
Spreadsheets located on the AERO website
(www.accurayexchange.com) under Support:
User Documentation
Monte Carlo spreadsheets For calculating Monte Carlo ECF and CCF
Spreadsheets located on the AERO website
(www.accurayexchange.com) under Support:
User Documentation
1075879-ENG A Commissioning and QA Equipment |2-5

Customer Site QA Equipment

The equipment list in Table 2 should not be considered complete and is meant only as a starting
point for decision making. To accommodate differences in CyberKnife System site environments
and different ways to perform some operations, Medical Physicists may change equipment
requirements as needed.
If you have questions about specific equipment, please contact Accuray Customer Support to
speak to a Medical Physicist for further details.
Table 2 Customer site QA equipment
Equipment Specification Use
MLC QA software Required for users with the InCise 2 Multileaf MLC Film QA
Collimator. The QA software must have the
ability to analyze Bayouth (Garden Fence) film
tests. (This software may be combined with
Isodose Comparison Software used for Patient
Specific QA Analysis, noted below.)
Water Tank 0.1 mm measurement accuracy, capable of OCR, TPR, Output Factors
0.2 mm step spacing; OCR in-plane and cross-
plane as well as 15° angles (required for the
Iris Collimator); to scan up to 80 mm off-axis
and 300 mm deep; diode compatible.
For the optional MLC: 0.1 mm measurement
accuracy, capable of 0.2 mm step spacing;
OCR in-plane and cross-plane as well as 45°
diagonals; to scan to at least 125 mm off-axis
and 300 mm deep; diode compatible.
TPR Option TPRs are directly measured, not converted TPR

from PDDs, so this option can save data
collection time.
Stereotactic Diodes Contact Accuray Physics Support as the OCR, TPR, Output Factors
with no buildup (2X) specifications for individual diodes are
continuously changing.
Computer For running water tank and analysis software. Water Tank, Analysis
Software
Computer must be running the 64 bit version of
Windows 10, and must have at least 1 GB of
RAM. The user must have administrator
privileges.
Farmer Chamber A Farmer chamber smaller than the 0.6 cc is Absolute Dose Calibration
(0.3 cc) recommended for absolute calibration to
reduce OCR effects.
2-6 | Commissioning and QA Equipment 1075879-ENG A

Calibration for May need build-up cap depending on regional Absolute Dose Calibration
Farmer Chamber calibration procedure.
Digital Barometer Calibrated. Absolute Dose Calibration
Thermometer Must be water compatible, calibrated with Absolute Dose Calibration

0.2°C scale.
Electrometer Calibrated over the ion chamber and diode Absolute Dose Calibration,
range used. Verifies Dose Delivery to
Phantom Output Factor
Measurements
Electrometer Calibration for each scale used by the Absolute Dose Calibration,
Calibration electrometer. Verifies Dose Delivery to
Phantom
Daily QA Device Meets regional QA requirements. Daily Output Check,

Flatness & Symmetry
Flatbed Film See current recommendations from Ashland/ Film analysis for targeting
Scanner ISP for scanning Radiochromic Film. A recent accuracy and QA tests
spatial calibration of the scanner is
recommended to give the most accurate film
results. Steps for calibrating the flatbed
scanner are available in Chapter 4, “AQA, E2E,
MLC, and Plan QA Tests”.
Slab Phantom with At least 200x200 mm with enough depth to Verifies Point Dose
fiducials provide for sufficient backscatter at the depth Delivery to Phantom
of measurement.
• plugs and holes for ion chamber and/or film
inserts and/or TLDs.
• accurately known dimensions for structural
features.
• inhomogeneities.
Film & micro volume Must be the same size (width & length) as the Verifies Dose Delivery to
ion chamber slabs slab phantom. Phantom
Micro Volume Ion Must be compatible with the above slab. Verifies Dose Delivery to
Chamber Phantom
Isodose Comparison Able to import film measurements and Accuray Patient Specific QA
Software Precision DICOM RT Dose files. Analysis
1075879-ENG A Commissioning and QA Equipment |2-7

kV Contrast & Ability to mount at a 45 deg. angle to the floor. Verify Imaging System
Resolution Phantom Analysis software very helpful but not required.
kVP Meter 80-150 kV range. Verify Imaging System
Dynamic Thorax Spinal anatomy present for image tracking. Verification of Lung
Phantom Tracking with Respiratory
Modeling imaging
Lung Rod Contains tissue density target with film inserts. Verification of Lung
Tracking with Respiratory
Modeling Treatments
Electron Density Mass and electron densities provided over the Convert Hounsfield Units
Phantom clinical range of use. (HU) to density values for
Treatment Planning
Survey Meter Standard vault survey meter for 6 MV LINAC. Radiation Surveys
Diode Detectors and Diode Test

All measurements should be made using a set of 2 detectors approved for radiosurgery
measurements. The smallest diode detectors produce measurements that most closely match the
beam properties of the linear accelerator (LINAC). See Figure 1 for examples of diode detectors.
WARNING: When acquiring beam data that will be imported to the CyberKnife System,
use a detector that is suitable for stereotactic radiosurgery. Otherwise, the spatial
resolution of the data will be too coarse, which can compromise the accuracy of dose
delivery.
Figure 1 Left: example stereotactic diode (PTW 60018).

Right: Sun Nuclear EDGE™ diode.
2-8 | Diode Detectors and Diode Test 1075879-ENG A

Diode Test
Perform the following diode test to determine if a diode used in commissioning measurements
responds within the recommended range for collecting beam data. If needed, please contact
Physics Support for assistance with calculating the % difference relative to 1000 mm SAD.
 To test the diode response, follow these steps:
1. Set the diode to 15 mm depth. Refer to the diode manufacturer’s manual for information
on the precise location of the diode sensitive volume.
2. Set the LINAC to 1000 mm SAD. Perform the diode centering procedure provided by the
water tank software or use a manual method. Make sure the diode is centered on the
beam and note the laser position on the diode.
3. Collect at least three readings, record the results, and calculate the average reading ( R ).
4. Correct the average reading for the inverse square effect relative to 1000 mm SAD using
the following equation:
SAD 2
R corr = R   ------------
-

1000
5. Repeat steps 2 through 5 for 900 mm, 800 mm, 700 mm, and 600 mm SAD. Recheck the
diode centering at each SAD before making measurements. Any misalignment could alter
the readings and confuse the results of the test.
6. Determine the % difference relative to the 1000 mm SAD corrected average reading. The
recommended acceptable individual % difference should be less than 2% and the
average % difference less than 1%
If the response of the diode is acceptable, it can be used for commissioning measurements. If not,
the diode should be replaced or used only as a reference signal when taking a profile
measurement.
1075879-ENG A Diode Detectors and Diode Test |2-9

Laser and Radiation Coincidence Check

WARNING: The laser and radiation coincidence check must be performed before
acquisition of beam data to prevent systemic error in the beam datasets.
The CyberKnife System uses a pinhole laser that is coincident with the radiation field central axis
(CAX) as a QA tool. The LINAC laser is reflected off of an adjustable mirror and aligned to the
mechanical center of the collimators. Then the center of the radiation beam is steered to the
mechanical center of the collimators.
Check laser alignment periodically as part of your regular QA program. Figure 2 shows examples
of misalignment where the mirror is at the incorrect vertical height or angle.
(a) Not Coincident (a) Not Coincident (a) Coincident
Figure 2 Laser and radiation beam

central axis (CAX) coincidence
2-10 | Laser and Radiation Coincidence Check 1075879-ENG A

Performing the Laser and Radiation Coincidence

Check
This procedure checks that the LINAC laser beam and radiation beam are aligned. Verify the
coincidence of the alignment of the laser beam and the radiation field prior to acquisition of beam
data. Perform the following procedure to check the mechanical alignment of the laser and its
congruence with the radiation beam central axis (CAX).
NOTE: Perform the garden-fence test before running this test for the MLC
collimator (see“Creating Multileaf Collimator Test Patterns” on page 4-93).
CAUTION: Do NOT adjust the position of the laser. Otherwise, the following may occur:
• For configurations that include the Xchange System, the Xchange table may
need to be recalibrated.
• Laser misalignment may occur and the laser beam may not pass through the
pinhole laser collimator. If this occurs, it will not be possible for Accuray Field
Service to successfully perform path verification using an isocrystal.
NOTE: If the laser is out of alignment, call Accuray Customer Support. Laser
adjustments should only be performed by Accuray service personnel.
The following materials are used to perform the laser and radiation coincidence check:
NOTE: A change in the position of the laser beam spot on the floor at the perch
position does not necessarily indicate that the treatment robot has lost robot
mastering. A change can also indicate that the laser itself has moved. In either
case, call Accuray Customer Support.
• Pinhole laser collimator

• ≤ 40 mm fixed circular collimator or IRIS dodecagon aperture. (15 mm works well and the
film can be used for both AQA image tests. For more information on film for the AQA
tests, see “Chapter 4: AQA, E2E, MLC, and Plan QA Tests” on page 4-1.
• < 30.8 x 30.8 mm2 MLC square field size. (15.4 mm x 15.4 mm works well and can be
used for both AQA image tests. For more information on film for the AQA tests, see
“Chapter 4: AQA, E2E, MLC, and Plan QA Tests” on page 4-1.
• Ready-Pack diagnostic film or radiochromic film
• Cup of water
• Sharp pin for non-radiochromic film.
• Fine point pen for radiochromic film.
• ImageJ software (optional)
 To perform the laser and radiation coincidence check:
1075879-ENG A Laser and Radiation Coincidence Check |2-11

1. Install the desired collimator (Fixed, IRIS, or MLC).

2. Install the pinhole collimator.
3. Move the treatment robot so that the pinhole collimator is approximately 400 mm from a
flat surface, such as the treatment couch.
4. Use a handheld level gauge to ensure the surface is level.
5. Place a cup of water on the surface and in the path of the laser. Adjust the treatment
robot so that the laser beam is reflected back into the hole in the pinhole collimator. This
will set the radiation beam perpendicular to the surface.
6. Place a sheet of film on the flat surface.
7. Adjust the SSD to 800 mm using the front distance pointer.
8. Remove the front distance pointer and install the desired collimator.
9. (Radiochromic film only) Use a sharp knife or fine tip pen to mark the center of the film.
Align the mark with the laser beam.
(Optional) If necessary, to ensure that the film is flat, tape the film to the flat surface.
10. Expose the film with the appropriate number of monitor units (MU) so as to not saturate it.
• For XV film, use about 25 MU without buildup.
• For EBT type film, deliver 1200 MU without buildup.
NOTE: Refer to the glossary for the specific EBT films that have been
validated for QA tests that require EBT type film.
11. (Ready-Pack film only) Using a sharp pin, poke a hole in the film where the laser hits. Be
careful not to shift the film inside the envelope.
12. (Ready-Pack film only) Immediately cover the pin prick with opaque tape to prevent
adding light exposure.
13. (Ready-Pack film only) Develop the film.
14. For 800 mm SSD, the location should be less than 1 mm from the center of the radiation
field. This step can be performed using the ImageJ software application. Repeat the
above procedure at 1600 mm SSD by placing film on the floor. To ensure an adequate
density on the film, use the following: MU:
• For XV film, use about 62 MU without buildup.
• For EBT type film, deliver 2000 MU without buildup.
15. Perform film analysis. An example film analysis procedure using ImageJ is described in
the next section.
• At 800 mm SSD, use film analysis to verify that the film demonstrates
congruence < 1 mm.
• At 1600 mm SSD, use film analysis to verify that the film demonstrates congruence
< 2 mm or  2 times the value at 800 mm SSD (whichever is greater).

Using ImageJ to Perform Film Analysis

The following procedure gives an example that describes using the ImageJ software application
to measure the alignment between the laser and the radiation beam central axis.
• “Film Analysis Using ImageJ and EBT Type Film” on page 2-13
NOTE: The following example procedure describes the use of software and/or
hardware products that are not developed by Accuray and which do not have
a formal relationship to the CyberKnife System.
This procedure describes one method for performing the task. Other, equally
effective methods may exist. The Medical Physicist is responsible for
determining which product and methodology to use for this task.
Accuray assumes no responsibility for the accuracy of this procedure with
regard to various software and/or hardware versions. Contact Accuray
Customer Support if you need further guidance.
Film Analysis Using ImageJ and EBT Type Film

The following procedure is an example that describes using the ImageJ software application and
EBT type film to measure the alignment between the laser and the radiation beam central axis.
NOTE: This procedure can be used for Fixed, Iris, and Multileaf collimators.
validated for QA tests that require EBT type films.
 To measure laser and radiation beam alignment using EBT type film:
1. Scan the film using the following settings:
• Professional Mode
• positive film
• 300 dpi
• 48-bit color
• no color corrections (the same as used for End-to-End (E2E) tests and Iris Quality
Assurance for EBT type film).
2. Open the scanned film TIFF image file using ImageJ software.
NOTE: The measurement unit is displayed along with the image size near the
top of each image. The measurement unit can be changed (for example, to
millimeters) using the Analyze > Set Scale menu item (see Figure 3).

Figure 3 Changing the measurement scale (example

for image scanned at 300 dpi)
3. Select Analyze > Set Measurements to enable calculation of the centroid.

4. Separate the color channels using Image > Color > Split Channels. Use only the
red channel for the steps that follow.
5. To read the X and Y coordinates of the laser in the main ImageJ window, move the
crosshairs to the “X” mark. Alternatively, use the point tool to mark the center position and
use Analyze > Measure to show the X, Y position of the defined point (see Figure 4).
Figure 4 Example ImageJ view showing

measurement of X and Y laser position

6. Use the rectangular marquee tool to select an approximately square region that covers
the full width at half maximum (FWHM) of the beam. The beam will be circular in shape
for the fixed collimator, dodecagon in shape for the IRIS Collimator, and square in shape
for MLC.
7. Select Image > Adjust > Threshold. In the Threshold dialog box, select
Default and B&W and adjust the threshold levels such that the background is white,
the "X" mark in the middle is not visible, and the size of the exposed region (circle for
Fixed, dodecagon for IRIS, and square for MLC) is about the same as the size of the
square. Once the threshold level is acceptable, adjust the marquee to consistently fit the
edges of the now black thresholded region (see Figure 5).
Figure 5 Example ImageJ view showing adjustment

of threshold level
8. Select Analyze > Measure to calculate the centroid of the black region, as defined by the
marquee. The actual centroid measured is the center of the marquee, so the marquee
needs to be adjusted consistently to fit the edges of the thresholded region (as noted in
step 7).
9. To obtain a radial distance, calculate the magnitude of the vector using the x and y
coordinates, note the measurement units, and convert to millimeters.
10. Repeat the above procedure at 1600 mm above the floor by placing film on the floor. The
laser beam spot should be within 2 mm from the center of the radiation field.
• At 800 mm SSD, verify that the film demonstrates congruence <1 mm.
• At 1600 mm SSD, use film analysis to verify that the film demonstrates congruence <
2 mm or ≤ 2 times the value at 800 mm SSD (whichever is greater).

Beam Commissioning
• “Overview of Beam Commissioning” on page 2-16
• “Beam Data Acquisition for the Ray-Tracing Dose Calculation” on page 2-24
• “Beam Data Acquisition for the Monte Carlo Dose Calculation
for the Fixed and Iris Collimators” on page 2-89
• “The Finite Size pencil beam (FSPB) is only used in conjunction with the InCise 2
Multileaf Collimator.” on page 2-100
• “Importing Beam Data to the Data Server” on page 2-132
• “Accuray Precision Commissioning Tools” on page 2-134
• “This section describes the process that should be followed to create a beam model for
the Monte Carlo Dose Calculation algorithm for the fixed collimators and the Iris
Collimator in the Accuray Precision System.” on page 2-134
• “Monte Carlo Commissioning Workflow for the Multileaf Collimator” on page 2-141
• “Decommissioning Beam Data” on page 2-153
Overview of Beam Commissioning

This section provides an overview of beam commissioning procedures for the Ray-Tracing dose
calculation algorithm and the Monte Carlo Dose Calculation option, for both fixed collimators and
the Iris Collimator. It covers the following topics:
• “Beam Commissioning for the Ray-Tracing Dose Calculation Algorithm
for Fixed and Iris Collimators” on page 2-17
• “Beam Commissioning for the Monte Carlo Dose Calculation
for Fixed and Iris Collimators” on page 2-19
• “Beam Commissioning for the Monte Carlo Dose Calculation for the Multileaf Collimator”
on page 2-23
• “Commissioning Requirements for Treatment Planning” on page 2-23
• “The Finite Size pencil beam (FSPB) is only used in conjunction with the InCise 2
Multileaf Collimator.” on page 2-100
NOTE: In addition to collecting beam data required for the Ray-Trace Dose
Calculation for fixed collimators and the Iris Collimator, additional beam data is
required for the Monte Carlo Dose Calculation for these collimators. However,
no additional beam data is required for the Monte Carlo Dose Calculation for
the Multileaf Collimator, except for beam data needed for the Finite Size Pencil
Beam Dose Calculation.
2-16 | Beam Commissioning 1075879-ENG A

Beam Commissioning for the Ray-Tracing Dose

Calculation Algorithm for Fixed and Iris Collimators
• “Required Beam Data Overview” on page 2-18
• “Beam Data Filenames” on page 2-22
The beam commissioning procedure for the Ray-Tracing dose calculation algorithm includes the
following general steps, which apply to both the fixed collimators and the Iris Collimator:
1. Acquire and process the required beam data.
2. Generate properly formatted and named beam data files in plain text (ASCII or ANSI)
format.
3. Import beam data files to the iDMS Data Management System using the Beam Data
Import application. The status of the beam data files changes to Imported when they are
successfully imported to the data server.
4. Access beam data tables. For more information about how create and print beam data,
see the Commissioning Tools chapter in the Treatment Planning Manual.
5. Print them and verify that they conform to your measured beam data.
6. Compare the calculated tissue phantom ratio (TPR) with the measured beam data. If
results are acceptable, then approve the calculated beam data.
7. Compare the calculated off center ratios (OCR) with the measured beam data. If results
are acceptable, then approve the calculated beam data.
8. Compare calculated output factor (OF) beam data with the measured output factor beam
data. If results are acceptable, then approve the beam data.
Upon completion of approval, the status of the beam data files in the iDMS Data
Management System changes to Commissioned.
Separate sets of beam data are required for the fixed collimators and the Iris Collimator. Each set
of beam data must be imported to the iDMS Data Management System individually, as described
in “Importing Beam Data to the Data Server” on page 2-132.
For more information on commissioning procedures in the Accuray Precision System, see the
Treatment Planning Manual.
1075879-ENG A Beam Commissioning |2-17

Required Beam Data Overview

The following types of relative measurements are required for beam commissioning of the Ray-
Tracing dose calculation algorithm for fixed collimators:
• “Tissue Phantom Ratio (TPR) Measurements” on page 2-41
• “Off Center Ratio (OCR) Measurements for Fixed and Iris Collimators” on page 2-50
• “Output Factor (OF) Measurements” on page 2-55
The above measurements, with different data acquisition procedures, are also required for beam
commissioning of the Ray-Tracing dose calculation algorithm for the Iris Collimator:
• “Tissue Phantom Ratio (TPR) Measurements for the Iris Collimator” on page 2-67
• “Off Center Ratio (OCR) Measurements for the Iris Collimator” on page 2-72
• “Output Factor (OF) Measurements for the Iris Collimator” on page 2-86
For more information on required beam data for commissioning the Ray-Tracing dose calculation
algorithm, see “Fixed Collimator Beam Data Acquisition” on page 2-36 and “Iris Collimator Beam
Data Acquisition” on page 2-59.
Beam Data Files

Plain text beam data files must be generated in accordance with a specific format as described
later in this chapter.
NOTE: Beam data files must be generated in plain text format (ASCII or ANSI).
Otherwise, they cannot be imported into the iDMS Data Management System.
The iDMS Data Management System recognizes beam data filenames with
both .dat and .txt file extensions.
WARNING: Extra spaces or line breaks in the beam data files will generate errors when
importing the data. Print all beam data tables from the Accuray Precision Treatment
Planning System and confirm that they match the initial measured values.
Table 3 lists beam data filenames for commissioning the Ray-Tracing dose calculation algorithm
for fixed collimators and for the Iris Collimator. Plain text file formats for both collimator types are
the same, though their filenames are different. Each filename for OCR beam data is associated
with a particular collimator size. Appendix 2A, “Beam Data Validation Rules”, lists the filenames
that correspond to each collimator size.
NOTE: The iDMS Data Management System recognizes beam data filenames
with both .dat and .txt file extensions.

Table 3 Beam data filenames for commissioning

the Ray-Tracing dose calculation algorithm
File Fixed Collimators Iris Collimator
Tissue phantom ratio (TPR) table TMRtable.dat irisTPRtable.dat
OCRtable0.dat irisOCRtable0.dat
Off center ratio (OCR) tables (12 files) OCRtable2.dat irisOCRtable2.dat
to to
Output factor (OF) table DMtable.dat irisOFtable.dat
Use the Beam Data Import application of the iDMS Data Management System to import the plain
text beam data files to the data server, as described later in this chapter. The Beam Data Import
application validates beam data files during the import process using Beam Data Validation rules.
If the data in a file violates any of these rules, the import option for that file is disabled, and the
Beam Data Import application displays an error or Warning message. See Appendix 2A for a list
of Beam Data Validation rules.
Certain measured beam data values have allowed maximum and minimum values, also listed in
Appendix 2A. The Beam Data Import application will disable the import option for a file if it
contains values that are outside these limits.
After the files are imported to the data server, the calculated beam data tables may be printed out
from the Accuray Precision System and compared with the initial measured values to verify that
the beam data was loaded into the Accuray Precision System successfully. Any errors should be
identified and the validity of the beam data confirmed before proceeding. For more information on
the Beam Data Import application, see the Data Management Manual.
Beam Commissioning for the Monte Carlo Dose

Calculation for Fixed and Iris Collimators
• “Required Beam Data” on page 2-21
• “Beam Data Filenames” on page 2-22
During Accuray Precision commissioning of the Monte Carlo Dose Calculation algorithm, you will
use the Monte Carlo Dose Calculation to perform various single-beam dose calculations in a
simulated water phantom. These dose calculations are intended to simulate the physical
configurations used to acquire the standard beam data (OCR, TPR, and output factor) for the
Ray-Tracing dose calculation algorithm. In effect, the Accuray Precision commissioning
procedure uses the Monte Carlo Dose Calculation to calculate the standard beam data.

The beam commissioning procedure for the Monte Carlo Dose Calculation option includes the
following general steps, which apply to both the fixed collimators and the Iris Collimator.
Dependencies between commissioning steps are described in “Commissioning Requirements for
Treatment Planning” on page 2-23.
1. Acquire and process required beam data.
2. Generate properly formatted and named beam data files in plain text (ASCII or ANSI)
format.
3. Import beam data files to the iDMS Data Management System using the Beam Data
Import application. The status of the beam data files changes to Imported when they are
successfully imported to the data server.
4. Access beam data tables from the Accuray Precision System. Print them and verify that
they conform to your measured beam data.
5. In the Accuray Precision System, generate a calculated source model for the LINAC
radiation source. The source model consists of 3 probability distributions: the source
distribution, the fluence distribution, and the energy spectrum. Two modeling methods
are available for generating the source distribution:
• Gaussian method that models the source distribution as a Gaussian function. With
this method, you specify a value for the photon source full width half maximum
(FWHM).
• In-air Output Factor method that calculates the source distribution using measured in-
air output factor beam data. This method is optional.
You then review and approve the source model. For more information on the source
model and probability distributions, see Chapter 5, “Algorithms for Dose Calculation and
Display”.
6. In the Accuray Precision System, calculate the TPR and OCR curves using the source
model generated in step 5. Then compare these curves with the measured TPR and
OCR data previously approved to commission the Ray-Tracing dose calculation
algorithm. If the Monte Carlo generated TPR and OCR curves satisfactorily match the
measured TPR and OCR curves, then move on to step 7. Otherwise, make adjustments
to the source model by adjusting the following parameters:
• Gaussian FWHM (if the Gaussian method was used)
• Energy Correction Factor (ECF)
• Collimator Correction Factor (CCF)
You then review and accept the source model parameters. For more information on the
correction factors, see Chapter 5, “Algorithms for Dose Calculation and Display”.

7. In the Accuray Precision System, calculate the output factor (OF) value for each
collimator size using the Monte Carlo Dose Calculation algorithm. The calculation also
generates an absolute dose normalization constant, Fnormal, to convert the deposited
energy to the absolute dose. The Iris Collimator uses the same Fnormal value that was
calculated for the fixed collimators.
You then review and approve the Monte Carlo calculated output factors and Fnormal.
After all commissioning steps in the Accuray Precision System are completed, the status
of the beam data files in the iDMS Data Management System changes to Commissioned.
Separate sets of beam data are required for the fixed collimators and the Iris Collimator. Each set
of beam data must be imported to the iDMS Data Management System individually, as described
in “Importing Beam Data to the Data Server” on page 2-132.
For a detailed description of the Monte Carlo commissioning workflow including flowcharts that
illustrate the process that should be followed to create a beam model in the Accuray Precision
System, see “This section describes the process that should be followed to create a beam model
for the Monte Carlo Dose Calculation algorithm for the fixed collimators and the Iris Collimator in
the Accuray Precision System.” on page 2-134. For detailed information on commissioning
procedures in the Accuray Precision System, see the Treatment Planning Manual.
Required Beam Data

If your Accuray Precision System includes the Monte Carlo Dose Calculation option for fixed
collimators and the Iris Collimator, the beam data described below is required, in addition to the
beam data required for commissioning the Ray-Tracing dose calculation algorithm.
The following types of relative measurements are required for beam commissioning of the Monte
Carlo Dose Calculation for fixed collimators:
• “In-air Output Factor (OF) Measurements (Optional)” on page 2-91: This is the in-air
output factor for each fixed collimator and is optional. This measurement is required only
if you intend to use the In-air Output Factor method in the Accuray Precision System to
generate the Monte Carlo source distribution.
• “Open Field Profile Measurements” on page 2-93: This is the open field dose profile of the
LINAC radiation beam, that is, a beam profile with no fixed collimator and retaining nut
present.
• “Central Percent Depth Dose (PDD) Measurements” on page 2-97: This is a central PDD
curve acquired with the 60 mm fixed collimator.

The above measurements are also required for beam commissioning of the Monte Carlo Dose
Calculation for the Iris Collimator, as shown below:
• “In-air Output Factor (OF) Measurements (Optional)” on page 2-91. This measurement is
optional. This measured data is required only if you intend to use the In-air Output Factor
method in the Accuray Precision System to generate the Monte Carlo source distribution
model.
• “Open Field Profile Measurements” on page 2-93: This measurement does not need to
be repeated for the Iris Collimator. The same beam data measured for fixed collimators is
used. The beam data filename, however, must be changed for the Iris Collimator.
• A central PDD curve acquired with the Iris Collimator 60 mm aperture.
For more information on required beam data for commissioning the Monte Carlo Dose
Calculation, see “Beam Data Acquisition” on page 2-89.
Beam Data Filenames

Plain text (ASCII or ANSI) beam data files must be generated in accordance with a specific format
as described later in this chapter. Table 4 lists beam data filenames for commissioning the Monte
Carlo Dose Calculation for fixed collimators, and for the Iris Collimator. Plain text file formats for
both collimator types are the same, though their filenames are different.
NOTE: The iDMS Data Management System recognizes beam data filenames
with both .dat and .txt file extensions.
Table 4 Beam data filenames for commissioning

the Monte Carlo Dose Calculation
File Fixed Collimators Iris Collimator
In-air output factor (OF) mc_outputfactor.dat iris_mc_outputfactor.dat

Optional
Open field dose profile mc_doseprofile.dat iris_mc_doseprofile.dat
Central percent depth mc_centralpdd.dat iris_mc_centralpdd.dat

dose (PDD)
You must use the Beam Data Import application of the iDMS Data Management System to import
the plain text beam data files to the data server, as described later in this chapter. The Beam Data
Import application validates beam data files during the import process using Beam Data Validation
rules. If the data in a file violates any of these rules, the import option for that file is disabled, and
the Beam Data Import application displays an error or Warning message. See Appendix 2A for a
list of Beam Data Validation rules.

Certain measured beam data values have allowed maximum and minimum values, also listed in
Appendix 2A. The Beam Data Import application will disable the import option for a file if it
contains values that are outside these limits.
After the files are imported to the data server, the calculated beam data tables may be printed out
from the Accuray Precision System and compared with the initial measured values to verify that
the beam data was loaded into the Accuray Precision System successfully. Any errors should be
identified and the validity of the beam data confirmed before proceeding. For more information on
the Beam Data Import application, see the Data Management Manual.
Beam Commissioning for the Monte Carlo Dose

Calculation for the Multileaf Collimator
There are no additional measurements required for the Monte Carlo Dose Calculation algorithm
for the Multileaf Collimator. For information on the workflow for commissioning the Monte Carlo
Dose Calculation algorithm for the Multileaf Collimator, see “Monte Carlo Commissioning
Workflow for the Multileaf Collimator” on page 2-141.
Commissioning Requirements for Treatment Planning

In the Accuray Precision System, commissioning of the Ray-Tracing dose calculation algorithm
must be completed before you can begin commissioning of the Monte Carlo Dose Calculation.
There are also dependencies between commissioning steps for the fixed collimators, and the Iris
Collimator. Commissioning dependencies for the Accuray Precision System are given in Table 5.
Table 5 Required beam commissioning for treatment planning
Treatment Plan Required Commissioning
Treatment plans for fixed • Ray-Tracing dose calculation algorithm with fixed collimators
collimators
Treatment plans for the Iris • Ray-Tracing dose calculation algorithm with fixed collimators
Collimator
• Ray-Tracing dose calculation algorithm with the Iris Collimator
Treatment plans for fixed • Ray-Tracing dose calculation algorithm with fixed collimators
collimators using the Monte
• Monte Carlo Dose Calculation with fixed collimators
Carlo Dose Calculation
option
Treatment plans for the Iris • Ray-Tracing dose calculation algorithm with fixed collimators
Collimator using the Monte
• Monte Carlo Dose Calculation with fixed collimators
Carlo Dose Calculation
option • Ray-Tracing dose calculation algorithm with the Iris Collimator
• Monte Carlo Dose Calculation with the Iris Collimator

Accuray Precision commissioning of the Ray-Tracing dose calculation algorithm for fixed
collimators must be completed before you can proceed with commissioning of the Monte Carlo
Dose Calculation for fixed collimators.
Accuray Precision commissioning of the Ray-Tracing dose calculation algorithm for fixed
collimators must be completed before Ray-Tracing commissioning for the Iris Collimator. This is
because Iris Collimator output factors are normalized with respect to the 60 mm fixed collimator.
For more information, see “Output Factor (OF) Measurements for the Iris Collimator” on
page 2-86.
Accuray Precision commissioning of the Ray-Tracing dose calculation algorithm for the Iris
Collimator must be completed before you can proceed with commissioning of the Monte Carlo
Dose Calculation for the Iris Collimator.
Accuray Precision commissioning of the Monte Carlo Dose Calculation with fixed collimators must
be completed before Monte Carlo commissioning with the Iris Collimator. This is because the Iris
Collimator uses the same Fnormal value that was calculated during Monte Carlo commissioning
for fixed collimators. For more information on commissioning procedures in the Accuray Precision
System, see the Treatment Planning Manual.
Beam Data Acquisition for the Ray-Tracing Dose

Calculation
• “Using the Accessories for the Fixed and Iris Collimators” on page 2-24
• “Fixed Collimator Beam Data Acquisition” on page 2-36
• “Iris Collimator Beam Data Acquisition” on page 2-59
Using the Accessories for the Fixed and Iris Collimators

This section describes how to use the birdcage assembly, front distance pointer, and pinhole
collimator for the fixed collimators and the Iris Collimator. It describes how to attach these
components to the collimator housing or to the birdcage. It covers the following topics:
• “Accessories for the Fixed and Iris Collimators” on page 2-25
• “Attaching the Birdcage to the Fixed or Iris Collimator Housing” on page 2-29
• “Attaching the Pinhole Collimator to the Fixed or Iris Collimator Housing” on page 2-30
• “Using the Front Pointer” on page 2-31

Accessories for the Fixed and Iris Collimators

The following accessories are provided:
• Birdcage assembly: Holds a diode detector or a Baldwin-Farmer type ion chamber at a
fixed distance from the radiation source. It also holds the Iris QA phantom.
NOTE: The same birdcage is used for the fixed collimator, Iris Collimator, and
Multileaf Collimator housing.
• The birdcage assembly is attached to the collimator housing using the Fixed/Iris
proximal coupler. The birdcage includes 2 alignment pins and 4 thumbscrews on one
end for attaching it to the coupler (see Figure 6). The opposite end includes a diode
mount.
2 Alignment Pins
And 4 Thumbscrews
Diode
Mount
Figure 6 Birdcage assembly

• Front distance pointer: For distance measurement. Includes a set screw for adjusting
its length (see Figure 7), a measurement scale, and two measurement readouts (see
Figure 8). Which measurement readout to use depends on how the front pointer is
mounted, as described in Table 6.
NOTE: The same front pointer is used for the fixed collimator, Iris Collimator,
and Multileaf Collimator housing.
• The mounting plates for attaching the front pointer to the collimator housing or
mounting it in the birdcage are different. The front pointer includes two holes for screws
to attach it to one of the mounting plates.
2 Screw Holes
For Attaching
Front Pointer
To Mounting
Plate
Figure 7 Front distance pointer
Figure 8 Measurement readouts on front pointer.

See Table 6 for description.

Table 6 Configurations for measurement readouts on front pointer
Figure 8 Readout Front Pointer Configuration Description

Readout Text Coupler
Front pointer mounted in birdcage using

B-CAGE birdcage mounting plate (see Figure 18 and
SET UP: Figure 19 on page 2-33).
IRIS, FCA,
INCISE I
Front pointer mounted on Fixed/Iris housing

using Fixed/Iris housing mounting plate (see
Figure 21 and Figure 22 on page 2-35).
ALL
OTHERS
Front pointer mounted on Multileaf Collimator
housing or in birdcage using MLC proximal
coupler and MLC front pointer adapter (see
Figure 76 on page 2-108 and Figure 77 on
page 2-109).
• Pinhole collimator for the fixed collimator and Iris Collimator housing: pinhole laser
collimator used for path calibration and QA tests. The pinhole collimator is attached to the
collimator housing using the proximal coupler. It includes 4 thumbscrews and 2 alignment
pins for attaching it to the coupler (see Figure 9).
Figure 9 Pinhole laser collimator for fixed collimator

and Iris Collimator

• Fixed/Iris proximal coupler: For attaching the birdcage or the pinhole collimator to the
fixed collimator or Iris Collimator housing (see Figure 10). It includes 2 alignment pins
(shown on left) and 4 thumbscrews (shown on right) for attaching it to the collimator
housing.
2 Alignment Pins
For Aligning On
Collimator Housing
Figure 10 Proximal coupler for fixed collimator and

Iris Collimator housing
• Fixed/Iris housing mounting plate: For attaching the front pointer to the fixed collimator
or Iris Collimator housing (see Figure 11). It includes 4 thumbscrews (not shown) and 2
alignment pins for attaching it to the collimator housing.
2 Alignment Pins
2 Holes for For Aligning On
Alignment Pins On Collimator Housing
Front Pointer
Figure 11 Round mounting plate for attaching front

pointer to fixed collimator or Iris Collimator housing

• Birdcage mounting plate: For mounting the front pointer in the birdcage (see
Figure 12). It includes holes for the alignment pins on the birdcage and the front pointer,
and 4 thumbscrews for attaching it to the birdcage.
2 Holes For
Alignment Pins On
Front Pointer
2 Screw Holes For

Attaching Plate To
Front Pointer
Figure 12 Flat mounting plate for attaching front

pointer to birdcage
Attaching the Birdcage to the Fixed or Iris Collimator Housing

Use the following procedure to attach the birdcage to the collimator housing, because it provides
good access to tighten the thumbscrews.
1. Insert the 2 alignment pins on the Fixed/Iris proximal coupler into the matching alignment
holes on the collimator housing.
2. Secure the proximal coupler by tightening the 4 thumbscrews, as shown in Figure 13.
Tighten the thumbscrews snugly but do not overtighten.
Figure 13 Attaching the Fixed/Iris proximal coupler

3. Then attach the birdcage to the proximal coupler using the outer 4 thumbscrews, as
shown in Figure 14.
Figure 14 Birdcage attached to collimator housing

using Fixed/Iris proximal coupler
Attaching the Pinhole Collimator to the Fixed or Iris Collimator

Housing
Use the following procedure to attach the pinhole collimator to the collimator housing, because it
provides good access to tighten the thumbscrews.
1. Attach the Fixed/Iris proximal coupler to the collimator housing as described in “Attaching
the Birdcage to the Fixed or Iris Collimator Housing” on page 2-29 and shown in
Figure 13.
2. Then attach the pinhole collimator to the proximal coupler using the outer 4 thumbscrews,
as shown in Figure 15.

Figure 15 Pinhole collimator attached to collimator

housing using Fixed/Iris proximal coupler
Using the Front Pointer

You can mount the front pointer in the birdcage, or you can attach the front pointer to the fixed
collimator or Iris Collimator housing, as described below.
You cannot attach the birdcage and front pointer simultaneously to the fixed collimator or Iris
Collimator housing. Therefore the process of positioning a detector at a fixed distance from the
radiation source is a two-step process:
1. Mount the front pointer in the birdcage, and use it to position the detector in the diode
holder.
2. Then remove the front pointer and attach the birdcage to the fixed collimator or Iris
Collimator housing with the detector already mounted, as described in “Attaching the
Birdcage to the Fixed or Iris Collimator Housing” on page 2-29 and shown in Figure 14 on
page 2-30.
 To mount the front pointer in the birdcage:
Use the birdcage mounting plate to mount the front pointer in the birdcage.
1. First attach the birdcage mounting plate to the front pointer. Align the 2 pins on the front
pointer with the 2 alignment holes on the mounting plate (see Figure 16).

Figure 16 Alignment pins on front pointer
2. Secure the mounting plate to the front pointer using two screws, as shown in Figure 17.
NOTE: The same attachment screws and alignment holes are used to attach
the front pointer to the other mounting plate and the Fixed/Iris proximal
coupler.
2 Alignment Pins On
Front Pointer
Inserted in Holes on
2 Screws Attaching Mounting Plate
Front Pointer To
Birdcage Mounting
Plate
Figure 17 Attachment screws for birdcage

mounting plate

3. Then attach the mounting plate to the birdcage using 4 thumbscrews, as shown in
Figure 18.
Figure 18 Front pointer mounted in birdcage
4. When the front pointer is mounted in the birdcage using the birdcage mounting plate,
read measurements using the front pointer readout labeled "B-CAGE SETUP" (see
Figure 19 and also Table 6 on page 2-27).
Measurement
Readout When
Using Birdcage
Mounting Plate
Figure 19 Measurement readout on front pointer when

mounted in birdcage using birdcage mounting plate

 To attach the front pointer to the fixed collimator or Iris Collimator housing:
Use the Fixed/Iris housing mounting plate to attach the front pointer to the collimator housing.
1. First attach the Fixed/Iris housing mounting plate to the front pointer. Align the 2 pins on
the front pointer with the 2 alignment holes on the mounting plate.
Then secure the mounting plate to the front pointer using two screws, as shown in
Figure 20.
NOTE: The same attachment screws and alignment holes are used to attach
the front pointer to the other mounting plate and the Fixed/Iris proximal
coupler.
2 Alignment Pins On
2 Screws Attaching Front Pointer
Front Pointer To Inserted in Holes on
Fixed/Iris Housing Mounting Plate
Mounting Plate
Figure 20 Attachment screws for Fixed/Iris housing

mounting plate
2. Insert the front pointer (attached to the Fixed/Iris housing mounting plate) into the
collimator housing.
3. Match the 2 alignment pins on the Fixed/Iris housing mounting plate with the alignment
holes on the collimator housing.
4. Secure the mounting plate by tightening the 4 thumbscrews, as shown in Figure 21.

Figure 21 Attaching the round mounting plate to the

collimator housing
5. When the front pointer is attached to the collimator housing, read measurements using
the front pointer readout labeled "ALL OTHERS" (see Figure 22 and also Table 6 on
page 2-27).
Measurement Readout
Attached to Collimator
Housing
Figure 22 Measurement readout on front pointer

when attached to collimator housing

Fixed Collimator Beam Data Acquisition

This section describes beam data acquisition procedures to commission the Ray-Tracing dose
calculation algorithm for secondary fixed collimators.
It covers the following topics:
• “Setting Up the Water Phantom” on page 2-36
• “Initializing Robot Tool Frame” on page 2-41
• “Tissue Phantom Ratio (TPR) Measurements” on page 2-41
• “Off Center Ratio (OCR) Measurements for Fixed and Iris Collimators” on page 2-50
• “Output Factor (OF) Measurements” on page 2-55
After you acquire the beam data and convert it to the required tabular format, send the data tables
to the Accuray Customer Support Physicist who has been assigned to your site for a preliminary
review prior to scheduling your on-site physics support. This will allow you and the Accuray
Customer Support Physicist to make the most efficient use of the on-site support visit.
The following materials are used during beam data acquisition:
• Birdcage assembly with proximal coupler for fixed collimators and the Iris Collimator (see
Figure 6 on page 2-25) and diode mount.
• Pinhole collimator for use with fixed collimators and the Iris Collimator.
• Front distance pointer.
• Water phantom with diode detector.
• Reference detector (diode detector or ion chamber).
Setting Up the Water Phantom

Ensure that the water phantom is in a position that enables you to perform the required
measurements. A reference detector should be used for all scanning.
NOTE: Ensure that the laser beam and LINAC radiation beam are aligned for
all subsequent beam measurement procedures.
NOTE: For information on setting up the water phantom for Iris Collimator
beam data acquisition, see “Setting Up the LINAC and Water Phantom for the
Iris Collimator” on page 2-61.

 To set up the water phantom for data collection:

1. Insert the pinhole laser collimator into the LINAC head.
2. Ensure that the laser is aligned mechanically according to specifications.
3. Place the water phantom so that it is no more than 20 cm from the floor, if possible (see
Figure 23).
Figure 23 Water phantom on the floor
NOTE: For a fixed 800 mm SAD setup, the distance from the floor is less
critical because the treatment robot remains stationary. Placing the water
phantom on or close to the floor reduces the likelihood of the LINAC colliding
with the ceiling of the Treatment Room.
• Ensure that the water phantom is level.

• Before you fill the tank with water, ensure you have enough room to move the
treatment robot to acquire all the beam data.

4. Move the Robot from Perch or Path Start to the area above the water tank. If the Perch or
InitFrames program has not been run since the CyberKnife System was powered on,
make sure to run the InitFrames program as described in Appendix 2D, "Robot
Positioning”.
WARNING: Keep your eyes on the treatment robot at all times, not the Teach Pendant,
when the robot is in motion, to avoid collision.
5. Translate the robot in Z through the full range of positions that are expected for
commissioning, that is roughly 10 cm and 40 cm above the expected water surface.
During this motion monitor the A5 joint angle and ensure that the angle does not drop
below 10 degrees.
 If the joint angle does fall below 10 degrees, translate the robot in Z to the position
that is 40 cm above the expected water surface. Rotate the robot in A such that the
A5 joint angle is around 45 degrees. Again, translate the robot in Z through the full
range of positions and ensure the angle does not drop below 10 degrees.
 If the joint angle continues to fall below 10 degrees, it may be necessary to move the
water phantom to another location that still satisfies the requirements stated above.
6. Translate the robot in X and Y to a position above the center of the scanning area of the
water tank. Stay in Tool Mode for the remainder of the setup steps.
7. Rotate the water phantom such that the sides of the LINAC are parallel to the sides of the
phantom.
8. Determine the proper orientation of the beam/collimator relative to the tank. This can be
done by translating the robot in Tool Mode X or Y and watching laser position as it moves
across the tank. The laser should follow the tank markings and/or fall on the point on
either side of the tank. The goal is to have the primary scanning axis of the tank aligned
with the X and Y Tool Mode axis as in Figure 24. Subsequently, this ensures that the
beam/collimator is aligned to the tank for proper scanning. Make sure that L1 = L2.
If L1 does not equal L2, first rotate the tank for coarse adjustments then rotate the robot in
A to achieve fine adjustments into the proper orientation.

Figure 24 Tracking the path of the laser beam spot

as the robot is translated in Tool mode Y.
Table 7
Item Description
Path of laser beam spot as the robot is translated in Tool mode Y.
The blue square represents the water phantom.
9. Add water. Use the reflection of the laser beam from a water surface to establish that the
beam is perpendicular to the surface. To do this, use the Teach Pendant to rotate the
treatment robot in B and C so that the reflected laser beam is aligned with the pinhole on
the pinhole collimator.
10. Ensure that the diode detector is set appropriately at the water surface.
• If your water phantom includes a surface alignment tool, use the alignment tool to set
the zero depth position.
If your water phantom does not include a surface alignment tool: While looking at the
diode detector from below the water surface, drive the diode detector up until it
touches its own reflection. Depending on the manufacturer of the diode detector, add
more distance until the active element of the detector is at the water surface. Then
set the zero depth position.

• Scan the diode detector across the surface in the XY plane and confirm that the diode
depth is constant along the X and Y axes across the scan field. If the depth is not
constant, adjust the tank appropriately. With the laser on the diode, you may also
move the diode vertically in Z to make sure the laser maintains the same position on
the diode at all depths.
11. Use the reference detector port located at the back of the LINAC cover to install the
reference detector (see Figure 25). There is a mechanical stop at the beam-end of the
reference detector port that will prevent standard diodes from entering the beam. If you
are using a small diode, it is possible to push the reference diode into the beam. With
your initial scans, verify that the diode has not been pushed into the beam.
Figure 25 Reference detector port
12. Remove the pinhole collimator and install the 7.5 mm fixed collimator.
13. Set the diode detector to 15 mm depth. Refer to the diode manufacturer’s manual for
information on the precise location of the sensitive volume.
14. Set the (0, 0, 0) origin of the water phantom scanning system to correspond to the central
axis of the LINAC radiation.
15. Confirm that the LINAC radiation beam is perpendicular to the water surface and aligned
with the Z axis of the water phantom. To do this, measure the beam profile in each
direction (X and Y) at 2 different depths. Verify that the scans at the different depths
overlay each other.

• When the effective point of measurement of the detector is at the water surface and
centered on the beam, this location should be set as the (0, 0, 0) origin of the water
phantom. Ensure that the electrometer gain is set so that a reliable signal is detected at
every depth and across the entire scan distance.
16. Perform the diode test to determine if a diode used in commissioning measurements
responds within the recommended range. See “Diode Detectors and Diode Test” on
page 2-8.
Initializing Robot Tool Frame

During commissioning, it is convenient to move the robot in the Tool frame and leave the robot
setup over the water phantom over night in order to maintain the position of the collimator for
subsequent measurements the following day. This is recommended, however when the system is
powered up the Tool Mode coordinate system is not initialized directly. If the user then needs to
adjust the robot position, say to account for water evaporation in the water phantom, moving in
Tool Mode may not give the expected results and may be surprising to the user. To avoid this, a
program should be run via the Teach Pendant that will initialize the Tool Frame and will
subsequently produce consistent movements in Tool Mode day after day.
Procedure:
1. Switch the Teach Pendant to T1 or T2 mode
2. Navigate to CKmain and select the InitFrames program
3. Run the InitFrames program just as you would for running the prch or PathStart
programs.
4. The program is very quick and you will know that it has completed when the R status
window on the Teach Pendant shows a black background.
Tissue Phantom Ratio (TPR) Measurements

The tissue phantom ratio (TPR) is the ratio of absorbed dose at a given point to the dose at a
fixed reference depth using constant SAD. The reference depth for the CyberKnife System is
15 mm for all collimator sizes. TPR data must be measured for each fixed collimator and prepared
as a single beam data file in plain text (ASCII or ANSI) file format.
TPR can be measured using TPR Option of the water tank. This section, however, explains an
alternative method of measurement using the birdcage.
TPR values can be measured directly at a constant SAD of 800 mm. As the depth of the diode
detector is changed, the SAD (also called the target-to-detector distance) remains fixed (see
Figure 26). After the TPR data has been acquired, it is compared with typical TPR data.

Figure 26 TPR measurement method

Preparing for TPR Measurements

The following materials are used during TPR measurements:
• Water phantom
• Diode detector
• Birdcage with diode holder attachment
To prepare for scanning, use the birdcage to mount the waterproof diode detector on the
treatment robot (see Figure 27). To change measurement depth, either change the LINAC and
diode detector Z position or adjust the water level for each measurement depth.
If you choose not to use the birdcage, mount the diode detector in the water phantom. Then move
the LINAC and water phantom vertically in step together to measure TPR data at various depths.
Figure 27 Birdcage with diode detector mounted
Recommended Depths and Fixed/Iris Aperture sizes for TPR Measurements
NOTE: The TPR Tools workbook to assist in TPR data collection is located on
the AERO website (www.accurayexchange.com) under Support: User
Documentation, or can be obtained by contacting Accuray Physics Support to
obtain a current copy.

Table 8 Take the recommended TPR measurements for your system’s Fixed or IRIS collimators
by following the measurement scheme outlined in Table 8. This measurement scheme is
developed to speed up commissioning time without sacrificing accuracy.
For Fixed and IRIS collimators, the checked boxes are required TPR measurements.
Unchecked boxes are not required*.
Depth (mm) Field Size (mm)
5 7.5 10 12.5 15 20 25 30 35 40 50 60
0 ✓ ✓ ✓ ✓ ✓ ✓ ✓
3 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
5 ✓ ✓ ✓ ✓ ✓ ✓ ✓
8 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
10 ✓ ✓ ✓ ✓ ✓ ✓ ✓
13 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
15 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
20 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
30 ✓ ✓ ✓ ✓ ✓ ✓ ✓
50 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
100 ✓ ✓ ✓ ✓ ✓ ✓ ✓
150 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
200 ✓ ✓ ✓ ✓ ✓ ✓ ✓
250 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
300 ✓ ✓ ✓ ✓ ✓ ✓ ✓
* All required data points must be populated in the workbook spreadsheet in order for the
TPR interpolation to occur.
At depths > 15 mm, the relationship of TPR vs. the natural log of the field size, referred to later as
ln[field diameter (mm)], is mostly linear.
This relationship makes it feasible to acquire a reduced TPR dataset and then use piecewise

linear interpolation to fill the remaining TPR data points without sacrificing accuracy (Figure 28).
Figure 28 TPR vs. Field Size

Left: Relationship between Measured TPR and ln[field] size) at 100
mm depth.
Right: Visual representation of piecewise linear interpolation
between neighboring TPR data.
At depths < 15 mm, TPR vs. In(field size) does not Left: Relationship between Measured TPR and
ln(field size) at 100 mm depth. Right: Visual representation of piecewise linear interpolation
between neighboring TPR data. follow a linear relationship, but the dynamic range of TPRs at
these surface depths is so narrow that TPRs can still be reasonably modeled using piecewise
interpolation.
Figure 29 shows an example in which a reduced set of TPRs was created from a full set and the
remaining TPRs were modeled by piecewise linear interpolation.
Figure 29 Measured TPR vs. TPR modeled by interpolation

at a depth of 10 mm. Arrows point to modeled TPRs.

 To perform direct TPR measurements:

1. Follow the steps on page 2-31 through 2-33 for using the front pointer in the birdcage to
install the diode and to set its distance. Refer to the diode manufacturers specification for
the depth of the sensitive volume and account for that when measuring the source-to-
detector distance with the front pointer.
2. Using the Teach Pendant, position the LINAC so the radiation beam central axis (CAX) is
perpendicular to the floor. If the Perch or InitFrames program has not been run since the
CyberKnife System was powered on, make sure to run the InitFrames program as
described in Appendix 2D for “Initializing Robot Tool Frame” on page 21-41.
3. Ensure the water phantom is level.
4. Fill the tank to the height necessary to obtain a reading at a 300 mm depth.
5. Position the LINAC so that the beam central axis (CAX) is perpendicular to the water
surface. Use the LINAC laser to verify this.
6. Attach the front distance pointer (shown in Figure 30) to the collimator housing. Then set
the LINAC-to-water surface distance to 800 mm.
Figure 30 The front distance pointer can be used

independently
7. Remove the front distance pointer and attach the birdcage to the collimator housing. See
“Using the Accessories for the Fixed and Iris Collimators” on page 2-24 for information on
attaching the birdcage.
8. Make sure the diode is aligned with the water surface and LINAC laser.
NOTE: If the diode has not been tested, perform the test to determine if a
diode used in commissioning measurements responds within the
recommended range. See “Diode Test” on page 2-9.
9. Move the treatment robot to position the diode at 300 mm depth to verify that there is
sufficient water in the tank.
10. Use incremental jogging on the Teach Pendant to move the treatment robot and take
readings at the recommended depths and aperture sizes in Table 8.
Press the Increment Jogging status icon at the upper right corner of the Teach Pendant
screen (see Figure 32). Then select the desired step sizes 0.1, 1.0, 10 or 100 mm step

sizes. For more information on using the Teach Pendant, see the Treatment Delivery
Manual.
11. Return the diode to the surface position using incremental jogging on the Teach Pendant.
Visually check the position to ensure it is correct.
12. Using the Teach Pendant to move the treatment robot using TOOL coordinates, take
readings at various depths and field sizes for each fixed collimator.
13. Record the measurements in the TPR worksheet to normalize the values for each
collimator to the value at the depth of 15 mm. It will also first interpolate the TPR vs. field
size using piecewise linear interpolation and then interpolate the field size vs. depth using
a cubic spline to generate TPR curves for all 12 aperture sizes. The TPR value for any
collimator is relative to the measurement at the reference depth (15 mm). Therefore, the
TPR value at 15 mm depth is 1.0 by definition for each collimator (see Figure 31).
14. From the TPR curve, interpolated TPR values are generated to produce equidistant 1 mm
data points. The TPR table requires 301 data points per collimator, at depths from 0 to
300 mm, in 1 mm steps.
NOTE: TPR data tables must contain no more than 301 data points.
15. Convert the data for all twelve collimators and combine into a single table in the required
plain text (ASCII or ANSI) format as described below and shown in Figure 32. See
Appendix 2A, “Beam Data Validation Rules” for a list of Beam Data Validation rules.
See Figure 31 for an example graph of a complete TPR dataset.
The filename of the TPR table is TMRtable.dat (or .txt) and the format is as follows:
• 1st line: version = 100
• 2nd line: sample = 0
• 3rd line: Identifier for the local institution
• 4th line: <Number of collimators (integer)> and label
• 5th line: <Number of depths (integer)> and label
• 6th line: <Field sizes in mm (floating point)>
• 7th - nth line: <Depth in mm (integer)> <TPR values (floating point)>
In Lines 1 and 2, the words version and sample must be lowercase.
16. Verify that the TPR table is correctly typed without extra spaces or line inserts as shown
in Figure 32.
WARNING: Extra spaces or line breaks will generate errors. Print all tables from the
Treatment Planning System and confirm that they match the initial measured values.

Figure 31 Example TPR plots normalized to 15 mm depth

Figure 32 Example plain text TPR table (TMRtable.dat)
17. After collecting all required beam data for commissioning the Ray-Tracing dose
calculation algorithm for fixed collimators and generating properly formatted beam data
files, import the beam data to the data server using the Beam Data Import application, as
described in “Importing Beam Data to the Data Server” on page 2-132. For more
information on the Beam Data Import application, see the Data Management Manual.
NOTE: The TPR, OCR and output factor data files for fixed collimators must
be imported together as a set using the Beam Data Import application.
18. After the files are imported to the data server, print out the calculated data tables from the
Accuray Precision System and compare them with the initial measured values (before
they were entered into a plain text file). The printed data tables are the interpolated and
extrapolated lookup tables that reside in computer memory when Ray-Tracing dose
calculations are performed for treatment planning.
Compare the printed values and their data formats against the initial measured values.
Verify that the overall data import process has occurred without error. Identify any errors
and confirm the validity of the beam data. For information on printing data tables, see the

Off Center Ratio (OCR) Measurements for Fixed and Iris

Collimators
• “OCR Scan Methods” on page 2-50
• “OCR Scan Parameters” on page 2-50
• “Performing OCR Measurements” on page 2-51
The off center ratio (OCR) is the ratio of the absorbed dose at a given off-axis point relative to the
dose at the radiation beam central axis (CAX) at the same depth. OCR data must be taken for
each collimator. Depths of 15,100, and 300 mm are recommended. By definition, the OCR value
for each depth and each collimator is 1.0 at a radial distance of 0 (at the central axis).
At each depth, take 2 orthogonal scans and average the results of each pair. Then average each
half of the average scan to produce a file containing the radial off-axis factors per collimator at 3
depths. This results in 12 beam data files in plain text (ASCII or ANSI) file format (see Table 3 on
page 2-19).
OCR Scan Methods

The OCR measurements are calculated from sets of orthogonal scans across the radiation field.
They can be scanned using either the fixed SAD or fixed SSD method. If the SSD method with a
constant 800 mm target-to-water surface distance is used, then geometrically correct the
measurements for an SAD equivalent setup.
In the fixed SAD method, OCR profiles are obtained by moving the treatment robot up and down
the Z axis with the Teach Pendant. The diode depth is then adjusted to maintain the 800 mm SAD
distance. Some scanning systems can change water levels to maintain the 800 mm SAD levels.
The SAD method reduces the amount of data processing required relative to the SSD method
and can be performed quickly and precisely.
OCR Scan Parameters

Table 9 and Table 10 list OCR measurement parameters that should be used for OCR beam
profile scans:
• The range values given in Table 9 are the recommended off-axis distances for the scans
when taken at 800 mm SAD.
• The range values given in Table 10 show the off-axis distances needed when scanning at
a fixed SSD distance of 800 mm in order to achieve the desired off-axis distances given
in Table 9.

Table 9 OCR scan measurement parameters for fixed SAD method
Measurement Description
Depths The following 3 depths: 15, 100, and 300 mm.
Resolution For 20 mm or smaller collimators, use 0.2 mm. For collimators with
aperture size greater than 20 mm, use 0.2 or 0.5 mm.
Range for fixed For 20 mm or larger collimators, 50 mm on each side of the central axis.
800 mm SAD For collimators 15 mm or smaller, 30 mm on each side of the central
axis. Do not exceed more than 500 data points.
SAD (Source-Axis The SAD can remain fixed at 800 mm if the treatment robot is moved
Distance, also called using the Teach Pendant in TOOL coordinates to adjust the distance
target-to-detector every time the diode detector depth is changed. Scanning takes a little
distance) longer but the time required for data processing is significantly reduced.
Associated errors are also minimized.
If the user scans at a fixed 800 mm SSD, then the width of the scans must increase with depth.
Use Table 10 for reference.
Table 10 OCR scan width for fixed SSD method

Depth (mm) Off-axis distance (mm)
If the range is 30 mm off-axis SAD, then use these values for fixed SSD:
15 ±35
100 ±38
300 ±46
If the range is 50 mm off-axis SAD, then use these values for fixed SSD:
15 ±55
100 ±61
300 ±73
Performing OCR Measurements

All measurements are performed at 800 mm SAD or are geometrically scaled from an SSD
measurement to the 800 mm SAD equivalent. For examples of processing OCR data using the
PTW water scanning system or IBA OmniPro, see Appendix 2B, “Processing OCR Beam Data
(Examples)”. If the Perch or InitFrames program has not been run since the CyberKnife System
was powered on, make sure to run the InitFrames program as described in Appendix 2D for

“Initializing Robot Tool Frame” on page 2-41.To perform OCR measurements:
WARNING: Use the measurement parameters described in Table 9 on page 2-51. The dose
calculation will extrapolate the dose using the last 2 data points entered for each OCR
curve. If the range is insufficient, dose will be incorrectly computed at extended radial
values.
 To perform OCR measurements:

2. Use the reflection of the laser beam from the water surface to establish that the beam is
perpendicular to the water surface. To do this, use the Teach Pendant to rotate the
treatment robot in B and C so that the laser is aligned with the pinhole of the pinhole
collimator.
3. Remove the pinhole collimator, and then install the 5 mm fixed collimator.
4. Set the diode detector to 15 mm depth. Refer to the diode detector manufacturer’s
manual for information on the precise location of the diode within the mechanical housing.
5. Leave the Treatment Room, secure the Treatment Room door, and return to the
treatment delivery computer.
6. Set the origin (0, 0) of the water phantom scanning system to correspond to the central
axis of the LINAC radiation beam in the XY plane:
• Turn on the LINAC radiation beam.
• Scan the diode detector in each direction (X and Y) and take readings to determine
the center of the radiation beam.
• Set the origin (0, 0) of the water phantom scanning system in the XY plane.
7. Return to the Treatment Room. Verify that the diode is located on the central axis of the
radiation beam:
With the 5 mm fixed collimator installed, run the diode detector up and down, making sure
the laser beam hits the same spot on the diode at all depths.
8. Confirm that the LINAC radiation beam is perpendicular to the water surface and aligned
with the Z axis of the water phantom. To do this, scan the detector in each direction (X
and Y) at 2 different depths. Verify that the scans at the different depths overlay each
other.
• Rotate the treatment robot in Tool Mode using the B and C toggles to make the LINAC
beam perpendicular to the water surface. Repeat step 8 to verify that the adjustment is
correct.
• When the effective point of measurement of the detector is at the water surface and
centered on the beam, this location should be set as the (0, 0, 0) origin of the water
phantom.

• Ensure that the electrometer gain is set so that a reliable signal is detected at every
depth and across the entire scan distance.
recommended range. See “Diode Detectors and Diode Test” on page 2-8.
9. Acquire a set of orthogonal scans (in-plane and cross-plane) at each required depth listed
above. Use the resolution appropriate for the collimator diameter. See Table 9 and
Table 10.
10. After scanning is complete, process the data by taking the average of the 2 orthogonal
scans.
11. Average each side so you will have the average of 4 half scans.
12. Renormalize to the central axis to produce the radial OCR data per collimator.
The profiles resemble those shown in Multiple depth in-plane and cross-plane scans.
See Figure 33
NOTE: The distance from the central axis of the 50% relative dose should be
approximately equal to the radius of the collimator.
Figure 33 Multiple depth in-plane and cross-plane scans
13. Generate the OCR values in numerical form.

14. Enter the numerical OCR values in the plain text (ASCII or ANSI) format as described
below and shown in the example OCR beam data file in Figure 34. See Appendix 2A,
“Beam Data Validation Rules” for a list of Beam Data Validation rules.
Verify that the format of each OCR beam data file is as follows:


• 3rd line: <Collimator size in mm (floating point)> and label
• 5th line: <Number of measurements at each depth (integer)> and label
• 6th line: <Depths in mm (integer)>
• 7th to nth line: <Radial distance in mm (floating point)> <OCR values
(floating point)>
In Lines 1 and 2, the words version and sample must be lowercase. The 5 mm
collimator filename will be OCRtable0.dat (or .txt), and the 60 mm collimator will be
the OCRtable11.dat (or .txt) as required by the file naming system (see Table 3)
Figure 34 Example plain text OCR table

(OCRtable0.dat, one of 12 OCR tables)
15. Verify that the OCR tables are correctly typed without extra spaces or line inserts as
shown in Figure 34.
NOTE: Confirm that the OCR values are similar to average values collected
from other sites before importing beam data to the data server. This data is
available on the AERO website (www.accurayexchange.com) under
Support: User Documentation.

Output Factor (OF) Measurements

The output factor (OF) is the ratio of the absorbed dose at a particular field size relative to the
dose at a reference field size for the same number of MU. The reference field size for the
CyberKnife System is the 60 mm fixed collimator.
NOTE: Output factors for all collimators are normalized to the 60 mm fixed
collimator output reading at 800 mm SAD.
Output factor data is measured per collimator and entered into a single beam data file in plain text
(ASCII or ANSI) file format.
The radiation field size is determined by the aperture size of the secondary collimator (see
Secondary fixed collimators). The radiation field size is defined at the reference SAD for the
CyberKnife System of 800 mm. The actual radiation field size is the FWHM, which is the distance
between ± 50% of the central axis maximum dose. The FWHM can be measured from the OCR
profiles (see “Off Center Ratio (OCR) Measurements for Fixed and Iris Collimators” on
page 2-50).
The following materials are used during output factor measurements:
• Water phantom with diode detector
• All 12 fixed collimators
Selecting the Diode Detector

There are several factors to consider when selecting the small field diode detector for the output
factor measurement [Ref. 3, Ref. 5]. In addition, detector setup geometry influences the accuracy
and validity of measurement results. Figure 37 shows the influence of the detector on output
factor measurements.

Figure 35 Detector influence on output factor (OF)

measurements
There is no universally established method to calculate output factors for small field sizes.
Attempts have been made to correct for the effect of different detectors. One example is
described in [Ref. 5] and shown in Figure 38.
with correction factor

total scatter factor
Monte Carlo
Exradin A16
Exradin T14P
PTW diamond
PTW Diode
collimator size (mm)
Figure 36 Monte Carlo-corrected output factors

Performing Output Factor Measurements

1. Set the diode detector at a depth of 15 mm in the water phantom. Start with the 5 mm
fixed collimator. Set up for an 800 mm Source-Axis Distance (SAD). The SSD will be
785 mm. If the Perch or InitFrames program has not been run since the CyberKnife
System was powered on, make sure to run the InitFrames program as described in
Appendix 2D for “Initializing Robot Tool Frame” on page 21-41.
2. Ensure that the radiation beam from the 5 mm collimator is perfectly centered on the
diode detector.
3. Search for the point of maximum output reading.
4. Measure the output for each collimator starting and ending with the 60 mm collimator
using the same number of MU.
NOTE: Take appropriate measures to correct for variability of detector types

(see “Selecting the Diode Detector” on page 2-55).
NOTE: Acquire beam data for the 5 mm collimator first as a benchmark.

Because this is the most difficult beam data to acquire, it is the best indicator
of the quality of the measurement setup.
5. To determine the output factor for each collimator, divide each reading by the 60 mm
collimator output reading.
The output factor of the 60 mm collimator is 1.
6. Repeat the first 4 steps at 650 mm SAD, SSD = 635 mm.
7. Repeat the first 4 steps at 1000 mm SAD, SSD = 985 mm.
8. Divide each reading for 650 mm and 1000 mm SAD by the reading obtained for the
60 mm collimator at 800 mm SAD.
9. Rescale the 650 mm and 1000 mm SAD values obtained in the previous step by factoring
out the inverse square (1/r2) ratio of the respective SAD and the 800 mm SAD.
For example, the 650 mm SAD values would be multiplied by (650/800)2 and the
1000 mm SAD values would by multiplied by (1000/800)2.
10. Plot the values.
NOTE: Confirm that the OF values are similar to average values collected
from other sites before importing beam data to the data server. available on
Documentation.

11. Enter the measurements in the required plain text format with filename DMtable.dat
(or .txt) as described below and shown in the example in Figure 37. See Appendix 2A,
“Beam Data Validation Rules” for a list of Beam Data Validation rules.
WARNING: To verify that the file contents and format are correct, print and/or plot the data
using the tools provided by your Treatment Planning System. Use of incorrect data can
result in patient mistreatment.
Verify that the format of the output factor table is as follows:

• 4th line: Must appear as shown in Figure 39.
• 6th line: <Field sizes in mm (floating point)>
• 7th to 9th line: <SAD in mm (integer)> <Output factor values (floating
point)>
In Lines 1 and 2, the words version and sample must be lowercase. The SADs in
millimeters (800, 650, and 1000) must be listed in the order shown in Figure 37.
Figure 37 Example plain text output factor table

(DMtable.dat) for multiple SADs
12. Verify that the output factor table is correctly typed without extra spaces or line inserts as
shown in Figure 39.
Extra spaces or line breaks will generate serious errors. Patient treatments will be compromised.
Print all tables from the Treatment Planning System and confirm that they match the initial
measured values.

Iris Collimator Beam Data Acquisition

This section describes the procedure for acquiring beam commissioning data for the optional Iris
Variable Aperture Collimator.
The beam data resides on the data server of the iDMS Data Management System. The data is
required by the Accuray Precision System software in order to generate treatment plans that use
the Iris Collimator.
This procedure applies to the Iris Collimator only. For information on acquiring beam data for fixed
collimators, see “Fixed Collimator Beam Data Acquisition” on page 2-36.
• “Prerequisites” on page 2-60
• “Setting Up the LINAC and Water Phantom for the Iris Collimator” on page 2-61
• “Characterization of the Iris Collimator OCR Profile” on page 2-77

Prerequisites
This section describes the prerequisites necessary to perform the Iris beam commissioning
procedure.
User-Supplied Equipment
For a list of required equipment, see “Commissioning and QA Equipment” on page 2-4. In addition
to the water phantom requirements described in the list, the water phantom should allow
acquisition of radial beam profiles along user-selectable angles about the central beam axis. An
accurate level is also required.
CyberKnife System Equipment

In order to perform the Iris beam commissioning procedure, you must have login access to
Physics mode on the treatment delivery computer. The Teach Pendant is required to operate the
treatment robot manually.
The accessories below are provided with the CyberKnife System and also used during this
procedure (see “Using the Accessories for the Fixed and Iris Collimators” on page 2-24):
• Birdcage assembly for the Iris Collimator and fixed collimators
• Front distance pointer
Skills Required
The following skills are required to acquire beam data for the Iris Collimator:
• Use of user-supplied equipment.
• Operation of the CyberKnife System from Physics mode on the treatment delivery
computer.
• Manual operation of treatment robot using the Teach Pendant.
You must also be familiar with the beam commissioning procedure for fixed collimators described
in “Fixed Collimator Beam Data Acquisition” on page 2-36.
Iris Collimator Temperature

The sensor system that monitors the position of the Iris Collimator tungsten segments is affected
by temperature. An active temperature control system maintains the Iris sensor system at an
elevated temperature above ambient room temperature to minimize this effect. The Iris Collimator
is maintained at 30 °C. The Iris Collimator electronics are maintained at 48 °C.
NOTE: The active temperature control system resides inside the Iris
Collimator. It is only functional when the Iris Collimator is attached to the X-ray
head. Wait 5 minutes each time the Iris Collimator is picked up from the
Xchange collimator table before acquiring any beam data. This waiting period
allows the Iris Collimator to achieve the desired temperature set by the active
temperature control system.
For information on the Active Temperature Control (ATC) unit for the Iris Collimator, see “Chapter
1: CyberKnife Treatment Delivery System Overview”.

Iris Collimator QA Features

Accuray has built in several automated QA features for the Iris Collimator:
• Hardware limit switches are checked whenever the Iris Collimator is initialized.
• A secondary backup position sensor is compared against the primary position sensor to
ensure that the position readings do not differ significantly from each other.
• An active temperature control system maintains the Iris sensor system temperature (see
“Iris Collimator Temperature” on page 2-60). If position sensor readings drift, an E-Stop
occurs and an error message is displayed on the treatment delivery computer. Click the
OK button in the error message window to close it. The Iris aperture automatically
resizes to the desired aperture.
Setting Up the LINAC and Water Phantom for the Iris Collimator
This section describes how to set up the LINAC and water phantom and perform beam alignment
for the Iris Collimator. These procedures are performed prior to acquisition of any beam data for
the Iris Collimator. They apply to all three beam data measurements:
The procedures include an initial setup followed by beam alignment. These procedures are
described below. For additional information, see “About the Initial Setup and Beam Alignment
Procedures” on page 2-65.
Initial Setup Procedure

During the initial setup procedure, the LINAC and water phantom are coarsely aligned. Coarse
alignment is necessary to permit the use of the beam-centering capabilities of the water phantom
with the Iris Collimator beam.
 To perform the initial setup procedure:
1. Using the Teach Pendant, move the treatment robot to position the LINAC in the vicinity
of the Treatment Room where measurements will be made. If the Perch or InitFrames
program has not been run since the CyberKnife System was powered on, make sure to
run the InitFrames program as described in Appendix 2D for “Initializing Robot Tool
Frame” on page 21-41. This location should meet the following conditions:
• A water phantom can be placed at this location.
• The water phantom when full of water will not be rolled over the In-Floor detectors of
the X-ray imaging system.
• When the LINAC is pointing vertically down, there is enough clearance for the
distance between the exit face of the lower bank of tungsten segments and the water
surface of the tank to range from 20 cm to 60 cm.
• The Source-to-Surface Distance (SSD) should be approximately 800 mm.

WARNING: To avoid collision, keep your eyes on the treatment robot at all times, not the
Teach Pendant.
2. Move the Robot from Perch or Path Start to the area above the water tank.
3. Switch to Tool Mode and rotate the robot in A to increase the A5 joint angle to roughly
around +45 degrees. For more information, follow the instructions in Appendix 2D for
“Monitoring the A5 Joint Angle” on page 2-6.
below 10 degrees.
that is 40cm above the expected water surface. Rotate the robot in A such that the A5
joint angle is around 45 degrees. Again, translate the robot in Z through the full range
of positions and ensure the angle does not drop below 10 degrees.
5. In order to appropriately orient the robot, follow the instructions in Appendix 2D for
“Monitoring the A5 Joint Angle” on page 2-6. Translate the robot in X and Y to a position
above the center of the scanning area of the water tank. Stay in Tool Mode for the
remainder of the setup steps.
phantom.
either side of the tank. The goal is to have the primary scanning axis of the tank aligned
with the X and Y Tool Mode axis as in Figure 24. Subsequently, this ensures that the

Figure 38 Tracking the spot as the robot is

translated in Tool mode Y.
Table 11
Item Description
NOTE: The location of the beam spot on the water tank can be difficult to
determine due to refractions and reflections of the laser beam on an optically
transparent water tank. Placing opaque pieces of masking tape on the water
tank where the laser beam hits it permits unambiguous measurement of L1
and L2.
8. Use the adjustment capabilities of your water phantom to level the tank.
The LINAC and the water tank are now roughly aligned. The next step is to perform beam
alignment, as described below.

Beam Alignment Procedure

After the initial setup procedure, a beam alignment procedure is performed that aligns the central
axis of the radiation beam of the Iris Collimator with the axis of vertical rail motion of the water
phantom.
 To perform the beam alignment procedure:
NOTE: The Iris Collimator must be initialized before the birdcage is attached
to the housing.
Fill the water tank with just a few centimeters of water.
2. Use the reflection of the collimated laser beam from the water in the tank back onto the
pinhole collimator to vertically align the laser beam. To do this, rotate the robot in B and C
in Tool Mode.
The laser beam is now vertical and incident normal to the water surface. The laser beam
therefore will not be refracted by the water.
NOTE: After successfully performing this step, it is acceptable if the

mechanical axis of the Iris Collimator is no longer perfectly vertical.
3. Fill the tank with water.
4. Mount the stereotactic diode detector in the water phantom.
5. Move the diode mount of the water phantom vertically so that the diode is just below
where the water surface would be if the tank is full. Then move the diode mount
horizontally so that the laser beam spot is centered on the middle of the diode.
6. Move the diode mount of the water phantom down along its vertical axis. Watch the laser
beam spot on the diode as the diode is moved deeper in the water tank. If the vertical
motion axis of the water phantom is indeed truly vertical (with respect to gravity), the laser
beam spot will remain well centered on the diode.
If the laser beam spot does not remain centered on the diode as it is moved deeper in the
tank, this can be corrected in step 8 and step 5.
7. Move the diode mount so that the diode sensitive volume is at the water surface. Then
reprogram the water phantom so that this position becomes the mechanical origin (0, 0,
0) of the water phantom coordinate axes.
NOTE: Refer to the documentation from the diode manufacturer for the
location of the sensitive volume.
8. Scan the diode detector across the surface in the XY plane and confirm that the diode
depth is constant along the X and Y axes across the scan field. If the depth is not
constant, adjust the tank appropriately.

9. Remove the pinhole collimator.

10. Use the Collimator application in Physics mode to set the Iris aperture to 7.5 mm.
CAUTION: Do not adjust the Iris field size with the pinhole collimator installed. It may result in
damage to the Iris collimator.
11. Turn on the radiation beam using controls in either the LINAC Warmup screen or
LINAC Calibration Check screen in Physics mode. Then use the center finding
routine of the water phantom at 2 different depths in the water tank.
12. If the X-Y coordinates of the beam center are different at the 2 different depths, then the
radiation beam is not vertical.
In this case, compute the degree of beam declination along the 2 axes. In this way, you
compute the necessary angles (Tool mode B and C adjustments) of the LINAC that are
required to bring the radiation beam into collinearity with the vertical travel axis of the
water phantom.
Use the Teach Pendant to move the treatment robot using small adjustments of the B and
C rotations to attempt to make the radiation beam vertical.
13. Once the radiation beam is vertical, reset the null point of the water phantom so that the
null point is coincident with the vertical radiation beam.
14. Install the front distance pointer. Then move the treatment robot in Z in TOOL coordinates
to set the LINAC at 800 mm SSD.
About the Initial Setup and Beam Alignment Procedures

The initial setup and beam alignment procedures described above are required in order to use the
beam center finding routine of the water phantoms recommended by Accuray. The null point of
the water phantom should be coincident with the central axis of the radiation beam in order to
acquire radial beam profiles.
The beam center finding routine works by scanning along 2 orthogonal axes in the patient plane.
It then determines the center of the beam profiles along each of the 2 axes. A horizontal line
passing through the center of and perpendicular to the profile measured along each axis is
assumed to intersect the center of the beam. This geometry is described below for a rectangular,
circular, and dodecagonal (12-sided) aperture (see Figure 41 and Figure 42).
• Rectangular Aperture: For a typical gantry-based radiotherapy LINAC with a
rectangular aperture, the beam center finding routine requires that the X-Y axes of the
water phantom motion system are parallel to the canonical "in-plane" and "cross-plane"
directions defined by the gantry rotation plane.
• If there is any relative rotational displacement between the axes of the water phantom
and the axes of the LINAC, the beam center finding routine does not work, as shown in
Figure 41. For a rectangular beam, if these axes are rotated at an arbitrary angle
relative to each other, a line passing through the center of the measured profile does
not intersect the center of the beam. For a rectangular beam, if room alignment lasers
are available, they can be used to align the water phantom.

(a) Rectangular Beam (b) Circular Beam
Figure 39 Primary axes of LINAC (dashed), motion axes of

water phantom (solid), and a line (white) bisecting the
profile for rectangular and circular beams
• Circular Aperture: Since the radiation beams in the CyberKnife System are non-
coplanar, it is more difficult to align the primary axes of the LINAC with the motion axes of
the water phantom than for rectangular beams. However, the fixed collimators of the
CyberKnife System produce circular beams. For fixed collimators, due to the symmetry of
the circular beam, it is not necessary to rotationally align the axes of the LINAC with axes
of the water phantom. The beam center finding routine works regardless of any relative
rotational displacement between them, as shown in Figure 42.
• Dodecagonal Aperture: For polygonal beams, the motion axes of the water phantom
should be parallel to the symmetry axes of the polygon. Otherwise, the beam center
finding routine does not work. This effect is shown in Figure 42 for a dodecagonal (12-
sided) beam.
• The Iris Collimator produces a 12-sided aperture that is a regular dodecagon. It
requires careful alignment between motion axes of the water phantom and the
symmetry axes of the radiation beam in order to find the center of the beam, as shown
on the left in Figure 42.
NOTE: Due to the symmetry of the Iris Collimator, the alignment shown on the
left in Figure 42 is not the only acceptable alignment. A relative rotational
displacement of 15° between the water phantom and the Iris Collimator is also
acceptable.

(a) Dodecagonal Beam (b) Arbitrary Rotation Angle
Figure 40 Primary axes of LINAC (dashed), motion axes of

water phantom (solid), and a line (white) bisecting the
profile for a dodecagonal beam
• The Iris Collimator also has a penumbral shape that is periodic but not uniform along its
perimeter, as described in “Characterization of the Iris Collimator OCR Profile” on
page 2-77. As a result, the shape of a beam profile measured along an arbitrary chord of
the dodecagon will not be symmetric. This effect is shown on the right in Figure 42 (the
degree of error introduced by misalignment is exaggerated).
Figure 41 and Figure 42 show that for non-circular beams, an error exists unless the axes of the
water phantom and the symmetry axes of the radiation beam are parallel. Because of the
accuracy required for radiosurgical procedures, however, the tolerable degree of error is less than
a millimeter. Performing the setup procedure carefully and extensively is therefore required in
order to achieve submillimeter accuracy.
Tissue Phantom Ratio (TPR) Measurements for the Iris Collimator

Prior to making tissue phantom ratio measurements for the Iris Collimator, set up the LINAC and
water phantom equipment as described in “Setting Up the LINAC and Water Phantom for the Iris
TPR beam data for the Iris Collimator is acquired using the same procedure and equipment as for
fixed collimators except for the following:
• The aperture of the Iris Collimator is changed remotely using Physics mode on the
• The Iris and fixed collimators use the same front distance pointer and birdcage.
• Using the Iris Collimator, it is possible to acquire TPR measurements at each depth for all
apertures (except for 5, 7.5, and 10 mm apertures) before moving to the next depth. This
is different from the procedure for fixed collimators, in which each aperture is stepped
through all depths before exchanging collimators.

For the TPR measurement procedure for fixed collimators, see “Tissue Phantom Ratio (TPR)
Measurements” on page 2-41.
NOTE: The TPR Tools workbook to assist in TPR data collection is located on
Documentation or can be obtained by contacting Contact Accuray Physics
Support to obtain a current copy.
 To perform TPR measurements:
WARNING: Due to the Iris aperture size repeatability, you should acquire TPR
measurements for the smallest apertures (5, 7.5, and 10 mm) without resizing the Iris
Collimator between depths, using the procedure below. Otherwise, less accurate beam
commissioning data can result.
A procedure for acquiring TPR measurements, including an example sequence of steps for the
smallest Iris apertures (5.0 and 7.5 mm), is given below.
1. Follow the steps on page 2-31 through 2-33 for using the front pointer in the birdcage to
install the diode and to set its distance. Refer to the diode manufacturers specification for
the depth of the sensitive volume and account for that when measuring the source-to-
detector distance with the front pointer.
2. Use the reflection of the laser beam from the water surface to position the LINAC
vertically.
NOTE: This step does not ensure that the LINAC is perfectly vertical unless
the laser beam and radiation beam are exactly aligned. A more precise
procedure for vertical alignment of the radiation beam is described in “Setting
Up the LINAC and Water Phantom for the Iris Collimator” on page 2-61.
3. Attach the front distance pointer to the collimator housing. Set the LINAC-to-water
surface distance to 800 mm. If the Perch or InitFrames program has not been run since
the CyberKnife System was powered on, make sure to run the InitFrames program as
described in Appendix 2D for “Initializing Robot Tool Frame” on page 21-41.
4. Remove the front distance pointer and attach the birdcage to the collimator housing.
5. Make sure the diode is aligned with the water surface and LINAC laser.
If you cannot reach 300 mm depth, add more water to the tank. Then readjust the
treatment robot position at 800 mm SSD with reference to the new water level surface.
7. Using incremental jogging on the Teach Pendant, move the treatment robot and take
readings at the recommended depths.

To use incremental jogging, press the Increment Jogging status icon at the upper right
corner of the Teach Pendant screen (see Figure 43). For more information on using the
Teach Pendant, see the Treatment Delivery Manual.
Figure 41 Incremental Jogging status icon (labeled 11) on

far right of Teach Pendant status bar
8. Exit the Treatment Room. Using controls in the Collimator window in Physics mode, set
the Iris aperture to 60 mm.
9. Deliver 100 MU three times. Then average the 3 diode readings. Repeat the
measurements at the same depth using the Iris apertures specified in Table 8, excluding
for the 5 mm and 7.5 mm apertures.
NOTE: If your electrometer/diode combination does not give a reliably

sufficient signal, consider increasing the monitor units uses for these
measurements. Also check your electrometer gain settings.
10. Repeat the above step for each TPR depth for each of the Iris apertures from 60 mm to
10 mm as specified in Table 8. Enter the measurements in the TPR spreadsheets. Move
the treatment robot back to the 300 mm depth. Set the Iris Collimator aperture to 5 mm.
Acquire 3 TPR measurements at 100 MU. Repeat the 3 measurements using the 5 mm
aperture for each TPR depth.
NOTE: Do not change the Iris aperture between these measurements.

• If for some reason the Iris Collimator needs to be reset or the aperture is inadvertently
changed, go back to the 300 mm depth. Then start the TPR measurement from the
beginning using the 5 mm aperture.
11. Repeat the above step for the 7.5 mm Iris aperture.
A comparison of TPR data for both the Iris and fixed collimators for several apertures on a test
CyberKnife System is shown in Figure 44 to Figure 47. The data shown is for example only.
Actual TPR data for your CyberKnife System may be different.

TPR for Iris vs. Fixed: 7.5 mm

Example Data
1.100
Fixed
1.000
Iris
0.900
0.800
0.700
0.600
TPR
0.500
0.400
0.300
0.200
0.100
0.000
0 50 100 150 200 250 300
Depth (mm)
Figure 42 TPR data for Iris and fixed collimators (7.5 mm

aperture)
TPR for Iris vs. Fixed: 15 mm

Example Data
1.100
Fixed
1.000
Iris
0.900
0.800
0.700
0.600
TPR
0.500
0.400
0.300
0.200
0.100
0.000
0 50 100 150 200 250 300
Depth (mm)
Figure 43 TPR data for Iris and fixed collimators (15 mm

aperture)


Example Data
1.100
Fixed
1.000
Iris
0.900
0.800
0.700
0.600
TPR
0.500
0.400
0.300
0.200
0.100
0.000
0 50 100 150 200 250 300
Depth (mm)

aperture)

Example Data
1.100
Fixed
1.000
Iris
0.900
0.800
0.700
0.600
TPR
0.500
0.400
0.300
0.200
0.100
0.000
0 50 100 150 200 250 300
Depth (mm)

aperture)

Off Center Ratio (OCR) Measurements for the Iris Collimator

• “OCR Profile Angles for the Iris Collimator” on page 2-72
• “Performing OCR Measurements” on page 2-74
• “Comparison of OCR Profiles for Fixed and Iris Collimators” on page 2-75
The procedure for acquiring off center ratio (OCR) beam data for the Iris Collimator is different
from that for fixed collimators as described below:
• For the Iris Collimator, 4 OCR profiles are averaged at each depth for each aperture.
• For fixed collimators, only 2 OCR profiles are averaged at each depth for each aperture.
OCR beam data for both the Iris and fixed collimators are acquired using the off-axis distance
(distance from central beam axis) and the same depths (distance from the surface of the water
phantom).
OCR Profile Angles for the Iris Collimator

OCR beam data for the Iris Collimator is acquired at 4 diagonal profiles: 0°, 15°, 90°, 105°. The
angles are set relative to an axis of the water tank after the tank is aligned as described in “Setting
Up the LINAC and Water Phantom for the Iris Collimator” on page 2-61. The 4 profiles are
averaged and folded in half to yield a single representative average radial profile of the beam at
each of the measured depths for each aperture, in the same way that fixed collimator profiles
acquired at 0° and 90° are averaged and folded in half.
Prior to acquiring OCR beam data for the Iris Collimator, it is very important to align the radiation
beam from the LINAC with the vertical and one of the horizontal motion axes of the water
phantom. Beam alignment is necessary because the Iris Collimator produces a polygonal beam.
Individual OCR profiles are therefore expected to be different. A beam alignment procedure is
described in “Setting Up the LINAC and Water Phantom for the Iris Collimator” on page 2-61.
The differences in individual OCR profiles is the greatest for a 60 mm Iris aperture. An example of
individual water phantom scans for a 60 mm Iris aperture is shown in Figure 48. Figure 49 and
Figure 50 show expanded views of the left and right penumbra of the OCR profiles.

60 mm Iris
Example of Individual Profile Scans
1
0.9
0.8
0.7
0.6
OCR Avg of 8 half profiles
OCR
0.5
0 Degree Profile
0.4 90 Degree Profile
0.1
0
-40.0 -30.0 -20.0 -10.0 0.0 10.0 20.0 30.0 40.0
Off Axis Distance (mm)
Figure 46 Individual OCR profiles for a 60 mm Iris aperture
60 mm Iris
0.8
OCR Avg of 8 half profiles
0.7
0 Degree Profile
105 Degree Profile
OCR
0.4
0.3
0.2
0.1
0
-36.0 -34.0 -32.0 -30.0 -28.0 -26.0
Figure 47 Expanded view of left penumbra of OCR profiles

for a 60 mm Iris aperture

60 mm Iris
0.8
0.7
0.6
0.5
OCR
0.4 OCR Avg of 8 half profiles

0 Degree Profile
0.3
90 Degree Profile
0
26.0 28.0 30.0 32.0 34.0 36.0
Figure 48 Expanded view of right penumbra of OCR profiles

for a 60 mm Iris aperture

For an example of processing OCR beam data for the Iris Collimator using IBA OmniPro version 6
and earlier, see Appendix 2B, “Processing OCR Beam Data (Examples)”.
Acquiring OCR Profiles

1. Complete the steps to set up the LINAC and water phantom as described in “Setting Up
the LINAC and Water Phantom for the Iris Collimator” on page 2-61. If the Perch or
make sure to run the InitFrames program as described in Appendix 2D for “Initializing
Robot Tool Frame” on page 21-41.
2. Acquire OCR profiles at the specified angles of 0°, 15°, 90°, 105° (see “OCR Profile
Angles for the Iris Collimator” on page 2-72) using one of the following methods:
• Command the water phantom to acquire OCR profiles at angles of 0°, 15°, 90°, 105°.
• Alternatively, acquire OCR profiles at 0° and 90° first. Then rotate the water phantom
15° and acquire 2 additional OCR profiles at 0° and 90° at this new rotational
position.
If you choose to rotate the water phantom instead of acquiring data along 4 diagonal
profiles:
• Perform the rotation of the water phantom carefully.

• The position of the laser beam on the diode detector should be carefully noted prior to
rotation of the water phantom. This position can be used to help realign the water
phantom after it has been rotated.
• If alignment lasers are available in the Treatment Room, they may be of assistance in
performing the rotation.
• Verify the vertical orientation of the water phantom, and realign the water phantom if
necessary after it is rotated.
3. For an example of processing OCR beam data for the Iris Collimator using IBA OmniPro
version 6 and earlier, see “Processing OCR Beam Data in IBA OmniPro
Version 6.4a (Examples)” on page 2B-9.
Comparison of OCR Profiles for Fixed and Iris Collimators

The penumbra and full width at half maximum (FWHM) of Iris Collimator beams do not exactly
match those of fixed collimator beams on a given CyberKnife System. A comparison of OCR
profiles for both Iris and fixed collimators from the same test CyberKnife System are shown in
Figure 51 and Figure 52. The data shown is for example only. Actual OCR data for your
CyberKnife System may be different.
OCR Comparison - 60012 Diode Data - 800 mm SAD - 100 mm Depth

Example Data
Fixed 5 mm
1
Iris 5 mm
Fixed 7.5 mm
0.9
Iris 7.5 mm
0.8 Fixed 10 mm
Iris 10 mm
0.7 Fixed 12.5 mm
Iris 12.5 mm
0.6
Fixed 15 mm
OCR
Iris 15 mm
0.5
0.4
0.3
0.2
0.1
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Radius (mm)
Figure 49 Comparison of OCR profiles for Iris and fixed

collimator beams ranging from 5 mm to 15 mm FWHM
(nominal aperture)

OCR Comparison - 60012 Diode Data - 800 mm SAD - 100 mm Depth

Example Data
0.9
0.8
Fixed 20 mm
0.7 Iris 20 mm
Fixed 25 mm
0.6 Iris 25 mm
Fixed 30 mm
OCR
0.5 Iris 30 mm
Fixed 35 mm
0.4
Iris 35 mm
0.3 Fixed 40 mm
Iris 40 mm
0.2 Fixed 50 mm
Iris 50 mm
0.1 Fixed 60 mm
Iris 60 mm
0
0 5 10 15 20 25 30 35 40
Radius (mm)
Figure 50 Comparison of OCR profiles for Iris and fixed

collimator beams ranging from 20 mm to 60 mm FWHM
(nominal aperture)

Characterization of the Iris Collimator OCR Profile

This section explains why the average of the 4 diagonal profiles described earlier is sufficient to
characterize the true average Iris Collimator OCR profile.
Beam Penumbra of the Iris Collimator

The aperture of the Iris Collimator is produced by 2 hexagonal banks of tungsten segments which
produce a dodecagonal (12-sided) radiation beam. Half of the flat sides forming the perimeter of
the beam are formed by the upper hexagonal bank and the other half are formed by the lower
hexagonal bank.
As a result of this beam shaping, the penumbra of the radial beam profile at any of the sides of the
dodecagon is different from that at the 2 nearest neighbor sides which are formed by the other
hexagonal bank. This effect is shown in Figure 53 and becomes more evident when examining
the isodose lines of the Iris Collimator beam in “Beam Isodose Lines of the Iris Collimator” on
page 2-78.
Because both the upper and lower hexagonal bank in the Iris Collimator produce collimation, it is
necessary to average at least 4 OCR profiles to achieve the measurement quality of the 2 profile
average used with fixed collimators.
Unlike for OCR profiles, the method for acquiring output factor and TPR data for the Iris Collimator
does not require special consideration. The reason is that output factor and TPR measurements
are all made along the central beam axis which is the axis of rotational symmetry of the Iris
Collimator. In contrast to the 1-dimensional output factor measurements and 2-dimensional TPR
measurements, OCR profiles require 3-dimensional measurements which include the penumbral
region of the beam.

Upper Lower
Bank Bank
Figure 51 Penumbra formed by upper and lower hexagonal

banks of tungsten segments
NOTE: Figure 53 shows an arbitrary orientation of the Iris Collimator. See

Figure 42 for the actual orientation of profiles for the Iris Collimator.
Beam Isodose Lines of the Iris Collimator

The diagonal angles chosen to measure OCR profiles for the Iris Collimator are determined by
examining the isodose lines of the Iris Collimator beam.
The isodose lines of the Iris Collimator beam profile for a large aperture in the plane perpendicular
to the central beam axis are shown in Figure 54. This plot was generated from a series of 120
diagonal profile measurements acquired using a water phantom at 1.5° intervals about the central
beam axis.

Figure 52 10% to 90% Isodose lines for 44 mm Iris aperture

at 100 mm depth and 800 mm SAD (water phantom data)
The plot shows that the beam shape of the Iris Collimator has the following periodicity:
• The 90% isodose line has little if any discernible periodicity because the central portion of
the beam is not collimated.
• In the penumbra region of the beam, the period is 30° which is expected for a regular
dodecagon.
• At the tail end of the penumbra, the period at the 20% isodose line is 60°. This periodicity
does not mean that the Iris Collimator has a hexagonal beam profile at the 20% isodose
line. Instead, the beam profile at this isodose line is a 12-sided dodecagon consisting of
alternating long and short sides, as shown in Figure 55.

Figure 53 Film image of an Iris Collimator beam (left) and a

numerical analysis of the film (right) using a 16-bit film
scanner
Figure 55 shows a film image of the Iris Collimator beam along with a numerical analysis of the
film. In the penumbral region of the beam, the isodose lines do appear to be regular dodecagons.
The film was exposed for a long enough duration so that the 20% isodose line lies in the middle of
the dynamic range of the film. Therefore, to the naked eye the 20% isodose line forms the
prominent transition between dark (exposed) and light (unexposed) regions of the film.
Measurement Sampling for OCR Profiles

If the Iris Collimator has a period of 60° and it is desired to sample evenly at 4 locations within that
period, it should be possible to calculate the average OCR profile by measuring at regular
intervals of 15° as shown in Figure 56. The red arrows in the graph indicate the points at which
measurements would be made.

Figure 54 Examples of sets of 4 angles that would evenly

sample a physical quantity that has a 60° period
superimposed on a 30° period
For a given set of 4 measurement angles, the addition of the same arbitrary angle to all 4 angles
would still result in an even measurement sampling. Performing the measurements using the set
of 4 angles labeled as Group B in Figure 56 should therefore be the same as using another set of
4 angles in which 7.5° is subtracted from each angle.
Also, if the period of the Iris aperture is 60°, then any profile of the Iris Collimator measured at an
angle  should be equivalent to a profile measured at an angle  ± n*60°, where n*60° is a
multiple of 60°.
In order to prove the above hypothesis, a series of measurements were performed in which 4
diagonal beam profiles of the Iris Collimator were measured using a water phantom. The 4
measurements were averaged and compared with the average radial profile over all pixels
measured using radiochromic film exposures.
Examples of the results are shown in the series of overlay plots for various Iris apertures (60, 40,
10, and 5 mm) shown in Figure 57 through Figure 60. Below each overlay plot is a plot of the
difference between the average of the 4 diagonal profiles and the film average over the entire
beam. This difference was less than 2% in all cases and typically less than 1%. These
measurements were made at 100 mm depth and 800 mm SAD.

Figure 55 Overlay of 4 diagonal OCR profile average vs.

film-based average for 60 mm nominal Iris aperture (top)
and the difference between the 2 averages (bottom)




film-based average for 5 mm nominal Iris aperture (top) and
the difference between the 2 averages (bottom)

Figure 61 shows the difference between the 4 diagonal OCR profile average measured using a
water phantom vs. a film-based average for a 60 mm nominal Iris aperture. For these
measurements, +5° added to the set of angles used to measure the data shown in Figure 55.
There is essentially no difference between the average OCR profile computed by averaging 4
diagonal profiles acquired at a set of angles, called Group A, and an average OCR profile
computed by averaging 4 diagonal profiles acquired at a set of angles Group A + . In this case 
is an arbitrary angle as long as the set of 4 angles meets the requirement that the beam profile is
sampled at the equivalent of 15° intervals.
Figure 59 Difference between 4 diagonal OCR profile

average vs. film-based average for a 60 mm nominal Iris
aperture with +5° added to the set of angles used to
measure the data shown in Figure 57
Figure 62 and Figure 63 show that results are the same when an arbitrary angle is added to the
set of 4 angles and measurements are made along these new diagonals.
Figure 62 shows the difference between the overall film average OCR profile and a 4 diagonal film
average OCR profile for a 50 mm nominal Iris aperture. In Figure 63, various offset angles were
added to the set of 4 angles. In all cases the difference between the 4 diagonal film average
profile and the overall (36 diagonal) film average profile is on the order of 1% or less.

Figure 60 Difference between 4 diagonal film average OCR

profile and overall film average OCR profile for 50 mm
nominal Iris aperture
Figure 61 Difference between 4 diagonal film average OCR

profile and overall film average OCR profile for 50 mm
nominal Iris aperture with various offset angles added to the
set of 4 angles

Recommended Set of Diagonal Angles

The data described in the preceding sections demonstrate that the average of a carefully selected
set of 4 diagonal profiles is sufficient to generate a representative OCR profile for the Iris
Collimator across the full range of possible aperture settings [Ref. 6].
Each set of 4 angles is chosen to sample the radiation beam at 15° intervals. As long as the
spacing between angles remains the same, if the same arbitrary offset angle is added to each
angle, the result is the same. Therefore the set of angles 0°, 15°, 90°, 105° is equivalent to the
sets that were tested in the preceding sections. This set of angles has the advantage that the 0°
and 90° profiles are parallel to intrinsic motion axes of the water phantom and do not require
diagonal scans. Motion along a single axis (either X or Y) of the water phantom is typically more
accurate than a diagonal motion involving pairs of sequenced steps in X and Y.
Output Factor (OF) Measurements for the Iris Collimator

Prior to making output factor measurements for the Iris Collimator, set up the LINAC and water
phantom equipment as described in “Setting Up the LINAC and Water Phantom for the Iris
The output factor (OF) is the ratio of the absorbed dose at a particular field size relative to the
dose at a reference field size for the same number of MU. The reference field size for the
CyberKnife System is based on the 60 mm fixed collimator at 800 mm SAD. To determine the
output factor for each aperture size of the Iris Collimator, divide each output reading by the 60 mm
fixed collimator output reading.
NOTE: Output factors for both the fixed collimators and the Iris Collimator are
normalized to the 60 mm fixed collimator output reading at 800 mm SAD. If the
60 mm fixed collimator output reading was not acquired on the same day as
the Iris Collimator output readings, then repeat the 60 mm fixed collimator
output reading on the same day as the Iris Collimator output readings for
purposes of generating the Iris Collimator output factor beam data table.
Output factor beam data for the Iris Collimator is acquired using the same procedure and
equipment as for fixed collimators except for the following:
• The aperture of the Iris Collimator is changed remotely using the Collimator application
in Physics mode on the treatment delivery computer.
• When the Iris aperture is resized, the aperture size repeatability can result in variability in
the output factor. This effect is less than a fraction of 1% for all but the smallest apertures.
• For the 5, 7.5, and 10 mm Iris apertures, the output factor should be determined by
averaging the electrometer readings from at least 10 repeated measurements. You
should resize the Iris aperture between each measurement (for example, by increasing
and then decreasing the aperture size) and note the standard deviation of the
measurements. The standard deviation provides an estimate of the variability in output
factor for the smallest apertures. This variability should be considered when choosing
the Iris Collimator for treatment planning and delivery.
Special Considerations for Iris Collimator Beams
Although the Iris Collimator is designed for and capable of collimating beams as
small as 5 mm diameter at 800 mm SAD, it is advantageous to limit the use of 5 mm

Iris collimator beams. The Accuray Precision System limits the total Monitor Units
(MU) which can be delivered to the target from these 5 mm Iris collimator beams at
the time of planning, decreasing the potential dose uncertainty at delivery to no
more than 2% of the prescription dose. The implementation of this limitation in the
planning system assumes that the Output Factor for the 5 mm aperture of the Iris
collimator could vary by up to 15%, based on a worst-case scenario analysis of
mechanical repeatability. This variability is used to calculate the maximum
allowable MU contribution delivered by beams from the 5 mm Iris collimator
aperture, restricting the potential dose variation to no more than 2% of the
prescription.
NOTE: When the Iris aperture changes, the tungsten segments move rapidly
to form an aperture that is slightly smaller than the desired size and then
approach the desired size. This motion control algorithm applies in both
Physics mode (using controls in the Collimator window) and in Treatment
delivery mode (when the aperture is resized automatically during treatment
delivery). You can therefore approach a desired aperture size from either a
larger or smaller starting aperture.
A comparison of output factors for both the Iris and fixed collimators on a test CyberKnife System
is shown in Figure 64. The data shown is only an example. The specific output factors for a given
CyberKnife System may be different.
For information on the procedure for acquiring output factor beam data for fixed collimators, see
“Output Factor (OF) Measurements” on page 2-55.

Output Factor Comparison - 60012 Diode Data - 800 mm SAD
0.9
Output Factor
0.8
Fixed Example Data

Iris Collimator Example Data
0.7
0.6
0.5
0 10 20 30 40 50 60 70
Nominal Field Size (mm)
Figure 62 Output Factors for both the Iris and fixed

collimators (example data)

Beam Data Acquisition for the Monte Carlo Dose

Calculation for the Fixed and Iris Collimators
The Monte Carlo Dose Calculation algorithm uses a mathematical source model for the LINAC.
The source model is constructed from a set of measured beam data that is in addition to the
standard TPR, OCR, and output factor data associated with the Ray-Tracing dose calculation
algorithm (see “Beam Commissioning for the Ray-Tracing Dose Calculation Algorithm
for Fixed and Iris Collimators” on page 2-17).
• “Beam Data Acquisition” on page 2-89
• “Iris Collimator Monte Carlo Beam Data Acquisition” on page 2-99
Beam Data Acquisition

• “Prerequisites” on page 2-89
• “Repeating TPR and OCR Measurements” on page 2-90
• “In-air Output Factor (OF) Measurements (Optional)” on page 2-91
• “Open Field Profile Measurements” on page 2-93
• “Central Percent Depth Dose (PDD) Measurements” on page 2-97
Prerequisites
WARNING: Before acquiring data for Monte Carlo Dose Calculation source modeling,
ensure that the beam properties of the LINAC meet Accuray specifications for the
CyberKnife System. Failure to meet this requirement could result in injury or death of
patients.
For a new CyberKnife System, the acceptance test procedure document, which was signed upon
completion of the installation, is evidence of the requisite working condition of the LINAC.
For an existing CyberKnife System, refer to your records in the CyberKnife® Robotic
Radiosurgery System QA Log Book provided by Accuray to determine whether the LINAC should
be adjusted prior to performing these procedures.

NOTE: For the Monte Carlo Dose Calculation, the LINAC source model is built
using relative dose measurements. Therefore, it is not necessary to perform
an absolute dose calibration of the LINAC before beginning the source model
commissioning procedure. However, if you discover an aberrant result from a
LINAC dose calibration check, it might indicate that the LINAC is not in suitable
condition for collection of beam data.
You must be familiar with manual operation of the treatment robot using the Teach Pendant. You
must also be familiar with the tasks available by clicking the Physics button on the CyberKnife
System Menu on the treatment delivery computer.
The following materials are used during the beam data acquisition procedure:
• Water phantom
• Stereotactic diode detectors
• Birdcage assembly
• Electrometer
Repeating TPR and OCR Measurements

During commissioning of the Monte Carlo Dose Calculation in the Accuray Precision System, you
will be required to compare TPR and OCR data calculated using the Monte Carlo Dose
Calculation algorithm with TPR and OCR beam data measured previously to commission all 12
fixed collimators for the Ray-Tracing dose calculation algorithm (see “Beam Data Acquisition for
the Ray-Tracing Dose Calculation” on page 2-24).
NOTE: If you are upgrading to Monte Carlo Dose Calculation sometime after
your existing beam data was measured, you should re-acquire a subset of the
TPR and OCR beam data measurements used to commission the Ray-
Tracing dose calculation algorithm, as described below. This subset of beam
data is used to verify that the beam characteristics have not changed since the
existing beam data was acquired. For new installations where Ray Tracing
data has just been acquired, this step is not necessary.

 To repeat a subset of TPR and OCR measurements:

1. Re-acquire a subset of the TPR and OCR beam data measurements used to commission
the Ray-Tracing dose calculation algorithm.
• For these measurements, use the same diode detectors that you use for
measurement of the Monte Carlo Dose Calculation beam data.
• At a minimum, include measurements using the 5, 10, 30, and 60 mm collimators for
this subset.
2. Compare the new subset of TPR and OCR beam data acquired in the previous step with
the existing beam data used to commission the Ray-Tracing dose calculation algorithm.
Ensure that the current beam characteristics are unchanged from those in the Ray-
Tracing beam dataset.
• If the two beam datasets are not in agreement, consider re-acquiring a complete set
of OCR, TPR, and output factor data for all 12 collimators.
• If the two beam datasets are in agreement, you can compare the calculations made
using the Monte Carlo Dose Calculation algorithm with the existing Ray-Tracing TPR
and OCR beam data.
The sections that follow describe beam data acquisition for commissioning of the Monte Carlo
Dose Calculation algorithm.
In-air Output Factor (OF) Measurements (Optional)

The in-air output factor is measured for each fixed collimator. The measured data values are
referred to as output factors in this procedure because the measurement geometry is similar to
the geometry used for the output factor measurements made to commission the Ray-Tracing
dose calculation algorithm (see “Output Factor (OF) Measurements” on page 2-55). The
difference for the Monte Carlo Dose Calculation is that the measurements are made in air instead
of water. The values measured in this procedure are more properly described as collimator
scatter factors due to the lack of phantom scatter from surrounding material.
The following materials are used to measure the in-air output factor:
• Diode detector
• Birdcage
• Electrometer

 To acquire in-air output factor data:

1. Insert the 5 mm secondary collimator.
2. Mount the diode detector in the birdcage at 800 mm SAD (so that the active element of
the detector is 800 mm from the X-ray source).
NOTE: Do not expose the diode detector to any other materials that could
scatter the radiation beam back toward the diode.
3. Deliver 100 MU and record the charge accumulated on the electrometer. Measure your
data to at least 3 significant digits after the decimal point.
4. Repeat as necessary in order to get a stable reading for each of the 12 fixed collimators.
5. Enter the measurements in the required plain text (ASCII or ANSI) format with filename
mc_outputfactor.dat (or .txt) as described below and shown in the example in-air
output factor beam data file in Figure 65. See Appendix 2A, “Beam Data Validation
Rules” for a list of Beam Data Validation rules.
Figure 63 Example plain text in-air output factor table

(mc_outputfactor.dat)
In Lines 1 and 2, the words version and sample must be lowercase. You may enter
comments on Line 3, but Lines 4, 5 and 6 must appear as shown in Figure 63.

The collimator sizes and corresponding in-air output factor values are listed in two
columns in order of ascending collimator size. All values are normalized to 1.000 for the
60 mm collimator.
shown in Figure 65.
WARNING: Extra spaces or line breaks will generate serious errors. Patient treatments
will be compromised. Print all tables from the Treatment Planning System and confirm
that they match the initial measured values.
7. After collecting all required beam data for commissioning the Monte Carlo Dose
Calculation algorithm for fixed collimators and generating properly formatted beam data
NOTE: The mc_outputfactor.dat, mc_centralpdd.dat, and

mc_doseprofile.dat files for fixed collimators must be imported together
as a single set of data using the Beam Data Import application.
NOTE: The iDMS System recognizes beam data filenames with both .dat
and .txt file extensions.
they were entered into a plain text file).
Open Field Profile Measurements

The measured open field dose profile of the LINAC beam (that is, the beam profile with no fixed
collimator and retaining nut present) must have a constant step size and include a measurement
on the radiation beam central axis (CAX). The CAX value should be set to 1.000. All other values
should be normalized to the CAX measurement. The open field dose profile should extend out to
80 mm on either side of the CAX.
The following materials are used to measure the open field profile:
• Water phantom
• Diode detector

 To measure the open field dose profile:

1. Set up the water phantom with the diode detector at a distance of 800 mm SAD or
800 mm SSD below the LINAC and at a depth of 25 mm below the water surface.
NOTE: Be sure to record whether the data was taken at 800 mm SSD or SAD,
because you will need to enter this information into the header of the beam
data file.
The procedures and tools required for setting up the LINAC and water phantom are
described in the LINAC beam commissioning section for the Ray-Tracing dose
calculation algorithm (see “Fixed Collimator Beam Data Acquisition” on page 2-36). If the
Perch or InitFrames program has not been run since the CyberKnife System was
powered on, make sure to run the InitFrames program as described in Appendix 2D for
“Initializing Robot Tool Frame” on page 21-41.
2. With the fixed collimator housing still installed, remove the fixed collimator, if currently
installed, from the LINAC. Do not reinstall the retaining nut.
3. Center the origin of the water phantom so it is coincident with the central axis of the
LINAC radiation beam.
4. Acquire a set of orthogonal dose profiles extending from at least -80 mm to +80 mm in
each direction. Ensure your data is measured to at least 3 significant digits after the
decimal point.
5. Center, normalize, and then average the data from the 2 orthogonal profiles. The data is
normalized to a value of 1.000 at the CAX (a radius of 0).
6. Extract from the averaged data a beam profile that ranges from -80 mm to +80 mm, in
1 mm increments. The profile data must have exactly 161 equally spaced points between
-80 mm to +80 mm.
7. Enter the data values in the required plain text (ASCII or ANSI) format with filename
mc_doseprofile.dat (or .txt) as described below and shown in the example in
Figure 66. See Appendix 2A, “Beam Data Validation Rules” for a list of Beam Data
Validation rules.

Figure 64 Example open field dose profile file

(mc_doseprofile.dat)
Verify that the format of the open field dose profile table is as follows:
• 4th line: <SSD (floating point)> and label
• 5th line: <Depth in mm (floating point)> and label
• 6th line: <Number of data points (integer)> and label
• 7th to nth line: <Radial position in mm (integer)> <Relative dose
(floating point)>
In Lines 1 and 2, the words version and sample must be lowercase. You may enter
comments on Line 3. Line 4 specifies the distance from the X-ray source to the water
phantom surface in millimeters. Line 5 specifies the depth of the diode detector used to
make the measurement. In Line 6 the number of data points must be 161.

In the example shown in Figure 66, the beam profile data was acquired at 800 mm SAD
with the diode detector at a depth of 25 mm.
The beam profile data is arranged in 2 columns with the radial position in the 1st column
and the relative dose in the 2nd column. The relative dose is relative to the dose at the
CAX (a radius of 0) which is 1.000. Ensure that the range of data goes from -80 mm to
+80 mm, in 1 mm increments.
NOTE: In the mc_doseprofile.dat beam data file, you must specify the
SSD distance, not the SAD distance (see Figure 66).
NOTE: The iDMS System recognizes beam data file names with both .dat
and .txt file extensions.).
8. Verify that the open field dose profile table is correctly typed without extra spaces or line
inserts as shown in Figure 66.
NOTE: The mc_outputfactor.dat, mc_centralpdd.dat, and

mc_doseprofile.dat files for fixed collimators must be imported together
as a single set of data using the Beam Data Import application.

Central Percent Depth Dose (PDD) Measurements

Percent Depth Dose (PDD) measurements are performed using the 60 mm fixed collimator.
Operate the water phantom so that the measurement time at each point is long enough to give a
reasonably smooth central PDD curve. Although it is not essential to have a measurement point
at Dmax, it is preferable to use 1 mm or finer spacing in the region of depth near Dmax.
As part of commissioning for the Monte Carlo Dose Calculation, you will reproduce TPR curves
using the Monte Carlo Dose Calculation algorithm. These TPR curves will be compared with your
measured TPR beam data. If you have measured your TPR values using a detector with inherent
buildup, be advised that the TPR values shallower than Dmax will be higher than the Monte Carlo
calculated values, as these detector types over measure the TPR values in this region.
 To measure the central percent depth dose:
1. Set up the water phantom at a distance of 800 mm SSD below the LINAC.
The procedures and tools required for setting up the LINAC and water phantom are
described for the LINAC beam commissioning procedure for the Ray-Tracing dose
calculation algorithm (see “Fixed Collimator Beam Data Acquisition” on page 2-36). If the
Perch or InitFrames program has not been run since the CyberKnife System was
powered on, make sure to run the InitFrames program as described in Appendix 2D for
“Initializing Robot Tool Frame” on page 21-41.
2. Center the origin of the water phantom so it is coincident with the axis of the LINAC
radiation beam.
3. Check the center of the LINAC beam at two depths in the water phantom, for example,
100 mm and 200 mm, to verify that the LINAC beam is pointing straight down.
4. Insert the 60 mm fixed collimator and acquire a central PDD curve.
The depths do not need to be uniformly spaced. Spacing of 1.0 mm is sufficient, except
use finer spacing around Dmax. You may include up to 500 data points. The data should
be normalized to a value of 100.0 at the depth of maximum relative dose. Do not include
a measurement point for the dose measured at zero depth.
5. Name the data file mc_centralpdd.dat (or .txt). The number of data points should
not exceed 500. The maximum depth should be 300 mm.
The required format for mc_centralpdd.dat is described below and shown in Figure
67. See Appendix 2A, “Beam Data Validation Rules” for a list of Beam Data Validation
rules.

Figure 65 Example central PDD file (mc_centralpdd.dat)
6. In Lines 1 and 2, the words version and sample must be lowercase. You may enter
comments on Line 3. Line 4 should appear exactly as shown in Figure 67. Line 5
specifies the number of depths you have entered into this file as data points. In the
example shown in the figure, Line 5 indicates that there are 284 data points (not that the
PDD was measured to a depth of 284 mm).
The central PDD data is arranged in two columns:
• 1st column: depth in millimeters
• 2nd column: relative dose as a percentage
shown in Figure 67.
Accuray Precision System and confirm that they match the initial measured values.
information on the Beam Data Import application, see the Data Management Manual.9

Iris Collimator Monte Carlo Beam Data Acquisition

This section describes beam data acquisition procedures to commission the Monte Carlo Dose
Calculation option for the Iris Collimator.
It covers the following topics:
• “Setup for Beam Data Acquisition” on page 2-99
• “In-air Output Factor (OF) Measurements (Optional)” on page 2-99
• “Open Field Profile Measurements” on page 2-100
• “Central Percent Depth Dose (PDD) Measurements” on page 2-100
Setup for Beam Data Acquisition

The setup for Monte Carlo beam data acquisition for the Iris Collimator is the same as that for
Ray-Tracing beam data acquisition for the Iris Collimator. For more information, see “Setting Up
the LINAC and Water Phantom for the Iris Collimator” on page 2-61. If the Perch or InitFrames
program has not been run since the CyberKnife System was powered on, make sure to run the
InitFrames program as described in Appendix 2D for “Initializing Robot Tool Frame” on
page 21-41.
In-air Output Factor (OF) Measurements (Optional)

In-air output factor (OF) beam data for the Iris Collimator is acquired using the same procedure
and equipment as for fixed collimators. For information on the procedure for fixed collimators, see
“In-air Output Factor (OF) Measurements (Optional)” on page 2-91.
Only in-air output factor measurements at the very smallest Iris Collimator apertures are expected
to be significantly different from those for fixed collimators. In-air output factors at the smallest Iris
Collimator apertures are smaller than those for fixed collimators.
The in-air output factor measurement for the Iris Collimator does not need to be repeated multiple
times as does the Iris Collimator output factor measurement for the Ray-Tracing dose calculation
algorithm (see “Output Factor (OF) Measurements for the Iris Collimator” on page 2-86).

Open Field Profile Measurements

The measured open field dose profile beam data for the Iris Collimator is the same as that
acquired for fixed collimators. You do not need to repeat the open field dose profile measurement
for the Iris Collimator. Use the fixed collimator beam data file (mc_doseprofile.dat or .txt)
and rename it for the Iris Collimator (iris_mc_doseprofile.dat or .txt). For information on
the open field dose profile measurement for fixed collimators, see “Open Field Profile
Measurements” on page 2-93.
Central Percent Depth Dose (PDD) Measurements

Central percent depth dose (PDD) measurements for the Iris Collimator are acquired using the
same procedure as for fixed collimators, except that the Iris Collimator 60 mm aperture size is
used. For information on the central PDD measurement for fixed collimators, see “Central Percent
Depth Dose (PDD) Measurements” on page 2-97.
Beam Data Acquisition for the Finite Size

Pencil Beam Dose Calculation
The Finite Size pencil beam (FSPB) is only used in conjunction with the InCise 2 Multileaf
Collimator.
The FSPB calculation algorithm uses a mathematical model to enable modeling of any shaped
beam using 6 parameters. Required beam data includes open field profiles, OCRs, TPRs and
output factors. Once the data are collected and imported into the Accuray Precision System, the
model must be approved prior to phantom and patient treatments delivery. Refer to the Treatment
Planning Manual for more information on modeling the FSPB algorithm.
Multileaf Collimator Beam Data Acquisition

This section describes the procedure for acquiring beam commissioning data for the optional
InCise 2 Multileaf Collimator. The beam data resides on the data server on the iDMS Data
Management System. The data is required by the Accuray Precision System software in order to
generate treatment plans that use the Multileaf Collimator. The procedures described in this
section apply to the Multileaf Collimator only.
This sections covers the following topics:
• “Using the Accessories for the Multileaf Collimator” on page 2-101
• “Coarse Alignment of the LINAC and Water Phantom” on page 2-111
• “Beam Alignment Procedure” on page 2-113
• “Tissue Phantom Ratio (TPR) Measurements for the Multileaf Collimator” on page 2-121
• “Off Center Ratio (OCR) Measurements for the Multileaf Collimator” on page 2-126
• “Open Field Profile Measurements for the Multileaf Collimator” on page 2-116

• “Output Factor (OF) Measurements for the Multileaf Collimator” on page 2-129
NOTE: In addition to collecting beam data required for the Ray-Trace Dose
Calculation for fixed collimators and the Iris Collimator, additional beam data
is required for the Monte Carlo Dose Calculation for these collimators.
However, no additional beam data is required for the Monte Carlo Dose
Calculation for the Multileaf Collimator, except for beam data needed for the
Finite Size Pencil Beam Dose Calculation.
This section describes the prerequisites necessary to perform the Multileaf Collimator beam
commissioning procedures. For a list of customer supplied equipment, see Table 2 on page 2-6.
In addition to the water phantom requirements described in Table 2, the water phantom should
allow acquisition of radial beam profiles along user-selectable angles about the central beam axis.
An accurate level is required.
The accessories listed below are provided with the CyberKnife System and are also used during
the procedures:
• Birdcage assembly with MLC proximal coupler and diode mount
• Pinhole collimator for use with the Multileaf Collimator.
• Front Distance Pointer
The following skills are required to acquire beam data for the Multileaf Collimator:
• Use of user-supplied equipment.
• Operation of the CyberKnife System from the Physics mode on the treatment delivery
computer.
• Manual operation of the treatment robot using the Teach Pendant.
• You must also be familiar with the beam commissioning procedures for fixed collimators,
described in“Fixed Collimator Beam Data Acquisition” on page 2-36.
Using the Accessories for the Multileaf Collimator

This section describes how to use the birdcage assembly, front distance pointer, and pinhole
collimator for the Multileaf Collimator. It describes how to attach these components to the
collimator housing or to the birdcage. It covers the following topics:
• “Accessories for the Multileaf Collimator” on page 2-101
• “Attaching the Birdcage to the Multileaf Collimator Housing” on page 2-104
• “Attaching the Pinhole Collimator to the Multileaf Collimator Housing” on page 2-105
• “Using the Front Pointer” on page 2-105
Accessories for the Multileaf Collimator

The following accessories are provided:
• birdcage assembly: The birdcage assembly is attached to the Multileaf Collimator
housing using the MLC adapter. The birdcage includes 2 alignment pins and 4

thumbscrews on one end for attaching it to the proximal coupler (see Figure 6 on
page 2-25).
NOTE: The same birdcage is used for the fixed collimator, Iris Collimator, and
Multileaf Collimator housing.
• front distance pointer: To attach the front pointer to the Multileaf Collimator housing,
you use the MLC front pointer adapter (see Figure 69 on page 2-103) combined with the
MLC proximal coupler.
• The front pointer includes two holes for screws to attach it to one of these accessories
(see Figure 68).
NOTE: The same front pointer is used for the fixed collimator, Iris Collimator,
and Multileaf Collimator.
2 Screws To Attach
To Mounting Plate
Figure 66 Front distance pointer
• pinhole collimator for the Multileaf Collimator: The pinhole collimator is attached to
the Multileaf Collimator housing using the MLC adapter. It includes 2 alignment holes that
match alignment pins on the adapter and 4 thumbscrews for attaching it to the adapter
(see Figure 69). The holes are different sizes.
MLC Proximal
Coupler
2 Alignment Holes
In Pinhole
Collimator Pinhole Collimator
for MLC
Figure 67 Pinhole laser collimator (black component) for

Multileaf Collimator attached to the MLC proximal coupler

• MLC proximal coupler: For attaching the birdcage, the front pointer, or the pinhole
collimator to the Multileaf Collimator housing (see Figure 70). It includes 2 pairs of
alignment pins, for aligning it with the collimator housing on one side and an MLC
accessory on the opposite side, and 4 thumbscrews, for attaching it to the collimator
housing. The pins on the MLC proximal coupler are two different sizes.
2 Alignment Pins
For Aligning With
MLC Pinhole
Collimator or MLC
Front Pointer
Adapter
2 Alignment Pins On
Opposite Side For
Aligning On
Collimator Housing
Figure 68 MLC proximal coupler for Multileaf Collimator

housing
• MLC front pointer adapter: For attaching the front pointer to the Multileaf Collimator
housing (see Figure 71). It is used in combination with the MLC proximal coupler and
includes 2 alignment holes for aligning it with pins on the front pointer and 2 screw holes
for attaching it to the front pointer.
• It also includes 2 alignment holes for aligning it with pins on the MLC proximal coupler.
These 2 holes and pins are different sizes.
2 Holes for
Alignment Pins On
2 Screw Holes For Front Pointer
Attaching Front
Pointer
Figure 69 MLC front pointer adapter for attaching front

pointer to Multileaf Collimator housing. Used in
combination with MLC adapter

Attaching the Birdcage to the Multileaf Collimator Housing

Use the following procedure to attach the birdcage to the collimator housing, because it provides
good access to tighten the thumbscrews.
1. Insert the 2 alignment pins on the MLC proximal coupler into the matching alignment
holes on the collimator housing. Note that the alignment pins have different diameters, so
there is only one correct alignment of the MLC proximal coupler on the collimator
housing.
2. Secure the MLC proximal coupler by tightening the 4 thumbscrews (see Figure 72).
Figure 70 Attaching the MLC proximal coupler
3. Then attach the birdcage to the MLC proximal coupler using the outer 4 thumbscrews
(see Figure 73).
Figure 71 Birdcage attached to collimator housing using

MLC proximal coupler

Attaching the Pinhole Collimator to the Multileaf Collimator

Housing
Use the following procedure to attach the pinhole collimator to the collimator housing.
1. Attach the MLC proximal coupler to the collimator housing as described in “Attaching the
Birdcage to the Multileaf Collimator Housing” on page 2-104 and shown in Figure 72.
2. Then attach the pinhole collimator to the MLC proximal coupler: Align the holes on the
pinhole collimator with the 2 alignment pins on the MLC proximal coupler. Note that the
alignment pins have different diameters, so there is only one correct alignment of the
pinhole collimator on the proximal coupler. Then attach the pinhole collimator using the
inner 4 thumbscrews (see Figure 74).
Figure 72 MLC pinhole collimator attached to collimator

housing using MLC proximal coupler
Using the Front Pointer

For the Multileaf Collimator, you can attach the front pointer to the Multileaf Collimator housing,
and you can attach both the birdcage and the front pointer to the collimator housing
simultaneously, as described below.
 To attach the front pointer to the Multileaf Collimator housing:
Use the MLC front pointer adapter in combination with the MLC proximal coupler to attach the
front pointer to the collimator housing.
1. First attach the MLC front pointer adapter to the front pointer. Align the 2 pins on the front
pointer with the 2 alignment holes on the MLC front pointer adapter.
Then secure the adapter to the front pointer using two screws (see Figure 75).

MLC
Proximal
Coupler
2 Screws
Attaching
Front
Pointer To
MLC Front
Pointer
Adapter
Figure 73 Front pointer attached to MLC front pointer

adapter
2. Attach the MLC front pointer adapter to the MLC proximal coupler: Align the 2 pins on the
MLC proximal coupler with the 2 alignment holes on the MLC front pointer adapter. Then
tighten the 4 thumbscrews (see Figure 76).

Figure 74 Front pointer attached to MLC front pointer

adapter and MLC proximal coupler
3. Insert the front pointer (attached to the adapter as shown in Figure 76) into the collimator
housing.
Match the 2 alignment pins on the MLC proximal coupler with the alignment holes on the
collimator housing. Note that the alignment pins on the proximal coupler have different
diameters, so there is only one correct alignment of the MLC proximal coupler on the
collimator housing.
Then secure the MLC proximal coupler to the collimator housing by tightening the
4 thumbscrews, as shown in Figure 77. Tighten the thumbscrews snugly but do not
overtighten.

Figure 75 Attaching the front pointer to the Multileaf

Collimator housing
4. When the front pointer is attached to the collimator housing, read measurements using
the front pointer readout labeled "ALL OTHERS" (see Figure 78 and also Table 6 on
page 2-27).
Measurement Readout
Attached to Collimator
Housing

attached to collimator housing

 To mount the front pointer in the birdcage:

Use the MLC front pointer adapter in combination with the MLC proximal coupler to mount the
front pointer in the birdcage.
1. First attach the MLC front pointer adapter to the front pointer, as described above (see
Figure 75).
2. Mount the front pointer (attached to the adapter as shown in Figure 76) in the birdcage.
Match the 2 alignment pins on the MLC proximal coupler with the alignment holes on the
birdcage.
Then secure the MLC proximal coupler to the birdcage by tightening the 4 thumbscrews,
as shown in Figure 77. Tighten the thumbscrews snugly but do not over-tighten.
3. When the front pointer is mounted in the birdcage using the MLC proximal coupler, read
measurements using the front pointer readout labeled "ALL OTHERS" (see Figure 79 and
also Table 6 on page 2-27).
Measurement Readout
When Using
MLC Proximal Coupler
in Birdcage

mounted in birdcage using MLC proximal coupler

 To attach the birdcage and front pointer simultaneously to the Multileaf Collimator
housing:
1. First attach the front pointer to the Multileaf Collimator housing, as described above.
2. Then attach the birdcage: Match the 2 alignment pins on the birdcage with the alignment
holes on the MLC adapter. Then tighten the outer 4 thumbscrews (see Figure 80).
Figure 78 Birdcage and front pointer attached

simultaneously to Multileaf Collimator housing

Coarse Alignment of the LINAC and Water Phantom

During the initial setup procedure, the LINAC and water phantom are coarsely aligned. Coarse
alignment is necessary to permit use of the beam-centering capabilities of the water phantom with
the Multileaf Collimator beam.
 To perform the coarse alignment procedure, follow these steps:
1. Using the Teach Pendant, move the treatment robot to position the LINAC in the vicinity
of the Treatment Room where measurements will be made. This location should meet the
following conditions:
• A water phantom can be placed at this location.
• The water phantom when full of water will not be rolled over the In-Floor detectors of
the X-ray imaging system.
• When the LINAC is pointing vertically down, there is enough clearance for the
distance between the exit face of the lower bank of tungsten segments and the water
surface of the tank to range from 20 cm to 60 cm.
• The Source-to-Surface Distance (SSD) should be approximately 800 mm.
2. Move the Robot from Perch or Path Start to the area above the water tank. If the Perch or
make sure to run the InitFrames program as described in Appendix 2D for “Initializing
Robot Tool Frame” on page 21-41.
3. Switch to Tool Mode and rotate the robot in A to increase the A5 joint angle to roughly
around +45 degrees. For more information, follow the instructions in Appendix 2D for
“Monitoring the A5 Joint Angle” on page 2-6.
below 10 degrees.
that is 40cm above the expected water surface. Rotate the robot in A such that the A5
joint angle is around 45 degrees. Again, translate the robot in Z through the full range
of positions and ensure the angle does not drop below 10 degrees.
5. In order to appropriately orient the robot, follow the instructions in Appendix 2D for
“Monitoring the A5 Joint Angle” on page 2-6. Translate the robot in X and Y to a position
above the center of the scanning area of the water tank. Stay in Tool Mode for the
remainder of the setup steps.

phantom.
either side of the tank. The goal is to have the primary scanning axes of the tank aligned
with the X and Y Tool Mode axes as in Figure 81. Subsequently, this ensures that the
Figure 79 Tracking the path of the laser beam spot

as the robot is translated in Tool mode Y.
Table 12
Item Description

NOTE: The location of the beam spot on the water tank can be difficult to
determine due to refractions and reflections of the laser beam on an optically
transparent water tank. Placing opaque pieces of masking tape on the water
tank where the laser beam hits it permits unambiguous measurement of L1
and L2.
8. Use the adjustment capabilities of your water phantom to level the tank.
The LINAC and the water tank are now roughly aligned. The next step is to perform beam
alignment, as described below.
Beam Alignment Procedure

After the initial setup procedure, a beam alignment procedure is performed that aligns the central
axis of the radiation beam of the Multileaf Collimator, with the axis of vertical rail motion of the
water phantom.
 To perform the beam alignment procedure, follow these steps:
1. Insert the pinhole collimator into the Multileaf Collimator. Fill the water tank with just a few
centimeters of water.
2. Use the reflection of the collimated laser beam from the water in the tank back onto the
laser collimator to vertically align the laser beam. To do this, adjust only the rotation of
Tool Mode B and C of the treatment robot.
The laser beam is now vertical and incident normal to the water surface.
3. Mount the stereotactic diode detector in the water phantom.
4. Move the diode mount of the water phantom vertically, so that the diode is just below
where the water surface would be if the tank is full. Then move the diode mount
horizontally, so that the laser beam spot is centered on the middle of the diode.
5. Move the diode mount of the water phantom down along its vertical axis. Watch the laser
beam spot on the diode as the diode is moved deeper in the water tank. If the vertical
motion axis of the water phantom is indeed truly vertical (with respect to gravity), the laser
beam spot will remain well centered on the diode.
If the laser beam spot does not remain centered on the diode as it is moved deeper in the
tank, this can be corrected in step 8 and step 13.
6. Fill the tank with water.
7. Move the diode mount so that the active volume of the diode detector is right at the water
surface. Then, reprogram the water phantom so that this position becomes the
mechanical origin (null point) of the water phantom coordinate axes.
NOTE: Refer to the documentation from the diode manufacturer for the
location of the radiation detecting element within the diode detector assembly.

8. Scan the diode detector across the surface in the XY plane and confirm that the diode
depth is constant along the X and Y axes across the scan field.
Beam verticality is then checked with the water tank centering program in step 13.
9. Remove the pinhole collimator. Then use the Multileaf Collimator application in
Physics mode to set the Multileaf aperture open to the center 2 leaves with the rest of
the leaves closed. This shape nominally corresponds to a centered rectangle of 115 mm
in X and 7.7 mm in Y.
10. Turn on the radiation beam. Scan across the open leaves in the short (Y) direction at
X = (-40) mm and then again at X = (+40) mm.
This can be a short scan between +/- 10 mm for example and can be taken at 50 mm
depth.
11. Adjust the tank or rotation, θ, of the LINAC (using rotation A in the tool frame) and repeat
step 10 as necessary to align the water phantom with the MLC leaf orientation such that
each of these scans intersects Y = 0 in the Y direction (see Figure 82).
Figure 80 Off-Axis Water Phantom Scans
NOTE: When referring to the Multileaf Collimator, X is the direction of leaf

travel and Y is orthogonal to it (see Figure 83). This is different from the Tool
mode X and Y.
You can calculate the required angle of rotation, θ, using Equation (1):
 = atan  CAX
---------------- (1)
80 
where CAX is the difference between the centers of the two scans (in millimeters).

Figure 81 Aligning the Water Phantom for an Off-Axis Scan
12. Set the MLC to a centered rectangle of 7.6 mm x 7.7 mm.

13. Use the center-finding routine of the water phantom at 2 different depths in the water
tank. If the X-Y coordinates of the beam center are different at the 2 different depths, then
the radiation beam is not vertical.
Use the Teach Pendant to move the treatment robot using small adjustments in the B and
C rotations in Tool Mode to attempt to make the radiation beam vertical.
14. Once the radiation beam is vertical, reset the null point of the water phantom so that the
null point is coincident with the vertical radiation beam.
15. Insert the front distance pointer then move the treatment robot in Z Tool coordinates to
set the LINAC at 800 mm SSD.
16. Use the MLC Application to create a "Top Right Rectangle" with a width of 40 mm and a
height of 100.1 mm.
17. Perform a quick profile scan at 15 mm depth in the X direction as shown in Figure 84.
Scan from -80 mm to +80 mm in 5 mm steps.
18. Perform a quick profile scan at 15 mm depth in the 45 degree direction as shown in
Figure 84. Scan from -80 mm to +80 mm in 5 mm steps.

19. Change the width of the "Top Right Rectangle" to 120 mm and the height to 38.5 mm.
20. Perform a quick profile scan at 15mm depth in the Y direction as shown in Figure 84.
Scan from -80 mm to +80 mm in 5 mm steps.
23. In each of the (5) scans obtained in step 17 to step 22, verify that the radiation peaks on
the (+) side of the of the profile axis. This will ensure that your water phantom is
measuring the profiles in the correct direction. This is an important step to prepare for the
open field profile and OCR measurements. If for some reason the phantom is not
measuring the profiles in the correct orientation, consult the user manual for your water
phantom to set the scan direction.
24. Perform the test to determine if a diode used in commissioning measurements responds
within the recommended range. See “Diode Detectors and Diode Test” on page 2-8.
Open Field Profile Measurements for the Multileaf

Collimator
A set of open field profile measurements is required for characterizing the Multileaf Collimator.
There are 4 required scans for the open field profile:
• X
• Y
• 45°
• 135°
See Figure 84 for the correct orientation of the water phantom and scans.

Figure 82 Open field scan orientation. MLC orientations are

shown here for clarity. When facing the robot and the
Accuray logo towards you, the X1 bank is to the left and leaf
1 is closest to you. The X2 bank is to the right and leaf 26 is
closer to the robot. (the gray box represents the MLC)
Scans should be made at one depth (20 mm) and can be measured at 800 mm SAD or
800 mm SSD. Scan from (-) to (+) to minimum off-axis values of 100 mm with a constant step size
of 0.5 mm. Recommended dwell time is at least 0.2 seconds. Normalize the readings to the
values at the origin (0, 0) point, not to the maximum value of the scan.
NOTE: Be sure to record whether the data was taken at 800 mm SSD or SAD,
because you will need to enter this information into the header of the beam
data file.

 To perform the open field profile measurements:

1. Set up the water phantom as described earlier in this chapter (see “Coarse Alignment of
the LINAC and Water Phantom” on page 2-111 and “Beam Alignment Procedure” on
page 2-113). You may use a 7.6 mm x 7.7 mm centered rectangle to verify the alignment
of the water phantom and the MLC. If the Perch or InitFrames program has not been run
since the CyberKnife System was powered on, make sure to run the InitFrames program
as described in Appendix 2D for “Initializing Robot Tool Frame” on page 2D-5.
2. Visually note the position of the laser spot on the face of the diode in the water tank. This
will allow you to re-align the laser to the diode in Step 5 on page 2-119. To store the robot
position, follow the instructions in Appendix 2D for “Storing the Robot Position” on
page 2D-1.
3. To remove the Multileaf Collimator housing from the LINAC and position the treatment
robot for the open field profile measurements, do the following:
• Move the treatment robot to the perch position using the prch program on the Teach
Pendant.
• On the treatment delivery computer in Physics mode, go to the Collimator
application and initiate a collimator exchange. Wait for the Multileaf Collimator
housing to drop off onto the Xchange table.
• Initiate an E-Stop by pressing one of the E-Stop buttons before the next collimator
housing is picked up. The E-Stop button should be pressed after the Multileaf
Collimator housing has been dropped off and the robot has lifted up a safe distance
over the Xchange table. This will allow you to safely return the treatment robot to the
perch position using the prch program on the Teach Pendant.
CAUTION: When the Teach Pendant is used to move the treatment robot to the perch position
using the prch program, the robot takes the most efficient route based on joint motion. Do not
use the prch program to move the treatment robot away from the Xchange collimator table if
there is any possibility of collision with the Xchange table. Be sure the treatment robot is a safe
distance above the table before moving to the perch position.
• Confirm the E-Stop on the Error Handling System screen of the treatment delivery
computer. You should now be able to proceed with manual robot positioning and
beam delivery in Physics mode without any collimator housing attached.

• Return the treatment robot to the perch position using the prch program on the
Teach Pendant.
CAUTION: Do not move the treatment robot directly to the stored robot position over the water
tank. Return to the perch position first. Otherwise, possible collision of the treatment robot with
the Xchange table may occur.
• Return to the stored robot position over the water tank.
NOTE: It is likely that, due to the weight of the MLC, the stored robot position
will not produce the same beam angle and position.
4. Determine the inclination of the radiation beam from the water surface by using your
water tank’s scanning method or by centering the diode on the laser and driving the diode
vertically in the tank.
Make the necessary robot corrections to ensure that the radiation beam is perpendicular
to the water surface. This procedure is described earlier in the section “Beam Alignment
Procedure” on page 2-113.
5. Translate the diode such that the laser spot appears at the same position as that noted in
step 2 above.
6. Repeat Step 10 on page 2-114 and Step 11 on page 2-114, but this time scan across the
entire open beam width in the Y direction. Adjust the robot-tank alignment if necessary. A
small correction may be needed due to robot sag. This correction is important for the
diagonal profiles.
7. Collect the open profile data according to the information provided at the beginning of this
section. It is important that the scans follow the direction convention as shown in
Figure 82 in this section. Confirm that your water phantom is moving the diode exactly as
shown in the figure. If there is any question about the scan direction of the X, Y, 45
degree, and 135 degree scans you must reinstall the MLC and repeat steps Step 16 on
page 2-115 through Step 23 on page 2-116 described earlier in this procedure.
8. When the data is complete, follow these steps to reinstall the collimator housing:
• Return the treatment robot to the perch position.
CAUTION: When the Teach Pendant is used to move the treatment robot to the perch position
using the prch program, the robot takes the most efficient route based on joint motion. Do not
use the prch program to move the treatment robot away from its position over the water tank if
there is any possibility of collision. Be sure the treatment robot can be moved safely before
moving to the perch position.
• On the treatment delivery computer in Physics mode, go to the Collimator

application.
• From the perch position, you can then install any available collimator housing
automatically.

9. Enter the data values in the required plain text (ASCII or ANSI) format as described below
and shown in the example data table in Figure 85. See Appendix 2A, “Beam Data
Validation Rules” for a list of Beam Data Validation rules.
Verify that the format of each open field profile table is as follows:
• 3rd line: collimator type = MLC
• 4th line: Identifier for the local institution
• 5th line: <SSD (floating point)> or <SAD (floating point)> and label
• 6th line: <Depth in mm (floating point)> and label
• 7th line: <Number of data points (integer)> and label
• 8th to nth line: <Radial position in mm (floating point)> <Relative
dose (floating point)>
In Lines 1 and 2, the words version and sample must be lowercase. Verify that the
value for version is 200. You may enter comments on Line 4. Line 3 must appear as
shown in Figure 85. You may enter comments on Line 4. In Line 5, you can enter either
SSD or SAD.
The beam profile data is arranged in 2 columns with the radial position in the 1st column
and the relative dose in the 2nd column.
NOTE: Create the tables using plain text (ASCII or ANSI) format. (Unicode will
not work). Do not use extra characters such as spaces or tabs at the end of a
line.

Figure 83 Example Multileaf Collimator dose profile

data table
NOTE: The data shown in Figure 83 is for example only. Do not use this
example data with your CyberKnife System.
Tissue Phantom Ratio (TPR) Measurements for the

Multileaf Collimator
Prior to making tissue phantom ratio measurements, set up the LINAC and water phantom
equipment as described in the previous section.
TPR beam data for the Multileaf Collimator is acquired using the same procedure and equipment
as for fixed collimators except for the following:
• The aperture of the Multileaf Collimator is changed remotely using Physics mode on the
treatment delivery computer. Fixed collimators must be exchanged for different apertures.
• The Multileaf Collimator, Iris Collimator, and fixed collimator housing use the same front
pointer, with a different mounting plate (see Figure 86). The front pointer indicates
distance from the radiation source, with an accuracy of ≤±1.0 mm.

Figure 84 Front distance pointer attached to the

MLC proximal for the Multileaf Collimator
• Using the Multileaf Collimator, it is possible to acquire TPR measurements at each depth
for all apertures before moving to the next depth. This is different from the procedure for
fixed collimators, in which each aperture is stepped through all depths before exchanging
collimators.
For the TPR measurement procedure for the Multileaf Collimator see below.
 To perform TPR measurements:
1. Fill water tank with sufficient water to be able to obtain a reading at 300 mm depth.
recommended range. See ““Diode Detectors and Diode Test” on page 2-8.
2. Position the LINAC so that the beam central axis (CAX) is perpendicular to the water
surface. Use the LINAC laser to verify this. If the Perch or InitFrames program has not
been run since the CyberKnife System was powered on, make sure to run the InitFrames
program as described in Appendix 2D, "Robot Positioning."
3. Attach the front distance pointer to the Multileaf Collimator housing and then attach the
birdcage to the housing, as described on pages 2-105 through 2-110.
4. Mount the diode in the birdcage and use the front pointer to set the target-to-detector
distance at 800 mm SAD.
5. Remove the front pointer and make sure the diode is aligned with the laser with the water
surface and LINAC laser.
7. Exit the Treatment room. Using the controls in the Collimator window in Physics
mode, set the MLC field size to the largest shown in Table 13.

Table 13 MLC field sizes
X (mm) Y (mm)
7.6 7.7
15.4 15.4
23.0 23.1
30.8 30.8
38.4 38.5
46.2 46.2
53.8 53.9
69.2 69.3
84.6 84.7
100.0 100.1
115.0 100.1
8. Deliver 100 MU three times. Then, average the 3 diode readings. Repeat the
measurements at the same depth using all of the Multileaf Collimator field sizes shown.
If the electrometer/diode combination does not give reliability sufficient signal, consider
increasing the monitor units uses for these measurements. Also, check your electrometer
gain settings.
9. Enter the Treatment Room. Using incremental jogging on the Teach Pendant to move the
treatment robot, take readings at recommended depths and field sizes (see Table 14).
• Start with the 15 mm TPR depth. Deliver 3 exposures at 100 MU for each Multileaf
Collimator field size.
• Enter the measurements into the MLC TPR spreadsheet in the TPR Tools workbook
located on the AERO website (www.accurayexchange.com) under Support: User
Documentation or obtained by contacting Contact Accuray Physics Support. Repeat
the above step for each recommended TPR depth and MLC field sizes (Table 14).
• Record the measurements in the MLC TPR spreadsheet which will normalize the
values for each field size to the value at the depth for 15 mm. All required data points
must be populated in the workbook spreadsheet in order for the TPR interpolation to
occur. It will also first interpolate the TPR vs. field size using piecewise linear
interpolation and then interpolate the field size vs. depth using a cubic spline to
generate TPR curves for all 11 field sizes. The TPR value for any collimator is relative
to the measurement at the reference depth (15 mm). Therefore, the TPR value at 15
mm depth is 1.0 by definition for each field size.

Table 14 For MLC, checked boxes are required TPR measurements. Unchecked boxes are
not required *.
Depths
Field Size (mm)
(mm)
7.6 × 15.4 × 23.0 × 30.8 × 38.4 × 46.2 × 53.8 × 69.2 × 84.6 × 100.0 × 115×
7.7 15.4 23.1 30.8 38.5 46.2 53.9 69.3 84.7 100.1 100.1
0 ✓ ✓ ✓ ✓ ✓ ✓ ✓
3 ✓ ✓ ✓ ✓ ✓ ✓ ✓
5 ✓ ✓ ✓ ✓ ✓ ✓ ✓
8 ✓ ✓ ✓ ✓ ✓ ✓ ✓
10 ✓ ✓ ✓ ✓ ✓ ✓ ✓
13 ✓ ✓ ✓ ✓ ✓ ✓ ✓
15 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
20 ✓ ✓ ✓ ✓ ✓ ✓ ✓
30 ✓ ✓ ✓ ✓ ✓ ✓ ✓
50 ✓ ✓ ✓ ✓ ✓ ✓ ✓
100 ✓ ✓ ✓ ✓ ✓ ✓ ✓
150 ✓ ✓ ✓ ✓ ✓ ✓ ✓
200 ✓ ✓ ✓ ✓ ✓ ✓ ✓
250 ✓ ✓ ✓ ✓ ✓ ✓ ✓
300 ✓ ✓ ✓ ✓ ✓ ✓ ✓
* All required data points must be populated in the workbook spreadsheet in order for the
TPR interpolation to occur.
10. When you have collected all of the TPR data, move the treatment robot back to the
15 mm depth. Repeat this depth measurement for all field sizes to verify your data
integrity.
11. Generate a single data table named mlc_TPRtable.dat (or .txt). The required
format is shown in Figure 87.
Verify that the format of the data table is as follows:


• 5th line: <Number of field sizes(integer)> and label
• 7th line: <X field sizes in mm (floating point)>
• 8th line: <Y field sizes in mm (floating point)>
• 9th to nth line: <Depth in mm (integer)> <TPR values (floating point)>
value for version is 200. Line 3 must appear as shown in Figure 85. You may enter
comments on Line 4.
Figure 85 Example MLC TPR data table

(mlc_TPRtable.dat)
NOTE: Create the table using plain text (ASCII or ANSI) format. (Unicode will
line.

Off Center Ratio (OCR) Measurements for the Multileaf

Collimator
The procedure for acquiring off center ratio (OCR) beam data for the Multileaf Collimator is similar
to that for fixed collimators. The procedure is described below:
• For fixed collimators, 2 OCR profiles are averaged at each depth for each aperture.
• For the Multileaf Collimator, 2 OCR profiles are measured at each of 5 depths and the
profile set results in a single OCR table. There are two OCR data tables for each field
size, one for X and one for Y.
NOTE: With the Multileaf Collimator, no averaging or centering of the data is

performed. For more information on OCR data table filenames, see Appendix
2A, Beam Data Validation Rules."
• OCR beam data for the Multileaf Collimator, the fixed collimators, and the Iris Collimator
are acquired using the same depths (distance from the surface of the water phantom).
Table 15 and Table 16 give the scan parameters to be used for the Multileaf Collimator
depending on how the data is scanned. Table 15 applies to fixed 800 mm SAD data
collection. Table 16 applies to fixed 800 mm SSD data collection.
Table 15 MLC OCR Scan Parameters for Fixed SAD Method

OCR scan ranges
X (mm) Y (mm) ± in mm OCR Scan Parameters
7.6 7.7 80 0.2 mm to 30 mm off-axis, then 5 mm to

80 mm off-axis
80 mm off-axis
80 mm off-axis
80 mm off-axis
80 mm off-axis
80 mm off-axis
80 mm off-axis
80 mm off-axis
100 mm off-axis
125 mm off-axis
125 mm off-axis

Table 16 MLC OCR Scan Parameters for Fixed SSD Method
Field Size Scan Depth

X (mm) x Y (mm) (mm) OCR Scan Parameters
7.6 x 7.7 15 0.20 mm to 30.56 mm off-axis, then 5.09 mm to

81.50 mm off-axis
15.4 x 15.4
90.00 mm off-axis
300 0.28 mm to 41.25 mm off-axis, then 6.88 mm to

110.00 mm off-axis

81.50 mm off-axis

90.00 mm off-axis

110.00 mm off-axis

81.50 mm off-axis

90.00 mm off-axis

110.00 mm off-axis

81.50 mm off-axis
53.8 x 53.9
90.00 mm off-axis

110.00 mm off-axis
84.6 x 84.6 15 0.51 mm to 61.13 mm off-axis, then 5.09 mm to 101.88

mm off-axis
100 0.56 mm to 67.50 mm off-axis, then 5.63 mm to 112.50

mm off-axis

mm off-axis

Table 16 MLC OCR Scan Parameters for Fixed SSD Method (continued)
Field Size Scan Depth

X (mm) x Y (mm) (mm) OCR Scan Parameters
100.0 x 100.1 15 0.51 mm to 71.31 mm off-axis, then 5.09 mm to 127.34

mm off-axis
115.0 x 100.1
mm off-axis

mm off-axis

1. Complete the steps to set up the LINAC and water phantom as described in the Beam
Alignment Procedure above. Please note, that if the open field profiles required rotating
the collimator in Tool mode A, recheck the MLC rotation with the ±40 mm scans as
described in the Beam Alignment procedure. If the Perch or InitFrames program has not
been run since the CyberKnife System was powered on, make sure to run the InitFrames
program as described in Appendix 2D for “Initializing Robot Tool Frame” on page 2D-5.
Only profiles in the X and Y directions are required. Profiles should be scanned at
800 mm SAD.
NOTE: If the data are collected at 800 mm SSD they must be back projected
to 800 mm SAD in order for the data to be imported correctly.
If the data are collected at 800 mm SSD, refer to Table 16 for the SSD scan increments
and ranges to collect the data.
2. Acquire OCR profiles at the specified angles of 0 degrees and 90 degrees, with the
specified scan spacing (see Table 15 or Table 16 as it applies to your setup) and a
recommended dwell time of at least 0.2 seconds per point. Each direction is measured at
all of the recommended depths (15,100, and 300 mm). A table is created from the data in
that scan. There is no averaging of the data.
3. Normalize to the values at the origin (0,0) and not to the maximum value.
4. Enter the numerical OCR values in the plain text (ASCII or ANSI) format as described
below and shown in the example data tables in Figure 88. See Appendix 2A, “Beam Data
There is one OCR beam data table for the X direction and one for the Y direction for each
field size. Verify that the format of each beam data table is as follows:

• 4th line: <X field size in mm (floating point)><Y field size in mm

(floating point)> and label
• 6th line: <Number of radial measurements at each depth (integer)>
and label
• 7th line: <Depths in mm (integer)>
• 8th to nth line: <Radial distance in mm (floating point)> <OCR values
(floating point)>
comments on Line 4.
Figure 86 Example pair of MLC OCR data tables,

mlc_OCRtableX7.dat (left) and mlc_OCRtableY7.dat (right)
line.
Output Factor (OF) Measurements for the Multileaf

Collimator
Prior to making output factor measurements, set up the LINAC and the water equipment as
described in this chapter.
The output factor (OF) is the ratio of the absorbed dose at a particular field size for the CyberKnife
System is based on the 60 mm fixed collimator at 800 mm SAD. To determine the output factor for
each field of the Multileaf Collimator, divide each output factor reading by the 60 mm fixed
collimator output reading;

Output factors for all the collimators are normalized to the 60 mm fixed collimator output reading
at 800 mm SAD. If the 60 mm fixed collimator output reading was not acquired on the same day
as the Multileaf Collimator output readings, then repeat the 60 mm fixed collimator output reading
on the same day as the Multileaf output reading for purposes of generating the Multileaf output
factor beam data table.
Output factor beam data for the Multileaf Collimator is acquired using the same procedure and
equipment as for fixed collimators (see “Output Factor (OF) Measurements” on page 2-55),
except for the following:
• Output factors for the Multileaf Collimator are measured only at 800 mm SAD.
• The aperture of the Multileaf Collimator is changed remotely using Physics mode on the
treatment delivery computer. The field sizes listed in Table 13 on page 2-123 should be
used.
• When the Multileaf aperture is resized, the aperture size repeatability can result in
variability in the output factor. This effect is less than a fraction of 1% for all but the
smallest apertures. For the smallest Multileaf field sizes the output factor should be
determined by averaging the electrometer readings from at least 10 repeated
measurements. You should resize the Multileaf aperture between each measurement (for
example, by increasing and then decreasing the field size) and note the standard
deviation of the measurements. The standard deviation provides an estimate of the
variability in output factor for the smallest apertures.
Generate a beam data table and enter the data values in the required plain text (ASCII or ANSI)
format as described below and shown in the example in Figure 89. See Appendix 2A, “Beam Data
Verify that the format of the output factor beam data table is as follows:
• 7th line: <X field sizes in mm (floating point)>
• 8th line: <Y field sizes in mm (floating point)>
• 9th line: <SAD in mm (integer)> <Output factor values (floating
point)>
comments on Line 4.

Figure 87 Example MLC OF data table, mlc_OFtable.dat
line.
Field Sizes Table

There is an additional beam data table required for Finite Size Pencil Beam (FSPB) data entry.
This table defines the field sizes used for the other data. The filename for this data table is
mlc_OCRFieldSize.dat (or .txt). The user can select one of two options to create this file:
• Option (1): Launch the Accuray Precision System with the sample beam data loaded and
retrieve the file mlc_OCRFieldSize.dat (or .txt) from the following location, if
available:
C:\accuray\tmp\1\tmp_machine_data\<plan_identifier>\
tmp_mlc_beam_data
If this default file is found, you should inspect the file to make sure the field sizes that
were measured are listed.
• Option (2): Create the file with the format and data shown in Figure 90.

Figure 88 OCR field size data table to use for Finite

Size Pencil Beam data entry
line.
When you import beam data to the iDMS Data Management System using the Beam Data Import
application, the file must be located in the same directory as your other beam data files (see
“Importing Beam Data to the Data Server” on page 2-132).
Estimated time to collect the beam data for the Multileaf Collimator is 3 to 5 days, depending on
the scanner selection.
Importing Beam Data to the Data Server

Use the Beam Data Import application of the iDMS Data Management System to import beam
data files to the data server. The beam data can then be accessed by and loaded into the Accuray
Precision System.
The beam data files must be formatted in a specific manner as explained earlier in this chapter
and in Appendix 2A, Beam Data Validation Rules”. All collimator beam data files are imported
using the same steps.
WARNING: After importing new or changed beam data, verify the dose calculation model.
Otherwise dose calculation errors can occur.
NOTE: For more information on the Beam Data Import application, see the
Data Management Manual.
 To import beam data files using the Beam Data Import application:
1. Click the Beam Data Import icon on the Accuray Precision System to launch the
Beam Data Import application. Enter the User ID and Password.

The Beam Data Import screen displays the CyberKnife System List, which
shows the available CyberKnife Systems. Double-click to select the correct CyberKnife
System.
The Beam Data Import screen also displays the Details tab, which shows a tree
view of stored beam data files. Stored beam data files are files that have already been
imported to the data server.
2. Click the Import tab. An unpopulated tree view of local beam data files is displayed.
3. Select the (Select Measured Beam Data Files Directory) icon.
The Browse for Folder dialog box is displayed. Browse to select the directory
containing the beam data files you want to import. Then click the OK button.
The tree view expands to show the individual beam data files stored in that directory.
4. Select all the files for a beam data type by enabling the top level checkbox for that type.
You can import one type of beam data at a time (Fixed, MC Fixed, Iris, MC Iris, or
MLC).
5. Select the (Import Checked Files) icon.
The Import Measured Beam Data window is displayed listing the stored beam
data files in the selected directory. Verify that the beam data files listed are the correct
files to be imported.
NOTE: Although there is a checkbox for MC MLC (Monte Carlo Dose

Calculation for the Multileaf Collimator), no MC MLC file needs to be imported.
6. In the Authorization box, enter required notes in the Import Notes text box. Then
enter your user password and click the OK button to authorize and begin the beam data
import process.
NOTE: Depending on the beam dataset that you import, you may need to
repeat one or more Accuray Precision commissioning procedures and
possibly reacquire beam data. For information, see “Decommissioning Beam
Data” on page 2-153.
After the beam data has been imported, a message indicating that the beam data was
imported successfully is displayed. The status of the imported beam data changes to
Imported.
After importing the formatted beam data files to the iDMS Data Management System, the
beam data can be accessed by the Accuray Precision System. You can then use the
commissioning tools on the Accuray Precision System to visually review the imported
data. For information on commissioning tools, see “Accuray Precision Commissioning
Tools” on page 2-134.
NOTE: When correctly formatted MLC beam data is imported into the Accuray
Precision System using the Beam Data Import application, it will not effect the
Ray Tracing algorithm used with fixed collimators and the Iris Collimator.
Incorrectly formatted MLC beam data may also be imported. However, the
Accuray Precision System will not run any of the dose calculation algorithms
with incorrectly formatted MLC beam data. Always check the validity of your
beam data tables.

7. After the beam data has been loaded into the Accuray Precision System and checked
using the commissioning tools, print out the data tables on the Accuray Precision System
using the Print Patient and Plan Information icon on the global tool bar. The
printed data tables are the interpolated lookup tables that reside in computer memory
when Ray-Tracing dose calculations are performed for treatment planning.
Compare the printed values and their data formats with your original water phantom
measured values. Verify that the overall data import process has occurred without error.
Accuray Precision Commissioning Tools

The procedure for commissioning the Ray-Tracing dose calculation algorithm and the Monte
Carlo Dose Calculation algorithm is described in detail in the Treatment Planning Manual, in the
chapter on commissioning tools.
For detailed information on the Monte Carlo Dose Calculation algorithm including the source
model, probability distributions, uncertainty value, and correction factors, see Chapter 5,
“Algorithms for Calculation and Display”.

for the Fixed and Iris Collimators
This section describes the process that should be followed to create a beam model for the Monte
Carlo Dose Calculation algorithm for the fixed collimators and the Iris Collimator in the Accuray
Precision System.
The process includes two flowcharts with numbered steps. It should be noted that some steps of
the process are not sequential, but are performed concurrently. Therefore, the numbered steps
should not necessarily be followed in sequence. Always refer to the flowchart.
Two Microsoft Excel worksheets are available to assist you in determining the Energy Correction
Factors (ECF) and Collimator Correction Factors (CCF) for your Monte Carlo beam model on the
AERO website (www.accurayexchange.com) under Support: User Documentation. Contact
Accuray Customer Support if you have questions.
NOTE: Please ensure that macros are enabled when opening these files,
because they use macros to automatically import your selected files into
specific sheets of the workbook.
For information on the measured data required for the Monte Carlo algorithm, see “Beam Data
Acquisition for the Monte Carlo Dose Calculation for the Fixed and Iris Collimators” on page 2-89.
For information on the Monte Carlo algorithm itself and its virtual source model, see “Chapter 5:
Algorithms for Dose Calculation and Display”. Similarly, information on the user interface for the
Monte Carlo Dose Calculation algorithm commissioning application can be found in the
Specific recommendations in this section (for example, the uncertainty and tolerance values) are
provided to assist with commissioning a Monte Carlo model. Commissioning is the responsibility
of the clinical Medical Physicist. Upon completion of the commissioning of the Monte Carlo model,
the clinical Medical Physicist must confirm that the system is ready for clinical use.

 To create a beam model for the Monte Carlo Dose Calculation algorithm for fixed
collimators and the Iris Collimator:
Refer to the flowcharts in Figure 91 and Figure 92, and the steps described below.
Figure 89 Monte Carlo commissioning flowchart for fixed

collimators and the Iris Collimator, Part 1
1. On the Accuray Precision System entry page, click the Beam Data Import icon to
import beam data into the iDMS Data Management System.
For more information, see “Importing Beam Data to the Data Server” on page 2-132.
2. On the Accuray Precision System entry page, click the Commissioning Tools icon.
Select your CyberKnife System treatment machine. On the MC Source tab under MC
Source Model, click Calculate.
3. Choose to use either In-air OF or Gaussian as a source model. The Gaussian method is
recommended.
If selecting Gaussian, enter a value for the photon source full width half maximum
(FWHM).

For more information, see the Treatment Planning Manual.

4. Under MC Source Model, click Approve after reviewing each part of the source
model.
• If using In-air OF, go to step 7.
5. In the MC TPR & OCR step, under Settings, click OCR Depths and select 100 mm
depth. You can also choose the 50 mm depth if desired.
Under Computation, click Calculate, and select only the 10 mm and 60 mm
collimators, and set Uncertainty % to 0.5%.
Click Accept to save the results.
NOTE: In order to save the data, ALL other Accuray Precision sessions MUST
be closed on ALL workstations before running or approving this calculation.
6. Under Layouts, click OCR and review the comparison of the penumbra widths of the
Monte Carlo-calculated OCR with the measured OCR.
If any differences exceed acceptable values, the calculation must be repeated using a
new Gaussian FWHM value. An increase in the FWHM value increases the penumbral
width. A decrease in FWHM value decreases the penumbral width.
7. Print or export reports using the Treatment Planning System Reports Viewer,
displayed by clicking the Print button on the Global tool bar. When you export reports,
export the files in .xlsx format. Print the Energy Spectrum and Measured TPR.
For more information on the reports viewer, see the Data Management Manual or the
8. Open the file MC ECF Correction Factors workbook, select the ECF worksheet,
and on the worksheet, click Import Spectrum. Browse to the file
CommissioningEnergySpectrum.xlsx transferred in step 7 and click Open. The
values for the energy spectrum will be automatically copied from the file, and pasted into
the ECF worksheet under the headings Energy and Bin Value, starting at cells A4
and B4 respectively.
9. Select the ECF worksheet, and on the worksheet, select whether the collimator is fixed or
Iris and then click Import Measured TPR. Browse to the file
CommissioningTPR.xlsx transferred in step 7 and click Open. The values for the
measured TPR will be automatically copied from the file and pasted into the Measured
TPR worksheet.

10. Record the ECF values from the ECF worksheet. This will initially be used for all
collimators.
• If you are coming to this step from step 16: subsequent ECF values for each
collimator are from the Compare X worksheets.
11. In the MC TPR & OCR step, select Correction Factors and enter the ECF value(s)
from step 10.
12. To speed up the iterative process of step 13 to step 21, an automated process is
available. Click the Fit Correction Factors button. Set the Maximum Iterations
to 5 and the Uncertainty (%) to 0.5%. Make sure both ECF and CCF checkboxes
are selected. If you started with your own correction factors following step 11, make sure
to select the User Defined CFs option.
Click OK to begin the automated fitting process for the correction factors.
13. Under Settings, click OCR Depths and select only 100 mm.
Under Computation, click Calculate, select CHANGED collimators, and set
Uncertainty % to 0.5%.
be closed on ALL workstations before running this calculation.
NOTE: Depending on hardware, this calculation can take from 2 to 20 hours.


Figure 90 Monte Carlo commissioning flowchart for fixed

collimators and the Iris Collimator, Part 2
14. Click the Print button to display the Treatment Planning System Reports
Viewer. Select the TPR report from the report list, and select Calculated from the
Data Type drop-down list.
Export the file in .xlsx format by selecting Excel from the drop-down list on the toolbar.
The default filename is CommissioningTPR.xlsx. You can change the filename. Then
specify a path to save the file. This file must be transferred to a computer with Microsoft
Excel installed.

15. Open the file MC ECF Correction Factors workbook, select the Compare 1
worksheet, and on the worksheet, click Import Calculated TPR. Browse to the file
transferred in step 14 and click Open. The values for the calculated TPR will be
automatically copied from the file and pasted into the MC Calculated 1 worksheet.
NOTE: For subsequent calculations, Compare 2, Compare 3, and so on,

worksheets should be used.
16. On the relevant Compare worksheet, review the comparison between the Monte Carlo-
calculated TPR data and measured TPR data. If any differences exceed acceptable
values, the calculation must be repeated using new ECF values.
• Go to step 10.
17. Under Layouts, click OCR to review the comparison of the Monte Carlo FWHM
calculated OCR data with the measured OCR data.
18. Under Settings, click Correction Factors and record the values for each collimator.
Review the MC OCR and Measured OCR data values.
• For the measured 100 mm depth OCR data, record the Radius (mm) and
corresponding ratio (%) that is closest to the 50% ratio.
• For the MC OCR data, record the radii and corresponding ratios for the points on
either side of the measured ratio above.
19. Open the file MC CCF Correction Factors workbook, and select the First CCF
worksheet.
• Enter the CCF values from step 18 into Old CCF, column H.
• Enter the measured radius and percent into columns F and G.
• Enter the MC calculated radii and percent into columns B and C, and D and E.
NOTE: For a subsequent calculation, the worksheet named Second CCF

should be used.
20. Record the new CCF values for each collimator from column I.
21. In the MC TPR & OCR step, select Correction Factors and enter the new CCF
value(s) from step 20.
• Go to step 13.
NOTE: If large CCF changes are made, the OCR penumbra should be re-
checked after the MC TPR and OCR calculation.

22. Under Settings, click OCR Depths and select all depths.
Under Computation, click Calculate, and select ALL collimators, and set
Uncertainty % to 0.5%.
NOTE: Depending on hardware, this calculation can take up to 12 hours.

be closed on ALL workstations before running this calculation.
23. Compare the comparison of the Monte Carlo calculations to the measured data for all
depths and field sizes. If the results are acceptable, continue to step 24. Otherwise, make
adjustments to the related ECF and/or CCF correction factor and calculate again.
24. In the MC OF step, under Computation, click Calculate. Set Uncertainty % to
0.2%.
be closed on ALL workstations before running or approving this calculation.
NOTE: Depending on hardware, this calculation can take up to 24 hours.

25. Compare the calculated OF values to the measured OF values. If acceptable, click
Accept to save the results and proceed to clinical testing. Otherwise, contact Physics
Support.


for the Multileaf Collimator
This section describes the process that should be followed to create a beam model for the Monte
Carlo Dose Calculation algorithm for the Multileaf Collimator in the Accuray Precision System.
No additional beam data is required for the Monte Carlo MLC algorithm. However, the Finite Size
Pencil Beam (FSPB) algorithm must be commissioned before moving forward with Monte Carlo
commissioning. Additional steps are required to use the existing data.
In order to use the existing MLC FSPB data, these steps must be followed:
• Open BDI (Beam Data Import) from dashboard
• Select CyberKnife machine
• Click Import tab
• Click checkbox beside MC MLC
• Click Import Checked Files button
• Enter any notes and password
• Click OK
For information on the Monte Carlo algorithm itself and its virtual source model, see Chapter 5,
"Algorithms for Dose Calculation and Display”. Similarly, information on the user interface for the
Monte Carlo Dose Calculation algorithm commissioning application can be found in the
Specific recommendations in this section (for example, the uncertainty and tolerance values) are
provided to assist with commissioning a Monte Carlo model. For information on optimization of
source model parameters, see “Optimization of Source Model Parameters” on page 2-143
Commissioning is the responsibility of the clinical Medical Physicist. Upon completion of the
commissioning of the Monte Carlo model, the clinical Medical Physicist must confirm that the
system is ready for clinical use.
 To create a beam model for the Monte Carlo Dose Calculation algorithm for the Multileaf
Collimator:
Refer to the flowchart in Figure 93 and the steps described below.

Figure 91 Monte Carlo commissioning flowchart for

the Multileaf Collimator
1. On the Accuray Precision System entry page, click the Commissioning Tools icon
then select your CyberKnife System treatment machine.
2. Go to the MLC task > MC Source step.
3. Enter a value for the photon source FWHM (mm). Start with a value of 1.8 mm. Click
Calculate. For more information, see the Treatment Planning Manual.
4. Choose the Open Beam Fluence layout and review the Open Beam Profile scans. These
are the same scans used in the FSPB algorithm. Review the calculated 2D Fluence
Distribution map.
5. Choose the Energy Spectrum layout. Choose the Beam Hardening state that is
appropriate for your LINAC. For more information on the Beam Hardening option, see
Chapter 5.
Next select an Energy Spectrum from the drop-down menu. Start with the 6.6 MeV
energy spectrum.

6. After visiting the 3 layouts, click Approve and confirm your selections for the MC Source
Model.
7. Go to the MC TPR step. Click Depths and choose only the 10, 15, 100, 200, and
300 mm depths. Click Calculate and select only the 15.4 x 15.4 and 84.6 x 84.7 fields.
Set the Uncertainty % to 0.5% and click Calculate.
8. Compare the calculated TPR values to the measured TPR values. If the difference is
acceptable, continue on to step 10.
9. If the % difference is not acceptable, return to the MC Source Energy Spectrum layout
and choose a new Input Energy Spectrum. A lower mean energy will create a
steeper TPR curve (higher relative values at smaller depths) and a higher mean energy
will create a less steep TPR curve (higher relative values at larger depths). Return to
step 6.
10. Go to the MC OCR step. Click Depths and choose only the 100 mm depth. Click
Calculate and select only the 15.4 x 15.4 and 84.6 x 84.7 fields. Set the
Uncertainty % to 0.5% and click Calculate.
11. Compare the calculated OCR values to the measured OCR values. In particular, inspect
the penumbra width. If the calculated OCR values are acceptable, continue to step 13.
12. If the calculated OCR values are not acceptable, return to the MC Source Distribution
layout and modify the MC Source Model FWHM (mm).
• An increase in the FWHM value increases the penumbral width.
• A decrease in FWHM value decreases the penumbral width.
13. After both the TPR and OCR values have shown acceptable agreement for a subset of
fields and depths, return to the MC TPR step and calculate all fields and all depths at
0.5% Uncertainty. Compare the calculated TPR values to the measured TPR values.
• If the % difference is not acceptable, contact Accuray Customer Support for
assistance.
• If the % difference is acceptable, click Accept to save the results and continue to the
next step.
14. Return to the MC OCR step and calculate all fields and all depths at 0.5% Uncertainty
Compare the calculated OCR values to the measured OCR values.
• If the comparison is not acceptable, contact Accuray Customer Support for assistance.
• If the comparison is acceptable, click Accept to save the results and continue to the
next step.
15. Go to the MC OF page. Click the Calculate button. Set the Uncertainty to 0.2% and
click Calculate.
16. Compare the calculated OF values to the measured OF values. If acceptable, click
Accept to save the results and proceed to clinical testing. Otherwise, contact Accuray
Customer Support.
Optimization of Source Model Parameters

This section elaborates on optimization of source model parameters, describes expected
agreement between calculated and measured beam commissioning data, and explains typically
observed differences.

Optimizing the Primary Source Distribution

The primary source distribution is defined by only one parameter, the full width half maximum
(FWHM) of the Gaussian distribution from which photon source positions are sampled in the X-
ray target plane. The principle effect of this setting is to change the width of the calculated beam
penumbra. There will be no impact on the position of the beam edge, which is fixed by the
geometric model of the Multileaf Collimator (MLC), but only on the gradient of the calculated OCR
on either side of this point. Note that the source distribution is circularly symmetric so the impact
of FWHM will be very similar on the calculated X- and Y- OCR, and in positive and negative off-
axis directions. Therefore, the optimum value should be assessed based on the calculation vs.
measurement differences at all four beam edges.
Optimizing this parameter involves iterations during which the agreement between calculated and
measured OCR is assessed. The impact of FWHM changes is most easily seen for relatively
small beams, and differences are more visible if the zoom tool is used to focus the displayed OCR
on the beam edges.
Figure 94 shows an example of calculated vs. measured Y-OCR for the 15.4 mm x 15.4 mm field
at 15 mm depth, with FWHM set to 1.5 mm, 2.5 mm, and 3.5 mm. The change in calculated beam
penumbra (yellow line) is evident with penumbral width increasing as FWHM increases. In this
case 2.5 mm is closest to optimal, and a finer search involving more depths and field sizes would
be conducted around that setting.
Figure 92 Example of Y-OCR calculations (yellow) vs.

measurements (red) for a 15.4 mm x 15.4 mm field at 15 mm
depth, using FWHM of 1.5 mm (left), 2.5 mm (middle), and
3.5 mm (right). The calculations were performed at 0.5%
uncertainty.
Optimizing the Energy Distribution

First, on the Energy Spectrum tab, select or clear the Beam Hardening check box. This
setting corresponds to the presence of a lead filter in the beam path (that is, the check box should
be selected if the filter is installed; clear if not). This filter is installed only on some S7 systems. If
you are unsure about your system configuration contact Accuray Customer Support.
Next, set the beam energy to a starting value (e.g. 6.6 MeV). The principle effect of this setting is
to change the TPR dose calculation, and therefore, optimizing this setting is an iterative process
of inspecting the match between calculated and measured TPR and altering the energy until the
differences are minimized. To make this procedure as fast as possible, it is recommended to start

with only a subset of field sizes and depths, increasing the calculation set only as the match
becomes closer. Also, optimization should be based on the overall distribution of results at
multiple depths and field sizes because of the influence of random uncertainty on the individual
results. The following shows an example of an optimization workflow:
Iteration 1: E = 6.8 MeV. TPRs calculated at field sizes 23.0 mm x 23.1 mm and 53.6 mm x 53.7
mm; at depths 15, 100, 200, 300 mm; and 1% uncertainty. All calculated TPRs were 2.0% to 4.5%
larger than measured TPRs.
Iteration 2: As above with E = 6.6 MeV. All calculated TPRs were 1.4% to 3.6% larger than
measured TPRs.
Iteration 3: As above with E = 6.4 MeV. All calculated TPRs were -1.3% to +1.3% vs. measured
TPRs.
Iterations 4–6: E = 6.4, 6.3, 6.2 MeV. All field sizes and depths calculated at 1% uncertainty.
Based on these results, the optimum energy was selected as E=6.3 MeV as this provided the
least biased offset between calculation and measurement over all depths and field sizes. A final
calculation was performed at this energy for all depths and field sizes using 0.5% uncertainty.
Over all fields and depths, the agreement between calculation and measurement was ≤±0.5% at
62% of points, ≤±1.0% at 91%, ≤±1.5% at 97%, with maximum difference of 1.6%. Most
importantly, as illustrated in Figure 95, the comparison shows no bias.
Table 17 % difference between calculated vs. measured TPRs.
TPR – Measured TPR (%) [range over all

depths]
X -field size
(mm) 6.4 MeV 6.3 MeV 6.2MeV
7.6 0 to 1.2 0.2 to 0.9 -0.2 to 1.5
15.4 -1.0 to 0.3 -2.8 to 0.7 -2.9 to -0.6
23.0 0.8 to 2.0 -0.8 to 0.6 -2.3 to -0.6
30.8 0.5 to 2.7 -0.2 to 0.5 -0.8 to 0.8
38.4 0.2 to 1.2 -0.3 to 1.8 -0.2 to 0.1
46.2 0.1 to 3.4 -0.2 to 1.3 -1.9 to 0.3
53.8 0.2 to 1.0 -1.1 to 1.4 -1.8 to -0.1
69.2 -0.2 to 1.9 -0.7 to 1.5 -1.7 to 0.5
84.6 0.3 to 1.8 -0.2 to 1.4 -1.4 to 1.8
100 -0.1 to 0.3 -0.8 to 0.7 -1.0 to 0.1
115 -0.4 to 1.2 -0.9 to 0.2 -0.6 to -0.2

Figure 93 Example of TPR calculations (yellow dots) vs.

measurements (red line) using an optimized Energy
distribution at field sizes 7.6 mm x 7.7 mm (top), 53.6 mm x
53.7 mm (middle), and 100 mm x 100.1 mm (bottom).
Calculations were performed at 0.5% uncertainty.

Note on Leaf Transmission Settings

The leaf transmission parameters and their use during dose calculation are described in the
Monte Carlo dose calculation algorithm section of Chapter 5 of the Physics Essentials Guide.
These values are displayed and can be changed in the MC OCR commissioning workspace.
However, it is recommended that the default values of these settings are used and no manual
modifications are made.
Typical OCR Agreement in the Tails of Large Beam Profiles

The largest observed disagreement during commissioning between MC calculation and
measurement is usually outside the field edge in the low-dose "tail" of the OCR curve, especially
when stereotactic diode detectors are used to perform the commissioning measurements. The
magnitude of these differences increases with increasing field size and depth. Figure 96 shows an
example where the difference between calculation and diode measurement increases to a
maximum of 4% (as percentage of central axis value) at the largest field size and depth. The
measurement perturbations associated with various detector and commissioning measurement
types with small beams have been studied extensively in the literature, and specifically for
CyberKnife System beam commissioning [18,19]. These studies show that for large circular
collimators or MLC fields at 300 mm depth, a stereotactic diode over-estimates OCR in the tail
region by more than 20% (as a percentage of local dose). This measurement perturbation is
caused by the high atomic number of the detector sensitive volume in combination with the large
decrease in photon and electron energies outside of the larger beams at larger depths. These
studies also show that some other detector types, such as synthetic microdiamond detectors, are
not subject to these large out-of-field perturbations. Figure 96 shows a better match between
calculated and measured OCR tails for large fields and depths if the OCR is measured with this
detector rather than a diode.
As stated in one of these studies: “The results also show a substantial out-of-field diode OAR
overestimation at large field sizes and depths which should be recognized during commissioning
although we do not recommend explicit corrections are applied. The correction factors are much
smaller for point scintillation and synthetic microdiamond detectors, although both of these suffer
from other limitations which make the microdiamond a more practical alternative currently.” [19]
Therefore, reasonable advice is to be aware of OCR measurement overestimation in the tails for
larger beams when stereotactic diodes are used and, if possible, to use a synthetic microdiamond
detector for these measurements.

Figure 94 Example of X-OCR tail calculations (yellow) vs.

measurements (red) for 100 mm x 100.1 mm field at 300 mm
depth. On the left, OCR is measured using a stereotactic
diode and in the tail region, the measured OCR is 3.7% -
4.2% (as percentage of central axis dose) higher than the
calculation. This difference reduces to 2.5% - 3.0% at 100
mm depth. On the right, measurements are made using a
synthetic microdiamond detector and the differences in the
tail region are smaller although there is still an offset of
1.7% - 2.2% at 300 mm depth, reducing to 0.8% - 0.9% at 100
mm depth. The equivalent values at a mid-range field size
(53.8 mm x 53.9 mm) are 1.8% - 2.2% (d=300 mm) and 1.6%
(d=100 mm) for a diode, reducing to 1.2% - 1.7% and ≤0.5%
respectively for a microdiamond. With a small field (15.4 mm
x 15.4 mm), the differences are ≤0.5% at all depths with both
detectors.
Typical OCR Agreement in the Shoulders of Large Beam Profiles

The second largest difference between calculation and measurement observed during
commissioning is typically in the “shoulders” of the OCR for larger beams and depths.
NOTE: As with all Monte Carlo dose calculations, when evaluating the differences between
calculated dose and measurement in the relatively large and uniform dose region within the
beam, it is important to consider average agreement over multiple points rather than the
maximum difference at any one point, which is likely to be exaggerated by random uncertainty in
the calculation. Also, use a low uncertainty dose calculation (0.5% recommended).
As illustrated in Figure 97 the calculation in the OCR shoulders is typically about 2% lower than
measurement at the largest field sizes and 300 mm depth. These differences get smaller as depth
or field size decrease so that with more typical treatment apertures and depths, differences of
≤1% are expected. Examples are shown in Figure 97 – Figure 99.
A similar pattern is found with the largest circular collimated fields (fixed and Iris). One possibility
sometimes used with circular collimators is to artificially increase the shoulders of the open beam

profile used to commission the source model fluence distribution (for more information, contact
Accuray Customer Support). This is problematic for MLC commissioning because the same open
beam fluence distribution is used by both the finite size pencil beam and Monte Carlo algorithms.
It is clear that modifying the source model parameters has no significant impact on agreement in
this region. The leaf transmission settings do not affect dose within the beam, and the source
distribution FWHM has no effect in this region either, as illustrated in Figure 100.
Unlike the differences observed in the tails, there is no evidence of significant measurement
perturbations associated with commonly used detectors in this region of the OCR [18,19], and
similar differences between calculation and measurement in this region are observed if a
synthetic microdiamond is used rather than a diode. The cause of this disagreement is likely to be
the relatively simple single virtual source model used in the Monte Carlo algorithm coupled with
the simplified particle transport through the secondary collimators (which models only particle
attenuation and not scatter) that are used to maximize the calculation speed. As the MLC
aperture is increased, sources of head scatter at increasing lateral distances from the X-ray target
are contributing particles to the edges of the beam and these are not included in the calculation.
This represents a limitation of the current algorithm.
Figure 95 Diode measured (red) vs. Monte Carlo calculated

(yellow) X-OCR for a 15.4 mm x 15.4 mm MLC field and 0.5%
uncertainty, at depths of 50 mm (top left), 100 mm (top
right), 200 mm (bottom left), and 300 mm (bottom right).
Within the central part of the profile (i.e. between the central
axis and the penumbra) the differences are ≤0.5%.

Figure 96 As Figure 97 for a 53.8 mm x 53.9 mm MLC field.

Within the central part of the profile (i.e. between the central
axis and the penumbra) the differences increase with depth
to approximately 1% at 300 mm, with the calculation
generally lower than measurement.

Figure 97 As Figure 97 for a 100.0 mm x 100.1 mm MLC

field. Within the central part of the profile (i.e. between the
central axis and the penumbra) the differences increase
with depth to approximately 2% at 300 mm, with the
calculation lower than measurement. Note that the much
larger disagreement in the OCR tails is discussed in a
previous section.

Figure 98 Diode measured (red) vs. calculated (yellow) X-

OCR for a 100 mm x 100.1 mm MLC field at 300mm depth,
using 0.5% uncertainty. On the left using a source
distribution with 1.5mm FWHM and on the right with 3.5mm.
There is no significant change in the agreement within the
shoulder region at these two settings. Note that the much
larger disagreement in the OCR tails is discussed in a
previous section.

Decommissioning Beam Data

Table 18 lists dependencies between beam datasets for Accuray Precision commissioning. As a
result, importing a beam dataset can decommission the beam model in the Accuray Precision
System. For example, re-importing currently approved beam data or replacing it with new
measured beam data may require that you repeat one or more commissioning procedures in the
Accuray Precision System. It may also require that you reacquire one or more beam datasets.
Table 18 Beam commissioning dependencies
Replaced Beam Data Required Re-approval
Fixed beam data Recommission entire beam model:

(OCR, TPR, and output factor):
• Ray-Tracing dose calculation algorithm with
• TMRtable.dat fixed collimators
• OCRtableN.dat (N = 0 to 11) • Monte Carlo Dose Calculation algorithm with
fixed collimators
• DMtable.dat
the Iris Collimator
• Monte Carlo Dose Calculation algorithm with
the Iris Collimator
• Finite Size Pencil Beam (FSPB) Dose
Calculation algorithm with the Multileaf
Collimator
the Multileaf Collimator
MC Fixed beam data Recommission the following:

(in-air output factor, open field dose profile,
central PDD):
fixed collimators
• mc_outputfactor.dat
• mc_doseprofile.dat the Iris Collimator
• mc_centralpdd.dat
Iris beam data Recommission the following:

(OCR, TPR, and output factor):
• irisTPRtable.dat the Iris Collimator
• irisOCRtableN.dat (N = 0 to 11) • Monte Carlo Dose Calculation algorithm with
the Iris Collimator
• irisOFtable.dat

Replaced Beam Data Required Re-approval
MC Iris beam data Recommission the following:

(in-air output factor, open field dose profile,
central PDD):
the Iris Collimator
• iris_mc_outputfactor.dat
• iris_mc_doseprofile.dat
• iris_mc_centralpdd.dat
MLC beam data Recommission the following:

(OCR, TPR, output factor, open field dose
• Finite Size Pencil Beam (FSPB) Dose
profile):
Calculation algorithm with the Multileaf
• mlc_OCRtableXN.dat Collimator
(N = 0 to 10)
• mlc_OCRtableYN.dat the Multileaf Collimator
(N = 0 to 10)
• mlc_TPRtable.dat
• mlc_OFtable.dat
• mlc_doseprofileX.dat
• mlc_doseprofileY.dat
• mlc_doseprofile45.dat
• mlc_doseprofile135.dat

Absolute LINAC Dose Calibration

An absolute dose calibration allows you to convert nanocoulombs (nC) to centigray (cGy) for a
given detector in a given configuration. The absolute dose calibration for the CyberKnife System
LINAC is performed so that 1 MU = 1 cGy at 800 mm SAD and 15 mm depth with the 60 mm
collimator. While the CyberKnife System dose output is defined with the ion chamber at 15 mm
depth, for the absolute dose calibration the chamber should be placed at appropriate depth as
specified by the Code of Practice.
You perform an absolute dose calibration for the CyberKnife System LINAC using a calibrated ion
chamber and a water phantom. To perform daily checks of the state of your CyberKnife System
LINAC dosimetry calibration, cross-calibrate using another method, such as an ion chamber with
a 6 MV build-up cap attached to the birdcage.
• “General Formalism for the TG-51 Protocol” on page 2-155
• “Beam Quality Conversion Factor” on page 2-156
• “LINAC Warmup” on page 2-160
• “LINAC Calibration Procedures Using Physics Mode” on page 2-161
General Formalism for the TG-51 Protocol

There are several absolute dose calibration protocols available throughout the world. In the U.S.,
the current protocol is published by Task Group 51 of the American Association of Physicists in
Medicine. IAEA TRS-398 is very similar to this protocol and is used in many countries. Task
Group 21 is an older calibration protocol still used at some sites in the U.S. A negligible difference
results using the different protocols. To perform the calibration for the CyberKnife System, some
accommodations are needed to obtain the measurements required by the protocol using the
800 mm SAD distance for the 60 mm circular field secondary collimator. If the optional InCise 2
Multileaf Collimator is available, the user could directly measure the percent depth dose (PDD) of
a 100 mm x 100.1 mm field. Sections that follow describe using the 60 mm circular fields to find
the equivalent PDD for a 100 mm x 100 mm square field.
A method of accomplishing this for the TG-51 protocol is presented below. This method is
published in a paper from the IAEA working group on small field dosimetry that presents a general
formalism for calibration for circumstances where the standard radiotherapy reference treatment
field of 10 cm x 10 cm square is not available [Ref. 7]. The same method can be used with the
IAEA TRS-398 protocol. If further assistance is required, contact Accuray Customer Support and
ask for a Physicist to supply commissioning information.
The TG-51 protocol is based on absorbed dose to water in a 60Co beam. Measuring the beam
quality conversion factor, kQ, is the only item that must be determined using 2 corrections for the
CyberKnife System configurations. Equations used in the TG-51 protocol are shown in Figure
101.
1075879-ENG A Absolute LINAC Dose Calibration |2-155

Dose in water equals the electrometer

reading times the chamber factor
corrected.
Electrometer Reading
Chamber Factor
Figure 99 Equations used in the TG-51 protocol
Since the CyberKnife System does not have a flattening filter, the beam profile gradient over the
chamber cavity (assuming standard Farmer chamber of length 24 mm) can lead to an
underestimation of dose by approximately 1.5%. This was calculated theoretically by [Ref. 8] and
measured experimentally by [Ref. 9]. This can be accounted for either by including an additional
factor Prp [Ref. 10], to account for the volume averaging effect over the chamber cavity for 60 mm
beam or using a short stem reference class Farmer chamber such as Exradin A12S [Ref. 10].
In addition the change of spectrum compared to standard LINACs due to lack of flattening filter
can modify the kQ factor by up to 0.5% and this can depend upon the beam-quality specifier being
used [Ref. 11].
Beam Quality Conversion Factor

The TG-51 protocol requires that the beam quality conversion factor, kQ, be determined from the
beam quality using a percent depth dose (PDD) measurement at 100 mm depth (hereafter
referred to as PDD100). Setup requirements for PDD100 measurement using the TG-51 protocol
are as follows:
• SSD = 1000 mm
• FS = 100 x 100 mm (at 1000 mm SSD)
where SSD is the source-to-surface distance and FS is field size.
Fixed collimator fields of the CyberKnife System are circular and defined at 800 mm SAD, and the
maximum collimator size is 60 mm. Therefore the approximations described in this section should
be used to determine kQ if only the fixed collimator option is available.
The general procedure for determining kQ is as follows:
1. Measure PDD100 at the extended distance of 1000 mm SSD with the 60 mm collimator.
2. Convert the 60 mm circular FS to the equivalent square field size (ESFS) at
SSD = 1000 mm.
2-156 | Absolute LINAC Dose Calibration 1075879-ENG A

As described in “Determining the Equivalent Square Field Size” on page 2-157, ESFS for
the 60 mm collimator at SSD = 1000 mm is 67.5 mm.
3. Compare your measured PDD100 value with a standard reference such as the British
Journal of Radiology [Ref. 12] for an ESFS of 67.5 mm. From this comparison, one can
infer what the equivalent PDD100 value would be for a 100 mm X 100 mm FS.
4. Use this equivalent 100 mm x 100 mm PDD100 value to determine the kQ value from the
TG-51 graphs [Ref. 3].
Figure 102 shows PDD100 values as a function of beam quality for different square field sizes
[Ref. 12]. As an example, consider a measured PDD100 value at 1000 mm SSD of 65.0% for a
7 cm x 7 cm square field. As shown in the graph, this is equivalent to a PDD100 value of 66.8% for
a 10 cm x 10 cm square field.
Figure 100 PDD100 values as a function of beam quality for

different square field sizes
Determining the Equivalent Square Field Size

Conversion of circular FS to ESFS is described in [Ref. 12] (see “References” on page 2-215).
The circular field size (FS) of the 60 mm collimator at SSD = 1000 mm is converted to the
equivalent square field size (ESFS) as follows (see Table 19):
• ESFS (at 800 mm SAD) = 0.9 x Circular FS (at 800 mm SAD)
• ESFS (at 1000 mm SAD) = 1000/800 x ESFS (at 800 mm SAD)
• Therefore, ESFS (at 1000 mm SAD) = 1.125 x Circular FS (at 800 mm SAD)
A 60 mm circular field at 800 mm SSD is therefore equivalent to a 67.5 mm square field at
1000 mm SSD.

Table 19 Collimator size and equivalent square field size (ESFS)
Collimator Size (mm) ESFS (mm) at 800 mm SSD ESFS (mm) at 1000 mm SSD
5 4.5 5.6
7.5 6.8 8.4
10 9.0 11.3
12.5 11.3 14.1
15 13.5 16.9
20 18.0 22.5
25 22.5 28.1
30 27.0 33.8
35 31.5 39.4
40 36.0 45.0
50 45.0 66.3
60 54.0 67.5
Measuring the Beam Quality Conversion Factor

 To measure the beam quality conversion factor, kQ, for the CyberKnife System:
1. Set up the water phantom.
2. Use the Teach Pendant to manually drive the treatment robot. Set the treatment robot
normal to surface using the laser and SSD = 900 mm with the front distance pointer (see
Figure 30 on page 2-46). Follow the guidelines for making sure the A5 joint is not below
10 degrees as described in each of the collimator specific beam commissioning sections
in this chapter. Also verify that the beam is perpendicular to the water surface just as you
would for commissioning.
3. With the treatment robot set to TOOL coordinates mode, move upward 100 mm so that
the LINAC source is 1000 mm from the water surface.
4. If the LINAC has not yet been warmed up, deliver 2000 MU to warm up the LINAC.
5. Acquire a PDD curve for the 60 mm collimator at 1000 mm SSD.
6. Compute the ratio of the reading at depth d = 100 mm / reading at Dmax (PDD100).
7. Compare the measured PDD100 for the CyberKnife System with the 67.5 mm equivalent
from a known data source such as the British Journal of Radiology [Ref. 12]. From this
value, the equivalent PDD100 value for a 100 mm x 100 mm square field can be inferred.
8. Use this equivalent 100 mm x 100 mm PDD100 value to determine the kQ value from the
TG-51 graphs [Ref. 3].

After determining the kQ value, use an absolute dose calibration protocol of your choice to
determine the conversion from nanocoulombs (nC) to centigray (cGy) for this beam measurement
configuration. For more information, see “References” on page 2-215. Regardless of which SAD
or SSD is required for the calibration protocol, the dosimetry calibration for the CyberKnife
System is performed at 800 mm SAD and 15 mm depth with the 60 mm collimator (see “LINAC
Calibration Point” on page 2-159).
After you determine the conversion from nanocoulombs to centigray, proceed with the output
calibration procedure “LINAC Calibration Procedures Using Physics Mode” on page 2-161.
LINAC Calibration Point

The absolute dose calibration is conducted so that at the calibration point, the CyberKnife System
output with the 60 mm fixed collimator at 800 mm SAD and 15 mm depth in water is
1cGy per 1 MU, as shown in Figure 101.
800 mm
15 mm
Figure 101 At the calibration point with the calibration

geometry, 1 MU = 1 cGy with the 60 mm collimator
Once your CyberKnife System is calibrated as described above, the dose in cGy/MU at other
points is determined from the following equation (see Figure 102):

800 2
D   MU  = OCR  coll, R 800, D eff    -----------  TPR  fieldsize D eff   DM  coll, SAD  (2)
 SAD
For more detailed information, see Chapter 5, “Algorithms for Dose Calculation and Display”.
800 mm
15 mm
Figure 102 Dose calculation when not at calibration point
LINAC Warmup
Accuray recommends a warmup of at least 2 minutes for LINACs with sealed ion chambers. Set
the desired warmup time in minutes using the Warmup screen (see “Daily LINAC Warmup” on
page 2-161) to warm up your LINAC before performing an absolute dose calibration or daily
output check. For information on performing these procedures, see “LINAC Calibration
Procedures Using Physics Mode” on page 2-161.

LINAC Calibration Procedures Using Physics

Mode
This section describes the following procedures:
• “Daily LINAC Warmup” on page 2-161
• “LINAC Calibration Check” on page 2-167
• “LINAC Calibration Adjustment” on page 2-170
• “LINAC Output Constancy Check” on page 2-175
To perform the above procedures, you must have login access to Physics mode from the
CyberKnife System Menu on the treatment delivery computer. Equipment power must be turned
on before you can access Physics mode. For more information on the CyberKnife System
Menu, see the Treatment Delivery Manual.
The typical order of the above procedures is as follows: Perform LINAC warmup first, then the
LINAC calibration check, and then the LINAC calibration adjustment. The LINAC calibration
adjustment is the least frequently performed procedure.
Daily LINAC Warmup

The LINAC warmup procedure should be performed daily, as specified in the CyberKnife®
Robotic Radiosurgery System QA Log Book. Otherwise, fluctuations in the dose rate can occur.
 To perform the daily LINAC warmup procedure:
1. On the treatment delivery computer, turn on CyberKnife System equipment power using
the Equipment Status window. The Physics button in the CyberKnife System Menu is
enabled only when equipment power is on (see Figure 103). For more information on
turning on equipment power, see the Treatment Delivery Manual.

Figure 103 CyberKnife System Menu after equipment

is powered on
2. Click the Physics button in the CyberKnife System Menu. The Physics menu is
displayed (see Figure 104).

Figure 104 Physics menu
The Physics menu contains the following buttons:

• LINAC button: Allows you to manually perform procedures for LINAC warmup,
calibration check, and calibration adjustment.
• X-Ray Warmup button: Allows you to warm up the X-ray tubes of the X-ray
imaging system. For more information on the X-ray tube warmup procedure, see the
• Collimator button: Allows you to exchange collimators outside of a treatment plan.
For more information on exchanging collimators, see the Treatment Delivery Manual.
• Laser Alignment button: Allows you to perform a quick verification of robot
pointing accuracy. For more information on performing a Laser Alignment Check in
Physics mode, see Chapter 3, "Quality Assurance Recommendations and Tests".
• Multileaf Collimator button: If you have the InCise 2 Multileaf Collimator option,
allows you to change the size and shape of the Multileaf Collimator aperture, and
perform Physics tasks associated with the Multileaf Collimator.
• Exit button: Returns you to the CyberKnife System Menu.
3. Click the LINAC button in the Physics menu. The LINAC menu is displayed (see
Figure 105).

Figure 105 LINAC menu
The LINAC menu contains the following buttons:

• Warmup button: Allows you to warm up the LINAC. This procedure is performed
daily.
• Calibration Check button: Allows you to verify LINAC dosimetry calibration. This
procedure is performed daily.
• Calibration Adjustment button: Allows you to adjust the dose calibration in
either cGy or Gy depending on the setting in the iDMS System. This procedure
should be performed at a frequency specified by the local site.
• Exit button: Returns you to the CyberKnife System Menu.
4. When the CyberKnife System is ready, the Warmup button is enabled. Click the
Warmup button in the LINAC menu. The Warmup screen is displayed (see
Figure 106).

Figure 106 Warmup screen
The Warmup screen allows you to enable the high voltage to the LINAC and specify a
desired warmup time to warm up the LINAC. This screen contains the controls described
in Table 20.
Table 20 Controls in Warmup screen
Control Function
HV WAIT/HV ON/HV OFF Displays the status of the LINAC high voltage. When the high
indicator 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 Displays the status of the LINAC X-ray beam. When the yellow
indicator BEAM ON indicator is displayed, dose is being delivered.
High Voltage Control Allows you to enable the high voltage to the LINAC.
section
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
Beam Control section Allows you to specify a desired warmup time 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 buttons: Allows you to start dose delivery to warm up the
LINAC.
Status bar: Displays the percentage of the specified warmup time
(0 to 100%) that has elapsed.
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.
Interlock button Triggers an Interlock. The high voltage is turned off when an
Interlock is triggered.
Exit button Returns you to the LINAC menu.
NOTE: Calibration factors are not applied to beams generated during LINAC
warmup using the Warmup screen. Checks to verify that the dose rate is
within ±10% of the nominal value and that Channels A and B are within 5% of
each other are also not applied when using the Warmup screen.
5. Click the Enable button in the Warmup screen. The high voltage indicator displays
HV WAIT and the Disable button becomes active. A message is displayed prompting
you to turn on the high voltage to the LINAC.
6. On the operator control panel, turn the safety interlock key to the ON position. Then push
the ON button in the HIGH VOLTAGE section of the operator control panel.
The high voltage indicator in the user interface displays HV ON in yellow.
7. Enter the desired warmup time in the Desired Time textbox. Then press <Enter>.
8. Click the Start button in the Warmup screen to start dose delivery. The beam status
indicator displays BEAM ON in yellow. The status bar indicates progress as the desired
dose is reached.
9. When the status bar reaches 100%, the LINAC warmup procedure is complete. Click the
Exit button to return to the LINAC menu.

LINAC Calibration Check

The LINAC Calibration Check screen can be used for the following procedures, among
others:
• To verify the dosimetry calibration of the LINAC after performing a LINAC calibration
adjustment. The LINAC calibration check procedure allows you to verify that the desired
dose is the same as the measured dose. See Step 10 on page 2-174 in “LINAC
Calibration Adjustment” on page 2-170.
• The LINAC output constancy check, including the baseline procedure and the daily
check, as described in “LINAC Output Constancy Check” on page 2-175.
 To perform the LINAC calibration check procedure:
1. Follow the steps described in the previous section (see “Daily LINAC Warmup” on
page 2-161) to turn on equipment power and display the LINAC menu.
2. Click the Calibration Check button in the LINAC menu. The Calibration Check
screen is displayed (see Figure 107).
Figure 107 Calibration Check screen

The Calibration Check screen contains the controls described in Table 21, in addition to the
controls displayed on the Warmup screen (Table 20).
Table 21 Controls in Calibration Check screen
Control Function
Beam Allows you to specify a desired dose to be delivered.

Control
Desired MU textbox: Allows you to enter the desired dose in monitor units
section
(MU).
Start button: Allows you to start dose delivery.
Status bar: Displays the percentage of the desired dose (0 to 100%) that has
been delivered during LINAC calibration check.
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 Displays the date and time of the last LINAC dosimetry calibration procedure.
Calibration
If no calibration is available, an Interlock may occur which prevents or interrupts
display area
beam delivery.
LINAC Displays the maximum deviation in percent (%) away from baseline symmetry
Symmetry as measured in any one segment in the B monitor chamber.
display area
Baseline symmetry is defined during system installation and acceptance
testing.
3. Click the Enable button in the Calibration Check screen. The high-voltage indicator
displays HV WAIT and the Disable button becomes active. A message is displayed
prompting you to turn on the high voltage to the LINAC.
The high-voltage indicator in the user interface displays HV ON in yellow.
5. Enter the desired dose for the calibration check in monitor units (MU) in the Desired
MU textbox.

6. Click the Start button in the Calibration Check screen to start dose delivery. The
beam status indicator displays BEAM ON in yellow. The status bar indicates progress
as the desired dose is reached.
During dose delivery, internal checks are performed to verify the following:
• The difference in dose measured for dose channel A and B does not exceed the
allowed range.
• Elapsed time during dose delivery does not exceed the expected time for the desired
dose to be reached.
• Dose rate fluctuation does not exceed the allowed range.
• The difference in measured signal in any one segment of chamber B compared to the
baseline symmetry value does not exceed the allowed range.
If an internal check fails, an Interlock is triggered and the high voltage turns off.
7. When the status bar reaches 100%, the LINAC calibration check procedure is complete.
and you can compare the delivered dose with the desired dose. If you are satisfied with
the results of the calibration check, click the Exit button to return to the LINAC menu.
If it is necessary to adjust the dosimetry calibration, see “LINAC Calibration Adjustment”
on page 2-170.

LINAC Calibration Adjustment
WARNING: Do not adjust the LINAC calibration unless you are the qualified Medical
Physicist.
NOTE: Use the 60 mm fixed collimator for the LINAC Calibration Adjustment
procedure.
The LINAC calibration adjustment procedure allows you to calibrate and adjust the LINAC
dosimetry system. During the procedure, 5 nominal (desired) dose amounts are delivered. For
each nominal dose, you measure the dose detected using your external dosimetry setup.
A linear best fit is performed using the measured data points to obtain dosimetry calibration
parameters. The gain is determined as the slope of the best fit line which goes through the origin
on a plot of nominal (uncalibrated) monitor units delivered by the system on the Y axis and user-
measured centigray (cGy) values on the X axis (see Figure 108).
Figure 108 LINAC calibration gain
NOTE: The software will not accept measured dose values entered by the
user if the linear best fit deviates from those values by more than 1% (for doses
100 cGy and above) or more than 1 cGy (for doses less than 100 cGy).
The LINAC calibration adjustment procedure is performed on a pre-determined schedule and as

necessary depending on the results of the LINAC calibration check (see “LINAC Calibration
Check” on page 2-167).

 To perform the LINAC calibration adjustment procedure:

1. Follow the steps described in the section “Daily LINAC Warmup” on page 2-161 to turn on
equipment power and display the LINAC menu.
2. Click the Calibration Adjustment button in the LINAC menu. The Calibration
screen is displayed (see Figure 109).
NOTE: All monitor units delivered using the Calibration screen are nominal
(uncalibrated), even if a calibration exists.
Figure 109 Calibration screen
The Calibration screen contains the controls described in Table 22, in addition to controls
displayed in the Warmup screen (Table 20) and Calibration Check screen (Table 21).

Table 22 Controls in Calibration screen
Control Function
Calibration Displays nominal dose values to be delivered for each calibration data point, and
section allows you to enter the corresponding measured dose value.
Nominal MUs fields: Display 5 preset nominal (uncalibrated) dose values (in
monitor units) to be delivered.
Measured cGy/Gy textboxes: Allow 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 Displays dosimetry calibration parameters obtained from a linear best fit to the 5
Model measured data points.
Information
Gain fields: Displays the gain value (slope of the linear best fit to the data
section
points) for dose Channel A and B. The gain is calculated as the slope of the
linear best fit to the data points for Channels A and B. Each channel therefore
has its own calibration. The software will not accept a computed gain value
outside the range 0.8 to 1.4 for the sealed ion chamber.
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. When you accept the values, they are no longer
displayed on the screen.
The fields below the Gain fields display information on calibration modeling
errors. Modelling errors at each point must not be larger than 1% or 1cGy
(whichever is larger). The point with the largest absolute difference may not be
the point with the largest relative difference.
Relative (%) fields: Displays the largest relative error as a percentage for
dose Channel A and B. This value is the largest relative difference between the
measured dose and the linear fit among the five data points (200, 100, 50, 20,
10 MU) that were entered.
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. This
value is the largest absolute difference between the measured dose and the
linear fit among the five data points (200, 100, 50, 20, 10 MU) that were entered.
Calibration Displays the status of the LINAC calibration adjustment procedure (Complete,
Status Not Complete, or Error).
section

NOTE: The best fit routine generates the relationship between delivered
monitor units (MU) vs. delivered dose. Delivered MU is actually shown as
counts which can be viewed on the backup dose counter or retrospectively in
the following file:
/accuray/datafiles/site_df/linac/calibration_history.dat
This file contains all the data from a calibration adjustment. In the file
model.dat located in the same directory, the last two numbers are the gain
values.
3. Click the Enable button in the Calibration screen. The high-voltage indicator displays
HV WAIT and the Disable button becomes active. A message is displayed prompting
you to turn on the high voltage to the LINAC.
The high-voltage indicator in the user interface displays HV ON in yellow. The Start
buttons in the Calibration screen become active.
5. Click the first Start button in the Calibration screen to start dose delivery. The other
Start buttons become inactive. The beam status indicator displays BEAM ON in
yellow. The status bar indicates progress as the nominal dose is delivered.
6. Perform the necessary hand calculations to calculate the measured dose value (in
centigray) that corresponds to the nominal dose that was delivered.
7. Enter the measured dose value in the Measured cGy/Gy textbox for each
corresponding Nominal MUs field.
The Start button changes to a Reset button. The other Start buttons become active. If
a mistake is made entering a value, press Reset to clear the entry and re-enter the
value.
8. Repeat the above steps to enter measured dose values for all 5 nominal doses.
Parameter values in the LINAC Model Information section are updated as data
points are added. To reset a data point, click the Reset button next to it.
When all 5 data points have been obtained, the Calibration Status field displays
Complete. The Accept & Save button becomes active.
If an error occurs after entering a data point, the Calibration Status field displays
Error and a new button is displayed next to it (a button with three dots). Click this button
to display information about the error.

9. When you are satisfied with the results of the LINAC calibration adjustment and ready to
save the new calibration parameters, record the displayed Gain values. Then click the
Accept & Save button.
When you accept the calibration parameters, the values are no longer displayed.
NOTE: Tracking the Gain values can help spot miscalibrations. The values
should always be close to the previous values.
10. After completing the above procedure, perform a LINAC calibration check (see “LINAC
Calibration Check” on page 2-167) to verify that the LINAC calibration is satisfactory.
Check the calibration at two different monitor unit settings. Use one setting in the
100 - 200 MU range and one in a lower clinical MU range.
11. Determine a new baseline for the daily LINAC output constancy check. See “Baseline
LINAC Output Constancy Procedure” on page 2-175.

LINAC Output Constancy Check

• “Baseline LINAC Output Constancy Procedure” on page 2-175
• “Daily LINAC Output Constancy Procedure” on page 2-175
The LINAC output constancy check uses the Calibration Check screen. A baseline procedure
is performed first to determine the conversion factor. Results from future daily LINAC output
constancy checks are compared to the baseline value.
Baseline LINAC Output Constancy Procedure

This procedure is designed to provide a baseline value against which LINAC output constancy is
checked on an ongoing daily basis as part of your regular QA program. For more information on
QA procedures, see Chapter 3, “QA Recommendations and Tests”.
Immediately after performing an absolute dose calibration (as described in “LINAC Calibration
Adjustment” on page 2-170), set up to perform the procedure described in the section below. This
setup should be the same one you will use for the daily LINAC output constancy checks. Deliver a
known number of monitor units (MU) using the Calibration Check screen (see Figure 107 on
page 2-167), not the Warmup screen. Then record the electrometer reading.
Take multiple readings in this configuration. Find the average result, and calculate the conversion
factor between the absolute dose calibration setup (60 mm fixed collimator, 800 mm SAD, and
15 mm depth in water) and the setup used for the daily LINAC output constancy check. This is the
baseline conversion factor.
Daily LINAC Output Constancy Procedure

As you perform future daily LINAC output constancy checks, compare the value to the nominal
calibration value of 1 MU = 1 cGy by using the baseline conversion factor determined above to
calculate the dose at the reference point based on the daily output check readings. Make sure the
value is within a certain tolerance that you have decided is appropriate for your clinical practice.

The following materials are used to establish LINAC output constancy:

• Either of the following:
• (1) Birdcage assembly and a Baldwin-Farmer ion chamber with a 6 MV build-up cap, or
• (2) Tissue equivalent slab phantom with an insert hole and a Baldwin-Farmer ion
chamber.
NOTE: If you choose to use a slab phantom, ensure that the laser position has
not moved with respect to the radiation beam since the baseline
measurement.
• Secondary collimator
• Electrometer
NOTE: There are optional Daily SRS QA devices available that can be used
for output checks as well as for flatness and symmetry checks. If using one of
these devices, follow the manufacturer's recommended procedures for
calibration of the device.
 To determine the LINAC output constancy:

1. Insert the 60 mm secondary collimator.
2. If you are using the birdcage with a Baldwin-Farmer ion chamber with a 6 MV build-up
cap, do the following:
• Attach the birdcage to the collimator housing.
• Mount the Baldwin-Farmer ion chamber in the birdcage detector mount so that the
center of the chamber is aligned with the laser. The chamber is then fixed to 800 mm
SAD.
NOTE: When you mount the Baldwin-Farmer chamber in the birdcage

detector mount, ensure that the detector mount is attached to the top side of
the bottom flange of the birdcage.
The correct location for mounting the Baldwin-Farmer chamber is on the

opposite side of the flange from the mounting location for a diode detector.
• Put a 6 MV buildup cap on the Baldwin-Farmer ion chamber.

If you are using a tissue equivalent slab phantom with a Baldwin-Farmer ion chamber, set
up the slab phantom at a known distance from the LINAC using the front distance pointer
and insert the ion chamber.

3. Attach the electrometer to the chamber.

4. Record the temperature and pressure readings inside the Treatment Room.
5. Turn on the electrometer and verify the correct bias voltage.
6. Log onto the treatment delivery computer and access Physics mode.
7. Warm up the LINAC as explained in “Daily LINAC Warmup” on page 2-161.
• If you have a sealed ion chamber: In the Warmup screen, enter 2 minutes to warm
up the LINAC.
8. Take several Baldwin-Farmer ion chamber readings for 200 MU delivered using the
Calibration Check screen (see Figure 107 on page 2-167).
9. Calculate the temperature and pressure correction factor (CT,P).
10. Average the ion chamber readings. Apply the temperature and pressure correction factor
to the averaged reading and then use the baseline conversion factor (determined in
“Baseline LINAC Output Constancy Procedure” on page 2-175) to calculate the
measured dose at the calibration point. Compare this value to the nominal calibration of
1 MU = 1 cGy. Verify that the LINAC output is within the clinically acceptable range.
11. (Optional) To set up a quick energy check, insert 5 cm of tissue equivalent slab phantom
or 2 cm of aluminum into the beam upstream of the Baldwin-Farmer ion chamber and set
the LINAC to deliver 200 MU.

Import Phantom CT Image Studies

 To import phantom CT image studies:
1. Acquire 3 scans of the CyberKnife System head and neck phantom with films loaded in
the ball cubes.
2. Acquire a scan of a slab phantom with ion chamber insert and/or film to be used for dose
verification tests. If an ion chamber will be used, it should be in place for the CT scan. If
film will be used, include film for the CT scan.
3. Acquire a scan of the AQA phantom with the plastic ball in the phantom.
4. The head and neck phantom and AQA phantom are provided with the CyberKnife
System. A scan of an electron density phantom should be acquired for each CT scanner
that will be used for CyberKnife System patient CT image studies.
5. Use the Image Review and Import application of the iDMS Data Management System to
import CT image studies and associate them with a “Phantom” patient record. Import at
least one of the CT scans of the head and neck phantom as a "Patient" patient record.
For information on the Image Review and Import application, see the Data Management
Manual.
6. Load the CT image studies on the Accuray Precision System.
7. On the Accuray Precision System, use the Ruler tool on the global tool bar to verify the
geometric accuracy of CT distance scales visible on the CT image with the known
dimensions of the phantom.
8. Generate custom CT density models associated with each CT scanner that you use (see
“CT Density Models” on page 2-179).
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CT Density Models
The Accuray Precision System provides several preset CT density models for use during
treatment planning. Review the preset models for clinical use. The models labeled Water/Air,
Lung Standard, and Body Standard cannot be modified and cannot be used for patient
treatment delivery; all models labeled Custom Model can be modified. Provided you have the
necessary access, you can enter custom CT density models and save as a default either for a
patient or globally.
To create, change, and apply CT density models, see the Treatment Planning Manual.
NOTE: The CT density has a significant influence on the dose delivered to the
patient. During treatment plan review QA, confirm that the appropriate CT
density model was used.
WARNING: If there are errors in the CT density model, they will result in incorrect dose
calculations. For the most accurate CT density models, use a standard electron density
phantom to derive the CT density curve for each CT scanner used with your CyberKnife
System.
Tissue Density Model Selection

The effective depth inhomogeneity correction algorithm is used for Ray-Tracing and Finite Size
Pencil Beam (FSPB) dose calculation. The effective depth is used during the lookup of TPR and
OCR data. The Accuray Precision System provides several options when applying tissue density
corrections for generating a treatment plan.
The Accuray Precision System provides 3 sample CT density models:
• Water/Air
• Lung Standard
• Body Standard
NOTE: If a patient treatment plan uses a sample CT density model, the plan
cannot be saved as deliverable.
1075879-ENG A CT Density Models |2-179

Water/Air
In the Accuray Precision System CT density model labeled Water/Air, all HU -800 or greater are
assigned a relative electron density of 1. All HU -801 or less are assigned a density of 0.
Therefore, you may observe an effective depth less than the actual for some of the beams.
Lung Standard
The HU can be selected to model areas that will be treated as lung tissue. Generally, these areas
have densities that are between those of air and water. The algorithm determines which voxels
have HU between 2 user-defined parameters. The default range is -800 to -200. Voxels that lie
within this range have density values set by the user that may differ from 0.0 and 1.0.
The default setting is the equivalent depth of 0.3 mm depth per 1 mm of beam transmission. For
treatment plans in the thoracic region of the body, this method generally yields lower dose
calculation errors than when treating all tissue as either water or air.
The dose calculation model does not consider effects related to electron disequilibrium, for
example, backscatter or sidescatter at soft-tissue-to-bone interfaces.
Body Standard
This density model is designed with 3 piece-wise linear components to model attenuation by 3
different types of matter: air, soft tissue, and bone. Voxels with a HU less than -800 are treated as
air, that is, they have no attenuation associated with them. Voxels with HU from -800 to 200 are
modeled as having linearly increasing relative density from 0.2 to 1.2, representing soft tissue of
varying density. Voxels with HU from 200 to 1500 have linearly increasing density from 1.2 to
1.77, representing bone. Voxels with intensity greater than 1500 are assigned a relative density of
1.77.
Custom CT Density Models
2-180 | CT Density Models 1075879-ENG A

Use an electron density phantom to measure the HU per known density for the treatment planning
CT scanner that is used to scan patients for treatment with the CyberKnife System. The
measured density values can be entered into a model for patient planning. Density Models can be
set or modified from the Home page using Planning Settings > Planning Parameters. Density
models cannot be edited while creating a plan or when a plan is loaded. The relative electron
density models are used for Ray-Tracing and Finite Size Pencil Beam (FSPB) dose calculation. If
you have the Monte Carlo Dose Calculation option, you must also specify mass density models in
addition to relative electron density models. Acquire reference information on both the relative
electron and mass densities for any CT density phantom you use to generate custom CT density
models. In order to use density overrides, you must have a mass density table and a relative
electron density table. For more information on density overrides, see the Treatment Planning
Manual.
WARNING: When evaluating your treatment plan, carefully consider the effects that CT
artifacts may have upon your dose calculation. The depth calculation can be inaccurate in
the presence of a significant CT artifact. Low HU streaks into the patient may lead to
underestimation of depth, and high HU streaks outside the patient or into lung/air cavities
may lead to overestimation of depth.
NOTE: For relative electron density models, the Accuray Precision System
forces the relative electron density values to be zero for HU less than -801.
Acquisition of correct HU-to-density curves is critical to have accurate dose calculations. The
Accuray Precision System uses two different types of density curves: one for the Ray-Tracing
dose calculation algorithm, and another for the Monte Carlo Dose Calculation algorithm.
The Ray-Tracing dose calculation algorithm requires a conversion from HU (-1024...31743) to
relative electron density (1.0 is water density). The Monte Carlo Dose Calculation algorithm
requires a conversion from HU to mass density (1.0 g/cm3 is water density).
The relative electron density curve should have a zero density for -1000 HU. The mass density
curve should have a density of 0.001 g/cm3 for -1000 HU. The remainder of the curve should be
entered based upon measurements of HU for materials of known relative electron and mass
densities. Phantoms to facilitate this process are listed in “Customer Site QA Equipment” on
page 2-6. It is important for a calibration phantom to include real water as a calibration point, and
that you incorporate this point in the calibration curves. There are some references that address
the uncertainties associated with using tissue mimicking materials for HU-to-density calibration
[Ref. 13, Ref. 14] and the impact of these uncertainties on patient dose calculation and plastic
phantom dose calculations. It is recommended to consult these resources before building the
appropriate density model.
NOTE: The Accuray Precision System automatically extends the last value
entered on the curve to cover any HU outside the user entered range. To
control this behavior directly, specify density ranges which cover the range of
HU.
1075879-ENG A CT Density Models |2-181

Accuray provides several sample curves that can be used as guidance for the creation of your
custom density curves. Some users may prefer to also create and use calibration curves for
water/air-only calculations. Accuray provides a sample calibration curve of this type for reference.
All example curves may not be appropriate for your CT scanner. As with any factor that impacts
dose calculation, quality assurance checks should be conducted to ensure that the density
calibration is correct for a particular CT scanner.
WARNING: Due to scanner artifacts, some CT scanners assign relatively high -700 to -600
HU in the air space outside the patient that occupies the remainder of the scan. To address
this, put a low density (such as zero) point in the range of these intermediate HU.
Otherwise, these HU can artificially attenuate the radiation beam resulting in erroneous
calculations.
The Accuray Precision System supports both conventional 12-bit CT scans (4096 discrete CT
values) and newer 16-bit CT scans (65536 discrete CT values). For 16-bit CT scans, density
curves can be entered only up to a maximum value of 31743. The value of the density curve at
31743 is therefore used for all HU above 31743.
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CT Geometric Accuracy Check

Acquire a CT image study with BB markers on a phantom such as the Beekley SPOTS® or
fiducials placed a known physical distance. (See Figure 110.)
A slab phantom is easier to use because it has regular geometry. However, you can use any
phantom that is large enough. In addition, the calibrated Baldwin-Farmer type chamber used for
the absolute dose calibration can be included during the scan.
NOTE: The Ball-cube film cassette is too small to provide accurate results.
Figure 110 Stereotactic Dose Verification Phantom from

Standard Imaging, Inc.
To confirm CT geometric accuracy, the following materials are used:

• Beekley SPOTS® or BBs
• Slab phantom
1075879-ENG A CT Geometric Accuracy Check |2-183

 To confirm the geometric accuracy of a CT scanner:

1. Place Beekley SPOTS® or BBs on the surface of a slab phantom.
2. Acquire a CT scan of the phantom with the fiducials. Use the thinnest slice thickness
available and the smallest Field of View.
3. Import the CT image study as a “Phantom”.
4. Identify the location using treatment planning system software.
5. On the Align step of the Plan task, select the Fiducials step. Select the Auto
Center checkbox. Double-click on each and record the X, Y, Z coordinates.
6. Click the Ruler tool on the global tool bar and measure the distance between the fiducials.
7. Calculate the separation of the fiducials from the position table using the Equation (3)
distance formula. Use at least one pair of fiducials in each direction (Anterior/Posterior,
Left/Right, and Inferior/Superior).
2 2 2 (3)
D12 =  X1 – X2  +  Y1 – Y2  +  Z1 – Z2 
8. From the diagram, locate the pairs you are measuring and enter the known distances
between them.
9. Compare actual and CT image distances as measured with the global measuring tool.
10. Verify that the actual and CT distances agree within 1 mm.
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Treatment Delivery Targeting Accuracy

The End-to-End (E2E) test is a targeting test designed to demonstrate the geometric targeting
accuracy of the CyberKnife System throughout all phases of treatment planning and treatment
delivery. Targeting accuracy is quantified based on radiation delivered to a Ball-cube phantom.
Dose distributions are recorded on films inserted into the Ball-cube and analyzed.
During commissioning of the CyberKnife System, the E2E test should be performed for each
tracking mode at the site and the results documented. The E2E test should be performed at least
monthly thereafter. Tracking modes include the Skull Tracking System, the Fiducial Tracking
System, the Spine Tracking Supine System, the Lung Tracking with Respiratory Modeling
System, and the Fiducial Tracking with Respiratory Modeling System.
For detailed information on the E2E test procedure, see Chapter 4, "AQA, E2E, MLC, and Plan
QA Tests". For detailed schedule information, see the CyberKnife® Robotic Radiosurgery System
QA Log Book.
1075879-ENG A Treatment Delivery Targeting Accuracy |2-185

Single Beam Calculation QA Test

• “Performing a Single Beam Calculation QA Test” on page 2-186
• “Reading the Exported Dose Data” on page 2-188
• “Reviewing the Dose Calculation in the Accuray Precision System” on page 2-193
• “Single Beam Calculation QA Test Hints and Tips” on page 2-195
The purpose of the single beam calculation QA test is to check the dose calculation algorithm in
the Accuray Precision System. To perform this procedure, the CyberKnife System should have
the single beam calculation QA path installed. Following import of new or changed beam data,
perform a dose calculation check using the single beam calculation QA test. Repeat this test
every time you make a change to the beam data.
For more information on generating a single beam QA plan, including a single beam QA plan for
the Multileaf Collimator that can be used to perform QA for individual MLC apertures, see the Plan
QA section in Chapter 4, "AQA, E2E, MLC, and Plan QA Tests".
Performing a Single Beam Calculation QA Test

The following materials are used to perform a single beam calculation QA test:
• Slab phantom
• CT scanner
 To perform a single beam calculation QA test:
1. Acquire a CT scan of the phantom.
This test is performed with a slab phantom, leveled before performing the scan. Use the
smallest field of view.
2. Import the CT image study as a “Phantom”.
3. On the Accuray Precision System, select the Phantom CT and load images for a new
single beam plan.
4. On the Setup task > Machine step, set the number of fractions to 1.
5. Make the following selections:
• Treatment Anatomy: QA anatomy (for example, QA iris-fixed)
• Template Path Set: Single Beam
• Synchrony Method: Fiducial
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6. Select a point on the phantom surface as the location of the fiducial.

This is a virtual fiducial, so ensure that the Auto Center checkbox is cleared.
NOTE: For a PDD QA test, place the virtual fiducial on the anterior surface of
the phantom. If the OCR measurements were acquired at fixed SAD, then
place the virtual fiducial at the depth at which you will examine the Accuray
Precision System single beam OCR dose calculation.
7. On the Setup task > Align step, confirm the CT center.
8. On the Plan task > Settings step, choose a density model.
Air/Water is acceptable for water equivalent phantoms.
9. Position the dose calculation box so that its anterior face is flush with the anterior surface
of the phantom.
10. In the coronal view, center the dose calculation box on the beam axis.
11. On the Plan task > Isocentric step, place the isocenter as follows:
• PDD: At the anterior surface of the phantom.
• OCR: At the anterior surface of the phantom if you wish to compare Accuray
Precision System dose calculations with OCR measurements acquired at fixed SSD.
• At the depth at which you will examine the Accuray Precision System OCR dose
calculation if your OCR measurements were acquired at fixed SAD.
12. Select a collimator size.
13. On the Evaluate task, prescribe a dose and perform a high-resolution dose calculation.
14. Click the Export DICOM Data icon on the global tool bar.
15. On the Export DICOM Data dialog box, select RT Dose and Dose Grid.
16. Select a destination for the file using the Select Remote Machine dropdown menu
and press the Export button. You can also add a machine, or you can use the Select
Local File Path option and then browse to select a location.
1075879-ENG A Single Beam Calculation QA Test |2-187

Reading the Exported Dose Data

You can read the exported RT Dose data using a DICOM-compliant reader software application.
The following procedure provides an example of importing data using ImageJ.
NOTE: The following example procedure describes the use of software and/or
hardware products that are not developed by Accuray and which do not have
a specific relationship to the CyberKnife System. This procedure describes
one method for performing the task. Other, equally effective, methods might
exist. The Medical Physicist is responsible for determining which product and
methodology to use for this task.
Accuray assumes no responsibility for the accuracy of this procedure with

 To read exported dose data:

1. For PDD analyses, select Edit > Options > Profile Plot Options on the ImageJ
Edit menu.
The Profile Plot Options menu is displayed on the desktop.
2. Ensure that the Vertical Profile and List Values checkboxes are selected and then
click OK.
3. On the ImageJ control window, select the Rectangular selections marquee tool
(see Figure 111).
Figure 111 Rectangular marquee tool in the ImageJ main

window

The Rectangular selections marquee tool enables you to select a portion of the 2D
image for analysis.
NOTE: For OCR analysis, ensure the Vertical Profile checkbox is cleared.
4. Select a region of interest for analysis, as follows:
• PDD: Select the central axial portion of the data (see Figure 112).
• OCR: Select a horizontal cross-section.
Figure 112 Central vertical portion of imported dose

calculation selected for PDD analysis
5. Use the ImageJ Analyze > Plot Profile menu to extract the values and display the
plot (see Figure 113).

Figure 113 Extracting OCR data from the DICOM file
Note how the rectangular selection tool was used to select a horizontal slice of the image
at a depth of several pixels below the surface.)
6. Save the data in the ImageJ Plot Values table as a text file. It can be imported into a
spreadsheet or other analysis package. See Figure 114 and Figure 115 for examples of
the measured PDD and OCR values compared to Accuray Precision System calculations
using Microsoft Excel.

Calculated vs. Example PDD
Figure 114 Overlay of measured PDD data with calculated

single beam dose calculation

Figure 115 Overlay of OCR data with single beam dose

calculation

Reviewing the Dose Calculation in the Accuray

Precision System
You can display and review the dose calculation at a given point from within the Accuray Precision
System using the point dose tool. You can also measure the PDD using the Measure image tool
(the ruler tool) provided by the Accuray Precision System.
 To display the dose calculation at a given point using the point dose tool:
• Click (left mouse click) on a point in the image (see Figure 116).
Figure 116 Measuring dose at a point using the point dose

tool) (magnified view)

 To measure the calculated PDD:

• Use the Measure image tool (the ruler tool) on the Global tool bar of the Accuray
Precision System (see Figure 117).
Figure 117 Determining PDD calculation using the Measure

image (ruler) tool

Single Beam Calculation QA Test Hints and Tips

You can read various PDD and OCR point dose values from the isodose lines on the Accuray
Precision System screen.
Dose Box Positioning

For SSD-based QA procedures, if you have difficulty aligning the anterior face of the dose grid
box/dose calculation box with the anterior face of the phantom CT in the Accuray Precision
System, use the Ruler tool on the global tool bar to measure the offset between the dose grid box/
dose calculation box and the phantom surface. Then, adjust your calculations as necessary
during the analysis. Also, resizing the dose box a single step larger or smaller along the Anterior/
Posterior direction prior to repositioning the dose grid box/dose calculation box may help achieve
better alignment with the phantom surface.
NOTE: The exported data file will contain the OCR data at a single depth in
the phantom. Therefore, in order to examine the dose profile at different
depths, you will need to keep track of several data files. If the dose box is not
sized to contain only a single row or column of voxels, use the ImageJ
rectangular selection tool to select a specific row or column of data within the
exported data file. However, if your OCR measurements were acquired at
fixed SAD, you will need to generate several different Accuray Precision
System dose calculations because the isocenter must be placed at each of the
depths you will examine.
Inhomogeneous Phantoms
Using Excel, Matlab, or another numerical analysis package, you can examine single-beam depth
dose profiles in inhomogeneous phantoms.
A phantom comprised of several different slabs of materials can be used to compare the Accuray
Precision System PDD calculation to a modified PDD curve based on measured PDD values
acquired with a water phantom. A mathematical model of the effective depth can be calculated
based upon the ratios (compared with water) of densities of the various slabs of material.
An example of an inhomogeneous slab phantom is shown in Figure 118. The composition of the
slab phantom is shown in Table 23.

Figure 118 CT scan of phantom comprised of several

different tissue equivalent plastic slabs
Table 23 Material densities
Material Density, 
1 cm water 1.0
2.5 cm bone 1.45
2 cm water 1.0
5.1 cm lung 0.3
14 cm water 1.0
A custom density model was defined for the Accuray Precision System based on the known
composition of the phantom. For a comparison of the Accuray Precision System dose calculation
and a modified PDD based on effective (density-compensated) depth in the phantom, see
Figure 119.

Figure 119 Percent Depth Dose profile for multi-density

phantom
Figure 119 depicts the relationship between the Accuray Precision System single beam dose
calculation and an independent calculation based on a mathematical model using known material
densities of the phantom and PDD measurement data acquired with a water phantom.

Dose Delivery Verification Check

The dose delivery verification check is performed to confirm treatment delivery dose accuracy.
Create a treatment plan to a phantom with ion chamber insert. Target the beams isocentrically to
the ion chamber. Deliver the treatment to the phantom and verify that the total dose measured is
within an acceptable range from the planned dose. Perform hand calculations for several of the
beams and confirm that the Monitor Units of beam correspond to the delivered dose.
The overall treatment system performance relative to dose as well as the absolute dose
calibration can be verified by planning and delivering a treatment plan of known prescription dose
and isodose shape to a calibrated ion chamber. The electrometer reading corrected for the
temperature and pressure should correspond within 5% of the expected reading relative to the
actual prescribed dose. Once the plan has been delivered, it can be repeated with a regular
frequency to determine the dose delivery accuracy of the CyberKnife System.
Patient dosimetry can be performed if a calibrated micro chamber is available for use. Plans can
be generated to test the small collimators and smaller, more structured and/or irregular targets.
In addition, plan QA can be used to recalculate a patient plan to a phantom of choice where both
the patient absolute dose and relative dose distribution can be verified using film. For information
on the plan QA procedure, see Chapter 4, “AQA, E2E, MLC, and Plan QA Tests”.
The following materials are used during this procedure:
• Tissue equivalent phantom with ion chamber insert
• Calibrated ion chamber
 To create a plan for a phantom with ion chamber:
1. On the Accuray Precision System, create a plan for the phantom with the calibrated ion
chamber in place.
2. Contour around the active volume of the chamber and create a Target VOI type.
3. In the Sequential step, click VOI Operations or Auto-shells to create a shell
structure with an isotropic volume of 8 mm.
NOTE: Choose a collimator that is appropriately matched to the size of the ion
chamber.
4. Develop a plan so that the 98% dose covers the chamber entirely.
5. Save the plan.
2-198 | Dose Delivery Verification Check 1075879-ENG A

6. Set up the phantom so that the ion chamber can be treated.

7. Deliver the plan and measure the delivered dose.
8. Verified that the measured dose and the calculated dose are acceptable.
9. Perform a hand calculation of several beams to develop familiarity with the hand
calculation Monitor Unit QA check that is performed for patient treatment plan delivery.
NOTE: The Accuray Precision System CT Density Model labeled Body

Standard actually treats any HU less than -800 as a zero value. Therefore,
you may note an effective depth less than the actual for some of the beams.
DeltaMan Adjustment
The treatment robot and imaging subsystems are independently calibrated to a single point, the
isocrystal or imaging center. The DeltaMan adjustment is a correction that accounts for any
systematic translational offset between the 2 subsystems. This correction is a part of the system
calibration files that reside on the treatment delivery computer of the CyberKnife System.
The DeltaMan correction is not relevant to the specific calibration of either independent
subsystem (treatment robot path calibration or imaging calibration), but is applied when the 2
subsystems are used together, such as during treatment simulation or treatment delivery. Accuray
service personnel calculate the DeltaMan adjustment using the results of multiple E2E tests
performed on the CyberKnife System and then save the appropriate correction factors to the
CyberKnife System server.
NOTE: Changes to DeltaMan do not result in changes to a plan’s status; for

example, approved deliverable plans being rendered undeliverable or
unapproved.
Recommissioning the LINAC

If you replace the LINAC, you then must acquire data for the Ray-Tracing dose calculation
algorithm, the Monte Carlo Dose calculation, and the FSPB calculation. In addition, replacing a
secondary fixed collimator or other changes that affect the radiation beam may require at least
spot checks of the beam to ensure that the current beam data is still applicable.
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Sample Beam Characteristics

This section provides user information on absorbed dose characteristics.
NOTE: All data presented in this section is for illustrative purposes only and
represents measurements made on a single CyberKnife System, except
where ranges or specifications are stated. This data should not be used for any
treatment planning dose calculations. A larger set of sample beam data,
including different collimation types and a wider range of field sizes, is included
with the Accuray Precision System, and system-specific data is measured
during acceptance testing and commissioning.
Table 24 Sample depth dose beam characteristics

Parameter Beam Collimation
1 cm fixed 6 cm fixed circular 1.5 cm x 10 cm x 11.5 cm x

circular reference field 1.5 cm MLC 10 cm MLC 10 cm MLC
Depth of 100% dose 1.35 cm 1.65 cm 1.45 cm 1.65 cm 1.65 cm

(80 cm SSD)
Depth of 80% dose 4.74 cm 5.93 cm 5.07 cm 6.28 cm N/A
(80 cm SSD)
Depth of 50% dose 11.35 cm 13.34 cm 11.78 cm 14.31 cm N/A
(80 cm SSD)
TPR 20cm / TPR 10 0.615 0.642 0.624 0.663 N/A
cm (80cm SAD)
Dsurface at 0 cm 6.2% 11.4% 7.8% 14.6% 14.1%
(80 cm SSD)
Dsurface at 0.5 mm
(linearly interpolated) 25.8% 27% 25.3% 29.7% 29.9%
(80 cm SSD)
This tables satisfies IEC 60976:2007 8.1.1 and 8.1.2 specifications for 6 cm fixed reference
field: Dmax (depth of 100% dose) of 15 mm +/-2 and for TPR20/10 of 0.62 - 0.67.
TPR20/10, flatness, and symmetry were measured on one system at 2 MU. For this small MU,
TPR was measured with an ion chamber in solid water, while flatness and symmetry were
measured with diode array for the 6 cm fixed collimator, 10 cm x 10.01 cm MLC, and 11.5 cm x
10.01 cm MLC field sizes. Relative to 200 MU, the 2 MU TPR20/10 varied by less than 0.2% on
average. For the 6 cm fixed collimator, 10 cm x 10.01 cm MLC, and 11.5 cm x 10.01 cm MLC field
sizes relative to 200 MU, the 2 MU flatness and symmetry measurements varied less than 1% on
average.
Figure 120 shows sample depth dose data for these fields measured at 80 cm SSD. These
curves are measured using a stereotactic diode with inherent build-up of ~1 mm. Figure 121
2-200 | Sample Beam Characteristics 1075879-ENG A

shows a close-up of the build-up region of these depth dose curves measured using a parallel
plate ionization chamber (PTW Advanced Markus) with a thin entrance window allowing more
accurate measurement of the surface dose.
Figure 120 Depth-dose curves measured for a 1 cm fixed

collimator (red), 6 cm fixed collimator (green), 1.54 cm x 1.54
cm MLC (blue), and 10.0 cm x 10.01 cm MLC (yellow).
Measured with a stereotactic diode at 80 cm SSD.
1075879-ENG A Sample Beam Characteristics |2-201

Figure 121 Surface depth dose measurements performed

using a parallel plate ionization chamber
Figure 122 to Figure 129 show isodose distributions for these sample beams. Note that while the
maximum dose is expected to be very close to central axis, doses up to 0.5% higher (i.e. 100.5%
of the central axis dose) can be measured just off-axis. Beam profiles in the X and Y directions
are constant with robot orientation to ≤2% within the beam (with the maximum open field size, the
OCR at a point 2/3rd of the field size away from central axis varies by ≤1.02 (Max OCR/Min OCR)
over all treatment robot orientations).

Figure 122 Coronal isodose chart for the 60 mm fixed

collimator at 800 mm SSD and 50 mm depth

Figure 123 Axial isodose chart for the 60 mm fixed

collimator at 800 mm SSD

Figure 124 Coronal isodose chart for the 10mm

fixed collimator at 800 mm SSD and 50 mm depth

Figure 125 Axial isodose chart for the 10mm fixed

collimator at 800 mm SSD and 50 mm depth

Figure 126 Coronal isodose chart for the 1.5 cm x 1.5 cm

MLC field at 800 mm SSD and 50 mm depth.

Figure 127 Axial isodose chart for the 1.5 cm x 1.5 cm fixed
collimator at 800 mm SSD

Figure 128 Coronal isodose chart for the 10 cm x 10 cm

MLC field at 800 mm SSD and 50 mm depth.

Figure 129 Axial isodose chart for the 10 cm x 10 cm MLC

field at 800 mm SSD
The CyberKnife System beam penumbra specifications are shown in Table 25. Penumbra is
defined as distance between 80% and 20% of central axis dose, at 800 mm SAD, and a depth of
50 mm. Note that this definition gives an artificially large measurement of the width of the edge
penumbra for large CyberKnife System fields because the primary beam is not flattened. For
example, the measured penumbra for the largest MLC field of 115 mm x 100.1 mm on one
representative CyberKnife System is 15.5 mm in X and 10.3 mm in Y.
Table 25 Beam Penumbra

Collimator Type Field Size / Direction System Requirement
Fixed and Iris 10 mm / radial 3.5 mm
MLC 10 mm x 10 mm / X & Y 3.5 mm
MLC 100 mm x 100 mm / X 12 mm
MLC 100 mm x 100 mm / Y 20 mm
Table 26 describes some of the performance characteristics outlined in IEC 60976 (2007) in the
reference conditions of 60 mm fixed collimator at 800 mm SAD and 15 mm depth (where 1 cGy =
1 MU) except where otherwise stated. System-level requirements for these parameters are
defined in the CyberKnife System Acceptance Test Procedures or Technical Specifications. In

addition, sample results measured on a single CyberKnife System are stated here.
Table 26 Performance Characteristics

IEC 60976:2007 clause
IEC 60977 (2008) Suggested Value Sample Result
name (Clause #)
Reproducibility (7.2) ±0.5% at 200MU Coefficient of variation =
0.05% at 200 MU*
Proportionality (7.3) ±1% or ±1MU whichever is larger (range <0.1% or ≤0.1MU whichever
100 MU-1000MU) and ±5% or ±1MU is greater, at 2MU - 1000MU
whichever is larger (range 1MU - 100MU)
Dependence on ±2% or ±2MU whichever is larger ≤0.4% or <0.1MU whichever
angular positions (7.4) is greater, at 2MU - 1000MU
Stability after high <2% 0.23%
absorbed dose (7.7.1)
Stability throughout the <2% <0.2%
day (7.72)
Stability throughout the <2% ≤0.2%

week (7.73)
Dependence on shape No suggested value given by IEC <2%
of radiation field (7.6)**
Deviation of dose <3% <2%
distribution with
angular position (9.1.2)
***
*Coefficient of variation for values other than 200MU are < 1% at 3MU - 1000MU and 1.1% at
2MU.
**This sample data shows the maximum variation in output factor measured for rectangular MLC
fields after reversing the X and Y aperture dimensions (for example, 46.2 mm x 100.1 mm vs. 100
mm x 46.2 mm.
***This sample data was collected using a 115mm x 100.1mm MLC aperture with point chamber
measurements at 800mm SAD over the 6 LINAC orientations described below. The result
specified in the table covers down to 2 MU.
The tests that depend on robot orientation (IEC 60976 7.4 and 9.1.2) utilize the following LINAC
positions: beam down, beam up, X1 side down, X2 side down, robot plate up, and robot plate
down. See Figure 130.

Figure 130 Various LINAC orientations used during robot

orientation tests
The field sizes stated in this guide, other CyberKnife System documentation, and shown on the
control system are geometric projections of the nominal collimator aperture from the X-ray source
to 800 mm SAD. The typical correspondence of these field sizes with the measured radiation
beam full width at half-maximum (FWHM) for MLC and Iris collimators is shown in Figure 131.
Although data is shown at 15mm depth, it is also representative of other depths.

Figure 131 Sample data showing nominal field size vs.

measured radiation FWHM at 800mm SAD and 15mm depth
for Iris and MLC
There is a clear trend for measured FWHM to be smaller than nominal field sizes to an increasing
degree with increasing field size. This is a consequence of the non-flat primary beam. Also, with
the MLC there is a larger offset between measured FWHM and nominal field sizes in the Y
direction than in the X direction. This is because the nominal field size is calculated based on the
MLC aperture before the MLC tilt of 0.5 degrees is applied (the tilt is to minimize inter-leaf
leakage), which reduces the projected aperture. All of these effects are included in the dose
calculation algorithms. For Iris, this is achieved by using OCR data measured at each aperture
size. For MLC, it is achieved by using measurements of the uncollimated primary beam to model
the non-flatness, and applying a geometric reduction to each Y-aperture to model the effect of
MLC tilt. For more information on the Multileaf Collimator, see [Ref. 15].
The corresponding data for fixed collimators is shown in Figure 132. Although data is shown at
15mm depth, it is also representative of other depths.

Figure 132 Sample data showing nominal field sizes vs.

measured radiation FWHM at 800mm SAD and 15mm depth
for fixed collimators
The trend here is reversed from the Iris Collimator and MLC, with measured FWHM being larger
than the nominal field size to a degree that increases with field size. This is because the fixed
collimators are focused at a point slightly behind the physical X-ray target, meaning that the
geometric projection is larger than the nominal field size. This effect is included in dose
calculation by using OCR data measured with each fixed collimator.

References
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2-216 | References 1075879-ENG A

Chapter 3: Quality Assurance
Recommendations and
Tests
Introduction
Certain aspects of quality assurance (QA) for the CyberKnife System are unique. This chapter
describes QA tests that may be unfamiliar to new users of the CyberKnife System.
• “QA Program and Documentation” on page 3-3
• “QA Tests and Schedules” on page 3-4
• “Daily QA Tests” on page 3-5
• “Monthly QA Tests” on page 3-15
• “Quarterly QA Tests” on page 3-20
• “Annual Testing Requirements” on page 3-21
• “Unscheduled Tests” on page 3-23

The CyberKnife System owner is responsible for ensuring that the system is used in accordance
with applicable regulations governing the operation of medical radiation linear accelerator (LINAC)
systems.
Typically, a qualified Medical Physicist performs all QA of the CyberKnife System, the LINAC, and
the Treatment Planning System. The Medical Physicist also maintains proper documentation of
QA procedures.
For detailed QA scheduling information, see the CyberKnife® Robotic Radiosurgery System QA
Log Book provided by Accuray.
For additional information on the CyberKnife System, contact Accuray Customer Support.
3-2 | Introduction 1075879-ENG A

Physics Essentials Guide Chapter 3: Quality Assurance Recommendations and Tests
QA Program and Documentation

To minimize the risk inherent to the use of medical radiation and robotic radiosurgery, each
CyberKnife System site must develop and implement a robust QA program of measuring and
maintaining system performance. Each site must maintain detailed documentation of the QA
program.
CyberKnife System site Medical Physicists play a pivotal role in QA by providing reliable
CyberKnife System performance, including high uptime and safe treatment delivery. Furthermore,
a well documented QA program minimizes risk for the human use of medical radiation and robotic
radiosurgery.
CyberKnife System QA provides benefits such as the following:
• Reliability: Easier to maintain the system in optimal condition over the life of the
equipment.
• Uptime: Reduces the time to troubleshoot and repair problems.
• Safety: Ensures accurate prescription delivery to the target.
• Risk reduction: Documentation satisfies regulatory and professional standards of
practice.
NOTE: If you would like to conduct an independent dose accuracy verification

test, you may perform a treatment delivery using the phantoms provided by the
Radiological Physics Center (RPC) at the MD Anderson Cancer Center.
1075879-ENG A QA Program and Documentation |3-3

QA Tests and Schedules

Accuray has developed several QA methodologies to ensure high quality CyberKnife System
treatments and maximum patient safety using these new technologies.
The CyberKnife System QA program is designed to be incorporated into the Radiation Safety and
Quality Management Programs of your institution. Accuray recommends that you present the
results of daily, monthly, quarterly, and annual testing with the Quarterly and Annual Radiation
Safety Reports so that the results are available for administrative oversight.
The QA test frequencies recommended in the CyberKnife® Robotic Radiosurgery System QA Log
Book are considered to be the essential minimum. Conventional, additional, or equivalent tests
may also be performed as necessary. An example of this would be patient-specific dosimetry
verification.
As traditionally practiced, QA tests are used to document and ensure the ongoing correct
performance of any medical radiation device and also to identify noncompliance with defined
performance criteria as soon as it might be manifested. This practice also applies to treatment
planning and treatment delivery of the CyberKnife System.
To support your comprehensive QA program, Accuray Customer Support Engineers will request
your QA records to determine the current performance status of your system. Accuray Customer
Support Engineers will provide a written record of all work completed and any relevant testing they
have performed to maintain optimal compliance with the CyberKnife System specifications.
3-4 | QA Tests and Schedules 1075879-ENG A

Daily QA Tests
This section describes QA test procedures that should be performed at least daily. For more
detailed information on QA test schedules and logging your results, see the CyberKnife® Robotic
Radiosurgery System QA Log Book.
• “Safety Interlocks Check” on page 3-5
• “System Status Check” on page 3-7
• “Laser Alignment Check Application” on page 3-8
• “Treatment Robot Perch Position Laser Check” on page 3-13
• “X-ray Tube Warmup” on page 3-13
• “LINAC Output Constancy Check” on page 3-14
• “Automated Quality Assurance (AQA) Test” on page 3-14
• “Visual Inspection of TG-50 Abutted Rectangular Field Test” on page 3-14
Safety Interlocks Check
WARNING: When testing the Treatment Room door interlock, take care to avoid exposure
to radiation if the beam does not terminate when the Treatment Room door is opened.
Otherwise, injury or death can occur.
At a minimum, check the Treatment Door interlock and the operator control panel E-Stop button
daily.
 To check the door interlock and the E-Stop button:
1. From the LINAC menu in Physics mode, use the Calibration Check screen to
deliver 400 MU. (You may also enter 2 minutes warmup time in the LINAC Warmup
screen.)
2. While the beam is on, open the Treatment Room door.
The radiation should terminate and a red E-Stop message should be displayed on the
treatment delivery computer describing the error.
3. Close the Treatment Room door, recover from the error, and continue to deliver the
radiation.
4. Again, while the beam is on, press the operator control panel E-Stop button.
The radiation should terminate and a red E-Stop message should be displayed on the
treatment delivery computer describing the error.
5. Again, while the beam is on, press the Interlock button at the bottom right of the left
screen of the treatment delivery computer (see Figure 1).
1075879-ENG A Daily QA Tests |3-5

Interlock Button
Figure 1 Interlock button in E-Stop/Interlock controls
Watch the MV BEAM ON and HV ON indicator lights on the operator control panel
closely as you press the Interlock button. The beam should turn off within approximately
0.5 seconds. If the beam stays on 1 second or longer, contact Accuray Customer
Support.
6. Repeat this process to check other safety interlocks as scheduled, and recover as
appropriate.
Safe operation of the CyberKnife System depends on the proper functioning of all safety interlocks
(see Table 1).
Table 1 Safety interlock tests
No. Test Pass Result
1 With the safety interlock key switch in the operator control panel in the High Voltage will not
OFF position, push the HIGH VOLTAGE button on the operator control come on.
panel when the message to do so is displayed on the treatment delivery
computer.
2 With the key switch in the ON position, turn on the high voltage. Note the Light is on.
condition of the warning light over the Treatment Room door.
3 Note the condition of the warning light in the Treatment Room. Light is on.
4 When the beam comes on, note the condition of the warning light Light is on.
on the operator control panel.
5 With the beam on, open the Treatment Room door taking care to Beam goes off and
avoid exposure to radiation if the beam does not go off. Close stays off until reset on
the door. Attempt to restart the high voltage before resetting the the treatment delivery
interlock on the treatment delivery computer. computer.
6 With the beam on, press the Emergency Stop (E-Stop) button on Beam goes off and
the operator control panel. Release the button. Attempt to restart stays off until reset on
the high voltage before resetting the interlock on the treatment the treatment delivery
delivery computer. computer.
3-6 | Daily QA Tests 1075879-ENG A

System Status Check

Perform a daily system status check to ensure that the CyberKnife System is within specifications
and to monitor any drift in operating parameters. See the CyberKnife® Robotic Radiosurgery
System QA Log Book for the acceptable range of values for operating parameters. Locations of
readouts are given in Table 2. For the location of equipment components, see Chapter 2,
"Commissioning".
Table 2 Parameter readout locations for daily system status check
Parameter Check Location of readout
LINAC Pressure regulator Mechanical Rack.
SF6 gas pressure (psi) Mechanical Rack.
Chiller flow rate Mechanical Rack
Water temperature (°C) Chiller front panel.
Water flow rate (liter/min) Chiller flow meter.
Dose rate (MU/min) The Calibration Check screen in Physics mode on the
NOTE: Use only one method to monitor and record the dose rate. Do not use
multiple methods or alternate between them.

Laser Alignment Check Application

The goal of the Laser Alignment Check application is to provide a quick verification of robot pointing
accuracy (via the LINAC laser) prior to every patient path. 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).
• “Laser Alignment Check Overview” on page 3-8
• “Laser Alignment Check Controls” on page 3-9
• “Laser Alignment Check Procedures” on page 3-12.
NOTE: The Laser Alignment Check application does not check laser and
radiation beam coincidence. For more information, see “LINAC Laser and
Radiation Coincidence Check” on page 3-16.
Laser Alignment Check Overview

The Laser Alignment Check moves the treatment robot to the check position, points the laser at
the sensor on the Xchange table or a sensor installed on the base of the treatment robot and,
based on sensor readings, calculates the current value for intensity and compares it to the
calibrated value. If the intensity value is within 80% of the calibrated intensity value, the check
passes. If it is not within 80%, the check fails.
If the Laser Alignment Check fails, but the laser position is within tolerance, you can adjust the
baseline value for laser intensity. This adjustment is intended to prevent failed checks caused by
the possible degradation of laser output over time. If, after the baseline is adjusted, the check
continues to fail, perform an AQA test. For information on the AQA test, see, “Chapter 4: AQA, E2E,
MLC, and Plan QA Tests” . If the AQA test passes, but the Laser Alignment Check fails again,
contact Accuray Customer Support.

Laser Alignment Check Controls

The Laser Alignment Check Application window is displayed when you click the Laser
Alignment button in the Physics menu (see Figure 2).
Figure 2 Laser Alignment button in Physics menu
The Laser Alignment Check Application window displays information about laser
alignment status and provides controls for executing Laser Alignment Check application
commands (see Figure 3), including moving the treatment robot to the perch position, executing a
Laser Alignment Check, viewing current and calibrated values for laser intensity and laser position,
and executing a baseline correction for laser intensity values.
The window includes the buttons listed in Table 3.

Figure 3 Laser Alignment Check Application window

Table 3 Controls in the Laser Alignment Check Application window
Button Function
Perch Moves the treatment robot to perch position if it is not at perch but in a valid
position for the Laser Alignment Check. If the treatment robot is in an invalid
position, move it to the perch position using the Teach Pendant.
Start Executes the Laser Alignment Check, updates the Last Check Status, Last
Check Date, and Last Check Time fields, and indicates if the check passed
or failed.
Verify Executes a laser intensity and position check and displays the current offset
position value and the current and calibrated intensity values.
Baseline Establishes a new laser intensity threshold if the intensity value has changed and
the current offset laser position is within tolerance.
The baseline adjustment compensates for laser intensity changes that result from
a failing laser power supply or laser tube or from environmental factors such as
room lighting. The baseline adjustment does not change the calibrated value for
laser position, but does update the intensity value to pass the test.
Values for position calibration and intensity threshold differ for fixed collimators, Iris
Collimator, and the Multileaf Collimator. If your system has an Iris Collimator and a
change in laser intensity requires a baseline adjustment, perform the adjustment for
both fixed collimators and the Iris Collimator.
Exit Returns you to the Physics menu.
The top section of the Laser Alignment Check Application window displays the following
information:
• Last Check Status: Indicates if the last check passed or failed.
• Last Check Date: Date last check was performed.
• Last Check Time: Time last check was performed.
• Robot Position: Indicates if the treatment robot is in a Ready or Invalid position for the
Laser Alignment Check. If the position is invalid, use the Teach Pendant to move it back
to the perch position.
• Collimator Type: Indicates if the currently installed collimator is a fixed collimator, an
Iris Collimator, or a Multileaf Collimator. Any collimator can be installed for the Laser
Alignment Check.
• Calibrated On: Date of laser alignment calibration.

The lower section displays the status of the Laser Alignment Check application and the results
when an application command is executed. The messages for command results are as follows:
• Perch: Result message indicates if the treatment robot is at the perch position.
• Start: Result message indicates if the Laser Alignment Check passed or failed and
displays the current and calibrated intensity values.
• Verify: Result message indicates if the verification of laser intensity and position
passed or failed and displays the current position offset value and current and calibrated
intensity values.
• Baseline: Result message indicates if the baseline procedure passed or failed and
displays the current position offset value and current and calibrated intensity values. If the
procedure passes, the current intensity value displayed is the new intensity baseline
value.
The Attention message is always displayed. It reminds the user that the baseline procedure
performs a verification scan of the sensor and, if it passes, updates the sensor threshold value
based on the current reading.
Laser Alignment Check Procedures

 To move the treatment robot to the perch position:
• To move the treatment robot from a valid position for the Laser Alignment Check to the
perch position, click the Perch button.
The message section indicates when the treatment robot returns to perch position, and
the Robot Position status is updated.
 To start the Laser Alignment Check:
• Click the Start button.
The message section indicates whether the Laser Alignment Check passed or failed. The
Last Check Status, Last Check Date, and Last Check Time fields are
updated.
 To view the current and calibrated vales for laser position and intensity:
• Click the Verify button.
The message section indicates whether the laser intensity and position check passed or
failed. The current position offset value and current and calibrated intensity values are
also displayed.
 To adjust the baseline value for laser intensity:
• Click the Baseline button.
The message section indicates whether the baseline procedure passed or failed. The
current position offset value and current and calibrated intensity values are also

displayed. If the procedure passes, the current intensity value displayed is the new
intensity baseline value.
NOTE: If your system has an Iris Collimator and a change in laser intensity
requires a baseline adjustment, perform the adjustment for both fixed
collimators and the Iris Collimator.
 To return to the Physics menu:

• Click the Exit button.
Treatment Robot Perch Position Laser Check

This procedure verifies that the location of the LINAC laser beam spot on the floor does not shift
from day-to-day.
 To perform the laser at perch position check:
1. At the time of installation, mark where the laser light hits the floor when the treatment
robot is in the perch position.
2. Daily thereafter check the location of the laser spot on the floor to confirm that robot
mastering of the treatment robot is unchanged.
NOTE: A change in the position of the laser beam spot on the floor at the perch
position does not necessarily indicate that the treatment robot has lost robot
mastering. A change can also indicate that the laser itself has moved. In either
case, call Accuray Customer Support.
X-ray Tube Warmup

Condition and warm up the X-ray source (XRS) tubes every morning. The intent is to minimize
target (anode) cracking due to thermal shock.
If the unit has not been energized for a period of 8 hours or more, it is necessary to start at a kVp
considerably lower than the highest kVp normally used on a given tube in order to re-align the
internal distribution of charges.
CAUTION: The X-ray tube warm-up procedure is designed to minimize target cracking due to
thermal shock. Thermal shock can cause a target to fracture. In extreme cases, the target may
break apart, causing damage to the insert and/or tube housing.

 To warm up the X-ray tube:

1. On the CyberKnife System Menu, click the Physics button.
2. Click the X-Ray Warmup button.
3. Click the Start button.
4. Click the Exit button.
For more information on the X-ray tube warmup procedure, see the Treatment Delivery Manual.
LINAC Output Constancy Check

Check LINAC output constancy daily. Additional checks throughout the day may be required if
dramatic environmental changes occur. Note that the daily output constancy check confirms that
the dosimetry electronics and all additional factors that have the potential to influence dose output
accuracy are also being evaluated. A dedicated Baldwin-Farmer ion chamber should be used for
this check.
To perform the daily LINAC output constancy check, see the instructions for establishing LINAC
output constancy in Chapter 2, "Commissioning".
Automated Quality Assurance (AQA) Test

The automated quality assurance (AQA) test should be performed daily to check robot mastering
of the treatment robot and alignment of the imaging system. The AQA test is a targeting
reproducibility test performed using the AQA phantom, a small plastic phantom that contains
fiducials. The AQA test checks the reproducibility of targeting two beams (vertical and horizontal).
The AQA test should be run for each collimator type (fixed collimators, the Iris Collimator, and the
Multileaf Collimator) to be used that day. For detailed information on the AQA test procedure, see
“Chapter 4: AQA, E2E, MLC, and Plan QA Tests”.
Visual Inspection of TG-50 Abutted Rectangular

Field Test
Check the Multileaf Collimator calibration daily. The TG-50 MLC test is a routine test for leaf
calibration and sticking. For more information on the TG-50 test procedure, see Chapter 4, "AQA,
E2E, MLC, and Plan QA Tests".

Monthly QA Tests
This section describes QA test procedures that should be performed at least monthly. For more
• “Beam Parameters Check” on page 3-15
• “LINAC Laser and Radiation Coincidence Check” on page 3-16
• “Dose Delivery Verification Check” on page 3-16
• “Imaging System Alignment Check” on page 3-17
• “Custom CT Density Model Check” on page 3-17
• “Treatment Couch Positioning Check” on page 3-18
• “End-to-End (E2E) Test” on page 3-19
• “Quality Assurance of the Iris Collimator” on page 3-19
• “Quality Assurance of the Multileaf Collimator” on page 3-19
Beam Parameters Check

On a monthly basis, check beam characteristics such as beam symmetry, flatness, and penumbra.
Furthermore, conduct a check of the beam energy. The following materials are used during the
beam parameters check: film in conjunction with build-up slabs, a diode with water phantom, or
other equivalent QA tools.
 To perform the beam parameters check:
1. Set up the measurement for 800 mm SAD and 50 mm depth.
2. Insert the 60 mm fixed collimator.
3. Measure the beam profile along 2 orthogonal directions.
4. Verify beam parameters along each direction are as follows:
• Flatness is less than 20% along each direction.
The flatness specification of the CyberKnife System is defined as the maximum
percentage deviation of the relative dose profile within the central 80% of the FWHM
of the beam.
• Asymmetry of the beam is less than 4%.
The asymmetry specification Equation (1) of the CyberKnife System is defined as
follows:
 D  x   D  – x   max  100 % (1)
1075879-ENG A Monthly QA Tests |3-15

The calculation is evaluated over the central 80% of the beam, measured at 50 mm
depth using the 60 mm fixed collimator.*
• The penumbra is less than 8 mm.
The penumbra specification of the CyberKnife System is defined as the distance
between the 80% and 20% dose decrement points along a relative dose profile.
5. Perform a measurement of the beam energy with the 60 mm fixed collimator. For
example, measure the TPR at 100 mm and 200 mm depth and 800 mm SAD to
determine the TPR 20/10 beam quality index.
6. Repeat Step 1 through Step 4 above for the 10 mm and 40 mm fixed collimators to verify
that the penumbra is less than 3.5 mm and 4.5 mm for the 10 mm and 40 mm collimators,
respectively.
* Other methods for calculating asymmetry exist and have been used on previous versions of the
CyberKnife System. One such method is the Area method, shown in Equation (2), where AL is the
area under the left half of the profile and AR is the area under the right half of the profile, calculated
from the central axis to the 50% field size. It should be clear that using this method to calculate
asymmetry will produce different values and should be compared to the specification stated in step
4 above.
(2)
LINAC Laser and Radiation Coincidence Check

The CyberKnife System uses a point laser that is coincident with the radiation field as a QA tool.
The laser is reflected off an adjustable mirror. The alignment of the laser relative to the radiation
field should be checked periodically.
Laser coincidence with the radiation field is checked using film. For information on the LINAC laser
and radiation coincidence check to confirm that the LINAC laser beam and radiation beam are
aligned, see “Chapter 2: Commissioning”.
Dose Delivery Verification Check

The dose delivery verification check is performed monthly to confirm treatment delivery dose
accuracy. For information on performing this check, see “Chapter 2: Commissioning”.
3-16 | Monthly QA Tests 1075879-ENG A

Imaging System Alignment Check

Check the mechanical alignment of the imaging system to document that it is performing according
to specifications. This is especially important if there has been major maintenance of any sort in
the treatment room or an earthquake or other possibly significant perturbation of the camera stands
or ceiling-mounted X-ray sources.
 To check the alignment of the imaging system:
1. Attach the isopost to the camera stand.
2. Exit the Treatment Room and close the door.
3. Use Treatment mode to acquire an image of the isopost as outlined below.
 To acquire an image of the isopost using Treatment mode:
1. From the main screen on the treatment delivery computer, select a treatment plan.
2. Proceed to the Alignment > Couch phase of the alignment process.
3. Adjust the X-ray imaging technique to 60 kVp, 50 mA, and 50 ms and acquire an image.
4. Adjust the image Window/Level and zoom in so that the isocrystal is clearly visualized.
5. Position the crosshairs on the center pixel of the image.
6. Using the Pointer, determine the (x, y) position of the center of the isocrystal. The
coordinates are displayed in millimeters. Verify that the isocrystal is at ±1 mm from the
baseline position where it was last calibrated.
7. Confirm that the isocrystal is within 1 mm of the center of the cross-hairs.
8. Record results.
9. Exit Treatment mode and remove the isopost.
Custom CT Density Model Check

A spot check of the custom density model should be conducted monthly. For more information on
custom CT density models, see "Chapter 2, "Commissioning".
 To perform a spot check of the custom density model:
1. Obtain a CT scan of your density phantom with at least a few different density inserts. A
minimum of water, air, and bone should be used.
2. Build a density model outside of the Accuray Precision System and check it against the
current custom CT density model.
3. Repeat these steps for each CT scanner used.
4. Values should be within acceptable limits. If they are not, a new density model should be
built using the most current CT scan of your density phantom.
NOTE: Custom CT density models should also be checked when significant

CT maintenance or software/hardware changes have been made.

Treatment Couch Positioning Check

This test is designed to demonstrate whether the standard treatment couch calibration is within
specifications for rotations and translations.
 To check the accuracy of the treatment couch position:
1. Press the HOME button on the Hand Controller while pressing both Enable buttons.
Continue to press the HOME button until the treatment couch has stopped moving.
2. Using a digital level, check the Head Up/Down and Roll Left/Right rotations and confirm
that they are 0 ± 0.3°.
3. For Left/Right translation, use a tape measure or other measuring device to check that
the center of the vertical lift column is positioned to within 5 mm of the center of the
treatment couch base.
NOTE: It may be convenient to make a mark on the base of the treatment

couch that lines up with a point on one of the retractable covers when the
treatment couch is in the HOME position. Then check that the mark continues
to line up with that point in the HOME position.
Retractable
Cover
Vertical Lift
Column
Base
Figure 4 Standard treatment couch
4. If any rotation or translation is out of specification, use the Hand Controller to manually
move the corresponding axis approximately 3° for a rotation or approximately 5 cm for a
translation.
• Press the HOME button again until motion stops.
• Recheck to see if the rotation or translation is within specification.
• If the rotation or translation is still out of specification, contact Accuray Customer
Support.
For more information on using the Hand Controller for the standard treatment couch, see the
3-18 | Monthly QA Tests 1075879-ENG A

End-to-End (E2E) Test

The End-to-End (E2E) test is a targeting test designed to demonstrate the geometric targeting
accuracy of the CyberKnife System throughout all phases of treatment planning and treatment
delivery. Targeting accuracy is quantified based on radiation delivered to a Ball-cube phantom.
Dose distributions are recorded on films inserted into the Ball-cube and analyzed. The E2E test
should be performed at least monthly for each tracking mode at the site and the results
documented. For detailed schedule information, see the CyberKnife® Robotic Radiosurgery
System QA Log Book.
For detailed information on the E2E test procedure, see “Chapter 4: AQA, E2E, MLC, and Plan QA
Tests”.
Quality Assurance of the Iris Collimator

If your configuration includes the optional Iris Collimator, perform a spot check of your Iris
Collimator beam data on a monthly basis as follows:
• Check a sample of aperture sizes per month. Checks should include OCR, TPR, and
output factor data.
• Check Iris aperture reproducibility by acquiring several repeated profile scans of the
radiation beam using a water phantom. Compare these scans to your original OCR scans
acquired during commissioning. This step is recommended for all aperture settings after
any Iris Collimator service or software upgrade is performed.
WARNING: Perform regular visual inspection to verify the Iris aperture shape. Make sure
the tungsten segments in the upper and lower banks still form a hexagon. If the aperture
shape changes from a regular dodecagon due to mechanical alignment problems,
mistreatment of the patient can result. If any misalignment is found, call Accuray
Customer Support.
• The Iris Quality Assurance (QA) tool is a film-based tool to check the reproducibility of the
radiation beam field sizes when the Iris Collimator is used. For information on using the
Iris QA tool, see Appendix 3A, "Using the Iris QA Tool".
Quality Assurance of the Multileaf Collimator

If your configuration includes the optional Multileaf Collimator (MLC), then you should perform the
Bayouth test monthly. The Bayouth test is also known as the "Garden Fence" test. Instead of using
abutted fields, as seen in the TG50 test, the Bayouth test uses narrow strips of exposure with
sufficient separation, so that the edges of each leaf can be located. For information on performing
the Bayouth test, see Chapter 4, "AQA, E2E, MLC, and Plan QA Tests".

Quarterly QA Tests
This section describes QA test procedures that should be performed at least quarterly. For more
This section covers the following topic:
• “TLS Tracking and Couch Movement Correspondence” on page 3-20
TLS Tracking and Couch Movement

Correspondence
The TLS subsystem is responsible for measuring and reporting patient motion. This procedure
checks correspondence between distance moved by the treatment couch and displacement
offsets determined by the TLS subsystem.
1. Obtain a CT scan of a phantom and import it as a phantom.
2. Create a plan and save it as deliverable. The iDMS Data Management System will
generate the DRR images after the plan is closed.
3. Place the phantom on the treatment couch.
4. In Phantom mode, on the treatment delivery computer, proceed to the Alignment >
Align phase.
5. Align the phantom so that the treatment couch offsets are close to zero.
6. For either the standard treatment couch or the optional RoboCouch System:
• Move the phantom to several different positions by entering values in the automatic
patient positioning controls on the left screen of the Alignment > Align phase.
Record these treatment couch position offsets (the values entered in the Couch
Position (mm) and Couch Rotation (deg) text boxes).
(For the standard treatment couch, you can also determine the position offsets using
the Readout Display Unit. For more information on the Readout Display Unit, see the
Treatment Delivery Manual.)
• At each position, acquire an image and record the TLS displacement estimate (the
Offsets values displayed on the left screen).
7. Compare the recorded Offsets values to the specified distance that the treatment couch
was moved using the automatic patient positioning controls. For each translation or
rotation, record the difference between these values in the CyberKnife® Robotic
The translation errors should be no more than ±2 mm. The rotation errors (roll and pitch)
should be no more than ±0.3°.
3-20 | Quarterly QA Tests 1075879-ENG A

Annual Testing Requirements

The following QA test procedures should be performed at least annually:
• Evaluate daily, monthly, and quarterly trends for compliance with system performance
specifications.
• Perform E2E tests by acquiring new CT image studies, generating new treatment plans,
and delivering the treatments for each tracking mode. Document treatment delivery
accuracy. Perform the E2E tests with scans from all CT scanners used with your
CyberKnife System. For more information on E2E tests, see “Chapter 4: AQA, E2E, MLC,
and Plan QA Tests”.
• Verify and document CT geometric accuracy for each CT scanner used with your
CyberKnife System.
• Perform a spot check of the beam data by re-collecting some or all of the beam data. You
may use spot checks to verify the accuracy of the data in the Accuray Precision System.
• Perform MLC leakage measurements, as described below.
MLC Leakage Measurements

Leaf and interleaf radiation leakage can be measured for the Multileaf Collimator using various
methods including EBT type film, ion chambers, TLDs, etc. Here one method is presented using
EBT type film. TG-142 recommends annual testing of the MLC leakage [Ref. 1].
 To perform MLC leakage measurements:

1. Place at least 50 mm of solid water on the treatment couch. Make sure the solid water is
level.
2. Move the treatment robot such that the radiation beam is above the solid water.
3. Install the pinhole collimator and place a cup of water on the solid water such that the
laser is shining onto the water surface near the center of the cup.
4. Observe the reflection of the laser on the pinhole and ensure the reflected spot falls on
the pinhole opening. Adjustments in Tool mode B and C may be necessary. When
finished, remove the pinhole collimator.
5. Install the front distance pointer and set the source-to-film distance (SFD) to 800 mm.
This setup can be seen in Figure 5. When finished, remove the front distance pointer.
1075879-ENG A Annual Testing Requirements |3-21

S7
LINAC
Multileaf Collimator (MLC)
800 mm Source-to-Film
Distance (SFD)
Film Depth 15 mm
Use EBT Type

Radiochromic Film
600-800cGy
Solid Water
Figure 5 Setup for MLC leakage measurements
6. Place the film on the solid water, visually centering the laser on the film. It may be helpful
to tape the corners of the film so that it does not move when adding the buildup material.
7. Place 15 mm of solid water on top of the film.
8. From the treatment delivery computer, in Physics mode, enter the Multileaf
Collimator application. In the Desired MLC Shape window, set the Shape to
Close Leaves Meet On Left.
9. Deliver 50,000 MU with the Multileaf Collimator in the fully closed position. For EBT type
film, this MU setting will allow the leakage dose to be at a reasonable level within the film
dynamic range for red channel dosimetry.
10. To test the opposite leaf bank, repeat Step 6 through Step 9 with a new piece of film and
set the Shape to Close Leaves Meet On Right.
11. Deliver a set of pixel value-to-dose calibration films using the 60 mm fixed collimator.
Refer to the guidance given by the film manufacturer for film calibration techniques. For
example, since the dose on the leakage film should be less than 250 cGy given the
50,000 MU exposure, one could deliver the following MU to a set of calibration films: 0,
50, 100, 150, 200, 250, 300, 350, and 400 MU.
12. Apply proper pixel value-to-dose calibration for the leakage film(s) and determine that the
maximum leakage within the MLC field does not exceed 0.5% dose relative to
50,000 cGy, that is, the dose on the leakage film does not exceed 250 cGy, ignoring film
artifacts such as dust or other extraneous marks.
3-22 | Annual Testing Requirements 1075879-ENG A

Unscheduled Tests
Patient-Specific QA Tests
Patient-specific tests, such as those that use radiochromic film to measure treatment accuracy, are
an important part of MLC QA. It is best if the method uses calibrated film and registration markers,
so that the resulting gamma function analysis is absolute in both dose and position. As needed,
perform patient-specific tests to ensure unique requirements are met. For information on creating
a QA plan associated with a specific patient treatment plan, for delivery to a phantom, see the
Plan QA section in “Chapter 4: AQA, E2E, MLC, and Plan QA Tests”.
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
Generating a Single Beam MLC QA Plan

In a single beam QA plan, all beams will be deliverable with the LINAC pointed down. This can be
used to perform QA for individual MLC apertures. For information on generating a single beam QA
plan for the Multileaf Collimator, see the Plan QA section in Chapter 4, "AQA, E2E, MLC, and Plan
QA Tests".
Robot Targeting Visual Check (BB Test)

The robot targeting visual check, also called a BB test, is used to visualize targeting accuracy of
the treatment robot and can be used as a qualitative check to see that all subsystems are working
properly. It is performed using a patient or phantom treatment plan in Demonstration delivery
mode. For information on performing a BB test using Demonstration mode, see the Treatment
Delivery Manual.
 To perform the robot targeting visual check using a BB test:
1. Ensure that the LINAC laser is aligned properly.
2. Power on the CyberKnife System.
3. Place a small metal BB on the phantom and line it up close to the isocenter using the wall
lasers. (A 2 mm Beekley Y-SPOT® can be used for this purpose.)
4. Create a new isocentric treatment plan from any CT image study.
5. Select a body/fiducial treatment.
6. Locate 1 fiducial in the appropriate location of the BB at the imaging center of the plan.
1075879-ENG A Unscheduled Tests |3-23

7. Calculate the dose and save the plan as deliverable.

8. Select Demonstration mode and advance to the patient alignment interface.
9. Align the BB close to the imaging center of the CyberKnife System.
WARNING: The Treatment Delivery System allows the user to acquire X-ray images
during the BB test. Ensure that no users or observers are in the Treatment Room when
Live X-ray images are acquired.
NOTE: Lower the kV, mA, and ms X-ray parameter settings since there is no
phantom material around the fiducial.
10. Follow the prompts on the screen and Teach Pendant to advance through the BB test.
11. Visually assess the positioning of the center line laser relative to the BB for each node.
WARNING: Always hold the Teach Pendant while performing a treatment simulation in
Demonstration mode, so that the E-Stop button is readily available.
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 BB test, no further X-ray images are
taken.
On the Teach Pendant, use SIM NODE to advance to the next node and pause there.
Use SIM ALL to advance through all nodes in the path, pausing briefly at each node.
References
1. Klein EE, Hanley J, et al. Task Group 142 report: Quality assurance of medical
accelerators. Medical Physics 2009; 36(9):4197-4212.

Chapter 4: AQA, E2E, MLC, and
Plan QA Tests
Introduction
This chapter describes procedures for performing Automated Quality Assurance (AQA) and End-
to-End (E2E) tests on the CyberKnife System, for creating Multileaf Collimator (MLC) test patterns
using the TG-50 and Bayouth test methods, and for performing plan QA for treatment plans.
• “General CT Imaging Guidelines for Phantoms” on page 4-2
• “Automated Quality Assurance (AQA) Test” on page 4-3
• “Equipment and Materials for E2E Tests” on page 4-23
• “Using the Ball-cube in E2E Tests” on page 4-36
• “Treatment Plans for E2E Tests” on page 4-41
• “E2E Dose Delivery for Stationary Tracking Modes” on page 4-55
• “E2E Dose Delivery for Synchrony Respiratory Motion Tracking Modes” on page 4-58
• “Film Analysis” on page 4-80
• “Creating Multileaf Collimator Test Patterns” on page 4-93
• “Plan QA for Treatment Plans” on page 4-127
For information on other recommended QA test procedures and their frequency, see Chapter 3,
“Quality Assurance Recommendations and Tests”.

General CT Imaging Guidelines for Phantoms

General CT imaging guidelines for phantoms are provided below.
NOTE: For pretreatment CT imaging guidelines for patients, see the

Treatment Delivery Manual, Chapter 5, "Patient Preparation".
• 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.
 Gantry angle = 0°.
 Maximum 512  512  512 slices.
NOTE: Pixels must be square.
 Constant slice thickness: 1.25 mm (0.6 mm – 1.5 mm) is recommended.
NOTE: Variable slice thickness is not supported.
 Contiguous slices (no gaps).

• Select a CT protocol to optimize resolution and reduce noise that favors the following:
 High contrast image.
 Reduced artifacts with Metal Artifact Reduction (MAR) if metal present.
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. Perform the CT scan with dummy film inside the
phantom. Do not use the dummy film for targeting tests.
• Carefully orient and align both the phantom and the Ball-cube inside the phantom,
according to their labels and to the CT lasers. The phantom position and orientation on
the CT flat table must be the same as during dose delivery.
• Include the entire phantom in the scan, with approximately 1 cm of air Superior and
Inferior.
4-2 | General CT Imaging Guidelines for Phantoms 1075879-ENG A

Physics Essentials Guide Chapter 4: AQA, E2E, MLC, and Plan QA Tests
Automated Quality Assurance (AQA) Test

• “AQA Overview” on page 4-3
• “Acquiring a CT Scan of the AQA Phantom” on page 4-4
• “AQA Treatment Planning for Fixed and Iris Collimators” on page 4-5
• “AQA Treatment Planning for the Multileaf Collimator” on page 4-7
• “Performing the AQA Test” on page 4-11
• “Film Analysis for the AQA Test” on page 4-14
AQA Overview
The automated quality assurance (AQA) test is a targeting reproducibility test. The AQA test should
be performed daily to check robot mastering of the treatment robot and stability of the imaging
system. The test is performed using the AQA phantom, a small plastic phantom that contains
fiducials (see Figure 1). The AQA phantom includes a 1.25 in (3.2 cm) acrylic ball and a 0.75 in
(1.9 cm) tungsten ball.
Figure 1 AQA phantom
The AQA test checks the reproducibility of targeting two beams (vertical and horizontal). The test
delivers a 1-path, 2-node treatment plan to film. From film analysis results, the robot targeting and
imaging system constancy can be determined and analyzed. The specification for the AQA test is
a radial error that is < 1 mm from baseline values.
1075879-ENG A Automated Quality Assurance (AQA) Test |4-3

The AQA phantom is based on the gantry LINAC Stereotactic QA technique of placing a
radiopaque ball at the treatment isocenter and observing the concentricity of the beam and shadow
of the ball.
For a non-isocentric image-guided system such as the CyberKnife System, the technique has been
modified. The target ball is not mechanically placed precisely at the room isocenter. Instead, the
ball is loaded into the AQA phantom. The image guidance of the CyberKnife System is used to
direct the LINAC radiation beam at the ball. Because the ball is spherically symmetric, this
technique can determine the translational targeting error, which is a combination of tracking and
delivery error.
NOTE: This type of AQA phantom cannot distinguish between tracking and
targeting error. The symmetric AQA phantom cannot determine rotational
targeting error.
The 2-node AQA path set contains one beam at each node. The nodes are located anterior and to
the right of the phantom. This 2-node path is calibrated using the results of three AQA tests run
from the same initial AQA plan. The same plan should be used for the daily AQA checks.
Acquiring a CT Scan of the AQA Phantom

Before generating a treatment plan for the AQA test, acquire a CT scan of the AQA phantom as
follows:
1. Open the AQA phantom and insert the acrylic ball. Then reassemble the AQA phantom.
NOTE: Use a 9/64-inch Allen wrench to open the AQA phantom.

2. Orient the AQA phantom on the CT table top as it will be oriented for dose delivery.
3. Perform a CT scan of the AQA phantom with the acrylic ball in place. Use general CT
imaging guidelines for phantoms (see “General CT Imaging Guidelines for Phantoms” on
page 4-2).
4. Use the iDMS Data Management System to import the CT image study as a phantom.
NOTE: The AQA plan will be delivered multiple times. Be sure to import the CT
image study as a phantom, not as a patient.
For more information on the iDMS Data Management System, see the Data Management
Manual.
5. Generate a 2-beam treatment plan for the AQA test using the acquired CT image study,
as described in the Treatment Planning Manual.
4-4 | Automated Quality Assurance (AQA) Test 1075879-ENG A

AQA Treatment Planning for Fixed and Iris

Collimators
To generate the initial treatment plan for the AQA test for the fixed collimators and the Iris
Collimator, perform the steps below in the Accuray Precision System. For more information on the
Accuray Precision System, see the Treatment Planning Manual.
NOTE: Use the same AQA test plan each day for each collimator (fixed
collimator, Iris Collimator, or Multileaf Collimator) being tested. If a new AQA
plan is created for any of the collimators, the AQA path for that specific
collimator type may need to be recalibrated by Accuray Service personnel.
New Plan
1. Click the New Plan icon on the home page.
2. Select the AQA Phantom from the patient list.
3. Click [Standard] and click [Next].
4. Select the CT exam and click [Select Exam]. Then click [Finish].
5. Go to the Contour Task > Ball-Cube step.
Contour Task > Ball-cube Step

In this step, you will create and contour the spherical target inside the AQA phantom .
1. Click the + sign in the Tools tab, next to Select VOI.
2. A VOI Properties box will open.
3. Name the new VOI Ball. Use the Type dropdown to designate it as a Target, and click
OK.
4. Move the cross hairs to the center of the ball in all 3 views.
5. In the Select VOI dropdown list, select Ball. An image of the ball will appear on the
screen.
6. Click Auto Detect and move the 3D Magic Wand cursor inside the lighter density ball.
Then left-click. The ball is contoured automatically.
7. Review the placement of the contour in all three views.
8. Go to the Setup Task > Machine step section.

Setup Task > Machine Step

1. Select the following parameters from the dropdown lists:
• Confirm the Treatment Machine selected earlier.
• Select the Density Model. The selection can be changed later in the Plan task >
Settings step also.
• Select the Treatment Machine.
• Planning Method: Sequential/Isocentric
• Number of Fractions: 1
• Select Collimator: Fixed or Iris
• Treatment Anatomy: QA_iris-fixed
• Template Path Set: AQA90deg
NOTE: If the collimator type is changed after entering any Treatment

Parameters, the selections will be lost. the collimator type needs to be selected
after entering the Number of Fractions, if it applies.
2. Go to the Setup task > Fiducials step.
Setup Task > Fiducials Step

1. Ensure that the Auto Center checkbox is selected.
2. Scroll through the transverse CT slices. Double-click on each fiducial on any slice where
fiducials are displayed. There are 4 fiducials in the AQA phantom.
3. Go to the Setup task > Align step.
Setup Task > Align Step

1. The DRR images are displayed. Do not shift the images.
2. Click Confirm when the images are positioned correctly.
3. Go to the Plan task > Settings step.
Plan Task > Settings Step

If the CT images were imported as a phantom, the Water/Air [Sample] density model may
be used. If the CT images were imported as a patient, then a Custom Model density model must
be used or the plan cannot be saved as deliverable.
1. Resize the dose calculation box so that it is flush with the cube faces of the AQA
phantom.
2. Go to the Plan task > Isocentric step.

Plan Task > Isocentric Step

1. Position the crosshairs at the center of the ball and magnify the image.
2. In the Isocenter section of the control panel, click New to create an isocenter.
3. Center the collimator on the sphere using the 30 mm collimator (default).
4. Resize the collimator to the 35 mm size.
5. Enter the correct dose to obtain 250 cGy at the surface of the film (approximately
605 cGy to the center of the sphere).
NOTE: Do not select the Conformal Weights checkbox.
NOTE: Depending on your site’s system configuration, units may be displayed

in gray (Gy).
6. Click Apply.
7. Go to the Evaluate task > Review step.
Evaluate Task > Review Step

1. Perform a Ray-Tracing High Resolution calculation.
2. When the optimization is complete, set the prescription to 80% at 500 cGy.
3. Inspect the dose at the surface of the film and verify that it is 250 cGy. Adjust the
prescription dose if required so that the dose at the center of the film is 250 cGy.
Alternatively, one can adjust the MU settings for each beam individually in the Evaluate
task > Finetune step to ensure that the dose at the center of the film is 250 cGy.
4. Save as a deliverable plan.
AQA Treatment Planning for the Multileaf

Collimator
Plan the AQA test using isocentric Sequential Optimization. Use the contoured ball object as a
target VOI. The planning system uses this VOI as the “template” to generate the circular aperture
mimicking the 35 mm fixed collimator.
The leaf positions are created by the Accuray Precision System. There are sometimes bumps on
the top and bottom of the dose distribution due to the finite thickness of the leaves in the vertical
direction. These bumps can be suppressed by closing the top and bottom leaves in the Finetune
step.
To generate the initial treatment plan for the AQA test for the Multileaf Collimator, perform the steps
below in the Accuray Precision System. For more information on the Accuray Precision System,
see the Treatment Planning Manual.

New Plan
2. Select the AQA phantom from the patient list.

In this step, you will create and contour the spherical target inside the AQA phantom.
1. Click the + sign in the Tools tab, next to Select VOI
2. A VOI Properties box will open
OK.
screen.
6. Click Auto Detect and move the 3D Magic Wand cursor inside the lighter density ball.
Then left-click. The ball is contoured automatically.
8. Go to the Setup task > Machine step section.

• Confirm the Treatment Machine selected earlier.
• Select the Density Model. The selection can be changed later in the Plan task >
Settings step also.
• Select the Treatment Machine
• Select Collimator: MLC
• Treatment Anatomy: QA_mlc
• Template Path Set: AQA90deg


2. Scroll through the transverse CT slices. Double-click on each fiducial on any slice where
fiducials are displayed. There are 4 fiducials in the AQA phantom.
3. Go to the Setup task > Align step section.
4. The DRR images are displayed. Do not shift the images.
5. Click Confirm.
6. Go to the Plan task > Settings step

1. Resize the dose calculation box so that it is flush with the cube faces of the
AQA phantom.
2. Go to the Plan task > Sequential step.
Plan Task > Sequential Step

1. Go to MU Limits. Leave Total MU blank and set Max MU per Segment and Max
MU per Node to 435.
2. Open Constraints and Steps from Script area.
3. In the Dose Objectives section, add:
• VOI Name: Ball
• Objective: Dose Volume Lower Limit (DVL)
• Goal: 420 cGy, 98% volume, 0% relaxation
4. Go to MLC Settings:
• Set Nodes = 2.
• Check Isocentric/Conformal.
• Set Leaf Margin = 3 mm.
• Set Leaf Justification = Middle.
• Click OK to close the window.
5. Run a low resolution Finite Size Pencil Beam (FSPB) optimization with the Play button.
6. Go to the Evaluate task > Review step.


1. Run a high resolution FSPB calculation.
2. Prescribe 250 cGy to the 40% isodose (this should set the maximum film dose to
250 cGy).
3. Go to Finetune step and look at leaf pattern. If leaf pattern has bumps at top and
bottom, manually close the top and bottom leaf by setting the positions to “68.5, 68.5” and
recalculate in High Resolution.
The goal is to create a circular dose pattern with approximately the same field size as
generated by the 35 mm fixed collimator. An example of leaf positions which create a
nearly circular dose distribution is shown in Figure 2.
Figure 2 An example of leaf patterns that creates a nearly

circular field similar to that of a 35 mm fixed collimator.
4. If the MU settings for each beam are different, you can make the values equivalent. An
example MU setting for both beams that produces roughly 250 cGy on both films is
410 MU. This value is only an example and may be different in practice. The goal is to
have approximately 250 cGy on the film, so some MU adjustments may be necessary.
5. Save as a deliverable plan.

Performing the AQA Test

 To perform the AQA test:
1. Open the AQA phantom and insert the tungsten ball.
NOTE: Use a 9/64-inch Allen wrench to open the AQA phantom.

Make sure there is no motion of the tungsten ball inside the phantom when you shake the
phantom. If there is motion, place a small piece of paper inside the phantom with the ball
to remove all motion. Then reassemble the AQA phantom.
2. Label two pieces of unexposed EBT type film and load them into the AQA phantom (see
Figure 3). Label one film “AS” and label the other “LS” depending on their position in the
phantom.
Notice that the film has an indexing cut that is not at 45º. This is to ensure that the film is
oriented correctly on a daily basis and to account for the polarity of the film. Correct film
orientation is essential for quality test results.
Notches
Plastic Arm
Figure 3 Film orientation in the AQA phantom
3. Orient the AQA phantom on the treatment couch as shown in Figure 4.

Imaging X-ray source
Film base
LINAC
Film
Imager
Figure 4 Orientation of the AQA phantom on the treatment

couch
4. Coarsely align the AQA phantom using room lasers, if available.

5. Click the Phantom button on the CyberKnife System Menu.
6. Select the daily AQA test plan.
7. Click the Acquire button on the treatment delivery computer.
8. Use the treatment couch to align the AQA phantom. Ensure that the phantom is aligned
to within 0.5 mm and 0.5°.
9. Deliver the AQA test plan.
NOTE: Do not leave EBT type film in the Treatment Room when the LINAC is
on unless the film is being used for a test.
10. Remove the AQA phantom from the treatment couch and unload the exposed films.
Confirm that the films are labeled correctly.
11. Scan the films for import into the AQA software. Scan the films in separate files using the
following parameters:
• Transmission
• 300 dpi (the VIDAR scanner uses 285 dpi)
• 48-bit if possible
• TIFF or BMP format
• Auto-calibration and color correction off
Orient the films so that the clipped corner is at the lower right and the superior edge is
away from the scanner hinge. Use the plastic template when scanning the films as shown
in Figure 5.

Figure 5 Film orientation in scanner
To achieve a repeatable process for targeting error, scan the films in the same orientation
that was used for previous tests. If necessary, another orientation can be used if it is
repeated for each test.
Figure 6 shows a film image acquired at 800 mm SAD using Gafchromic EBT film. In the
figure, the “A” and “S” labels identify the anterior and superior sides of the film. The long
axis of the film is identified either by a thin black line along the long axis edge, if hand cut
by the user or by a cut-out with long dimension along the long axis, or if the film was laser
cut.
Figure 6 Image of a typical AQA film after delivery
12. Perform AQA film analysis as described in “Film Analysis for the AQA Test” on page 4-14.

13. After performing film analysis, record the resulting targeting error in the CyberKnife®
Robotic Radiosurgery System QA Log Book.
Film Analysis for the AQA Test

• “Installing AQA Software Package” on page 4-14
• “Rotating and Flipping Images” on page 4-17
• “Setting the Image Resolution” on page 4-20
• “Processing the Images” on page 4-20
• “Printing and Saving Analysis Results” on page 4-21
Installing AQA Software Package

1. Install disk PN 023351 and view the contents
2. Follow the instructions in “Installation Procedure.txt”

Loading Images for AQA Film Analysis

Launch the AQA software application (see Figure 7).
Figure 7 Main screen of the AQA film analysis software
1. Select the Settings > Image Resolution menu item and set the pixel resolution for
your scanner. For more information, see “Setting the Image Resolution” on page 4-20).

Figure 8 Image Resolution dialog box
2. Select the image type from the Select Image dropdown list on the upper left of the
screen (see Figure 9).
Figure 9 Select Image dropdown list
• Image A represents the image with edges corresponding to the right, superior, left,
and inferior directions.
• Image B represents the image with edges corresponding to the posterior, inferior,
anterior and superior directions.
3. Click the Browse button next to the dropdown list (see Figure 10).
Figure 10 Browse button
NOTE: If you click the Browse button before selecting the image type, an
error message is displayed at the bottom of the window.
4. The File Selection dialog box is displayed. Go to the directory where the scanned
image file is saved and click Open to select the image file. After you select the file, the
image is displayed in the corresponding window on the left.

Rotating and Flipping Images

The algorithm requires that images be oriented in a certain way. Images should be labeled prior to
scanning to indicate which direction corresponds to which edge of the film.
The image display panels on the left of the screen display abbreviations for coordinate directions
as a reference. See Figure 12 for an example of images in the correct orientation. Loaded images
should be rotated so that the abbreviations displayed on the screen match the labels on the
scanned films.
Follow the instructions at the top of the screen to load, adjust (rotate or flip as necessary), and
process the images (see Figure 11).
Operations to rotate and flip images are available for both images using the Image A and
Image B menus. To rotate Image A by 90o in the counterclockwise direction, select the
Image A > Rotate 90 degrees CCW menu item (see Figure 11).
Figure 11 Image dropdown menu

Figure 12 Images correctly aligned for processing

Figure 13 Main screen showing processing results

Setting the Image Resolution

Image resolution information is necessary to convert from pixels to millimeters. The pixels/inch
values in the X and Y directions are obtained by scanning a ruler using the same scanner. Radial
error is also calculated after you enter the resolution information.
NOTE: This step must be performed each time the AQA software is opened.
1. Select the Settings > Image Resolution menu item (see Figure 14).
Figure 14 Image Resolution menu item
2. In the Image Resolution dialog box, enter the spatial calibration in pixels per inch for
the X (horizontal) and Y (vertical) directions (see Figure 15).
Figure 15 Image Resolution dialog box
Processing the Images

After loading both images and adjusting (rotating or flipping) them for the correct alignment, click
the Process button on the upper right of the screen to start image processing operations (see
Figure 13).
Images in the image display panels on the left of the screen are replaced with the processed
images. The processed images show the detected beam region in white and the ball shadow in
black.
Figure 13 shows example results after processing is performed. Tracking accuracy data is
displayed in millimeters. Pixel intensity at the beam centroid location is also displayed.

Printing and Saving Analysis Results

You can enter notes for future reference, print film analysis results, and save film analysis results
to a file.
 To enter notes:
• Select the Settings > Notes menu item (see Figure 16). The Notes dialog box is
displayed, allowing you to enter notes for future reference.
Figure 16 Notes dialog box
 To print analysis results:

• Select the File > Print menu item at any time to print the displayed screen (see
Figure 17).
Figure 17 Print menu item
 To save analysis results:

• Select the File > Save Analysis Results menu item to save the processing results
to a file (see Figure 18).
Figure 18 Save Analysis Results menu item

The File Selection dialog box is displayed, allowing you to browse to select a directory and enter
a name for the output file. The resulting file is a text file that includes the information Multi-displayed
on the screen, the names of the image files, and the date and time.
In order to help determine the source of errors using the AQA test, data in the
report must be carefully tracked.
It is important to keep an image of A and B. Record the X centroid offset
and Y centroid offset for both the A and B images. Record the X offset,
Y offset, and Z offset, and the Radial Error displayed in the Patient
Plane Coordinates section of the main screen of the AQA software.
The specification for the AQA test is less than 1 mm difference for the Radial
Error from the baseline measurement. If the daily reading for Radial Error is
not within specification, you should either repeat the AQA test 3 - 4 times to
get an average measurement, or run an End-to-End (E2E) test to verify the
targeting accuracy of the system.

Equipment and Materials for E2E Tests

This section describes the equipment and materials used to perform E2E tests. It covers the
following topics:
• “Phantoms Used in E2E Tests” on page 4-24
• “Radiochromic or EBT Type Film” on page 4-27
• “Film Scanner” on page 4-27
• “E2E Test Film Analysis Software” on page 4-35
E2E Test Procedure Overview

The complete E2E test procedure includes the following general steps:
1. Perform a CT scan of the phantom(s) that will be used in the E2E test for each tracking
mode available on your CyberKnife System and each CT scanner that will be used.
Phantoms should be loaded with film during the CT scans.
2. Import the CT image studies to the iDMS Data Management System using the Image
Review and Import application.
3. In the Accuray Precision System, identify and delineate the treatment target. Then design
a treatment plan and save it as deliverable.
4. Load films into the Ball-cube or film insert, orient the Ball-cube or film insert inside a
phantom, and deliver the treatment plan.
5. After the plan is delivered, perform digital film analysis using a film scanner and Accuray
E2E test film analysis software. The film analysis software determines the film size and
performs the appropriate analysis based on the size of the scanned film. Digital analysis
takes about 15 minutes and yields an accuracy of ±0.3 mm. The centroid of the actual
delivered dose distribution on the exposed film is compared with the centroid of the
planned dose distribution.
The E2E test is used to determine the total positional error for each stationary tracking mode and
respiratory modeling motion tracking mode installed on a CyberKnife System. Stationary tracking
modes include the Synchrony Skull Tracking System, the Synchrony Fiducial Tracking System,
and the Synchrony Spine Tracking Supine System. Respiratory modeling motion tracking modes
include the Synchrony Spine Tracking Prone with Respiratory Modeling System, the Synchrony
Fiducial Tracking with Respiratory Modeling System, and the Synchrony Lung Tracking with
Respiratory Modeling System. The specification for total positional error for the E2E test is
 0.95 mm for all stationary and respiratory modeling motion tracking modes.
In order to perform an E2E test for Synchrony Lung with Respiratory, you must purchase a specific
phantom from CIRS, Inc. The calibration for the CyberKnife System is based on the results of E2E
tests performed by Accuray Service personnel using the Synchrony Skull Tracking System, the
Synchrony Fiducial Tracking System, and Synchrony Spine Tracking with Respiratory Modeling.
1075879-ENG A Equipment and Materials for E2E Tests |4-23

E2E Test for Multileaf Collimator

Although there are no changes to the Ball-cubes for the film analysis software, there are some
differences in how the E2E test for the Multileaf Collimator is planned. With the Multileaf Collimator,
there are no fixed field sizes. The ball object is used as a target volume of interest (VOI). Thus, the
circular MLC shape is generated based on the VOI. Plan using isocentric Sequential Optimization
and use a shell 3 mm outside the target to improve dose conformality.
Phantoms Used in E2E Tests

Table 1 lists tracking modes and the corresponding phantoms used in E2E tests. The phantoms
are described in the sections that follow.
Table 1 Tracking modes and corresponding phantom
Mode Phantom
Synchrony Skull Tracking System CyberKnife head and neck phantom with Ball-cube.
Synchrony Fiducial Tracking System CyberKnife head and neck phantom with Ball-cube.
Synchrony Spine Tracking with CyberKnife head and neck phantom with mini Ball-
Respiratory Modeling cube.
Synchrony Fiducial Tracking with Ball-cube with Synchrony Respiratory Motion QA tool
Respiratory Modeling System with Ball-cube
Synchrony Lung with Respiratory (Optional) Lung Motion phantom with thorax body and
low density lung tumor film insert.
Original Ball-cube Film Cassette

The original Ball-cube film cassette is a cube 2.5 inch (6.35 cm) on a side. The standard Ball-cube
is used in E2E tests for the Synchrony Skull Tracking System, the Synchrony Fiducial Tracking
System, and the Synchrony Fiducial Tracking with Respiratory Modeling System. The Ball-cube
accommodates radiochromic film and contains 5 fiducials. The Ball-cube is placed in the cranium
cavity of the head and neck phantom.
The standard Ball-cube is composed of 4 pieces which connect together using threaded nylon rods
and nuts (see Figure 19). A 31.75 mm diameter acrylic ball is embedded in the center of the cube.
4-24 | Equipment and Materials for E2E Tests 1075879-ENG A

Figure 19 Diagram of Ball-cube
The procedure for using the original Ball-cube is described in “Using the Original Ball-cube” on
page 4-37.
Ball-cube II Film Cassette

The Ball-cube II contains 6 fiducials.
For Synchrony Fiducial Tracking and Synchrony Fiducial Tracking with Respiratory Modeling,
select only gold fiducials. Plastic posts contain tiny copper markers that can be used for film to dose
registration.

Copper Gold
marker fiducials
Figure 20 Copper markers and gold fiducials
The copper markers are only in the film planes: 4 in the axial plane and 4 in the sagittal plane. The
6 standard gold fiducials are for tracking.
The Ball-cube II film cassette uses film of a different precut shape than the original Ball-cube. For
more information about the Ball-cube ll, see “End-to-End Film Analysis” on page 4-80.
Mini Ball-cube Film Cassette

The mini Ball-cube film cassette is a cube 1.25 inch (3.2 cm) on a side. The mini Ball-cube is used
in E2E tests for the Synchrony Spine Tracking with Respiratory Modeling. The Ball-cube
accommodates radiochromic film. It contains no fiducials. The mini Ball-cube is placed in the neck
cavity of the head and neck phantom.
The mini Ball-cube is composed of 4 pieces which connect together using nylon locator pins. A
19 mm diameter acrylic ball is embedded in the center of the cube.
Procedures for using the Ball-cube and mini Ball-cube are similar and are described in “Using the
Ball-cube in E2E Tests” on page 4-36.

Head and Neck Phantom

The head and neck phantom is used in E2E tests for the Synchrony Skull Tracking system, the
Synchrony Fiducial Tracking System, and Synchrony Spine Tracking with Respiratory Modeling.
The phantom has skull and spine features that are suitable for accurate tracking. A Ball-cube
containing film is inserted into a cavity in the phantom. There are 2 cavities, one for the Ball-cube
and one for the mini Ball-cube.
Synchrony Respiratory Motion QA Tool for Respiratory

Motion Tracking
The Respiratory Motion QA tool for respiratory motion tracking is used in E2E tests for the
Synchrony Fiducial Tracking with Respiratory Modeling System. The Ball-cube containing film is
inserted inside the dome of the Synchrony Respiratory Motion QA tool. Procedures for using the
Synchrony Respiratory Motion QA tool are described in “E2E Test for Synchrony Fiducial Tracking
with Respiratory Modeling System” on page 4-58.
Lung Motion Phantom (Optional)

The optional Lung Motion phantom is used in E2E tests for the Synchrony Lung with Respiratory
The Lung Motion phantom includes thorax phantoms and moving rods for testing the Synchrony
Lung with Respiratory. The Lung Motion phantom does not use the standard Ball-cube film
cassette. Instead, it uses a special low-density ball-cube, so that only the ball is visible in the x-ray.
The motion phantom requires pre-cut radiochromic films.
This Lung Motion phantom is not provided with the CyberKnife System. It is available for purchase
from its vendor CIRS. For information, see Chapter 2, “Commissioning”. Procedures for using the
Lung Motion phantom are described in “E2E Test for the Synchrony Lung with Respiratory” on
page 4-66
Radiochromic or EBT Type Film

Accuray recommends Gafchromic EBT type pre-cut radiochromic film. An initial supply of EBT type
film is provided with your CyberKnife System. Replacement films can be purchased from Accuray
or the manufacturer. For manufacturer information, see Chapter 2, “Commissioning”.
Film Scanner
A film scanner is required for digital film analysis. Accuray recommends using a 16-bit grayscale
(or 48-bit color) film scanner with the ability to generate consistent and accurate optical density and
position measurements. For information on selecting a flatbed film scanner, see Chapter 2,
“Commissioning”.

When using a non-medical professional quality scanner, perform regular calibration because these
scanners do not guarantee spatial accuracy. A suggested procedure for film scanner calibration is
provided below.
If you use a VIDAR scanner, place the small pieces of radiochromic film in clear plastic pockets or
tape them to blank X-ray films or clear plastic sheets before scanning them.
Film Scanner Calibration

Although you will scan E2E films at 300 dpi on your scanner, you should calibrate your scanner in
order to achieve the most accurate results. The E2E software assumes 300 dpi film scans by
default, but you may change this value if your scanner resolution is not exactly 300 dpi.
Film scanner calibration is recommended at least annually. It is also recommended when you set
up a new film scanner, move the film scanner to a new location, or power it off for a significant
period of time. You may want to consider always leaving the film scanner powered on.
Familiarize yourself with the software included with the film scanner that you have purchased. Use
a transparent, precision ruler to calibrate the pixel scale resolution of your scanner, as described
below.
The actual film scanner dots per inch (dpi) resolution should be measured in the X and Y directions,
which depend on the film scanner. Example orientations using an Epson scanner are shown in
Figure 21 and Figure 22. The default X and Y directions for the film scanner can generally be
changed using the scanner software.
E2E Films AQA Film

Cover
Scan Hinge
Direction
Epson V700
Figure 21 Default X and Y directions for Epson V700. X is

parallel to the cover hinge. Y is parallel to scan direction.

E2E Films Scan AQA Film

Direction
Cover
Hinge
X
Epson 10000XL and 11000XL
Figure 22 Default X and Y directions for Epson 10000XL and

11000XL. X is parallel to the cover hinge. Y is perpendicular
to scan direction.
NOTE: Slits in the E2E films should be parallel to the Y direction of the film
scanner (shown in Figure 21 and Figure 22).
 To perform film scanner calibration:

This procedure is an example that describes using an Epson 11000XL film scanner with Epson
Scan software. In this procedure, you scan a transparent, precision ruler and then count the
number of pixels between ruler marks to determine the dpi resolution as follows:
Number of pixels between ruler marks-

dpi = ---------------------------------------------------------------------------------------------- (1)
Distance in inches between ruler marks
The ImageJ software application is used to measure the number of pixels between ruler marks.
NOTE: Calibrate the film scanner in the area where you place film.
1. Position a precision ruler on the scanner parallel to the scan direction, as shown in
Figure 23. Place it in the area of the scan field where you routinely place film to be
scanned.

Figure 23 Ruler placed parallel to the scan direction
2. Start the Epson Scan software and select the following settings (see Figure 24):
NOTE: Depending on the software for your film scanner, choose similar
settings.
• Mode: Professional Mode
• Document Type: Film
• Film Type: Positive Film
• Image Type: 48-bit color
• Resolution: 300 dpi

Figure 24 Epson Scan settings for scanner

calibration
3. Click the Configuration button. On the Color tab, select No Color Correction
(see Figure 25). This is the same setting as used for End-to-End (E2E) tests and Iris
Quality Assurance for EBT type film.
NOTE: Depending on the software for your film scanner, choose a similar
setting.

Figure 25 No color correction
4. Click the Scan button to scan the ruler. Save the image with a filename indicating the
ruler position, such as RulerParallelToScanDirection.tif.
5. Next, to make sure that measurement results are given in pixels, remove any ImageJ
spatial scale. To do this, select the Analyze > Set Scale menu item. Then click the
Click to Remove Scale button.
6. Open the image file in the ImageJ application and zoom in on the image by pressing the
<+> key on the keyboard.
Use the ImageJ Straight line selections tool (see Figure 26) to draw a 5 or 6-inch
line parallel to the scan direction. You will measure the number of pixels along this line in
the next step.
Straight Line Selections Tool
Figure 26 ImageJ Straight lines selection tool
It is helpful to align the line against vertical marks on the ruler, to ensure the line is
horizontal, as shown in Figure 27.

Measurement Line
Figure 27 Portion of measurement line parallel to scan

direction (yellow line in ImageJ), aligned against vertical
ruler marks
7. Press the <m> key on the keyboard to generate a measurement of the number of pixels
spanned by the line. This value is displayed in the Results window in the Area column.
The Results window also displays the angle of the line, which indicates whether the line
is actually parallel to the scan direction.
NOTE: You can also use Microsoft Paint to measure the number of pixels
instead of ImageJ. To do this, scan and save the image as a .tif file. Then
open the image file in Paint. Draw the measurement line using the Line tool.
The number of pixels spanned by the line in the horizontal and vertical
directions in the image is displayed in the status bar at the bottom of the Paint
window.
8. Calculate the resolution (dpi) of the scanner in the parallel direction using Equation (1) on
page 4-29. Include one decimal place.
Alternatively, you can draw a single 1-inch line and measure the number of pixels it
spans. Repeat this measurement 5 to 6 times at consecutive locations along the ruler.
Then calculate the measurement average to determine the resolution (dpi) of the scanner
in the parallel direction to one decimal place.
9. Next repeat the above procedure, but position the ruler on the scanner perpendicular to
the scan direction, as shown in Figure 28. Place it in the area of the scan field where you
routinely place film to be scanned.

Figure 28 Ruler placed perpendicular to the scan

direction
10. Scan the ruler, and save the image with a filename indicating the ruler position, such as
RulerPerpendicularToScanDirection.tif.
11. Open the image file in the ImageJ application, zoom in, and use the ImageJ Straight
lines selections tool (see Figure 26) to draw a line perpendicular to the scan direction.
Draw a single 5 or 6-inch line, or 5 to 6 consecutive 1-inch lines, as described above.
12. Press the <m> key on the keyboard to generate a measurement of the number of pixels
spanned by the line. The Results window also displays the angle of the line, which
indicates whether the line is actually perpendicular to the scan direction.
13. Calculate the resolution (dpi) of the scanner in the perpendicular direction using
Equation (1) on page 4-29. Include one decimal place.
Alternatively, if you are drawing consecutive 1-inch lines, calculate the measurement
average to determine the resolution (dpi) of the scanner in the perpendicular direction to
one decimal place.
14. Save the horizontal and vertical dpi calibration values to enter into film analysis software.
15. You may want to repeat the calibration procedure for different dpi settings, depending on
the dpi settings you use, or at different locations across the scan field, depending on
where you typically place film on the scanner.
For example, you could repeat the calibration at 600 dpi or with the ruler positioned at
several locations across the scan field.

E2E Test Film Analysis Software

E2E test film analysis software is provided by Accuray. The film analysis software automatically
identifies the film size (mini 1.25 inch versus standard 2.50 inch) and performs the analysis
accordingly.
Film analysis is performed using a film scanner and the E2E film analysis software provided by
Accuray. Visual film analysis can be performed in minutes and yields accuracy of about 1 mm.
Digital analysis takes about 15 minutes and yields an accuracy of ±0.3 mm.
Prior to performing any E2E film analysis, the software must be installed. Begin by installing disk
PN 029810 and viewing the contents. Run the installer and follow the prompts. Windows 10 may
report that shared memory access is blocked. You must either have Administrator privileges or you
may have to consult your IT department for installing this software. Once installed, the E2E film
analysis program must be run as Administrator.

Using the Ball-cube in E2E Tests

Your CyberKnife System may include either the original Ball-cube film cassette or the Ball-cube II
film cassette. The mini Ball-cube is provided with both. The original ball-cube and the Ball-cube ll
both use EBT type film as the film of choice. The following section describes precautions to
observe when using EBT type film.
• “Precautions When Using EBT Type Film” on page 4-36
• “Using the Original Ball-cube” on page 4-37
• “Loading Films into the Ball-cube II” on page 4-38
Precautions When Using EBT Type Film

Observe the following precautions when working with the film:
• EBT type film is rated by the manufacturer1 for exposure up to 800 cGy (red channel). It is
important to ensure that the planned maximum dose is consistent with the film dose
range.
• EBT type film is most sensitive in red channel, so scan in color (typically 48-bit color).
• Follow standard precautions for working with film as recommended by manufacturer. For
example, keep the film away from heat and UV and avoid bending the film more than is
necessary to load and unload it.
• When marking the film, use an extra fine permanent marker and only mark the outer
5 mm of the film. If no identification or orientation marks are placed on the film, at least
place a small black dot using permanent marker on the outer edge of the film. The
Accuray E2E software needs this to display the images properly.
• Consistent placement of film on the scanner is recommended.
• EBT type film optical density can depend upon scan orientation. Films must be scanned
in the same orientation, for example, with the slit aligned vertically with the scanner for
Ball-cube II. It is also important to note which side of the film is on the scanner surface.
Films such as EBT2 are asymmetric in their layered construction, which causes readings
to differ depending on which side of the film is facing the scanner. Be consistent in all of
your scanning.
• Perform the CT scan with film loaded in the Ball-cube to achieve the correct geometry.
NOTE: Multiple CT scans can deliver a significant exposure to the EBT type
film.
1. The EBT type film manufacturer is Ashland, Inc. Their website (www.ashland.com) has ad-
ditional information on the film specifications and properties.
4-36 | Using the Ball-cube in E2E Tests 1075879-ENG A

Using the Original Ball-cube

This section describes how to insert film into the original or mini Ball-cube. Figure 29 shows the
original Ball-cube and the film used with it.
Figure 29 Original Ball-cube and film
 To insert film into the original Ball-cube or the mini Ball-cube:

1. Label the film reference edges with a fine tip permanent marker. The writing will be
preserved in the scanned image of the exposed films for identification purposes.
2. Join the 2 pieces of film. Figure 29 shows joined films for the original Ball-cube.
3. Open the original Ball-cube or mini Ball-cube, then insert the joined films into the film
cassette. If you are using the original Ball-cube, do not tighten the nuts yet.
Use the following alignment guidelines for the joined films:
• Axial film: Aligned with the anterior and left edges of the film cassette.
• Sagittal film: Aligned with the anterior and superior edges of the film cassette.
4. Press each face of the film cassette against a hard flat surface so that the film edges are
flush with the cube faces. If the film becomes stuck, push the film from the opposite side
using a stiff piece of paper such as a business card.
5. Confirm that the films are aligned flush with the anterior, superior and left faces of the
assembled film cassette.
To determine this, look at the reference edges from a 45° angle with respect to the
surface of the Ball-cube. The film edges should appear as black lines. If the film is below
the surface, a black line is not visible. If the film is sticking out too far, you can see it
sticking out and/or can feel it with your fingers.
6. When the films are aligned flush with the faces of the original Ball-cube, tighten the nuts
to secure the film. The mini Ball-cube is held together by friction only.
1075879-ENG A Using the Ball-cube in E2E Tests |4-37

Loading Films into the Ball-cube II

 To load films into the Ball-cube II:
1. Open the package of laser-cut film and remove one piece of each cut of film. There are
two distinct cuts:
• One for the axial plane
• One for the sagittal plane
Figure 30 shows axial film on the left and sagittal film on the right.
Figure 30 Laser-cut film for Ball-cube II (axial film

on left, sagittal film on right)
Unclip the two latches on the top and bottom of the film cassette.
Figure 31 Ball-cube ll with latches closed and

opened
2. Slide the four sections of the film cassette apart. One section can be detached.

3. Join the films together. Figure 32 shows the correct way to orient the films with respect to
each other before loading them into the film cassette.
In both views shown, the axial film is oriented from rear-left to front-right. The image on
the left shows the view from the Anterior-Left-Inferior quadrant. The image on the right
shows the view from the Anterior-Right-Superior quadrant.
Figure 32 Correct orientation of films before loading
4. Drop the joined films into the film cassette. Figure 33 shows how to drop the films into the
film cassette. Make sure the registration holes in the films match the position of the
alignment pins.
NOTE: Avoid touching the films with oily hands. Hold films by the edges only.
1075879-ENG A Using the Ball-cube in E2E Tests |4-39

Figure 33 Drop the joined films into the Ball-cube II
5. If significant resistance is felt when pushing the sections together, check to make sure the
films are correctly oriented.
CAUTION: Do not push too hard when sliding the sections together to prevent damage to the
film.
Figure 34 Slide the sections together to close the

Ball-cube II.
6. When the Ball-cube II film is closed, insert it into the phantom.
CAUTION: Do not leave the film cassette uncovered after loading the film. Leaving the film cas-
sette uncovered for several days will result in exposure to film edges.

Treatment Plans for E2E Tests

• “E2E Planning with Isocentric Sequential Optimization” on page 4-41
• “E2E Plans for Stationary Tracking Modes” on page 4-41
• “E2E Plans for Respiratory Motion Tracking Modes” on page 4-48
E2E Planning with Isocentric Sequential

Optimization
E2E planning for fixed collimators and the Iris collimator can be done using Isocentric Sequential
Optimization. The steps are the same and allow the user to save the script once a successful plan
has been generated.
E2E Plans for Stationary Tracking Modes

To perform the E2E test using the Ball-cube film cassette, treatment plans are generated using the
Accuray Precision System. This section provides details on treatment planning for E2E tests for
the following stationary tracking modes:
• Synchrony Skull Tracking System
• Synchrony Fiducial Tracking System
• Synchrony Spine Supine Tracking System
Depending on the tracking mode, you generate treatment plans using the treatment parameters
given in Table 2.
Table 2 Suggested starting values of treatment planning parameters for E2E test
Ball-cube
Synchrony Mini Ball-cube Film Insert (25.4mm
Ball-cube Ball-cube Fiducial Synchrony ball only) Synchrony
Synchrony Synchron Tracking with Spine Supine- Lung Tracking with
Planning Skull y Fiducial Respiratory Tracking Respiratory
Constraints Tracking Tracking Modeling Modeling
Anatomy Head Body Body Body Body
Field Size 30 mm 25 mm 25 mm 15 mm 15 mm
Ball VOI Resize -1 mm -3 mm -3 mm -3 mm -5 mm

Parameters
(MLC E2E Only)
Dose, cGy 600 600 600 600 600
1075879-ENG A Treatment Plans for E2E Tests |4-41

Table 2 Suggested starting values of treatment planning parameters for E2E test
Ball-cube
Synchrony Mini Ball-cube Film Insert (25.4mm
Ball-cube Ball-cube Fiducial Synchrony ball only) Synchrony
Synchrony Synchron Tracking with Spine Supine- Lung Tracking with
Planning Skull y Fiducial Respiratory Tracking Respiratory
Constraints Tracking Tracking Modeling Modeling
Prescription 70% - 420 70% - 420 70% - 420 70% - 420 cGy 70% - 420 cGy
cGy cGy cGy
NOTE: The doses used in this table assume EBT type film is used. If you are
using MD film, multiply these values by 5 to produce an acceptable optical
density on the film.
New Plan
2. Select the head and neck phantom from the patient list.

In this step, you will create and contour the spherical target inside the Ball-cube.
OK.
screen.
6. Click Auto Detect and move the 3D Magic Wand cursor is inside the ball. Then left-
click. The ball is contoured automatically.
For Fixed and Iris plans only

Go to the Setup task > Machine step section.
4-42 | Treatment Plans for E2E Tests 1075879-ENG A

For Multileaf Collimator plans only, continue with the following steps:
1. Go to the Contour task > Manual step section.
2. Click Ball VOI.
3. Click VOI Operations. Set VOI A to be the Ball VOI and the Operator to be
Resize.
4. Select Isotropic and choose the offset that is appropriate for the Ball-cube and tracking
method that is being used in the E2E plan. For a list of the required offsets for MLC E2E
plans, refer to Table 2.
5. Click OK and the Ball VOI will be resized.
6. Got to the Setup task > Machine step section.
NOTE: The Ball VOI must be resized for MLC E2E plans to allow Sequential
Optimization to produce field sizes that are comparable to those that are
chosen for Fixed and Iris E2E plans. It is important for the dose distribution in
an MLC E2E plan to be similar in size to Fixed and Iris plans using the same
tracking method and Ball-cube.

• Select the Density Model.
• Select the appropriate collimator.
• Treatment Anatomy:
For the Synchrony Skull Tracking System, select head_iris-fixed or head_mlc.
For the Synchrony Fiducial Tracking System and the Synchrony Spine Supine
Tracking System, select body_iris-fixed or body_mlc.
• Choose a Template Path Set.
• Choose an appropriate Synchrony Method from treatment planning parameters
for E2E test.
2. For the Synchrony Skull Tracking System or the Synchrony Spine Supine Tracking
System go to the Setup task > Align step.
3. For the Synchrony Fiducial Tracking System, go to the Setup task > Fiducials step
section.


2. Scroll through the transverse CT slices. Double-click on the center of each fiducial on any
slice where fiducials are displayed. There are 5 fiducials in the original Ball-cube,
6 fiducials in the Ball-cube II, and no fiducials in the mini Ball-cube.
3. Visually confirm that auto centering has correctly identified the centroid of each fiducial in
each of the 3 views. Manually reposition the location of the center of the fiducial if
necessary.
4. Go to the Setup task > Align Center step section.

In the Align step, the images are automatically centered in the frame.
1. Depending on the tracking mode, perform the following alignment steps:
• Synchrony Skull Tracking System: Use the green crosshairs in the 2D planar views at
the bottom of the screen to shift the DRR images until there is a 10 - 15 mm gap
between the Superior and Anterior sides of the phantom skull and the edges of the
DRR image display panels.
• Synchrony Fiducial Tracking System: Do not shift the DRR images.
• Synchrony Spine Tracking: Use the green crosshairs in the 2D planar views at the
bottom of the screen to shift the images. Set the alignment center at the inferior C5
spine or the superior C6 spine of the head and neck phantom.
2. Select Confirm in the left screen when the images are correctly positioned.
3. Go to the Plan task > Settings step section.

1. Resize the dose calculation box so that it is flush with the faces of the Ball-cube.
2. Select the Contour Correction checkbox.
3. Go to the Plan task > Isocentric step section for the Fixed and Iris collimators only.
Go to Plan task > Sequential step for the Multileaf Collimator only.
Plan Task > Isocentric Step for Fixed and Iris Collimators
In all fixed and Iris cases, start with an isocentric plan, with the collimator centered on the ball.
1. Magnify the images and position the green crosshairs at the center of the ball.
2. With the crosshairs centered within the sphere, click NEW in the Isocenter section of the
control panel to create an isocenter.
3. Choose the correct collimator size from the suggested values of the treatment planning
parameters for the E2E test.
4. Resize the collimator using the pointer tool double arrow on the collimator, on the screen.

5. Recenter the collimator, if necessary, by dragging the collimator and moving it to a

different position.
6. Select the Conformal Weights checkbox.
7. Click Apply.
Plan Task > Sequential Step for Fixed and Iris Collimators
NOTE: A dialog box opens containing the following message: "This plan
contains isocentric conformal beams. They will be included in the optimization.
If you select additional collimators on this step, new beams will be generated
in addition to the isocentric beams previously created."
2. Click OK to close the message window.
3. In the Script section of the control panel, click MU Limits. Enter the following:
• Max MU per Beam = 10
Then click OK.
4. Click Auto-shells. Add an auto-shell as follows:
• Click Add
• Source = Ball.
• Auto-shell Name = [Ball] Shell 1
• Select the Symmetric checkbox. Make the shell 3 mm.
Then click OK.
5. Click Constraints and Steps.
6. In the Maximum Dose Constraints and Dose Volume Constraints section
click the following:
• VOI Name = Ball
• Dose (cGy) = 600
• VOI Name = [Ball] Shell 1
• Dose (cGy) = 240
7. In the Dose Objective section, click Add to add a step to optimize minimum dose:
• VOI Name = Ball
• Objective is Optimize Minimum Dose (OMI)
• Goal Value = 480
8. Click Update to show the total number of sample points. If the number is greater than
50000, click Show VOI Setup and modify the Skip Factor for each VOI used in the
optimization until the number of sample points is less than 50000. Each time you change
a Skip Factor you must click Update again to see the new total number of sample
points.

9. Click OK to close the window.
Plan Task > Sequential Step for Multileaf Collimator

• Total MU = 5000
• Max MU per Segment = 10
• Max MU per Node = 10
Increasing the values of MU per Segment and MU per Node may result in a more
spherical dose distribution.
3. Click on Auto-shells.
Add a symmetric 3 mm shell to the Ball VOI.
5. In the Dose Constraints section:
• Add a maximum dose constraint on the Ball VOI of 600 cGy.
• Add a maximum dose constraint on the Ball Shell VOI of 240 cGy.
6. In the Dose Objectives section:
• Add an OMI Objective on the Ball VOI of 480 cGy.
7. Press the Update button to calculate the total constraint points
8. In the Sampling section, click on Show VOI Setup to enter skip factors if the total
number of sample points is above 50000.
9. Click OK to close the Constraints and Steps window
10. Select MLC Settings.
11. Choose the maximum number of available nodes.
12. Choose Isocentric Conformal.
13. Select Leaf Margin (mm): 0
14. Select Leaf Justification: Middle.
NOTE: If the 70% isodose line is not well within the film edges, use a smaller
leaf margin and tighter leaf justification. For example: a -3 mm leaf margin and
trailing edge leaf justification.
Plan Task > Sequential Step for All Collimator Types

1. Click the Play button. When the optimization is completed, review your results. If you
have an acceptable result, be sure to save the script using the Save Script button in
the upper left corner of the control panel.
2. Prescribe 420 cGy to the 70% isodose line if you are using EBT type film.

3. Click Beam Reduction (called Segment Reduction when performing Sequential

Optimization for Multileaf Collimator plans). Remove any beams with 5 MU or less. Click
Reduce and then click OK.
4. Carefully center the dose on the ball using the steps that follow. Go to the Utilities
task > Ball-cube Plan step.
Utilities Task > Ball-cube Plan Step

1. Select Ball from the Target VOI dropdown list.
2. Enter 70 for the Target Dose % value.
NOTE: This is the default % value that the E2E film analysis software will use
to evaluate the targeting accuracy of your CyberKnife.
3. Click Center Dose button to center the dose cloud on the target.
A message window displaying Success is displayed. You may choose to refine the
center with a high-resolution calculation.
4. Go to the Evaluate task > Review step section.

1. Perform a high resolution dose calculation. Prescribe 420 cGy to the 70% isodose line, if
you are using EBT type film. Prescribe 2100 cGy to the 70% line, if you are using MD film.
2. Use the Measure image tool (the ruler tool) on the Global tool bar to measure the
distance of the 70% isodose line from the center of the ball. Verify that the dose
distribution is symmetric and well centered.
3. Make sure the 45% isodose line and higher is within the film plane.
4. Save the plan as a Deliverable Plan.
5. Print the plan using the Print Patient and Plan Information icon on the global
tool bar. Print the beam data that was used for the dose calculations.

E2E Plans for Respiratory Motion Tracking Modes

This section provides details on treatment planning for the following E2E tests using the Accuray
Precision System:
• “E2E Plan for Synchrony Fiducial Tracking with Respiratory Modeling System” on
page 4-48
• “E2E Plan for Synchrony Lung with Respiratory” on page 4-48
E2E Plan for Synchrony Fiducial Tracking with

Respiratory Modeling System
This section provides information on generating an E2E treatment plan for the Synchrony Fiducial
Tracking with Respiratory Modeling System, which is similar to a Synchrony Fiducial Tracking
System E2E plan. You follow the same steps described in “E2E Plans for Stationary Tracking
Modes” on page 4-41, except for the following difference:
• In the Setup task > Machine step, for Synchrony Method, choose Fiducial
with Respiratory.
All other steps are the same as for the Synchrony Fiducial Tracking System.
E2E Plan for Synchrony Lung with Respiratory

This section provides information on generating an E2E treatment plan for the Synchrony Lung
with Respiratory. For instructions on performing a CT scan of the Lung Motion phantom, see
“Performing a CT Scan for the Synchrony Lung with Respiratory E2E Test” on page 4-75.
NOTE: The following planning steps require the 25.4 mm ball size XLT film
insert.
New Plan Task

2. Select the head and neck phantom from the patient list.
5. Go to the Contour Task > Manual section.
Contour Task > Manual Step

In this step, you will create and name VOIs to be used later in planning.

3. Name the new VOI Tumor. Use the Type dropdown to designate it as a Target, and
click OK.
4. Create an additional VOI for the Spine Tracking Volume, designating it a Critical
structure.

1. Scroll through the CT slices until center of ball is visible in axial view.
2. Magnify the image of the sphere.
3. On the top left of the screen, select Tumor from the VOI dropdown list.
4. Using the window level tool, adjust the grey scale to enhance the contrast of the sphere
relative to the lung.
5. Click Auto Detect.
6. Position the 3D Magic Wand cursor over the ball sphere and left-click once.
7. Verify that the red circle is centered on the ball.
8. Create the Spine Tracking Volume.
9. Go to the Contour Task> Manual step.
Contour Task > Manual Step

In this step you will create a target VOI called “InnerBall”.
1. Click VOI Operations.
2. Set the following:
• Set VOI A to be the Tumor VOI.
• Set Operator to be Copy.
• Set Effect on Destination to be Replace.
• Set Destination to be InnerBall.
• Set Grow to be VOI A.
3. Select Isotropic and enter a value of -5 mm. This step will create the InnerBall
structure with a radius 5 mm smaller than the Tumor structure.
4. Click OK to copy and resize the InnerBall VOI from the Tumor VOI.
5. Go to the Setup task > Machine step.
NOTE: In the above steps, the InnerBall VOI is appropriately sized for fixed,
andIris, and Multileaf Collimators (consistent with Table 2 on page 4-41,
resizing using the Ball VOI Resize Parameter for MLC E2E tests for the
Synchrony Lung with Respiratory). Additional resizing of the target for the
Multileaf Collimator is not required for this plan.


1. Define Parameters as listed below:
• Select the Density Model.
• Number of Fractions = 1 and then click Set.
• Choose the desired collimator type.
• Treatment Anatomy = body_iris-fixed or body_mlc
• Template Path Set = Full_Path
• Synchrony Method = Lung with Respiratory
2. Go to the Setup task > Align step.

1. Use the green crosshairs in the 2D planar views at the bottom of the screen to select the
axial image at the center of the target.
2. Without changing the axial position, adjust the alignment center at the spine such that the
amount of bony spinal anatomy is maximized in the tracking mesh. The amount of soft
tissue outside of the tracking mesh should be minimized. Small adjustment of the ROI
tracking mesh might be needed.
3. Click the Confirm button.
4. Go to the Setup task > DRR Review step.
Setup Task > DRR Review Step

1. Select the Tumor structure as the Tracking Tumor VOI.
NOTE: Make sure you select the Tumor VOI as the Tracking
Tumor, because it is important to track the entire ball and not the
inner (reduced size) ball, InnerBall.
2. When Display Contour is selected in the Treatment CT Center section of the
control panel, the contoured structure is displayed.
3. Confirm that the contoured sphere is displayed in the DRR.
4. The axis cursors in the lower planar views should all be centered on the sphere.
5. Click the Apply button in the control panel.
6. Go to the Plan task > Settings step.

1. Select the appropriate CT Density Model for your phantom CT.
2. Select Contour Correction (Fixed and Iris only).

3. Adjust the Dose Calculation Grid to encompassed.

4. Go to the Plan task > Isocentric step for Fixed and Iris plans or go to the Plan task >
Sequential step for MLC plans.
Plan Task > Isocentric Step for Fixed and Iris Collimators
1. Ensure that the crosshairs are centered within the InnerBall VOI in all views.
2. Under Isocenter in the control panel, click New.
3. Magnify the region in the vicinity of the film insert.
4. Select the 15 mm collimator. Under All Isocenters, select the Conformal Weights
checkbox.
5. Click the Apply button.
NOTE: It is necessary to create Synchrony Lung Tracking with Respiratory

Modeling E2E plans with the 15 mm collimator due to the small size of the film.
The ball diameter in the film insert is 1 in. (2.54 cm) and should be used for
contouring of the phantom tumor volume and used as the tracking target.
However, the isodose contour that will be used for film analysis should be
smaller than 1 in. (2.54 cm) to ensure that it is within the physical bounds of the
film.
The nomenclature for field size of a collimator for the CyberKnife System is
based on a LINAC beam Source-Axis distance of 800 mm. The distance for
lung treatments is approximately 950 mm. Therefore, the beam size at the
distance to the Synchrony Lung with Respiratory film insert will be greater than
15 mm.
Plan Task > Sequential Step for Fixed and Iris Collimators
NOTE: A dialog box opens containing the following message: "This plan
contains isocentric conformal beams. They will be included in the optimization.
If you select additional collimators on this step, new beams will be generated
in addition to the isocentric beams previously created."
2. Click OK to close the message window.
• Total MU = 5000
• Max MU per Beam = 10
Then click OK.
4. Click Auto-shells. Add an auto-shell as follows:
• Click Add.

• Source = InnerBall.
• Auto-shell Name = [InnerBall] Shell 1
• Select the Symmetric checkbox. Make the shell 3 mm.
Then click OK.
6. In the Dose Constraints section click the following:
• VOI Name = InnerBall
• Dose (cGy) = 600
• VOI Name = [InnerBall] Shell 1
• Dose (cGy) = 240
7. In the Dose Objectives section, select the following:
• VOI Name = InnerBall
• Objective is = Optimize Minimum Dose (OMI).
• Goal Value = 480
8. Click Update and adjust the skip factors so that the total number of Sample Points is
less than 50000.
9. Click OK to close the window.
Plan Task > Sequential Step for Multileaf Collimator

• Total MU = 5000
• Max MU per Segment = 10
3. Click on Auto-shells.
Add a symmetric 3 mm shell to the InnerBall VOI.
5. In the Dose Constraints section:
• Add a maximum dose constraint on the InnerBall VOI of 600 cGy.
• Add a maximum dose constraint on the InnerBall Shell VOI of 240 cGy.

6. In the Dose Objectives section:

• Add an OMI Objective on the InnerBall VOI of 480 cGy with a 20 cGy Relaxation
Value.
7. Press the Update button to calculate the total constraint points
8. In the Sampling section, click on Show VOI Setup to enter skip factors if the total
number of sample points is above 50000.
9. Click OK to close the Constraints and Steps window
10. Select MLC Settings.
• Choose the maximum number of available nodes.
• Choose Isocentric Conformal for the InnerBall VOI.
• Select Leaf Margin (mm): 0
• Select Leaf Justification: Middle.
NOTE: If the 70% isodose line is not well within the film edges, use a smaller
leaf margin and tighter leaf justification. For example: a -3 mm leaf margin and
trailing edge leaf justification.
Plan Task > Sequential Step for All Collimator Types

1. Click the Play button. If you have an acceptable result, be sure to save the script using
the Save Script button in the upper left corner of the control panel.
2. If you are using EBT type film, prescribe 420 cGy to the 70% isodose line.
3. Left-click in the isodose list and edit the values. Change 100% to 98% and change 40%
to 45%. Then turn off all values except 98, 90, 70, 45, and 20.
4. Click Beam Reduction (called Segment Reduction when performing Sequential
Optimization for Multileaf Collimators plans). Remove any beams with 5 MU or less. Click
Reduce and then click OK.
5. Go to the Utilities task > Ball-cube Plan step.
Utilities Task > Ball-cube Plan Step

1. Select Tumor from the Target VOI dropdown list.
2. Enter 70 for the Target Dose % value.
NOTE: This is the default % value that the E2E film analysis software will use
to evaluate the targeting accuracy of your CyberKnife System.
3. Click Center Dose button to center the dose cloud on the target.
A message window displaying Success is displayed. You may choose to refine the
center with a high resolution calculation. However, you will also need to recalculate with
High Resolution on the Finetune step in order to save the plan as deliverable.
4. Go to the Evaluate task > Review step section.


1. Perform high resolution calculation.
2. If EBT type film is used, prescribe 420 cGy to the 70% isodose line. Prescribe 2100 cGy
to the 70% line, if you are using MD film.
3. Use the Measure image tool (the ruler tool) on the Global tool bar to measure the
distance of the 70% isodose line from the center of the ball. Verify that the dose
distribution is symmetric and well centered.
4. Make sure the 45% isodose line and higher is within the film plane.
5. Save the plan as deliverable.
6. Close the planning session to initiate DRR generation.

E2E Dose Delivery for Stationary Tracking

Modes
Stationary tracking modes include the Synchrony Skull Tracking System, Synchrony Fiducial
Tracking System, and Synchrony Spine Tracking with Respiratory Modeling. Many of the steps are
similar for all of the tracking modes. Differences are indicated below as needed.
 To perform E2E dose delivery for a stationary tracking mode:
1. Mark the film to be loaded into the Ball-cube. One film should be labeled with "A"
(Anterior) and "S" (Superior). The other film should be labeled with “S" (Superior) and "L"
(Left).
2. Insert the film into the Ball-cube and verify the proper film orientation (see “Using the
Original Ball-cube” on page 4-37). Be careful to align the Superior, Anterior, and Left
edges of the film exactly along the edges of the cube. Ball-cube II users should be careful
to align the film on the alignment pins.
NOTE: The Ball-cube II users do not need to align the film edges, because the
alignment pins and associated film holes control the alignment of the films.
3. Place the Ball-cube into the head and neck phantom. Be sure to correctly orient the Ball-
cube.
The orientation of the Ball-cube when loaded into the phantom for dose delivery should
correspond to its orientation during the CT scan. Figure 35 shows the Ball-cube inside the
phantom.
• For testing the Synchrony Skull Tracking System and Synchrony Fiducial Tracking
System, Figure 35 shows the location of the slot for the Ball-cube in the head and
neck phantom. The “S” (Superior) and “L” (Left) sides of the Ball-cube should be
oriented as shown.
• For testing the Synchrony Spine Tracking with Respiratory Modeling, Figure 36
shows the location of the slot for the Mini Ball-cube in the head and neck phantom.
1075879-ENG A E2E Dose Delivery for Stationary Tracking Modes |4-55

Ball-cube “S”
“L”
Figure 35 Head and neck phantom with standard

Ball-cube inserted into slot
4-56 | E2E Dose Delivery for Stationary Tracking Modes 1075879-ENG A

Mini Ball-cube
Slot
Figure 36 Head and neck phantom with slot for mini Ball-
cube
4. Place the head and neck phantom on the treatment couch table top (either the standard
treatment couch or the optional RoboCouch System) in the same orientation used for the
CT scan. The phantom should be placed at the Superior end of the treatment couch for
Synchrony Skull Tracking mode. The phantom should be placed in the middle of the
treatment couch for body tracking modes (the Synchrony Fiducial Tracking System, the
Synchrony Spine Tracking with Respiratory Modeling, and Synchrony Fiducial Tracking
with Respiratory Modeling System).
5. On the treatment delivery computer, deliver the E2E treatment plan to the head and neck
phantom containing the Ball-cube.
NOTE: For the Multileaf Collimator, if you are using room alignment lasers,
turn them off before starting treatment delivery. Otherwise, the room lasers
may potentially interfere with the MLC Secondary Feedback System and
Secondary Feedback System check failures may occur.
6. When treatment is completed, remove the Ball-cube from the phantom.
When you dismantle the Ball-cube, evaluate the position of the Ball-cube in the phantom
and the position of the film in the Ball-cube. Verify the correct orientation of the Ball-cube
and confirm that the film is labeled properly.
7. To perform digital analysis, see “Film Analysis for E2E Tests” on page 4-81 for the
procedure to follow for automated Ball-cube test film analysis.
1075879-ENG A E2E Dose Delivery for Stationary Tracking Modes |4-57

E2E Dose Delivery for Synchrony Respiratory

Motion Tracking Modes
Respiratory motion tracking modes include the Synchrony Fiducial Tracking with Respiratory
Modeling System and the Synchrony Lung with Respiratory. The E2E test for the Synchrony
Fiducial Tracking with Respiratory Modeling System uses the Synchrony Respiratory Motion QA
tool for respiratory modeling. The E2E test for the Synchrony Lung with Respiratory uses the
optional Lung Motion phantom. The Lung Motion phantom is not provided with the CyberKnife
System. It is available for purchase from its vendor CIRS. For information, see Chapter 2,
• “E2E Test for Synchrony Fiducial Tracking with Respiratory Modeling System” on
page 4-58
• “E2E Test for the Synchrony Lung with Respiratory” on page 4-66
E2E Test for Synchrony Fiducial Tracking with

This section describes the E2E test for the Synchrony Fiducial Tracking with Respiratory Modeling
System. It also describes procedures for using the Synchrony Respiratory Motion QA tool for
respiratory motion tracking.
• “Overview” on page 4-58
• “Synchrony Respiratory Motion QA Tool Controls” on page 4-59
• “Charging the Synchrony Respiratory Motion QA Tool” on page 4-60
• “Performing a CT Scan for the Synchrony Fiducial Tracking with Respiratory
Modeling E2E Test” on page 4-60
• “Generating a Synchrony Fiducial Tracking with Respiratory Modeling E2E Treatment
Plan” on page 4-61
• “Delivering the Synchrony Fiducial with Respiratory Modeling E2E Treatment Plan” on
page 4-62
• “Synchrony Respiratory Motion QA Tool Maintenance” on page 4-64
Overview
The Synchrony Respiratory Motion QA tool for respiratory motion tracking (also referred to as the
Synchrony Respiratory Motion table) is used to verify the proper operation of Synchrony Fiducial
Tracking with Respiratory Modeling at a clinical site. This verification is performed by comparing
the targeting accuracy and dose profiles of static and moving E2E tests. In the E2E test, both
positioning accuracy and radiation distribution shape will be measured.
4-58 | E2E Dose Delivery for Synchrony Respiratory Motion Tracking Modes 1075879-ENG A
The following equipment and materials are used during the E2E test:
• Original Ball-cube or Ball-cube II.
• 12 cm diameter dome which fits over the Ball-cube.
• Synchrony Respiratory Motion QA tool for respiratory motion tracking.
• Box of Gafchromic EBT type film containing 20 2.5 in x 2.5 in (6.35 cm x 6.35 cm) pre-
notched sheets.
• Film scanner.
• E2E test film analysis software provided by Accuray.
• NIH ImageJ film analysis software, or another software application capable of analyzing
film and reading RT/DICOM files. For more information on ImageJ film analysis software,
see Chapter 2, “Commissioning”.
Using the Synchrony Respiratory Motion QA tool, two E2E tests are performed.
The suggested E2E tests are:
• Static, with no-motion (ideal) of the Synchrony Respiratory Motion QA tool.
• Full motion, with 10º phase shift between Anterior/Posterior chest movement and
Superior/Inferior tumor movement.
Synchrony Respiratory Motion QA Tool Controls

Figure 37 shows the location of Synchrony Respiratory Motion QA tool controls on the front panel.
4
1
5 2 3
Figure 37 Controls on the front panel of the Synchrony

Respiratory Motion QA tool
• (1) Battery selection sliding switch: Used to select which of two batteries runs the device.
In Figure 37, BAT 1 is selected to run the device. The DC jack for other battery BAT 2 is
available for charging using the AC adaptor.
1075879-ENG A E2E Dose Delivery for Synchrony Respiratory Motion Tracking Modes |4-59
• (2) Power-on switch: Green toggle switch used to turn on the Synchrony Respiratory
Motion QA tool.
• (3) Speed control dial: Used to adjust the speed of the Synchrony Respiratory Motion QA
tool.
• (4) DC jacks: One on each side of the sliding switch (1). Used to connect AC adaptor for
battery charging.
• (5) Fuse holder: Contains the fuse for the motor.
Charging the Synchrony Respiratory Motion QA Tool

Charge at least 1 battery pack on the Synchrony Respiratory Motion QA tool using the provided
charger. Use the sliding switch on the front panel of the Synchrony Respiratory Motion QA tool to
select the desired battery pack to charge (see Figure 37). When one battery pack is selected for
charging, the other battery pack is automatically used to drive the motion table. Thus the unit can
be charged and operated at the same time.
NOTE: Do not over-charge the batteries. Disconnect the power after charging
for 24 hours. Over-charging will significantly reduce the life of the batteries.
Performing a CT Scan for the Synchrony Fiducial

Tracking with Respiratory Modeling E2E Test
Obtain a CT image study of the standard Ball-cube inside the 12 cm dome:
1. Load the Ball-cube with film.
2. Insert the Ball-cube into the dome (see Figure 38).
Figure 38 Inserting the Ball-cube inside the dome
3. To position the Ball-cube for the CT scan, place the Ball-cube (with the dome on top) so
that it is in the proper anatomical orientation (anterior facing up). The Ball-cube should be
parallel to the centerline axis of the CT table top and flat on the table.
NOTE: It is not necessary to include the entire Synchrony Respiratory Motion

QA tool in the CT scan. It is only necessary to include the Ball-cube inserted
inside the dome.
4. For the CT scan, use 120 kVp and thin slices. Use minimum pitch if a multi-slice scanner
is used.
Generating a Synchrony Fiducial Tracking with

Respiratory Modeling E2E Treatment Plan
1. Generate an E2E treatment plan for the Synchrony Fiducial Tracking with Respiratory
Modeling System using standard Accuray procedures. This plan will be copied and
repeated for all measurements in this protocol.
For E2E treatment planning details for the Synchrony Fiducial Tracking with Respiratory
Modeling System, “E2E Plan for Synchrony Fiducial Tracking with Respiratory Modeling
System” on page 4-48.
2. Export the DICOM RT dose format from the Accuray Precision System using the Export
DICOM Data icon on the global tool bar.
3. Using a third-party software application, such as ImageJ or FilmQA, create profiles
through the center of the target in each direction. The profiles will be overlaid with the film
results produced later to do the comparison (see Figure 39).
Figure 39 Planned dose distribution in Synchrony Respira-

tory Motion Ball-cube E2E test
Delivering the Synchrony Fiducial with Respiratory

Modeling E2E Treatment Plan
Deliver the treatment plan to the Ball-cube, as described below. First deliver the plan without
motion to establish the expected targeting accuracy. Then deliver the plan with full motion of the
Synchrony Respiratory Motion QA tool.
1. Load the Ball-cube with film (see “Using the Ball-cube in E2E Tests” on page 4-36).
2. In the Respiratory phase, disable respiratory tracking by selecting the Skip
Respiratory checkbox (see Figure 40).
Figure 40 Respiratory phase (left screen) of Synchrony

Fiducial Tracking mode with respiratory tracking disabled
3. Deliver your E2E test plan with fiducial tracking to the Ball-cube with no target motion.
4. Place the Synchrony Respiratory Motion QA tool and the Ball-cube (inside the dome) on
the treatment couch (see Figure 41).
• Use at least two Synchrony Respiratory External LED Markers with maximum
Anterior/Posterior motion.
• Elevate the target at least 3 in (7.6 cm) to facilitate fiducial extraction. To do this, use
a 5 cm Styrofoam block (for example, as shown in Figure 41) to elevate the Ball-cube
(inside the dome) to minimize image interference of the fiducials with the Synchrony
Respiratory Motion QA tool components. The orientation of the Ball-cube for
treatment delivery must match the orientation used for the CT scan.
Figure 41 Synchrony Respiratory Motion QA tool set up

with Ball-cube inside the dome on treatment couch
5. To obtain simple linear motion, verify that the Synchrony Respiratory Motion QA tool
phase shift is set to zero degrees (0.
If necessary, loosen the 2 set screws (see Figure 42) and align the cam as follows: The
0° mark should be aligned with the indicator line on the motor shaft. Tighten the set
screws. Ensure the cam is aligned to 10° or less.
Figure 42 Example of cam aligned at 30° position
6. When setting up for delivery of a Synchrony Fiducial Tracking with Respiratory Modeling
QA plan, position the center of the range of motion of the Synchrony Respiratory Motion
QA tool approximately 5 mm off-center from the machine center along each axis in the
robot coordinate frame (Superior/Inferior, Left/Right, and Anterior/Posterior directions).
Using this off-center position demonstrates that the treatment robot can correct for motion
that is offset from the machine center.
7. Perform an alignment step before starting E2E dose delivery. Acquire images to match
the plan DRR images using the following X-ray imaging parameters: kV = 110 kVp,
mA = 100 mA; mS = 50 milliseconds.
NOTE: For the Synchrony Fiducial Tracking with Respiratory Modeling

System, select exposure times of 75 milliseconds or less.
8. Verify by sweep second hand or stopwatch that the variable speed motor control
produces a motion frequency between 15 and 16 cycles per minute. If necessary, adjust
the speed using the dial to the right of the green toggle switch (see Figure 37).
9. Deliver the E2E test plan to the Ball-cube with the Synchrony Respiratory Motion QA tool
moving.
10. Remove the film from the Ball-cube for analysis.
CAUTION: If the phase shift exceeds 10°, excessive treatment robot movement or vibration may
result.
11. For information on film analysis for the Synchrony Fiducial Tracking with Respiratory
Modeling E2E test, see “Film Analysis for the Synchrony Fiducial Tracking with
Respiratory Modeling E2E Test (Optional)” on page 4-88.
Synchrony Respiratory Motion QA Tool Maintenance

This section provides information on Synchrony Respiratory Motion QA tool maintenance. It covers
the following topics:
• “Replacement Parts” on page 4-64
• “Fuse Replacement” on page 4-65
• “Battery Charging, Replacement, and Disposal” on page 4-65
• “Cleaning the Synchrony Respiratory Motion QA Tool” on page 4-65
Replacement Parts
Replacement fuses, traction bands, batteries, and battery charging adaptors are available from
Accuray. For information on replacement parts, contact Accuray Customer Support.
Fuse Replacement
Replace the fuse with a 5 mm x 20 mm T1AL250V fuse only.
CAUTION: Use of fuses other than those approved by Accuray can result in damage to the
Synchrony Respiratory Motion QA tool.
Battery Charging, Replacement, and Disposal
 To charge the batteries:

When the desired speed of Synchrony Respiratory Motion QA tool motion cannot be attained,
switch the battery selection switch to the unused (charged) battery and charge the depleted battery
as follows.
1. Connect the AC adaptor supplied with the unit to the exposed DC jack.
2. Plug the adaptor into the wall. The battery will charge in 3 to 4 hours. For maximum
battery life, do not leave the adaptor connected to the unit after battery charging is
complete. If desired, the Synchrony Respiratory Motion QA tool can be run using the
battery that is not being charged while the depleted battery is being charged.
The following battery charging adaptors are used with the unit:
• GlobTek Inc. Model GT-341-12-500D for 120VAC, 60Hz (North America)
• GlobTek Inc. Model GT-3T41-12-500D-3 for 230VAC 50 Hz (Europe).
 To replace the batteries:
When the unit can no longer run the Synchrony Respiratory Motion QA tool for the desired length
of time after being recharged, the battery pack(s) will need to be replaced. When the replacement
pack(s) have been received, they can be installed as follows.
1. Remove the 10 nylon screws that hold the cover onto the base.
2. Remove the old battery pack(s) by disconnecting the wires at the in-line connector (pulls
apart) and pulling the pack(s) from their Velcro mounts.
3. Install the new pack(s) by pressing them into place, and connecting the wires.
4. Reinstall the cover and secure it with the nylon screws.
 To dispose of the batteries:
• DO NOT dispose of old battery packs in the regular trash. These NiCd battery packs
should be taken to appropriate facilities for correct disposal or handled as directed by
state or local waste handling laws.
Cleaning the Synchrony Respiratory Motion QA Tool

It is recommended that periodic cleaning of the Synchrony Respiratory Motion QA tool be
performed using a soft cloth dampened with a mild detergent solution or an alcohol wipe.
NOTE: The use of high-level disinfectants such as Cidex may discolor the unit.
E2E Test for the Synchrony Lung with Respiratory

The optional Lung Motion phantom permits demonstration of the targeting accuracy of the
Synchrony Lung with Respiratory with the CyberKnife System.
• “Major Components of the Lung Motion Phantom” on page 4-66
• “Using the Motion Controller” on page 4-69
• “Setting Up for the Synchrony Lung Tracking with Respiratory Modeling E2E Test” on
page 4-71
• “Performing a CT Scan for the Synchrony Lung with Respiratory E2E Test” on page 4-75
• “Treatment Delivery for the Synchrony Lung Tracking with Respiratory Modeling E2E
Test” on page 4-77
The Lung Motion phantom is designed to work in conjunction with the Synchrony Lung with
Respiratory. This phantom is not provided with the CyberKnife System. It is available for purchase
from its vendor CIRS. For information, see Chapter 2, “Commissioning”. For a list of all
components included with the motion phantom, see the vendor’s documentation.
NOTE: Accuray Service personnel use E2E test results from the Synchrony
Skull Tracking mode, the Synchrony Fiducial Tracking mode, and the
Synchrony Spine Tracking with Respiratory Modeling for the purpose of
setting the DeltaMan value. The Synchrony Lung with Respiratory is not used
for setting the DeltaMan value.
For more information on the Synchrony Lung with Respiratory, see the Treatment Planning Manual
and the Treatment Delivery Manual.
Major Components of the Lung Motion Phantom

The optional Lung Motion phantom simulates respiratory motion of a human torso and provides
radiochromic film-based test capability at locations inside the phantom that correspond to a typical
lung tumor and a critical structure in a patient. Components of the Lung Motion phantom are similar
to the standard torso motion phantom from CIRS, Inc. but are designed specifically for use with the
Synchrony Lung with Respiratory option on the CyberKnife System. Figure 43 shows the motion
phantom attached to the lung tracking phantom thorax.
Thorax Body Moving Rod LED Platform Motion Motion

Actuator Controller Box
Figure 43 Motion phantom attached to the Lung

Motion Tracking thorax
For instructions on unpacking the Lung Motion phantom and setting up the motion actuator with
the motion controller box, see the vendor’s documentation.
Major components of the Lung Motion phantom include the following:
• Motion controller box
• Motion actuator
• LED platform
• Thorax body
• Moving rods
• Film insert for dosimetry (inserted into the moving rod)
The motion controller box provides the option of choosing 16 motion profiles and drives the motion
actuator to provide such motion. Figure 44 shows how the Synchrony Respiratory External LED
Markers are attached to the LED platform. The LED platform moves up-down to simulate Anterior-
Posterior chest motion. Figure 45 shows the thorax body and film insert for performing E2E tests
for the Synchrony Lung with Respiratory.
Figure 44 LED platform with Synchrony Respiratory

External LED Markers
Figure 45 Synchrony Lung with Respiratory thorax body

(top left), moving rod (top right), and film insert with film
(bottom)
The moving rod can simultaneously translate in-out to simulate Superior-Anterior motion and rotate
around the central axis of the rod to simulate lateral motion. Dosimetry and beam targeting
accuracy measurements are possible using the film insert while the motion is activated so that a
user can perform the E2E test for the Synchrony Lung with Respiratory on the CyberKnife System.
Using the Motion Controller

• “Operating the Motion Controller” on page 4-69
• “Replacing the Fuses” on page 4-70
Operating the Motion Controller

Only minimal operator control is required in order to activate the motion phantom for the Synchrony
Lung with Respiratory. There are 4 binary switches along the face of the motion controller (see
Figure 46). Set the switches appropriately for the Synchrony Lung with Respiratory.
Figure 46 Motion controller
 To operate the motion controller:

1. Turn on the motion controller.
2. Leave the control switch in the LOCAL setting.
3. Press the START switch once.
The motion actuator performs a homing cycle.
4. When the motion stops, press the START switch (second time).
The actuator moves to its starting position. The starting position is also the midpoint of the
full range of motion for the actuator.
5. When the motion stops, press the START switch (third time).
6. The system begins executing the selected preprogrammed motion.
The phantom is ready for delivery of the treatment beam.
Replacing the Fuses

If the motion controller does not power up as indicated by the green light on the switch, check the
power cord and source. If connections are good, check the fuses on the back of the control box
(see Figure 47.)
Figure 47 Fuse replacement
 To replace a fuse:
1. Unplug the unit.
2. Using a flat head screwdriver, pry open the fuse tray.
3. Slide the tray out and fold down the fuse drawer.
4. Remove and replace fuses with 2 Amp, F fast acting fuses 5 x 20 mm.
CAUTION: Use of fuses other than those approved by Accuray can result in damage to the unit.
5. Close fuse tray and proceed.
Setting Up for the Synchrony Lung Tracking with

Respiratory Modeling E2E Test
This section describes procedures for setting up the Lung Motion phantom for the Synchrony Lung
with Respiratory E2E test. The following equipment and materials are used:
• Optional Lung Motion phantom with Synchrony Lung with Respiratory components
• Low density film insert
• Radiochromic film
• Motion controller
• Motion actuator
• Synchrony External Respiratory LED Markers
 To set up for Synchrony Lung Tracking with Respiratory Modeling E2E dose delivery:
NOTE: To set up to acquire a CT scan of the phantom, load film into the film
insert as described below. For the CT scan, the moving rod should also be
positioned and oriented in the starting position described below. For the CT
scan, it is not necessary to attach the LED markers to the platform or to connect
the motion control box to the motion actuator.
1. Load 2 crossed films in the low density film insert shown in Figure 48.
Figure 48 Low-density film insert
NOTE: It is important to properly align the films with the straight edges of the
cube to minimize variation in test results.
Align the films precisely as follows:

• Install the films in the film insert.
• Press each side of the film insert against a hard flat surface so the film edges are
flush with the cube faces. If the film becomes stuck, push the film from the opposite
side using a stiff piece of paper such as a business card. The important edges of the
film are the Anterior, Superior and Left edges.
• To determine if the films are aligned with the edges of the assembled film insert, look
at the reference edges from a 45° angle with respect to the surface of the film insert.
• The edge of the unexposed film should appear as a black line.
• If the film is below the surface the black line is not visible. If the film is sticking out too
far, you can see it sticking out can feel it with your fingers.
2. Place the film insert into the cavity in the moving rod (see Figure 49.) Make sure that the
film insert is properly oriented within the phantom.
Figure 49 Synchrony Lung with Respiratory moving rod

without and with the film insert
3. Attach the Synchrony Lung with Respiratory thorax body and the moving rod to the
actuator, shown in Figure 50. Be sure the white part of the moving rod is flush with the
actuator as shown.
Figure 50 Lung Motion Phantom body separated (left) and

attached (right)
4. Align the Lung Motion phantom on the treatment couch as you would for an actual patient
by using the spine alignment feature of the Synchrony Lung with Respiratory user
interface of the CyberKnife System. For more information on patient alignment using the
Synchrony Spine Tracking with Respiratory Modeling, see the Treatment Delivery
Manual.
5. Attach the LED markers to the platform (see Figure 53.)
6. Connect the motion control box to the motion actuator using the DB15 cable provided.
7. Use the START button to move the motion actuator to its starting position as explained
above.
8. Insert the moving rod into the thorax and orient the film cassette (see Figure 51.)
9. Attach the moving rod to the motion actuator by tightening the screws on the motion
actuator.
It is acceptable if the moving rod does not slip all the way into the receiving end of the
motion actuator. However, it is important to achieve consistent positioning and alignment
of the moving rod to the actuator each time you use it for QA procedures.
To facilitate returning the moving rod to this starting position after each time that the rod is
disconnected from the actuator, you can mark the moving rod and the thorax with a pencil
or fine point permanent ink pen.
Figure 51 Orientation of film insert for Synchrony Lung with

Respiratory phantom with motion actuator in starting posi-
tion
Figure 52 Phantom setup with LED markers on treatment

couch
Figure 53 Phantom setup with motion controller on treat-

ment couch
Performing a CT Scan for the Synchrony Lung with

Respiratory E2E Test
It is essential to set up the Lung Motion Phantom and its insert rods in exactly the same way for
the CT scan and treatment delivery. During the CT scan, the rod will be stationary. The static
position of the target ball should be somewhere along its normal motion path. It should be at the
starting point of the motion or at the center of the motion. The Head First Supine (HFS) position of
the phantom on the treatment couch is shown in Figure 43 on page 4-67. Make sure that the
Superior and Inferior faces of the phantom are outside of the field of view of the CT as shown in
Figure 54. This means that the CT of the phantom will extend to the very Superior and Inferior
edges of the CT field of view just like an actual patient torso. Use the CT scanner’s lasers and a
level to ensure that the phantom is oriented as straight as possible with the axes of the CT scanner.
If the CT scanner has a curved patient table, you will need to either use a table insert or improvise
a flat surface for the motion phantom base plate to rest on.
Figure 54 CT scan Superior-Inferior limits for phantom

thorax
In order to create a plan, the user will obtain a CT scan of the Lung Motion Tracking phantom (with
motion off) containing the film insert loaded with film. To minimize measurement error due to
localization, use 1.5 mm slice thickness or less, and use sequential axial slices. Helical CT scans
may sometimes not be precise enough to function satisfactorily with the CyberKnife System which
is capable of delivering beams with sub-millimeter precision.
NOTE: Follow the appropriate Accuray procedure for CT scanning.
Import the CT images to the iDMS Data Management System. If a multi-slice scanner is used,
confirm that the kVp is 120, and that minimum pitch is set.
After taking the CT images of the phantom and importing them to the iDMS Data Management
System, the user will load the CT data into the Accuray Precision System. Figure 55 on page 4-77
shows phantom CT images loaded into the Accuray Precision System. Generate a treatment plan
for the Synchrony Lung with Respiratory E2E test as described in “E2E Plan for Synchrony Lung
with Respiratory” on page 4-48.
Figure 55 3D and planar view of Lung Motion Phantom for

the Synchrony Lung with Respiratory
Treatment Delivery for the Synchrony Lung Tracking with

This section describes the treatment delivery procedure for the Synchrony Lung with Respiratory
E2E test. After setting up the Lung Motion phantom on the treatment couch, you will first align the
phantom using the Synchrony Spine Tracking with Respiratory Modeling in the Alignment >
Align screen. Next, you will use the Synchrony Lung with Respiratory to align the tumor, create a
Respiratory Model, and track the tumor during the treatment.
NOTE: Rotational corrections are not applied during treatment delivery using
the Synchrony Lung with Respiratory.
Figure 56 through Figure 57 show examples of the Alignment > Align screen and
Respiratory phase screens during the Synchrony Lung Tracking with Respiratory Modeling E2E
test. For information on Synchrony Lung Tracking with Respiratory Modeling treatment delivery,
see the Treatment Delivery Manual.
NOTE: Live X-ray image acquisition of the Synchrony Lung with Respiratory
phantom can result in “false positive” results and inaccurate Offset values
due to the uniformity of the target in the phantom. (A false positive result
occurs when image correlation is performed without generating an error even
though the target is not identified correctly by the tracking algorithm.) Be sure
to review images of the Lung Motion phantom for proper alignment.
Figure 56 Alignment > Align phase of a Synchrony

Lung Tracking with Respiratory Modeling treatment
delivery
The following parameter selection in the Respiratory phase should be used for the Synchrony
Lung Tracking with Respiratory Modeling E2E test:
• Preferred Projection (ON) checkbox: When this option is selected, the Synchrony
Lung Tracking with Respiratory Modeling algorithm uses the tracking result from a
preferred projection to assist tracking in the secondary projection. This option is helpful in
cases when the Target dxAB value is large. When the Preferred Projection (ON)
checkbox is selected for the Synchrony Lung Tracking with Respiratory Modeling E2E
test, visual inspection is recommended to include the tumor inside the tracking range.
Offset Mode may be used together with the Preferred Projection (ON) checkbox to
build the Respiratory Model.
Figure 57 Respiratory phase (left screen) of a

Synchrony Lung Tracking with Respiratory Modeling
treatment delivery
For information on film analysis for the Synchrony Lung Tracking with Respiratory Modeling E2E
test, see “Film Analysis for the Synchrony Lung Tracking with Respiratory Modeling E2E Test” on
page 4-91.
Film Analysis
• “End-to-End Film Analysis” on page 4-80
• “Film Analysis for E2E Tests” on page 4-81
• “Film Analysis for the Synchrony Fiducial Tracking with Respiratory Modeling E2E Test
(Optional)” on page 4-88
• “Film Analysis for the Synchrony Fiducial Tracking with Respiratory Modeling System” on
page 4-89
End-to-End Film Analysis

Each phase of the End-to-End test, including treatment planning, treatment delivery, and film
analysis, can be performed using the Ball-cube II, the Accuray head phantom, and Accuray End-
to-End test film analysis software.
Figure 58 shows the Ball-cube II films analyzed using Accuray standard film analysis software
(Accuray End-to-End (E2E) Film Analysis version 4.0). The film analysis software can be used to
calculate End-to-End targeting errors.
NOTE: If the film analysis software has difficulty identifying film orientation,
then use one film per file.
The films in Figure 58 have film labels added (Anterior, Left, and Superior) to use as a reference
for associating film shape and anatomical position.
NOTE: It is important to put a black mark on each film to help the auto window/
level display the dose properly.
4-80 | Film Analysis 1075879-ENG A

Figure 58 End-to-End film analysis software

showing Ball Cube II film
Film Analysis for E2E Tests

CAUTION: Since the results from EBT type film can depend upon scan orientation, care must be
taken to scan all the films in the same orientation, for example, with the slit aligned vertically with
the scanner.
Support for film analysis of EBT type film is provided by Accuray. Find the location of the E2E film
analysis software and run the program. The user interface is displayed. All of the commands
needed to use this software can be found in the menu bars.
You must select the EBT film from the Film_Type dropdown menu on the End-to-End (E2E)
Film Analysis (version 4.0) screen.
Note the following:
• Pixel value intensity measurements are displayed with 2 significant digit precision.
• Log files that document all user actions are saved and available for review as needed.
• “Calibration Information” on page 4-82
1075879-ENG A Film Analysis |4-81

• “Load Images” on page 4-82

• “Process the Films” on page 4-83
• “Reorient the Images” on page 4-84
• “Modify Other Information” on page 4-84
• “Perform Analysis” on page 4-85
• “Print” on page 4-86
• “Save Results to a Text File” on page 4-86
• “Show DeltaMan Values” on page 4-87
• “Export Images” on page 4-87
• “Exit” on page 4-87
• “Solutions to Common Problems” on page 4-87
Calibration Information
To enter the calibration factors (pixels per inch) that were determined previously for your film
scanner, click CALIBRATION > SET DPI. This brings up a user interface where the X and Y
direction pixels can be entered. Clicking OK will save those settings. Clicking CANCEL will keep
the old settings.
WARNING: Do NOT use auto calibration selection with E2E. The precision is inadequate
and erroneous targeting data may result.
Load Images
 To load 3 films at once:
1. To open an image of 3 films (Anterior-Left, Anterior-Superior, Blank), click FILE >
OPEN 3 FILMS. A dialog box will pop up asking for a file name.
2. After selecting the file, if the films from this image set have been stored on the hard disk in
the same folder, the program will ask if those images should instead be loaded. If this is
desired, the rotated and cropped images will be immediately loaded and displayed.
If this is the first time opening a dataset, many preprocessing routines will be called upon
the image. The status bar in the lower right of the User Interface will inform the user of
which step is currently being processed.
3. The E2E Open 3 Films menu option uses the default image orientation, which is Anterior/
Left for Image 1 and Anterior/Superior for Image 2.

4. To avoid visual misinterpretation, verify image orientation in the dropdown menus before
proceeding with image analysis. Use the dropdown Image1 and Image2 menus to verify
the correct orientation of Image 1 and Image 2 of a 3-film set.
NOTE: It is extremely important to verify the correct orientation of Image1 and

Image2 using the dropdown menus. Failure to do so may result in incorrect
and/or inconsistent results.
If a second set of films is loaded immediately in succession, the image analysis will be
based on the default image orientation, even if the films are in a different orientation, such
as Anterior/Superior for Image 1 and Anterior/Left for Image 2.This will persist even after
using the dropdown Image1 and Image2 menus to verify orientation.
NOTE: To avoid this, you must restart the E2E software after each analysis of
a 3-film set imported with the Open 3 Films option.
NOTE: This will not occur if you use the Open Single Film option for E2E
software image analysis.
 To load single To images (optional):

1. To select a single image, click FILE > OPEN SINGLE FILM.
Another user interface will load to import images.
2. Select BROWSE and select an image file for the film set. The image is loaded, allowing
for the determination of the type of film. Use the dropdown box to select the appropriate
film.
3. Transform the image.
If any rotations or flips are needed to place the Anterior (A) and Superior/Left (S/L) edges
in the correct location, use the Image1 and Image2 dropdown menus to perform
those transformations. Next, select Process, and alignment and cropping will be
performed. When it is complete, the new image will be displayed on the right. Similarly, a
value for AAD (Absolute Angle Difference) will be displayed, that shows the difference of
the angles of perpendicular edges. For a finely cut edge, this should be close to zero
degrees. If it is not within reason, then another edge should be used in rotation or the
films should be cut better next time.
Repeat these steps two more times for the remaining films, at which point the Complete button
in the bottom right will be enabled. Click on that to send the images to the main user interface.
Process the Films

Film processing is done automatically in the background. Here is how it is done:
1. To isolate the film, the image is segmented such that the films are the foreground and the
scanner glass is the background. The foreground regions are grouped and labeled, and
the two largest regions are determined to be the two films. The two images are created by
cropping around each film region.
2. To find the BG film, the standard deviation of the pixel values of each image is
determined. The image with the lowest standard deviation is determined to be the
background film.

3. To align the films, the best edge of each image is used. The best edge is defined as the
angles along each perpendicular edges are measured. The edge where these angles are
most identical to each other is the edge on which the image is aligned.
4. After determining the proper rotation, the images are rotated and interpolated in a bilinear
manner. This is by far the most computationally intensive step, unless the original pre-
separated image is excessively large, so for slower computers this could take significantly
longer than the other steps.
NOTE: The maximum change in degrees from horizontal is 5º.

5. To crop films, each rotated film is assumed to have horizontal and vertical edges. The
films are cropped using those edges.
Reorient the Images

Any images that are rotated or flipped can be transformed using the options under the Image1
and Image2 dropdown menus. Image1 is considered to be the upper image, while Image2 is the
lower image.
Use the Image1 and Image2 dropdown menus to confirm the proper labeling of each image.
Make sure the Left/Anterior Image is checked for the proper image, as well as the
Superior/Anterior Image. When an image is changed, the other image is automatically
selected as the other option. Be sure to verify the orientation in the dropdown menu. It is possible
for the on-screen graphic not to update correctly. If this occurs, the result will be inconsistent E2E
test results.
NOTE: It is extremely important to verify the correct orientation of Image1 and

Image2 using the dropdown menus. Failure to do so may result in incorrect
and/or inconsistent results.
Modify Other Information

When the images are ready to go, it is important to make sure the other information about the films
is correct.
 To add or update reference information
Reference information does not affect the analytical process of this test in any way; if the results
are to be printed afterwards, having this information on the printout is helpful.
1. To add or update the Reference Information, click FILE > NEW REFERENCE
INFORMATION. A dialog box will open, where six different fields can be entered to
describe information about the test.
2. Click OK when finished, and the new data will be displayed in the Reference box of the
main User Interface.

Perform Analysis
The specification is for all of the stationary tracking methods to average less than 0.95 mm TOTAL
TARGETING ERROR mm. With all the fields set correctly, the threshold analysis can be
completed. Terms used in E2E processing are listed in Table 3 and Table 4.
Table 3 Pixel value measurements
Centroid Area Number of pixels in main dark region of thresholded image.
Pixels to Left X location of the selected isodose centroid with respect to the left
edge of the film.
Pixels to Top Y location of selected isodose centroid with respect to the anterior
edge of the film.
Eccentricity The ratio of the longest to shortest radii from the centroid-to-threshold
distance.
Table 4 Analysis measurements
mm from left edge (A/L Distance to left edge, found by converting the A/L image’s
image) Pixels to Left from pixels to mm.
mm from anterior edge Distance to anterior edge, found by converting the A/L image’s
(A/L image) Pixels to Top from pixels to mm.
contour area/ball area Ratio of A/L ball area to the area determined using the target
(A/L image) ball dimensions and calibration settings.
mm from superior edge Distance to superior edge, found by converting the A/S image’s
(A/S image) Pixels to Left from pixels to mm.
mm from anterior edge Distance to anterior edge, found by converting the A/S image’s
(A/S image) Pixels to Top from pixels to mm.
contour area/ball area Ratio of A/S ball area to the area determined using the target
(A/S image) ball dimensions and calibration settings.
left error mm Error in mm – difference between mm from left edge (A/L

image) and distance from target ball.
anterior error mm (A/L Error in mm – difference between mm from anterior edge

image) (A/L image) and distance from target ball.
superior error mm Error in mm – difference between mm from superior edge

(A/S image) and distance from target ball.
anterior error mm (A/S Error in mm – difference between mm from anterior edge

image) (A/S image) and distance from target ball.

average anterior error Error in mm – average of 2 anterior error mm.

mm
TOTAL TARGETING Square root of sum of the square of the left error, the superior
ERROR mm error, and the anterior error.
Selecting the Correct Threshold

The end-to-end analysis process requires that the isodose line used in planning the end-to-end test
is approximately the same as the isodose line used in analyzing the film. Since the films are un-
calibrated, you can only estimate the film isodose line use when selecting it from the pull-down
menu in the end-to-end software. Thus, the end-to-end software also provides information about
the ratio of the physical ball area to the exposed isodose line area.
For the standard 2.5 inch ball cubes, this optimum ratio is 1.0, with an acceptable range of 0.8 to
1.2. For the mini ball-cube, the optimum ratio is 1.44, with an acceptable range from 1.3 to 1.6.
This method allows for the calculation of the centroid location and region area for a single threshold
level. For the desired threshold level, the minimum pixel intensity value for both exposed films is
determined as well as the mean background intensity from the unexposed film. Then the image is
thresholded with the desired value (the default being 70%).
The final step is filling in the slot and deleting the rest of the image. From this image the centroid
location, area, uncertainties, and other quantitative values are displayed in the Analysis box. In
addition, on the black blob displayed for each image is a line that circles the approximate ideal dose
region prescribed in the treatment plan.
To execute a Single Threshold, click EXECUTE > ONCE. A warning will pop up asking to ensure
that the images were correctly rotated. Click YES to continue. See on page 4-85, which displays
the E2E screen after analysis is complete.
Changing Threshold
The default threshold value is 70%. To change this, click EXECUTE >THRESHOLD and select
a contour level that is more desirable. If it is not there, click CUSTOM to pull up a user interface
to manually select a value. As the value strays from 65 - 75%, the accuracy of the area and centroid
calculation diminishes.
Print
To print a record of the analysis, use either the <Print Screen> button from the keyboard or import
a screen capture into WordPad or Paint to print the image.
Save Results to a Text File

After an analysis of either a single threshold or a multiple threshold has been completed, one of
the Save options is to save the results to a text file, by clicking File > SAVE TO TXT FILE...
Either enter the name of a new text file or browse the directory to select and update an existing
TXT FILE. The data from the user interface is saved, but not the images.

For the 3 film image set, you can save each individual film as a TIF file. These images are the ones
that have been either rotated or cropped. This includes images in any rotation, images that have
been flipped, or images that have been designated as Anterior/Superior (A/S) or Anterior/Left (A/
L). Once saved, these images can be examined using ImageJ or any other image viewing
software.
Show DeltaMan Values

After analysis, the suggested DeltaMan values can be displayed under EXECUTE > SHOW
DELTA MAN. Similarly, they will be displayed in the text file if that is saved. Changes to DeltaMan
values are performed by Accuray Customer Support. Contact Accuray Customer Support to
perform the DeltaMan adjustment.
Export Images
To export images, click FILE > EXPORT IMAGES.
Exit
Also upon closing the program, any reference information, dimension sizes of the main User
Interface window, and last path location are saved for the next time E2E is run.
Solutions to Common Problems

Below are some known issues.
• Noise from dust or fingerprints on the film or on the scanner: Dust and fingerprints
both can darken the film and interfere with the dark regions from X-ray exposure
(Figure 59). Keep the films as clean as possible. Usually the noise will be insignificant,
but be aware of the possibility.
• Optical interference fringes: Use baseball card sleeves or coins in the corners to
correct this problem (by lifting the film from the glass).
• Cropping errors: The cropping algorithm relies on 2 directional high pass filters to
determine the hard edges of each film. If the pieces of film are too close together, the
algorithm might crop the film too much, resulting in a miscalculation of the distance from
the centroid to the edge of the film.
• Dark/Saturated Film: Ensure that the maximum dose to the EBT type film is less than
800 cGy.

Figure 59 Examples of optical interference fringes (left) and

dust (right) on image quality.
NOTE: Both films were histogram equalized to enhance contrast.
Film Analysis for the Synchrony Fiducial Tracking

with Respiratory Modeling E2E Test (Optional)
• “Film Dosimetry” on page 4-88
• “Film Analysis for the Synchrony Fiducial Tracking with Respiratory Modeling System” on
page 4-89
Film Dosimetry
This section describes the procedure to generate calibration curves for optical density vs. dose. In
this procedure, a piece of Gafchromic film is used to develop a dose calibration curve for the film
scanner. This procedure establishes an absolute dose calibration curve for E2E dose profile
corrections.
 To generate calibration curves for optical density versus dose:
1. Prepare a standard set of radiochromic calibration films from the same film batch. Cut a
sheet of film into 2 cm squares.
2. Expose the films to 100, 200, 300, 400, 500, 600, 700 and 800 cGy at 1.5 cm depth,
800 mm SAD, in a unit density plastic or tissue equivalent slab phantom.
3. Wait at least 24 hours.
4. Scan the exposed films and an unexposed piece of film from the same box. The
unexposed film provides a zero dose point. Scanning should be conducted using the
same time span between irradiation and scanning that was used for the delivery films. For

example, if it was 24 hours between irradiation and scanning for the treatment delivery
films, the calibration films should be scanned at 24 hours as well.
5. Measure the optical densities. An example of film optical densities is shown in Figure 60.
Figure 60 Example of film optical densities
6. From this data, calculate the relationship between pixel intensity and dose in cGy. In most
cases, a linear or quadratic relationship between dose and optical density is sufficient.
optical density = constant*log[Pbkgr/Pexp]
where:
Pbkgr is the background film pixel intensity, and
Pexp is the exposed film pixel intensity.
Film Analysis for the Synchrony Fiducial Tracking with

This section describes the film analysis procedure for the E2E test for the Synchrony Fiducial
Tracking with Respiratory Modeling System.
 To perform film analysis for the Synchrony Fiducial Tracking with Respiratory Modeling E2E
test:
1. Scan all radiochromic targeting result films as near to 24 hours after exposure as
possible.
2. Overlay the measured dose profiles of the static and moving Synchrony Respiratory
Modeling E2E tests. Also include the plan dose from the RT/DICOM file.
Figure 61 below shows an example of overlay. The example compares static and moving
test results for the Superior/Inferior dose distribution determined from Gafchromic film in a
Ball-cube. In this example, the Respiratory Model points were not properly distributed
throughout the range of motion of the Synchrony Respiratory Motion QA tool, resulting in
a deviation of the measured curve (upper right side of curve) from the static and
treatment plan curves. This kind of deviation can be avoided by proper distribution of the
model points in phase space.

Figure 61 Example of Synchrony Respiratory

Motion QA test

Film Analysis for the Synchrony Lung Tracking with

This section describes the film analysis procedure for the Synchrony Lung with Respiratory E2E
test and the inherent uncertainties of the proposed method.
 To perform film analysis for the Synchrony Lung with Respiratory E2E test:
1. After delivering the treatment, remove the film insert from the Lung Motion phantom body.
2. Promptly after removing the film from the film insert, label the orientations of the film
reference edges with a fine tip permanent marker. It is important that the labels on the
films match the edges of the cube. The writing will be preserved in the scanned image for
identification purposes.
3. Scan the film in a calibrated film scanner. For information on proper setup of the film
scanner, see “Film Scanner” on page 4-27.
4. Analyze the film using E2E film analysis software. For more information on using the E2E
film analysis software, see “Film Analysis for E2E Tests” on page 4-81. Figure 62 shows
the E2E software with the films analyzed from the Lung Motion phantom with the
Synchrony Lung with Respiratory body.
Figure 62 E2E software analysis of the films used in the

Synchrony Lung with Respiratory phantom

Uncertainties in the Synchrony Lung with Respiratory E2E

Analysis Method
As proposed, the Synchrony Lung with Respiratory E2E analysis method includes a few
uncertainties that are not present with other tracking method E2E tests. These uncertainties
contribute to the calculated total targeting error:
• First, the Ray-Tracing dose calculation algorithm and the Finite Size Pencil Beam
algorithm are less accurate in the heterogeneous lung phantom. Since the dose centering
tool in the Accuray Precision System uses these algorithms when centering the dose for
an E2E test, this can introduce an offset from a truly centered dose distribution.
• Second, the dose centering tool in the Accuray Precision System translates the 3D
centroid of the dose volume with respect to the center of the target ball VOI. Centering the
3D centroid of the dose volume to the center of the ball VOI does not automatically
ensure that the dose in each of the 2D film planes is centered, especially if the 3D dose
distribution is asymmetric. In the lung phantom, often the dose distribution within the Lung
Motion phantom ball cube is asymmetric. Combined with dose calculation uncertainty,
this can cause the calculated 2D dose planes to be offset from the center of the films,
which the Accuray E2E software assumes to be zero (0) for the perfect plan.
• Finally, the intensity threshold that is chosen in the Accuray E2E software never perfectly
agrees with the isodose line that was chosen to center on using the dose centering tool.
The E2E software applies a nominal film calibration, which is sufficient when the planned
and delivered isodose lines are concentric. However, the calculated dose in the Lung
Motion phantom may not have good concentricity in the 2D film planes such that different
isodose lines will have different centroids.
In light of these uncertainties, a more robust method for analyzing Synchrony Lung with
Respiratory E2E films would be to center the dose in the Accuray Precision System with the Ray-
Tracing dose calculation algorithm or Finite Size Pencil Beam algorithm, and then perform a Monte
Carlo Dose Calculation (if available) to calculate the dose. After the final dose calculation (using
the Monte Carlo Dose Calculation algorithm, if possible) the dose distribution should be evaluated
using the Accuray Precision System in the two film planes to check whether the isodose lines are
correctly centered. Alternatively, one could use a third-party software package or routine to
compare the measured dose distribution with the Monte Carlo-calculated dose distribution (that is,
import the dose calculation and measurements and register the two before analyzing the positional
differences using something like a Distance-to-Agreement metric).
Regarding targeting calibration, that is, DeltaMan adjustments, the Synchrony Lung with
Respiratory E2E results are not typically used.

Creating Multileaf Collimator Test Patterns

• “Setting up for the TG-50 and Bayouth Tests” on page 4-93
• “Delivering the TG-50 and Bayouth Tests” on page 4-95
• “Analyzing Multileaf Collimator Test Patterns” on page 4-104
Multileaf Collimator test patterns are an efficient way of testing leaf positioning accuracy. The
TG-50 pattern also referred to as a “Picket Fence” pattern is particularly suited for visual analysis,
since small shifts in the positions of abutted fields with sharp penumbras will cause large shifts in
dose along the intersection line, referred to as the “Match Line”.
Although TG-50 is sensitive, the complexity of overlapping penumbras makes it unsuited for
analysis of individual leaf positions. Thus, we also use the Bayouth or “Garden Fence” method. In
the Bayouth method, the fields are strips separated by gaps so that the penumbra from one field
does not significantly affect the neighboring fields. Both methods use multiple fields so the leaf
positions can be measured at multiple positions across the field.
Setting up for the TG-50 and Bayouth Tests

The MLC Quality Assurance (QA) Tool is used for TG-50 and Bayouth tests. Figure 63 and
Figure 64 show the components of the MLC QA Tool. The tool mounts the test film just below the
MLC (see Figure 65). A film template is provided to cut the test film to match the insert area in the
MLC QA Tool as closely as possible. Since the irradiated pattern comes very close to the long
edges of the film, there is no need to mark the film to indicate alignment, and any pen marks within
the irradiated area may corrupt the test analysis. However, until you are familiar with consistently
aligning the tool with the MLC, it may be advisable to mark X1 and X2 on the relevant sides of the
film. If you choose to mark the film, the marks should be small and near the short edges of the film.
1075879-ENG A Creating Multileaf Collimator Test Patterns |4-93

Figure 63 Disassembled MLC Quality Assurance (QA) Tool

with test film (left) and metal film cutting template (right)
Figure 64 Assembled MLC QA Tool illustrating film

position and radio-opaque markers
4-94 | Creating Multileaf Collimator Test Patterns 1075879-ENG A

Figure 65 Setup for creating Multileaf test patterns

(TG-50 and Bayouth tests)
Delivering the TG-50 and Bayouth Tests

This section describes the steps to deliver the TG-50 test and the Bayouth test.
NOTE: The steps are almost the same for the TG-50 and Bayouth tests, ex-
cept as described below.
 To deliver the TG-50 test:

1. Figure 66 shows the main menu of the CyberKnife Treatment Delivery System. Select
Physics mode and log in to start the procedure.

Figure 66 CyberKnife System Menu
2. Figure 67 shows the main Physics menu. Before running the test patterns, warm up the
LINAC using the Warmup screen in the LINAC application.

Figure 67 Physics Menu
3. Click the Multileaf Collimator button at the bottom of the Physics menu.
Figure 68 shows the left screen of the Multileaf Collimator application. The left side
of this screen shows a real-time display of leaf positions. The center of the screen lists the
leaf positions. The right side of the screen contains the controls for delivering single beam
exposures.

Figure 68 Left screen of the Multileaf Collimator

application [UPDATED SCREENSHOT]
4. The TG-50 test consists of ten fields, each 10 mm wide. Abutted fields are delivered with
no gap between them. Visual analysis will consist of observing the dose along each of the
nine “match lines” that separated the fields.
Figure 69 shows the right screen of the Multileaf Collimator application in Physics
mode.

Figure 69 Right screen of Multileaf Collimator application

showing a TG-50 test
The left panel of the screen allows the user to select pre-defined test patterns. These are
not used for the TG-50 or Bayouth tests. Instead, manually define the fields using the
Geometry Parameters and Dose Parameters boxes in the middle of the screen.
5. For TG-50, enter 10 for Strip Width (mm), 0 for Gap (mm), and 170 for
MU per Strip. Select X1 to X2 for Picket Fence Direction.
6. Use the metal film cutting template to prepare test film for the MLC QA Tool. Trace the
outline of the template with a very fine marker, and then cut the film along the inner edge
of the outline you marked.
7. Assemble the MLC QA Tool on the MLC one piece at a time. Note that the buildup
(translucent) part of the tool is fitted to the MLC. The buildup section with one hole is
positioned on the X1 side and the section with two holes is positioned on the X2 side.
After installing the buildup part, tighten the 4 screws to fix it to the MLC. Position the film
in the recess of the backscatter (black) part of the tool and then carefully attach it to the
buildup and tighten the three screws. It may be helpful to use a small piece of tape on one
corner of the film to ensure the film does not shift while installing the backscatter.

8. When the film has been loaded in the MLC QA Tool and the Treatment Room is ready for
exposure, use the controls at the bottom of the right screen to start delivering the beam.
Watch the leaves move in the MLC Live View on the left screen. Dose will be
terminated when the test is complete. The user must turn off the High Voltage
manually.
The display panel in the upper right of the screen in Figure 70 shows which strip is being
processed. The processed strip turns yellow.
Figure 70 Display panel (upper right) shows which

strip is being processed Park Position
9. For TG-50, the film can be analyzed visually immediately. The analysis is described in
“Analyzing Multileaf Collimator Test Patterns” on page 4-104.

 General Bayouth test workflow:

It is recommended to run the Bayouth test before and after a simulated treatment delivery, as
follows:
1. Initialize the Multileaf Collimator.
2. Perform the Bayouth test.
3. Under MLC Leaves Drive Test, select Bank X1 and Bank X2 from the Bank
drop-down menu, and enter 60 in the Repeat Count field to move the leaves to
simulate a treatment delivery. See Figure 71.
.
Figure 71 MLC Leaves Drive Test
4. Click Start and move the leaves for approximately 15 minutes.

5. Immediately after the leaf drive test is complete, perform another Bayouth test (without
initializing the MLC).
 To deliver the Bayouth test:
Steps to deliver the Bayouth test are almost the same as for the TG-50 test, except that the Strip
Width (mm) is 10 mm and the Gap (mm) is 15 mm for the Bayouth test.
Although this test does not use absolute dose, it does require a calibration dataset. The calibration
dataset should be from the same batch of film that is used for the Bayouth test, and the delay
between exposure and scanning of the calibration films should be as similar as possible to that
used for the Bayouth tests (for example, if the Bayouth test films are typically scanned 15 minutes
after exposure then the dose calibration films used with the test should also have been scanned
about 15 minutes after exposure). The film scanning direction must be consistent between all of
the calibration films and Bayouth test films, and color correction should not be used for any of these
scans. The calibration should be based on the red channel only and have a range up to 1000 cGy.

MLC Live View

The Secondary Feedback System Camera supplies a video feed of the MLC leaves. Graphics are
superimposed on the camera image to provide additional information (see Table 5).
Table 5 Visual information and controls in MLC Live View
Item Description
The two vertical regions of cross-hatching represent the Primary Shield over
the left (X1) and right (X2) banks of MLC leaves.
The blue and green lines superimposed on the camera image represent the
primary leaf positions determined by the MLC motor control system:
• Blue rectangles surrounding each leaf extend out from each bank to
show the position of each leaf according to the MLC motor control
system. Horizontal blue lines on either side of each leaf extend out from
each bank to show how far each leaf has moved. Blue lines end at the
frontmost edge of each leaf (in shadow in the camera image).
• Vertical green lines represent the top corner of each leaf. Vertical green
lines do not mark the frontmost edge of each leaf. The frontmost edge is
in shadow.
Blue highlights indicate leaf movement.
There is one detection marker for each leaf, located at the leading edge of
the leaf notch. The color of each detection marker indicates the detection
confidence for the leaf detection algorithm of the Secondary Feedback
System:
• green: 80% to 100%
• yellow: 60% to < 80%
• red: < 60%
Show primary leaf Select the Show primary leaf positions check box to view the
positions overlay images and additional visual information provided with the video
feed.
Show camera Select the Show camera image check box to view the video from the
image Secondary Feedback System camera.

Table 5 Visual information and controls in MLC Live View
Item Description
Show detection Select the Show detection results check box to view the detection
results markers in the MLC Live View. Detection markers are displayed in the static
image when the beam is ON. They are not displayed in the live image when
the beam is OFF.
Desired MLC Shape

You may evaluate a wide variety of MLC patterns using the Desired MLC Shape and Single
Beam Exposure controls (see Table 6). The controls allow you to specify a pattern by selecting
a shape template, defining aperture width and height, or manually clicking and dragging leaves in
the MLC display to create a unique pattern.
Table 6 Single Beam Exposure MLC Shape Controls
Control Description
The Shape drop-down list provides a number of preset MLC shape
Shape templates.
Width (mm) Enter a value in the Width (mm) field to specify aperture width.
Height (mm) Enter a value in the Height (mm) field to specify aperture height.
The Park Position drop-down list defines the position for closed MLC
Park Position leaves. The default option, Configuration Data, positions the closed
leaves in their calibrated home position.

Analyzing Multileaf Collimator Test Patterns

• “TG-50 Picket Fence” on page 4-104
• “Examples of CyberKnife TG-50 Test” on page 4-104
• “Bayouth MLC QA Method” on page 4-105
• “Installing the Multileaf Collimator QA Tool Software” on page 4-107
• “Performing Bayouth Analysis” on page 4-113
• “Bayouth Analysis Using RIT” on page 4-114
• “Bayouth Test Criteria” on page 4-126
TG-50 Picket Fence

Analysis is performed by visually inspecting the vertical “match lines” on the film. These match lines
are created along the junction between adjoining fields. The overlapping beam penumbra create a
characteristic pattern of light and dark lines at the abutted field edges, and this pattern is sensitive
to errors in leaf position. Therefore, the test involves qualitative comparison of the test film to a
baseline film acquired at the time of MLC calibration. It is important to note that quantitative
evaluation of the net optical variation along the field junctions, as suggested in AAPM TG-50, is
complicated by the non-flat CyberKnife primary beam.
You may also perform visual analysis with scanned images instead of raw film. Scanned images
help facilitate the comparison of multiple tests. Color correction and image enhancements may
also be useful, but should be consistent for all images. To compare scans of films, set the scanner
to a recommended resolution of 600 dpi (if this setting is not available in the scanner software, use
the closest setting that is larger than 600 dpi). Verify that any color correction options enabled in
the scanner software are the same for all Picket Fence film scans.
NOTE: Tests of the CyberKnife system that use film normally require color
correction to be off or disabled. MLC film testing is one of the few times that
Accuray Incorporated recommends the use of color correction.
Examples of CyberKnife TG-50 Test

To demonstrate how to interpret the TG-50 films we present some examples. Figure 65 shows a
series of tests, some with slightly adjusted leaf positions. These include the nominal pattern
obtained with a correctly calibrated MLC, the result of offsetting the left (X1) bank by 0.5 mm at
isocenter to create leaf over-extension, and the result of applying the same offset but in the
opposite direction to create leaf under-extension.

Figure 72 TG-50 test result with correctly calibrated MLC

(left); one bank under-extending by 0.5mm (middle); one
bank over-extending by 0.5mm (right).
Bayouth MLC QA Method

TG-50 presents a good qualitative analysis of leaf positions, however it does not quantify the
amount of error, identify the offending leaf or demonstrate the absolute position of the leaves with
respect to the central axis of the collimator. In 2003, Bayouth published a method for quantitative
analysis of a Multileaf Collimator using film [Ref. 1].
Instead of using abutted fields as in TG-50, the Bayouth (also known as Garden Fence) test uses
narrow strips of exposure with sufficient separation so the field edges for each leaf can be located.
The offset between the mechanical leaf tip position and the projected radiation field edge due to
partial leaf tip transmission is corrected in the leaf calibration scheme. Therefore, this effect should
be ignored in the analysis of QA tests of leaf position, and the position of the measured radiation
field edge in the x-direction should correspond to the requested leaf position within the accuracy
tolerance.
In the example presented in Figure 73, 5 strips are exposed with each strip having a nominal width
of 10 mm and spaced 15 mm apart (dimensions at 800 mm SAD). The individual leaf positions can
be identified using third party software tools. The orientation of the film relative to the MLC is
defined by the features on the film (the notch and the asymmetric pattern of radio-opaque dots)
and the mechanical pins in the buildup plate that facilitate mounting to the MLC. As shown in
Figure 73, this film has bank X1 on the left and X2 on the right. Leaf pair 1 is at the bottom of the
image, and leaf pair 26 is at the top.

Figure 73 An example of a Bayouth MLC test exposure.

Leaf pair 26 is at the top, and leaf pair 1 is at the bottom.
The Bayouth test film must be scanned for analysis. Follow the general guidelines for dosimetric
test film scanning, such as scanner type, turning off color corrections, etc. as in End-to-End film
scanning. Due to the short test SAD, a higher scan resolution (≥ 600 dpi) is recommended because
the image size is relatively small.

Installing the Multileaf Collimator QA Tool Software

1. Install disk PN 1066293 and copy the files to your preferred location.
2. Run FilmAlignment.exe
3. Errors might arise pointing to the following missing files:
MSVCP100.dll missing
MSVCR100.dll missing
If there are errors pointing to these missing files, download and install Microsoft Visual C++ 2010
x86 Redistributable.
Aligning the Scanned Bayouth Test Film

After scanning the film, you must correctly rotate and align the image for analysis using the film
alignment tool software, MLC Film Alignment Tool, provided (see Figure 74).
 To use the film alignment tool:
1. Navigate to the appropriate workstation location, and run the FilmAlignment.exe
application. Figure 74 shows the main screen.

Figure 74 Main screen of MLC Film Alignment Tool
2. Click the Load Image button and navigate to the Bayouth test film image.
3. Select the test image file and click Open (see Figure 75). Make sure that the two circles
on the central strip, representing the radio-opaque markers of the MLC QA Tool, are
within the blue ROI boxes. If they are not, you can resize the ROI boxes using the
Search Window tools.

Figure 75 Scanned Bayouth test film loaded in film

alignment tool
4. Without changing any of the default parameters, click the Get Alignment button to
automatically rotate and align the test film based on the detected positions of the two
radio-opaque markers (see Figure 76).

Figure 76 Using the film alignment tool to

automatically rotate a Bayouth test film based on
radio-opaque markers.
5. If errors are displayed when you click the Get Alignment button, such as a message
reporting "Unable to detect the circles", you can try using the automatic
threshold feature of the film alignment tool. To do this:
• Click the Circle Finder tab.
• Select the Automatic levels checkbox (see Figure 77).

Figure 77 Automatic levels checkbox
• Then click Get Alignment again.
NOTE: For any gross inconsistencies or artifacts in the film, it is recommended

that you redo the Bayouth film exposure. If additional help is needed, contact
Accuray Customer Support.
6. Select the Crop Output check box.

7. Enter Width = 1775 and Height = 1345 as shown in Figure 78.

Figure 78 Crop Output: Width=1775 and

Height=1345
8. Click Save Result to save the adjusted image.

9. Click OK to display a message with the cropped output size and origin (see Figure 79).
Figure 79 Cropped output size and origin
10. The rotation-corrected image will be saved with the filename

<original_filename>_transformed.tif where <original_filename> is the
filename you selected in Step 3 on page 4-108. This file will be placed in a sub-folder
named out, in the same directory as the original image.

Performing Bayouth Analysis

The aligned image should be imported into a third-party software tool that supports Bayouth test
analysis (examples include FilmQA, RIT, and DoseLab). When an image is imported, it is important
to check that the pixel size is set correctly and that only the red channel of the image is used for
dosimetric analysis. For example, if an image is scanned at 600 dpi, the pixel size should be
0.042 mm x 0.042 mm. After the file is imported, the film should be converted to dose using
calibration data measured for the same film batch.
Next, the Bayouth analysis can be performed. Most third-party software packages require an MLC-
specific leaf template to be created in order to perform this analysis. In the template definition, it is
important to remember that the MLC QA Tool places the film at 433.5 mm SAD, but all leaf widths,
positions, and tolerances defined in CyberKnife software and technical specifications are at
800 mm SAD. Therefore, the leaf template should include 26 leaf pairs, each of which has a width
of 2.09 mm (=3.85 mm * 433.5/800). When defining the expected leaf positions and tolerances for
the test, any values specified at 800 mm should be minimized by a scaling factor 433.5/800. For
example, at 800 mm SAD the nominal strip width is 10 mm and the center-to-center spacing is
25 mm in this test, but in the film plane the corresponding values are 5.4 mm and 13.5 mm.
Bearing this distance projection in mind, the instructions provided with the third-party software
should be used to analyze the Bayouth test. When entering test tolerances it is important to realize
that some software tools like FilmQA and RIT113 express tolerances as ± value whereas other
tools like Doselab list tolerance as the total range. Thus, a 0.5 mm tolerance value in FilmQA or
RIT113 is equivalent to a 1.0 mm tolerance in DoseLab. When evaluating the result, ensure that
any artifacts associated with the two radio-opaque position markers are not mistaken as leaf
positioning errors. These markers can usually be identified by displaying the X profiles measured
along the center of each leaf in the analysis software. If artifacts are present, it may be possible to
shift the leaf template slightly in Y so that the X profiles used during analysis do not include the
artifacts. Check that dust specks and pen marks did not corrupt any detected leaf positions. Do not
include corrupted leaf positions in the analysis.
Bayouth test analysis using RIT is described in the next section.

Bayouth Analysis Using RIT

[anomaly #32345]The procedure below gives instructions for using either the RITG142 or RIT113
software tool (both available from Radiological Imaging Technology, Inc.) to perform Bayouth
analysis.
If you need to install RIT, follow their installation guidelines.
First you import the aligned image into RIT and convert it to dose. Then you perform the Bayouth
MLC Test in RIT.
 To convert the aligned image to dose using RIT:
1. Using RITG142 or RIT113, select File > Open Reference Image. Then browse to
the folder containing the rotation-corrected image file that you generated using the MLC
Film Alignment Tool (see “” on page 4-107).
2. For File Type, select Graphic File Import. Then select the file and click Open.
3. Ignore the warning message that appears and click OK. The Graphic File
Conversion Options window is displayed (see Figure 80).
Ensure that the Red Channel Only and Mean RGB Value options are selected.
In the Pixel Size (cm) section, check the values for X(cm) and Y(cm) to ensure
they are correct. If they are not, manually edit the values to the correct settings. The
values should be 0.0042333 cm for 600 dpi. For other dpi settings, the pixel size (cm) can
be calculated as 2.54/dpi.
Figure 80 Graphic File Conversion Options window
Click OK. The film will appear as in the example shown in Figure 81.

Figure 81 Aligned film in RITG142
4. Ensure Filter Type is set to none.

5. Click the Get .CAL File button. The Calibration File Manager window is displayed
(see Figure 82).
In the Select CAL File section, choose the calibration file that is for the batch of film
being used for this Bayouth test.

Figure 82 Calibration File Manager
Click the Apply .CAL Curve button. Then click OK when the excessive dose warning
is displayed (see Figure 83).
Figure 83 Calibration File Warning message
The displayed image will be converted to dose (cGy), as shown in Figure 84.

Figure 84 Aligned image after calibration curve

applied
 To perform the Bayouth MLC Test in RIT:

1. From the main menu, select MLC QA > Bayouth MLC Test.
2. Select the Tolerances & Settings tab (see Figure 85) and ensure the parameters
are set as follows:
• Position Tolerance +-mm: 0.51
• FWHM Estimate (mm): 5.42
• FWHM Tolerance +-mm: 0.54
• SSD (cm): 100
• Number of Fields: 6
• Field Spacing (cm): 1.355
• Open Gap Width (cm): 0.542
• Left Gap Pos (cm): 2.71
• Use Auto Align: Unchecked

Figure 85 Bayouth analysis settings
Select the Bayouth MLC Test tab and click Open Leaf Template. The
Open .LFS File window is displayed.
NOTE: Occasionally during the Bayouth MLC Test procedure, the error shown
in Figure 86 will occur. If this happens, return to this step, reload the template,
then continue.
Figure 86 General Error message
3. Browse to the file S7 Standard-26 @ 433_5 SAD_1345.lfs and click Open.
NOTE: If you do not have this file, please contact Accuray Customer Support
or an Accuray Field Service Engineer.
In the Plot View area, select only Aligned Image and deselect any other views.
This will display the film with the leaf template overlaid, as shown in Figure 87. The red
lines indicate the centers of each of the 26 leaves. Note the film is already aligned in the
vertical direction.

Figure 87 Aligned image displayed with default

alignment immediately after template file is opened.
Move the BB Column marker to 3.761. To do this, right-click on the yellow BB Column
box and enter the value. It may be helpful to zoom in and move the BB Column marker
around in the zoomed in view (see Figure 88). Small adjustments can be made by
entering the value manually or by dragging the yellow line to the left or right. Note that you
must deselect the zoom tool before dragging the BB Column line.

Figure 88 BB Column marker aligned in zoomed in

view.
4. Zoom out on the image and deselect the zoom tool.

5. Click Analyze Image.
In the Plot View area, uncheck Aligned Image and check X1 Position and X2
Position to see the Position Delta vs. Field Junction and Leaf Pair for X1 and X2 (see
Figure 89).
NOTE: All results from Bayouth test films acquired using the MLC QA Tool are
displayed in RIT at 433.5 mm SAD. All CyberKnife specifications are
expressed at 800 mm SAD. Therefore, all results in RIT need to be multiplied
by a factor of (800/433.5) if one is to compare the film results to CyberKnife
specifications.

Figure 89 Position Delta vs. Field Junction and Leaf

Pair for X1 and X2 charts
6. For the Bayouth MLC Test to pass, all leaf positions must have less than 0.95 mm (at
800 mm SAD) or 0.51 mm (at 433.5 mm SAD) deviation from their expected positions:
• Count the number of red marks displayed in the X1 Position Delta vs. Field Junction
and Leaf Pair chart. For the test to pass, there must be 0.
and Leaf Pair chart. For the test to pass, there must be 0.
Figure 90 shows an example of failing criteria.

Figure 90 Figure 23Example of failing criteria for Bayouth

MLC Test in Step 6. X1 has one failure at Leaf 23. X2 has one
failure at Leaf 23.
In some cases, leaf position failures are caused by artifacts such as dust particles or pen
marks on the film. It is best to remove these artifacts if possible.
7. Select the Tolerances & Settings tab and change the value for Position
Tolerance +-mm to 0.27 (see Figure 91). Then press <Enter>.

Figure 91 Figure 24Position Tolerance changed to

0.27 mm.
The X1 Position Delta vs. Field Junction and Leaf Pair and X2 Position Delta vs. Field
Junction and Leaf Pair charts will update automatically with the new tolerance value.
8. For the Bayouth MLC Test to pass, each bank can have no more than 13 leaf junctions
higher than 0.5 mm (at 800 mm SAD) or 0.27 mm (at 433.5 mm SAD) deviation from their
expected positions (see Figure 92):
and Leaf Pair chart. For the test to pass, there must be no more than 13.
• Count the red marks displayed in the X2 Position Delta vs. Field Junction and Leaf
Pair chart. For the test to pass, there must be no more than 13.

Figure 92 Example of passing criteria for Bayouth MLC Test

in Step 8. Bank X1 has one failure and bank X2 has two fail-
ures.
9. For the Bayouth MLC Test to pass, there can be no more than 1 position per leaf greater
than 0.5 mm (at 800 mm SAD) or 0.27 mm (at 433.5 mm SAD) deviation from their
expected positions (see Figure 93):
• Count the number of red marks for each leaf displayed in the X1 Position Delta vs.
Field Junction and Leaf Pair. For the test to pass, there must be no more than 1 per
leaf.

• Count the number of red marks for each leaf displayed in the X2 Position Delta vs.
Field Junction and Leaf Pair. For the test to pass, there must be no more than 1 per
leaf.
Figure 93 All leaves passing the criteria Bayouth MLC Test

in Step 9. X1 Leaf 23 has one failure. X2 Leaf 18 and X2 Leaf
23 each have one failure.

Bayouth Test Criteria

The criteria below are to be applied to Bayouth films that were delivered using the MLC QA Tool
(provided by Accuray) and the method described in this chapter. Furthermore, these values are
expressed at 800 mm SAD.
For a Bayouth test run at perch, the following criteria should be met:
• The mean bank offset from the expected positions should be less than or equal to 0.2 mm
for each bank.
• At least 90% of the measured leaf positions should have an offset of less than or equal to
0.5 mm from the expected position for each bank.
• [anomaly #34165]For a single leaf on each bank, there can be no more than 1 deviation
from the expected position that is greater than 0.5 mm
• All measured leaf positions for each bank must be less than 0.95 mm.
For a Bayouth test run at any other orientation, the following criteria should be met:
• All measured leaf positions for each bank must be less than 0.95 mm.
In addition to the leaf position accuracy specifications above, the following data is an example of
leaf position reproducibility data from running six Bayouth tests at the perch position. Although
Accuray does not have a specification for testing reproducibility, sample test data is provided here:
From six repeated Bayouth tests at perch, the maximum deviation from the mean leaf junction
position was found to be less than 0.3mm at 800mm SAD in all cases (every leaf, every junction,
and both banks).

Plan QA for Treatment Plans

Support for plan QA is provided in the Accuray Precision System, the iDMS Data Management
System and the Treatment Delivery System.
The plan QA procedure allows you to create a QA plan associated with a specific patient treatment
plan and deliver the QA plan to a phantom. In this procedure, the beam set of the patient plan is
overlaid onto a phantom. The QA plan is then delivered to the phantom to verify that the planned
dose is consistent with the measured dose.
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
In the plan QA procedure, the beams delivered to the phantom are the same as in the patient
treatment plan, the treatment robot moves to the same positions as for the patient, and the same
number of monitor units (MU) are delivered. However, if SingleBeam QA path is selected for the
template plan, all beams are delivered from the SingleBeam QA node. This may be useful for
delivering MLC apertures to a flat panel or detector array QA device.
Other conditions or parameters that are set for delivery of the patient plan (in Treatment mode)
are not automatically taken into account during delivery of the QA plan (in Plan QA mode). This
includes, for example, the X-ray technique, the imaging frequency, the treatment couch position,
and any other conditions that may need to be different in order to deliver the QA plan to the
phantom.
NOTE: Plan QA mode does not take into account differences between the
treatment couch position needed for alignment of the phantom and alignment
of the patient. Consider where the actual patient anatomy and any accessories
such as immobilization devices would be located on the treatment couch when
positioning the phantom.
The plan QA procedure requires the following steps that are performed using the Accuray
Precision System, the iDMS Data Management System, and the Treatment Delivery System:
• “Creating a QA Template Plan” on page 4-128
• “Creating a Patient Treatment Plan” on page 4-131
• “Creating a QA Plan” on page 4-131
• “Creating a Deliverable QA Plan Fraction” on page 4-137
• “Delivering the QA Plan to a Phantom” on page 4-138
• “QA Plan Film Analysis” on page 4-138
• “Recording Analysis Results” on page 4-138
Complete workflow details are provided in the following user documentation: the Treatment
Planning Manual, the Data Management Manual, and the Treatment Delivery Manual.
1075879-ENG A Plan QA for Treatment Plans |4-127

Creating a QA Template Plan

A QA template plan is a prerequisite for creating a QA plan. A template plan is created using CT
images of the dose analysis phantom. A template plan can be used to create multiple QA plans.
Template plans to be used with MLC patient plans must be saved with MLC as the collimator type.
The template plan is used to ensure that the following parameters are saved with the QA Plan:
• phantom CT images
• VOI contour
• tracking parameters
• location of fiducials (if applicable)
• dose calculation box and CT Density Model
A QA template plan is a prerequisite for creating a QA plan.
 To create a QA template plan:
1. Click the New Plan icon in the Patients and Plans section of the Accuray Precision
System home page.
2. Click a patient name from the Patient Name/Patient ID list on the New Plan
page.
3. Click the Standard icon in the Select Type panel. Then click Next.
4. Chose CT images of a phantom. Click Select Exam and then click Finish.
NOTE: Accuray recommends using a stereotactic dose verification phantom.

5. Create VOIs for the phantom in Contour > Manual.
NOTE: Contours on the QA template plan can be used to register the patient
plan with the phantom image series. The contours should also be large
enough to allow aperture creation by the optimizer.
6. Define the treatment parameters suitable for use with the CT image series of the QA
template plan in Setup > Machine.
For the Multileaf Collimator, if you select the SingleBeam QA template path, then all
beams for the QA plan will be deliverable with the LINAC pointed down (see Figure 94).
This can be used to perform QA for individual MLC apertures from the vertical beam
position.
NOTE: When selecting treatment parameters, the collimator type to be used

in the patient plan must match the collimator type in the template plan, that is,
fixed/Iris for fixed or Iris patient plans, and MLC for MLC patient plans.
4-128 | Plan QA for Treatment Plans 1075879-ENG A

7. Identify location and region of tracking features depending on the tracking method
chosen.
8. Define the align center in Align.
9. Select an appropriate CT density model in Plan > Settings.
NOTE: A sample density model cannot be used to save a QA

plan as deliverable.
10. Set the dose calculation box in Plan > Settings.
11. Depending on the collimator used, do one of the following:
• For Fixed and Iris, define a single isocenter in the Isocentric step and click the
Apply button.
• For MLC, go to the Sequential step and set the following parameters:
For Maximum Dose Constraints and Dose Volume Constraints, set
Dose (cGy): 1000.
For Dose Objectives, set Objective and Goal: Optimize Minimum Dose (OMI),
600 cGY.
Maximum Number Of Nodes: As many as the path allows. For SingleBeam
path, choose 1.
Select the Isocentric Conformal method to run the optimizer.
A beam set will be generated. For all collimator types, these steps are performed to
create a generic beam set and then save the plan as Deliverable, so the values
entered are not important.
12. Set the resolution for the dose calculation to High in Evaluate > Review and press
the Calculate button.
Setting the resolution to High is done only to save the plan as Deliverable.
13. Save the plan as deliverable by selecting Make Deliverable.
For more information on creating a QA template plan, see the Treatment Planning Manual.

Figure 94 Selecting SingleBeam QA template path

Creating a Patient Treatment Plan

 To create a patient treatment plan:
1. Follow the usual clinical workflow to generate a patient treatment plan.
2. Save the patient treatment plan as deliverable.
For more information on creating a patient treatment plan, see the Treatment Planning Manual.
Creating a QA Plan
 To select a patient plan and QA template plan:
1. Click the New Plan icon in the Patients and Plans section of the Accuray Precision
System home page.
2. Click a patient name from the Patient Name/Patient ID list on the New Plan
page.
3. Click the QA icon in the Select Type panel.
4. Click Next >>.
The Select a patient plan for a new QA plan screen is displayed. (Figure 95).
5. Select a patient plan on the Plan Name list.
NOTE: Only non-QA plans are listed to be selected as a patient plan.
NOTE: The patient plan list only contains plans with a status of
Deliverable, Authorized, Completed, Under Treatment, or
Discontinued.

Figure 95 Select a patient plan for a new QA plan screen
6. Click Next >>.

The Select a template plan for a new QA plan screen is displayed. Only
phantom patients and the patient selected on the previous screen will be displayed (see
Figure 96).
7. Select a patient on the Patient Name list.
8. Select a patient plan on the Plan Name list.
NOTE: The associated QA template plan must have a status of

Deliverable, Authorized, Completed, or Under Treatment.

Figure 96 Select a template plan for a new QA plan screen
9. Click Finish.
The system loads the data from the patient plan and the QA template plan, and the
Setup > Register step is loaded, and the Auto Registration dialog box, appears.
(See Figure 97).

Figure 97 Auto Registration dialog box
10. Select the appropriate VOIs from the drop-down menus and click OK. Shift the images
relative to one another, if necessary, and click Confirm.
NOTE: If the QA template plan tracking method is set as Synchrony

Fiducial and is different than the patient plan, a warning message will be
displayed requiring confirmation from the user to continue the process.
NOTE: If the QA template plan tracking method is not set as Synchrony

Fiducial and is different than that of the patient plan, an error message is
displayed indicating that a QA plan cannot be created.
NOTE: If there are beams from the patient plan that do not intersect with the
CT volume, a message is displayed and no beams are transferred.
11. Confirm the align center in the Setup > Align step.
In the Setup > Align task, you can review the alignment of the phantom. Make sure
that your phantom fiducials are visible on the DRRs as shown in Figure 98. You may
make adjustments to the align center in the 3 views at the bottom of the screen, just as for
patient plan alignment.

Figure 98 Setup > Align task to review phantom

alignment
12. For the Multileaf Collimator, go to the Setup > Finetune task. You may inspect
individual beams in this task.
For MLC plans that you would like to deliver from the vertical QA position (SingleBeam
QA template path), click the Nominal Position button, shown in Figure 99. You will be
asked to confirm this action by clicking Yes in a dialog box, as shown in Figure 100.

Figure 99 (Multileaf Collimator only) Setup >

Finetune task to inspect individual beams
Figure 100 Dialog box to confirm setting all beams

to the CyberKnife nominal position

13. In the Evaluate task, initiate a high resolution calculation and set your desired
prescription dose.
14. Save the plan as deliverable by selecting Make Deliverable.
After a QA plan is created and saved, you can export the RTDOSE or Planar Dose to the iDMS
Data Management System or to a specified folder by browsing to a local file path. This step is
performed to allow third party software applications (film analysis software) to perform the 2D plan
analysis as a part of the patient plan QA analysis. For information on exporting the DICOM RT
Dose or Planar Dose, see the Exporting DICOM Data section of the Treatment Planning Manual.
For additional information on exporting the DICOM series directly to the iDMS System, see the
Plan Administration chapter of the Data Management Manual.
If the DICOM series is exported to the iDMS Data Management System, use the DICOM Series
tab of the Treatment Plan Management screen to download the RTDOSE to a selected
location. For information on downloading the RTDOSE, see the Plan Administration chapter of the
Data Management Manual.
Creating a Deliverable QA Plan Fraction

You manage a QA plan using the QA Plans section of the Plan Administration application
of the iDMS Data Management System. The Plan Administration application allows you to
view details about the QA plan, create a deliverable QA plan fraction, discontinue a QA plan
fraction, and record analysis results from the plan QA procedure.
Only a single fraction is created for a QA plan. If the fraction is partially delivered and treatment is
aborted, the iDMS Data Management System must be used to create a new deliverable
QA fraction.
 To create a deliverable a QA plan fraction:
1. Click the Plan Administration icon on the Accuray Precision System home page.
2. Select the patient, the patient treatment plan, and the QA plan to be delivered.
3. Click the Manage QA Treatment Plan icon to open the Treatment Plan
Management screen displaying the QA Plans tab.
4. Click the Create a Deliverable QA Plan Fraction icon, and click Yes in the
Caution message to create the deliverable fraction.
5. Click the QA Plan DICOM Series tab.
6. Select RTDOSE from the list and click the Export Selected Series icon.
7. Export the RTDOSE file, and copy the file to the computer where the film analysis
software is installed.
For information on managing QA plans in the Accuray Precision System, see the Data
Management Manual.

Delivering the QA Plan to a Phantom

You deliver a QA plan to a phantom using Plan QA mode of the Treatment Delivery System on
the treatment delivery computer. In Plan QA mode, you select a patient, patient treatment plan,
and QA plan. After aligning the phantom on the treatment couch, you deliver the QA plan to the
phantom.
 To deliver the QA plan:
1. Place film in the phantom and align the phantom on the treatment table.
2. Click the Plan QA icon on the CyberKnife System Dashboard.
3. Deliver the QA plan to the phantom.
For more information on delivering a QA plan to a phantom, see the Treatment Delivery Manual.
QA Plan Film Analysis

Film analysis software, such as “FilmQA”, is used to perform QA plan film analysis. For information
on suggested film analysis software, see “Chapter 2: Commissioning”.
 To analyze the QA plan film:
1. Scan the film and import the scan into the film analysis software.
2. Import the dose distribution.
3. Run the film analysis using the software instructions.
4. Optionally, capture a screenshot of the analysis results for import into the iDMS Data
Management System (save as .TIF).
Recording Analysis Results

After analyzing results of the plan QA procedure, you record analysis results using the QA Plans
section of the Plan Administration application of the iDMS Data Management System. You
can also add notes and attach files to the analysis record.
For information on recording analysis results, see the Data Management Manual.
1. Click the Plan Administration icon on the Accuray Precision System home page.
2. Select the patient and the patient treatment plan.
3. Highlight the associated QA plan and click the Manage Selected QA Plan icon.
4. In the QA Plan Fractions section, highlight the QA Plan.
5. Click the Add or Update Analysis Record icon.
6. Enter the result of the analysis (pass/fail).
7. Optionally, import the screenshot of the analysis results captured in Step 4 of “QA Plan
Film Analysis” on page 4-138.

References
1. J. E. Bayouth, D. Wendy, and S. M. Morrill. MLC quality assurance techniques for IMRT
applications. Medical Physics 2003; 30(5): 743-750.


Chapter 5: Algorithms for Dose
Calculation and Display
Introduction
This chapter provides detailed reference information on Accuray Precision System algorithms.
• “Fusion” on page 5-2
• “Contouring Anatomy” on page 5-2
• “DRR Generation for Treatment Planning” on page 5-8
• “DVH Calculation” on page 5-8
• “MLC Secondary Feedback System (SFB)” on page 5-9
• “Ray-Tracing Dose Calculation Algorithm” on page 5-10
• “Monte Carlo Dose Calculation Algorithm (Option)” on page 5-15
• “Finite Size Pencil Beam Algorithm” on page 5-57
• “Beam Targeting and Optimization Algorithms” on page 5-65
• “Sequential Optimization” on page 5-74
• “VOLO Algorithms for CyberKnife” on page 5-108
• “Treatment Planning Beam Data for Ray-Tracing and FSPB Dose Calculations” on
page 5-128
• “References” on page 5-146

Fusion
Seedless fusion is based on an existing algorithm that uses seed point pairs as input to generate
a starting point for the intensity based registration. Three virtual seed point pairs are generated
based on Dataset A and Dataset B properties.
Seed point 1 on Dataset A is defined as the centroid of Dataset A’s volume. Seed point 2 on
Dataset A is defined as a point towards the left anatomical direction of Dataset A’s centroid at a
fixed distance X, and seed point 3 on Dataset A is defined as a point towards the superior
anatomical direction of Dataset A’s centroid at a fixed distance Z.
Seed point 1 on Dataset B is defined as the centroid of Dataset B’s volume. Seed point 2 on
Dataset B is defined as a point towards the left anatomical direction of Dataset B’s centroid at a
fixed distance X, and seed point 3 on Dataset B is defined as a point towards the superior
anatomical direction of Dataset B’s centroid at a fixed distance Z.
Contouring Anatomy
• “ITTV Generation Algorithm for Simulation Plan” on page 5-2
• “ITV Generation Algorithm for Lung Optimized Treatment Plan” on page 5-3
• “PTV Generation Algorithm for Lung Optimized Treatment Plan” on page 5-4
• “AutoSegmentation” on page 5-4
• “VOI Contour to Mask Volume Conversion” on page 5-6
• “VOI Operations Algorithm Description” on page 5-7
ITTV Generation Algorithm for Simulation Plan

In the Simulation Plan procedure, the Internal Tracking Target Volume (ITTV) is created by an ITTV
generation algorithm. The ITTV algorithm generates the VOI of ITTV from TTV (primary) and TTV
(secondary) for a dual CT Simulation Plan, which the two CT scans, CT (primary) acquired in
exhale and CT (secondary) in inhale are loaded and fused. If only a single CT (primary) is loaded
or the loaded CT pairs are not registered, the VOI of ITTV will be generated from TTV (primary)
and a range of motion of the tracking tumor from the TTV (primary).
Prior to ITTV creation, the user must delineate TTV (primary) on CT (primary) image and TTV
(secondary) on CT (secondary) image. The TTV (secondary) delineation will be only required for
the dual CT simulation plan.
1. Generate ITTV from TTV (primary) and TTV (secondary)
The algorithm will first generate an initial VOI mask by overlaying the TTV (secondary) on
TTV (primary) aligning the centroid of the 2 volumes creating a VOI that contains the
superset of voxels. Then it will shift this superset of voxels from the centroid of TTV
(primary) to the centroid of TTV (secondary) turning on all voxels along the way as the
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Physics Essentials Guide Chapter 5: Algorithms for Dose Calculation and Display
superset VOI is shifted. Finally a set of contours are extracted from the voxel
representation.
2. Generate ITTV from TTV (primary) and range of motion
The ITTV will be generated by shifting the initial VOI mask, the TTV (primary) from the
centroid of TTV (primary) to the location obtained by adding the 3D vector of range of
motion to the TTV (primary) centroid. All voxels in the path of the shifted VOI are turned
on. Finally a set of contours are extracted from the voxel representation.
ITV Generation Algorithm for Lung Optimized

Treatment Plan
In the Lung Optimized Treatment Plan procedure, the Internal Target Volume (ITV) is created by
an ITV generation algorithm if Lung 1 View (A) / (B) or Spine Supine is selected as the tracking
method. The ITV algorithm generates the ITV VOI from CTV (primary) and CTV (secondary). If
more than CT series is present, CT (primary) is acquired in exhale and CT (secondary) in inhale.
The images are loaded and registered based on the spine. If only a single CT (primary) is loaded
or the loaded CT (secondary) is not registered to the CT (primary), the VOI of ITV will be generated
from CTV (primary) and a range of motion of the tumor from the CTV (primary).
Prior to the ITV creation, the user must delineate CTV (primary) on CT (primary) image and/or CTV
(secondary) on CT (secondary) image. The CTV (secondary) delineation is only required if the CT
(secondary) was loaded and registered to the CT (primary).
1. Generate ITV for Lung 1 View (A) / (B) Tracking
When Lung 1 View (A) or Lung 1 View (B) is selected as the tracking method, a projection
of the target tumor position by the motion on the tracking axis (A) or (B) will be made to
achieve the best possible accuracy for the combination of Respiratory Motion Modeling
tracking and fixed offset from Spine tracking. The tracking axis (A) or (B) is defined as the
axis that is passing through the centroid of CTV (primary) and parallel to the DRR imager
X-Ray axis (A) or (B)
• Generate ITV from CTV (primary) and CTV (secondary)
The algorithm will first generate an initial VOI mask by overlapping the CTV
(secondary) on CTV (primary). Then the algorithm projects the centroid of CTV
(secondary) on the tracking axis (A) for Lung 1 View (A) tracking or the tracking axis
(B) for Lung 1 View (B) tracking. The algorithm shifts the initial VOI mask from the
centroid of CTV (primary) to the projected centroid of CTV (secondary) turning on all
voxels along the way. Finally contours are extracted from the voxel representation.
• Generate ITV from CTV (primary) and range of motion
The ITV will be generated by shifting the initial VOI mask, the CTV (primary), from the
centroid of CTV (primary) to the location obtained by projecting the point. This
destination point is calculated by adding the 3D vector of range of motion to the CTV
(primary) centroid along the tracking axis (A) or (B).
1075879-ENG A Contouring Anatomy |5-3

2. Generate ITV for Spine SupineTracking

When Spine Supine tracking is selected, a fixed offset from Spine tracking will be used for
lung tumor treatment. The ITV VOI will be generated from the CTV (primary) and CTV
(secondary) or the CTV (primary) and a range of motion by using the same approach
proposed for the ITTV generation in the Simulation plan. See “ITTV Generation Algorithm
for Simulation Plan” for details.
PTV Generation Algorithm for Lung Optimized

Treatment Plan
In the Lung Optimized Treatment Plan procedure, the Planning Target Volume (PTV) is created by
a PTV generation algorithm if Lung 1 View (A) / (B) or Spine Supine is selected as the tracking
method. The PTV algorithm generates the PTV from the ITV and the user specified expansion
margins. Prior to PTV creation, the ITV must be generated using the ITV generation algorithm.
1. Generate PTV for Lung 1 View (A / (B) Tracking
When Lung 1 View (A) or Lung 1 View (B) is selected as the tracking method, the user
should specify the margins in the in-plane and out-plane directions. The in-plane is the
DRR imager plane (A) for the Lung 1 View (A) tracking, or the DRR imager plane (B) for
the Lung 1 View (B) tracking. Out-plane is the plane orthogonal to in-plane. The algorithm
generates an initial ellipsoid type mask or a structure element by using the in-plane and
out-plane margins in 3D oblique space. Then the algorithm applies the structure element
to every surface voxel of the ITV to generate the PTV.
2. Generate PTV for Spine SupineTracking
When Spine Supine tracking is selected, the user specifies the margins in the three
cardinal directions. The algorithm generates the ellipsoid type structure element by using
the six margins for the Left, Right, Anterior, Posterior, Superior and Inferior in the 3D
Cartesian space. Then the PTV is generated by applying the structure element to every
surface voxel of the ITV.
AutoSegmentation
• “Brain AutoSegmentation” on page 5-4
• “Prostate AutoSegmentation” on page 5-6
Brain AutoSegmentation
Automatic segmentation of cranial structures in Brain AutoSegmentation™ in the Accuray
Precision System is performed using an atlas-based segmentation approach. The approach uses
a curated set of 50 neuroanatomical atlases, consisting of T1w MR scans with manually contoured
expert segmentations of over 130 anatomical regions including cortical regions as defined by the
brain COLOR parcellation protocol (www.braincolor.org). An example of a neuroanatomical atlas
and a result of the Brain AutoSegmentation algorithm are shown in Figure 1.
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Figure 1 Example of one neuroanatomical atlas (left) vs. Brain AutoSegmentation results
on the same MR scan (right).
A subset of 20 morphologically similar atlases is automatically identified by the system and

deformed to the patient T1w MR scan using a proprietary deformable image registration algorithm
[1]. The registration scheme involves an affine registration stage followed by a hierarchical nonrigid
matching performed at four resolution levels using a local normalized correlation coefficient (NCC)
similarity criterion. The algorithm uses a nonparametric non-rigid transformation to represent the
deformation field. It assumes no specific parameterization of the transformation; instead it explicitly
estimates the deformation field subject to smoothness regularization. Such an approach allows
estimating even complex organ deformations.
The deformation fields between atlas T1w scans and patient T1w scan provide a mapping between
expert segmentations and the patient MR scan. Multiple expert segmentations are combined
(fused) using a voting algorithm to obtain the final multi-atlas segmentation.
Brain AutoSegmentation uses model-based segmentation methods for delineating the eye and
lens structures. The model-based segmentation algorithm is initialized by the results from the atlas-
based segmentation algorithm and uses anatomical size and shape constraints to provide robust
segmentations even on MR scans with suboptimal image quality in the eye and lens region.
The set of neuroanatomical atlases provided with Brain AutoSegmentation is

defined on T1w MR scans using a specific acquisition protocol. While the
image registration algorithms are relatively insensitive to variations in image
intensity due to T1w protocol differences, it is recommended to use scans with
acquisition parameters similar to those specified in Table 1.
Table 1 MR image acquisition protocol used in all scans contained in the Brain
AutoSegmentation neuroanatomical atlas database (see [2] for more details).
Sequence MP-RAGE
TR 9.7
TE (msec) 4.0
Flip angle (°) 10

Table 1 MR image acquisition protocol used in all scans contained in the Brain
AutoSegmentation neuroanatomical atlas database (see [2] for more details). (continued)
TI (msec) 20
TD (msec) 200
Prostate AutoSegmentation
The Prostate AutoSegmentation™ algorithm is classified as a model-based algorithm. Model-
based algorithms have explicit models for the organs of interest. These include the range of shapes
that each may assume under various conditions (for example, bladder empty or full, distension of
the rectum). The models also include the expected spatial relationships among the organs (for
example, the bladder is superior to the prostate), the typical image intensities associated with the
organs and other material (surrounding tissue, fat, urine, fecal matter, and gas) and various visible
landmarks in the images.
The models are developed via a process called training. During training, data is extracted from a
series of segmentations of the desired anatomy.The data is encapsulated into a shape model that
captures the typical shape variations seen in the training data and an associated appearance
model that captures the distribution of image intensities typically seen in each region of the shape
model.
The AutoSegmentation algorithm leverages this model-based information, CT image intensities of
the user-supplied image set, and user-defined initialization points to automatically segment the
anatomy. If supplied, the initialization points are used to guide the automatic segmentation process
in areas where the image data is ambiguous. This allows the user to guide the automatic
segmentation to produce a result that better matches their own judgment of where the VOI’s
boundary is. After AutoSegmentation, the user can adjust the resulting boundary using the editing
tools in the Accuray Precision System as needed.
The algorithm operates in 3 dimensions. Once the algorithm has reached a solution, 2D contours
are extracted from the 3D objects. These 2D contours are then displayed to the user as overlays
on associated image data. The resulting contours that are displayed in the Accuray Precision
System have been smoothed using first-order interpolation between points in 2D and 3D; however
a voxel representation of the VOI is used when computing dosimetric information. The voxel
representation is deduced from the smoothed 2D line segment representation. Users can view the
voxel representation by choosing to view VOIs as semi-opaque overlays and zooming in on a VOI.
VOI Contour to Mask Volume Conversion

The Accuray Precision System uses what is termed a “mask volume” to store a volumetric
representation of the VOIs contoured by the user during the process of treatment plan creation.
This volumetric representation is used by the system for various purposes during the planning
process, primary amongst which are the calculation of the DVH graphs and the dose statistics
table. The mask volume consists of a series of integer values conceptually arranged into a
rectangular prism whose dimensions match the base CT scan and which represent sub-volumes
called voxels. The volumetric representation of a VOI indicates which voxels in the mask volume
are parts of a VOI.
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The mask volume generation algorithm is designed to convert the VOI contours, either drawn by
the user or generated by the system via contouring algorithms, into the volumetric representation
stored in the mask volume. The algorithm processes the contours on a slice-by-slice basis and
therefore is similar in nature to the rasterization algorithms used in 2D computer graphics. The
Accuray Precision System features an enhanced version of this algorithm which is designed to
provide more precise handling of the contours and improved speed. This algorithm uses the
following rule to determine whether a voxel should be considered part of a VOI: if the center of a
voxel, viewed in the same plane as the contour, falls inside or on the contour, then the voxel is
treated as inside the contour.
WARNING: If a VOI has contours that extend beyond the boundary of the primary CT
image, the density override that the user has defined for this VOI will not be applied to the
portion that is outside the boundary of the primary CT image. If this occurs, an invalid
dose calculation will result.
VOI Operations Algorithm Description

VOI Operations in Accuray Precision System are performed by converting the contour
representation of one or more VOIs into a single volumetric representation. Then new contours are
extracted from the volumetric representation based upon the desired operation.
All VOI Operations are performed in three steps.
1. Convert a VOI into its volumetric representation. Optionally, this volumetric
representation is grown (or shrunk) during the conversion process.
Growth can be performed independently along the six patient directions (Anterior,
Posterior, Superior, Inferior, Patient Left and Patient Right)
2. Optionally convert a second VOI into its volumetric representation with the same optional
growth.
The result of these two steps is a single volumetric representation where individual voxels
are tagged as belonging either to VOI 1, VOI 2, both or neither.
3. Generate a new set of contours that encompasses all of the voxels in the volumetric
representation that meet the criteria defined by the operand and either combine them with
or replace the destination VOI.
There are a total of 5 possible VOI Operation operands.
1. Plus – The new set of contours encompass voxels that are tagged as either the first VOI,
the second VOI or both.
2. Minus – The new set of contours encompass voxels that are tagged as the first VOI but
not the second VOI.
3. Copy – The new set of contours encompass voxels that are tagged as the first VOI.
4. Intersect – The new set of contours encompass only the voxels that are tagged as both
the first and second VOI.
5. Resize – The new set of contours encompass voxels that are tagged as the first VOI and
the destination VOI is constrained to be the same as the first VOI.

The destination VOI can be affected in two ways by a VOI Operation.

1. Add To – The current destination VOI is combined with the resultant contours produced
from the VOI Operation. The combination is done in the same manner as a Plus
operation (both sets of contours are converted to their volumetric representation and a
final set of contours is extracted).
2. Replace – Any contours that are contained in the destination VOI are deleted and the
contours produced by the VOI Operation are copied to become the new destination VOI.
Specific descriptions of the algorithms used to convert between the contour and volumetric
representations can be found elsewhere in the PEG.
References
1. P. Jordan, A. Myronenko, K. Gorczowski, M. Foskey, R. Holloway, C.R. Maurer Jr.
“Accuray Deformable Image Registration: Description and Evaluation.” White Paper,
Accuray Incorporated, 2017.
2. D.S. Marcus, T.H. Wang, J. Parker, J.G. Csernansky, J.C. Morris, R.L. Buckner. Open
Access Series of Imaging Studies (OASIS): Cross-Sectional MRI Data in Young, Middle
Aged, Nondemented, and Demented Older Adults. Journal of Cognitive Neuroscience,
19, 1498-1507.
DRR Generation for Treatment Planning

The DRR is a synthetically computed X-ray image generated via tracing of exponential attenuation
of X-rays through the patient CT data. The attenuation is based on the relative CT numbers in the
patient CT scan and is sampled every 0.5 mm along each ray path. A CT density model is not
applied when generating DRRs. The generated image is the projection onto a plane that is
perpendicular to the beam axis of the simulated X-ray imaging source. The spatial sampling of the
CT is performed so as to produce a 512 x 512 image at the alignment center point.
DVH Calculation
The Accuray Precision System calculates a DVH for each VOI that the user has defined in a plan.
The DVH is only calculated within the dose volume, which covers the dose calculation box for a
Ray-Tracing treatment plan, FSPB treatment plan, and the entire CT volume for a Monte Carlo
treatment plan, that is, voxels of a VOI that are outside of the dose volume are not counted in the
DVH for that VOI either as dose or volume.
The Accuray Precision System calculates the DVH of a VOI at CT resolution. If the dose volume
has lower resolution than the resolution of the CT image, the Accuray Precision System perform
tri-linear interpolation between voxels in the dose volume to calculate the dose at the resolution of
the CT image.
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The DVH calculation divides the minimum to maximum dose range for each VOI into 256 evenly
spaced bins. Dose at every voxel within the dose calculation box (Ray-Tracing dose calculation or
FSPB dose calculation) or CT volume (Monte Carlo Dose Calculation) is then placed into one of
these bins. The DVH display window then provides a mechanism to examine the dose and volume
at each of these bins.
MLC Secondary Feedback System (SFB)

The confidence measure for leaf detection in the MLC Secondary Feedback System (SFB)
corresponds to the confidence that the objects used for detecting the leaf position in the image
have been correctly identified. This is done by computing the Normalized Correlation Coefficient
(NCC) [1,2] for the matched leaf template and the corresponding sub-region of the SFB camera
image centered about the notch on the leaf. This area is 13 x 30 pixels in size where each pixel is
approximately 0.15 mm. The NCC is a modification of the standard cross-correlation measure
where the standard cross-correlation includes subtracting the mean and dividing by the standard
deviation of the sub-region, making this metric more suitable for image-processing applications in
which the brightness of the image can vary due to lighting and exposure conditions. The NCC
values are floating point numbers, ranging from 0 to 1. A value of 1.0 corresponds to an exact
match (after mean and standard deviation normalization) between the leaf tracking template and
the SFB image region, while a value of 0 corresponds to no correlation. Based upon data from
testing, a value of 0.6 is used by the SFB system as the threshold for determining acceptable
detection confidence. This value was selected to minimize false failures while also minimizing false
passes.
For the grayscale intensities of a patch of the camera image, u, and the matching leaf edge
template, v, a NCC value is computed as
(1)
where p and q are the row and column indexes of the pixels spanned by the leaf notch/edge
template (and by the patch of the SFB camera image detected as corresponding to the leaf notch).
References
1. Lewis, J. P. "Fast normalized cross-correlation." Vision interface. Vol. 10. No. 1. 1995.
2. http://en.wikipedia.org/wiki/Cross-correlation#Normalized_cross-correlation.
1075879-ENG A MLC Secondary Feedback System (SFB) |5-9

Ray-Tracing Dose Calculation Algorithm

The Accuray Precision System offers two dose calculation algorithms to be used with the fixed and
Iris Collimator: the Ray-Tracing dose calculation algorithm and the Monte Carlo Dose Calculation
algorithm. The Ray-Tracing dose calculation accounts for primary path heterogeneity corrections
only (effective path length) while the Monte Carlo Dose Calculation also accounts for heterogeneity
effects on the scattered dose. The Ray-Tracing dose calculation has the advantage of being a
deterministic calculation method while the Monte Carlo Dose Calculation has an uncertainty
associated with the results. The Monte Carlo Dose Calculation is preferred when the clinical
situation has significant inhomogeneity. Examples of areas of large inhomogeneity are in the lungs
and near the sinus cavities. In other situations, either the Ray-Tracing dose calculation or the
Monte Carlo Dose Calculation offer similar dose results.
The Ray-Tracing dose calculation algorithm uses 3 system-specific beam description tables
comprised of data measured in water using a water phantom.
The following beam data tables are used:
• Tissue Phantom Ratio (TPR, TMRtable.dat): The TPR values for each collimator are
normalized to a value of 1.0 at a depth of 15 mm.
• Off-Center Ratio (OCR; OCRtableN.dat, where N = 0 through 11): The OCR values for
each collimator are normalized to a value of 1.0 at a radius of 0 mm.
• Output Factor (DM, DMtable.dat): The OF value for each collimator is normalized to
the value of the OF for the 60 mm collimator at 800 mm SAD, which is defined to be 1.0.
The TPR table values are measured values based on the depth and the collimator size:
TPR(D,collimator). The TPR value used in the dose calculation depends upon the effective depth
to the plane perpendicular to the central axis (CAX) which contains the reference point. The
effective depth is determined by summing the contribution of each voxel along the ray from the
source to plane containing the target voxel using the CT electron density relative to water.
The field size (FS) is the collimator diameter (in millimeters) projected from the reference distance
of 800 mm to the Source-Axis Distance (SAD) (in millimeters) by the relation shown in
Equation (2):
SAD
FS = Collimator_Diameter   ----------- (2)
 800 
5-10 | Ray-Tracing Dose Calculation Algorithm 1075879 ENG A

The SAD is the distance along the central axis of the beam to a plane perpendicular to the beam
and containing the target voxel.
NOTE: Collimator_Diameter refers to the nominal field size defined at

800 mm SAD. For example, the collimator labeled as 60 mm produces a
circular field of 60 mm FWHM at 800 mm SAD. The actual physical diameter
of the collimator is approximately 30 mm because the secondary collimator is
situated at a distance of 400 mm from the X-ray source.
The SAD acronym is an anachronism for the CyberKnife System because there is no rotational
axis for the system (though the planning can be done relative to defined isocenters). The measured
beam data tables are interpolated at higher resolution as well as extrapolated beyond the
measured range to create the stored (also known as, calculated) beam data tables (explained in
“Construction of Beam Data Stored Tables” on page 5-128). On top of these stored tables, the
individual quantities of OF, TPR and OCR are further inter- and extrapolated as described in
“Interpolation and Extrapolation of the Stored Beam Data Tables” on page 5-138. The TPR
at (FS, Deff), at points between or beyond the measured TPR values are inter- and extrapolated
in FS and depth.
There is an OCR table for each collimator, and each of these tables depends on the SAD and the
off-center radius to the target voxel projected to 800 mm by the relation
800
R 800 = R SAD   ----------- (3)
 SAD
The effective depth is calculated along the CAX only. See Figure 2 on page 5-12, for a lung
example.
The OCR (Collimator, SAD, R800) values in between or beyond the measured OCR values are
inter- and extrapolated in depth and radius.
The output factor table is a function of the collimator size and the SAD, DM (Collimator, SAD). OF
values in between or beyond the measured SADs are inter- and extrapolated in SAD for each
collimator. Chapter 2, “Commissioning,” describes the methods for measuring the beam
parameters and generating the data that comprise these tables. At each point, the dose, D, in cGy
(= RAD), from each beam is given by the equation:
800 2 (4)
D   MU  = OCR  coll, R 800, D eff    -----------  TPR  fieldsize D eff   DM  coll, SAD 
SAD
where MU is the number of monitor units for the beam.
1075879-ENG A Ray-Tracing Dose Calculation Algorithm |5-11

The LINAC is calibrated so that on the beam axis of a 60 mm collimator, at 15 mm Deff and 800 mm
SAD this ratio is:
2
800
D   MU  = OCR  60 0 15    ---------  TPR  60 15   DM  60 800 
800 (5)
2
800
= OCR  *, 0, *    ---------  TPR  * 15   DM  60 800  = 1  1  1  1 = 1
2
 800
Where the * indicates any input will produce the same output because the OCR and TPR tables
are ratios normalized to 1 at zero radius (OCR) and 15 mm effective depth (TPR). The number of
stored beam data points, the number of beams, and the beam geometry affect the amount of error
associated with this dose calculation. Generally, more beams in a plan will yield smaller
interpolation errors, because each beam’s error should be random, and summing the contributions
from many beams averages the positive and negative errors.
Figure 2 Lung Example

Contour Correction
Contour Correction is an algorithm that estimates the effective depth value for any point not on the
central axis of a beam, when using the ray-tracing dose calculation method. To estimate the
effective depth value for any given point, the algorithm first pre-calculates effective depth values in
1 mm geometric depth steps along rays that are located on the surface of a set of 10 evenly spaced
concentric cones that share the same central axis as the central axis of the beam. The set of cones
covers the beam cross section, with the largest cone generated having radius at 800 mm SAD
equal to the nominal collimator size, and the spacing between cones being the collimator radius
divided by 10. Each cone contains twelve rays equally spaced at 30 degree intervals around the
cone. The algorithm then finds the four rays surrounding the given point, and performs a tri-linear
interpolation using the points on the rays that intersect the plane perpendicular to the central axis
and containing the point being calculated. When the calculation point lies outside the largest cone,
the two nearest rays on the largest cone are used.
Ray-Tracing Dose Calculation Grid

The standard Accuray Precision System dose calculation is based on a Ray-Tracing algorithm.
This section describes the algorithm. For instructions on commissioning the Ray-Tracing dose
calculation algorithm, see the Treatment Planning Manual.
Isocontour and DVH Calculation

Dose volume histograms (DVHs), and minimum and maximum dose statistics for defined
structures, are generated at native CT resolution, using linear interpolation on the dose values
stored in the dose calculation grid. Isodose curves are generated using a curve-fitting algorithm,
again using the values stored in the dose calculation grid. Therefore, using a dose calculation grid
with smaller elements will yield more accurate DVHs and isodose curves, because interpolation
inaccuracies are reduced.
Volumes of interest (VOI) are defined in the CT coordinate frame and are therefore generally
unaffected by changes in the size of the dose calculation grid. However, note that the volumes (in
cubic millimeters, mm3) of VOIs displayed with the DVHs reflect the volume of the intersection of
the VOI with the dose calculation grid. Hence, if the grid is defined so that it does not completely
enclose a given VOI, only a fraction of the volume of the VOI will be used for calculation of the
corresponding DVH.
1075879-ENG A Ray-Tracing Dose Calculation Algorithm |5-13

Fine Dose Calculation

The fine dose calculation covers the dose calculation region of interest defined by the user. Within
this region, the calculation resolution is selected by the user.
Point Dose Calculation

When the mouse is positioned over the 2D images, a value representing the dose in cGy delivered
by the current plan to the point represented by the cursor is displayed. This value has no inherent
resolution limit, and is not affected by the spatial relationship between the cursor and the dose
calculation grid.
The value is calculated at the position defined by the cursor. Because the dose calculation voxels
have finite resolution, it is possible for the point dose value to exceed the maximum dose calculated
in the dose volume (for example, when the true maximum falls between 2 calculation points).

Monte Carlo Dose Calculation Algorithm

(Option)
This section provides detailed reference information on aspects of the Monte Carlo Dose
Calculation algorithm as implemented by Accuray for use with the Accuray Precision System.
The Monte Carlo Dose Calculation algorithm is an option on the Accuray Precision System. The
Monte Carlo Dose Calculation algorithm was developed in collaboration with Fox Chase Cancer
Center and incorporates many ideas from Monte Carlo algorithms previously developed by this
group such as MCDOSE, DOSIMETER, MCSIM and MCBEAM. These and similar algorithms
have been widely described in the literature (see “References” on page 5-146). For a general
description of the Monte Carlo Dose Calculation techniques in the context of other dose calculation
techniques, see the AAPM Report 85 (2004) [Ref. 5].
The variance reduction methods employed within this algorithm utilize a voxel model that considers
various materials as being equivalent to variable-density water for the purpose of the electron
transport calculations. Therefore, the electron transport algorithm calculates absorbed dose to
variable-density water.
This is not strictly identical to the conventional Monte Carlo absorbed dose to medium calculations
or to the absorbed dose to water in medium calculations as described in AAPM Report 97 (2007,
TG-105) and elsewhere. However, in all biological tissues (including lung and bone), the absorbed
dose to variable density water calculation performed by the Accuray Precision System Monte Carlo
Dose Calculation algorithm is essentially equivalent to an absorbed dose to medium calculation.
There may be a greater difference between the absorbed dose to variable density water calculation
and the absorbed dose to medium calculation in other materials. For example, in metallic implants
and air, the difference between the absorbed dose to variable density water calculation and the
absorbed dose to medium may be greater.
The electron transport method is explained fully in the section “Electron History Repeating and
Russian Roulette Algorithms” on page 5-38. See Appendix 5A, “Electron Transport in the MC Dose
Calculation Algorithm”, for a comparison of this method with direct absorbed dose to medium
electron transport.
The Monte Carlo Dose Calculation procedure comprises an iterative loop (see Figure 3 on
page 5-16) in which:
• An individual photon incident on the patient model originating in a single beam of the
beam model is generated using the source model by a sampling procedure.
• As the photon is transported through the patient model, it might interact with the patient.
The occurrence of an interaction is based on probabilistic models.
• Photon interactions generate and scatter particles.
• These particles are transported through the patient model and might in turn interact with
the patient.
• These interactions deposit energy that the algorithm records at each voxel of the patient
model.
• The process is repeated to calculate a dose distribution for each beam.
1075879-ENG A Monte Carlo Dose Calculation Algorithm (Option) |5-15

Figure 3 Major components of the Monte Carlo Dose Calcu-

lation algorithm
The dose distribution resulting from each beam is stored independently, allowing re-optimization
of beam weights based on the Monte Carlo Dose Calculation if required.
After the dose calculation is completed, it can be evaluated using tools such as Isodose line, dose-
volume histogram, point-dose, and the dose metrics coverage, homogeneity index, and
conformality indices. In addition, the user can apply a smoothing algorithm to the raw dose
distribution, and then evaluate the raw and/or smoothed versions.
The user can visualize the statistical calculation uncertainty at any point in the patient model by
using a point tool or displaying an uncertainty map.
Required Inputs to the Algorithm

The required inputs to the Monte Carlo Dose Calculation procedure are:
• “Source Model” on page 5-17
• “Patient Model” on page 5-22
• “Beam Geometry” on page 5-23
• “User Preferences” on page 5-23
5-16 | Monte Carlo Dose Calculation Algorithm (Option) 1075879 ENG A

Source Model
Independent source models are used for each secondary collimation type (fixed, Iris, MLC). The
Monte Carlo Dose Calculation source model is used to generate the required initial properties
(position, direction, energy) of each photon incident on the patient. The source model is generated
on the treatment planning system from dosimetric data measured on each LINAC during
commissioning by the user and reference dosimetric data provided with the software. The source
model is generated during commissioning of the Monte Carlo Dose Calculation option on the
treatment planning system.
The Monte Carlo Dose Calculation source model describes the distribution of photon energies and
trajectories produced by the LINAC. The source model contains 3 independent probability
distributions:
• The photon energy distribution is the energy spectrum of photons generated by the
LINAC.
• The source distribution describes the origin points of photons in the plane of the X-ray
target (SAD = 0).
• The fluence distribution is used to weight the dose delivered by a given photon that was
randomly generated from the source in a plane normal to the beam central axis
(SAD = 800 mm).
All 3 distributions are independent of secondary collimator size, that is, there is a single distribution
for each parameter. The effects of the secondary collimator on the direction and energy
parameters are included within the sampling procedure. The following physical assumptions are
made:
• Photon fluence at the patient can be described as originating from a single 2D radiation
source in the plane of the focal spot. There are no extra-focal sources of radiation in the
implemented model.
• Energy, source, and fluence are independent variables.
• Initial photon weighting factor and energy can be modified during the sampling procedure
to account for variations associated with the choice of secondary collimator. (These
modifications are described in the sampling procedure section.)
Each of the 3 distributions is defined during Monte Carlo Dose Calculation algorithm
commissioning based on measured data entered by the user. These steps are defined below.

Energy Spectrum
The energy spectrum represents the distribution of initial photon energies incident on the patient
model.
Fixed and Iris Collimators

This distribution is generated using one measured percent depth dose (PDD) curve and a library
of precalculated mono energetic PDDs. The PDD measurement is made with a beam at normal
incidence in a water phantom at SSD = 800 mm using the 60 mm collimator. The library of
reference PDD data was calculated using EGS4/PRESTA Monte Carlo simulation code for the
same phantom geometry. This library data is provided with the software and is not editable by the
user. The resulting energy probability distribution is divided into 40 even bins, width 0.2 MeV, range
0 – 8 MeV.
A set of predefined energy bin weights is used to give a starting estimate of the energy distribution
and the resulting depth dose curve, that is:
PDDMC (Z ) =  PDD  E, Z   Weight(E ) (6)

all E
where PDD (E, Z) is the PDD data point at depth Z for mono-energetic beam energy E stored in
the data library, and Weight (E) is the starting point weighting factor for this energy.
The correlation between the calculated depth-dose curve and the measured data is then calculated
using the expression
  PDD MC  PDD measured 

all z
---------------------------------------------------------------------------------------- (7)
  PDD   PDD
2 2
MC   measured 
all z all z
A perfect match results in a correlation value of unity, and tends towards zero as the match
degrades.
Next, a “random creep” process iteratively adjusts the weight of randomly selected bins up and
down by a small increment. Each bin weight must remain  0. With each change the resulting
Monte Carlo Dose Calculation depth dose curve is recalculated, and the change is retained if the
match between resulting PDD and measured PDD is improved (assessed using the correlation
factor). The process repeats until the correlation factor exceeds a predefined threshold (= 0.9999)
or the number of repeats exceeds another predefined threshold (= 1,000).

The energy spectrum is manually selected from a set of pre-generated spectra. There are two sets
of 11 spectra that can be toggled by selecting or unselecting the Beam Hardening option in the
commissioning workspace. Each set of 11 spectra range from 6.0 MeV to 7.0 MeV input energy.
The hardened spectra will have a higher mean output photon energy, as the data was created by
simulating presence of a lead (Pb) hardening filter. Some model CyberKnife LINACs have this filter
in place. In the commissioning workspace, Beam Hardening is set to off by default. The user should
choose this option for the particular LINAC being commissioned and find the best match to the
measured data. Furthermore, the selection of the input energy level is optimized by comparing
calculated beam data (primarily TPRs) with corresponding measured data.
Fluence Distribution
The fluence distribution represents the distribution of directions in which photons are emitted from
the target.

This is calculated as a 1 D (radial) probability distribution of direction points in a plane normal to
beam central axis from the source in the absence of a secondary collimator. This is calculated from
a measured beam profile at user-specified SAD and depth, with the secondary collimator removed.
The probability distribution is stored internally as a function of radius in the radial range 0-80 mm,
with resolution of 0.5 mm, and an SAD = 800 mm.
Therefore the suggested measurement for SAD is 800 mm, and the profile should be measured to
an off-axis distance corresponding to at least 80 mm at this SAD. The measurement depth i)
should be close to zero to avoid phantom scatter significantly affecting the profile shape (since the
source model assumes straight line transport from origin to direction point), but ii) should be deep
enough that, even with slight mechanical misalignment of the measuring system, the detector is
never within the build-up region. Note that in the situation with no secondary collimator the build-
up depth cannot be assumed to be 15 mm. A possible compromise is between 20 mm and 50 mm.
Since only a single radial profile is stored, it is best to obtain profiles in at least 2 orthogonal
directions and average them before using as input. Specific measurement recommendations are
given in Monte Carlo Dose Calculation Source Model Commissioning, in Chapter 2,
The distribution is calculated on the Accuray Precision System by averaging the 2 halves of the
input profile on either side of the central axis (where the central axis is found by calculating the full-
width of half maximum of the input profile, and taking the middle point). The off-axis distances in
this average radial data-set are then geometrically projected from the measurement Source-
Detector distance to the reference distance of 800 mm. Data points at 0.5 mm radial increments at
this distance are calculated by linear interpolation of the averaged data.

This is stored as a 2D distribution based on four profiles (X, Y, and both diagonals) measured with
the secondary collimation removed so that the beam is collimated only by the primary collimator.
This distribution is identical to that used in the Finite Size Pencil Beam dose calculation algorithm,
and more details of the measurement recommendations can be found in the commissioning
recommendations for that algorithm.
Source Distribution
The source distribution represents the distribution of photon points of origin. The source distribution
is calculated as a radial function in a plane at SSD = 0 (that is, in the X-ray focal spot plane). There
are two alternative methods to generate the source distribution:
• In-air Output Factor method (available for fixed collimators and the Iris Collimator only)
• Gaussian method (available for all secondary collimators)
In-air Output Factor Method

The In-air Output Factor method calculation is based on output factors (OF) measured in air for
each collimator size.
The increase in OF measured in air with increasing collimator size is assumed to be proportional
to the photon fluence originating from the increased area of the source plane subtended at the
detector. Therefore, it is assumed that there is no variation in the ratio of primary to scattered
photons detected with collimator size.
The source distribution is divided initially into 12 radial bins (1 for the smallest collimator, and 1 for
the annular region subtended by the difference between each successive pair of collimators)
according to
W(0) = OF(0)   r (0)

2 (8)
and
OF(n) – OF(n – 1) (9)

W(n) = ---------------------------------------------
-
 (r  n  2 – r  n – 1  2)
Where W is the origin point probability corresponding to the source plane radius, r, subtended by
the smallest collimator (n = 0) or the radius increment between each other collimator and the
collimator immediately smaller than it  1  n  11  as shown in Figure 4 on page 5-21.
The inner bin is then subdivided into 4 smaller equally-sized bins in order to improve the distribution
resolution. This is performed using weighting factors based on Monte Carlo Dose Calculation
simulation of a CyberKnife System LINAC treatment head. These factors are embedded in the
software and cannot be edited by the user. The total weight of these 4 bins is equal to the weight
of the original single inner bin. The final distribution is therefore divided into 15 bins.

Figure 4 The difference in OF measured in air with collima-

tors n and n – 1 determines the origin point probability cor-
responding to source plane radius r(n – 1) < r< r(n).
Gaussian Method
The Gaussian method models the source distribution as a Gaussian function. The Gaussian model
for the source model has one user-specified input parameter: the source full width half maximum
(FWHM) for the photon source. The FWHM (in millimeters) can have a spot size between 1.0 and
4.0 mm. Smaller values for the Gaussian spot size yield steeper slopes through the penumbra of
the OCR.

Patient Model
The patient model provides the physical material information (density and photon mean free path)
at each position within the patient needed for the Monte Carlo Dose Calculation transport
calculations, together with an external patient contour. This model is generated from a CT scan
acquired of each patient and from reference material data embedded in the software. Generation
of the patient model occurs during treatment planning for each patient.
The patient model is comprised of:
• Mass density at each voxel
• Material type at each voxel
Mass Density
The mass density of each voxel is calculated from the average CT number within the voxel. This
conversion is performed using a calibration function selected during treatment planning. Several
default mass density curves are provided and you can define custom curves based on
measurements you perform for individual CT scanners used at your site. The mass density is used
to calculate the mass of each voxel, and also to scale the mean free paths (MFPs) of photons and
the steps of electron and positron tracks which pass through each voxel. These are explained in
the sections dealing with dose summation, and photon and particle transport respectively.
NOTE: CT density phantoms are designed to simulate electron density.

Therefore, ensure that you know both the electron and mass density values for
the CT density phantom(s) you use to create your CT density model curves.
Material Type
Each voxel is assigned a material type: air, soft-tissue, or bone. This is done by conversion of the
mass density at each voxel, using the ranges shown in Table 2. These values cannot be edited by
the user. The material type is used to define photon MFP within each material type at a reference
density, as a function of photon energy. This is used during photon interaction calculations, and is
explained in the section covering photon and particle transport. The tabulated MFP vs energy data
for each material type is pre-defined and cannot be edited by the user.
Table 2 Conversion of mass density to material type
Mass density range (g/cc) Material Type Material Type Mass Density (g/cc)
0.1 Air 0.0012
0.1 – 1.125 Soft-tissue 1.0
1.125 Bone 1.85

Beam Geometry
The beam geometry provides the spatial information (node position, beam target position,
collimator size or MLC leaf positions) for each beam that will undergo dose calculation. The beam
set is generated during treatment planning for each patient.
User Preferences
Monte Carlo Dose Calculation is subject to statistical uncertainty with a trade-off between
calculation time and uncertainty/spatial resolution. The user can determine the trade-off by
selecting the statistical uncertainty (relative uncertainty in the maximum dose point for the dose
summed from all beams) and the calculation resolution. These parameters are defined during
treatment planning.
Calculation Resolution
The patient model is divided into a 3D voxel array covering the entire CT volume. The user can
adjust the resolution of this model in the axial plane as low, medium, or high as defined in
“Resolution of the Dose Calculation Grid” on page 5-65. Along the axial direction, the voxel
resolution is fixed at 1 voxel per CT slice, and therefore the Z voxel dimension is given by the slice
separation.
Statistical Uncertainty
The statistical uncertainty in the calculated dose is controlled by the number of photon histories
simulated. It is also dependent on the voxel dimensions, patient and beam geometries, and patient
composition. The user can specify the desired uncertainty at the maximum dose point. This setting
is used to determine the total number of photon histories simulated, where the relationship of this
parameter and the resulting maximum uncertainty is obtained empirically from test cases, and
includes dependency on the number of voxels in the patient model. This algorithm is designed to
slightly overestimate the number of histories required to achieve any given level of uncertainty.

History Allocation and Dose Summation

The Monte Carlo Dose Calculation algorithm simulates the energy deposited by individual photons
as they traverse the patient model. Each individual photon simulation, including simulation of all
secondary particles and photons resulting from interactions of the initial photon within the patient
model, is referred to as a history. A large number of photon histories are simulated for every beam
of the beam set. By summing the energy deposited within the patient model from all of these
histories the absorbed dose distribution per beam is calculated. Finally, by summing the dose
distribution from all beams, the total dose distribution and its statistical uncertainty are calculated.
After importing the beam geometry, patient model, source model, and user preferences, the dose
calculation algorithm proceeds as shown in Figure 5 on page 5-24. Lines 40 and 50 are described
in detail in separate sections. Lines 20, 70, and 90 are described below.
10 Loop n = 1 to NBeams
20 Calculate the number of photon histories to simulate for beam n (= NHistories)
30 Loop m = 1 to NHistories
40 Sample photon from source model
50 Transport photon through the patient model
60 Next m
70 Convert energy deposition to absorbed dose distribution
80 Next n
90 Calculate uncertainty in absorbed dose distribution
Figure 5 A pseudo-code overview of the dose calculation

procedure

Converting Energy to Absorbed Dose

The required calculation at each voxel is absorbed dose per MU, and this is calculated separately
for each beam. This is denoted as Dbeam below. Dbeam is a function of the voxel location, v, and
the collimator size, Cbeam. Dbeam(v,Cbeam) is calculated by
D beam   C beam  =   E   C beam    CF()  d15(C beam)  OF(C beam)  fnormal (10)
all histories
The first term on the right hand side of the equation is the total energy deposited at this voxel for
all simulated photon histories, and is calculated by the Monte Carlo Dose Calculation transport
method. This term could be re-written as
 E   C beam  = E   C beam   n hist (11)

all histories
Where the first term is the average energy deposited per history, and nhist is the total number of
histories simulated.
CF(v) is a voxel specific correction factor which converts the total energy deposited for all histories
into the average dose deposited per history. This has the form
1 1 (12)
CF() = e  ---------  ------------
n hist M()

Here e is the charge on an electron. Expressed in the appropriate units it converts energy from
MeV (the output of the simulation), into cJ (the requirement for treatment planning). M(v) is the
mass of voxel v, given by the voxel dimensions and mass density. Multiplying Equation (11) by
Equation (12) therefore gives the average dose deposited at each voxel, per simulated history.
This parameter will be denoted as D’(v,Cbeam), that is:
(13)
E   C beam   n hist  CF() = D'   C beam 
d15 is a factor required to normalize the D’(v,Cbeam) result to a fixed value in the situation of a
measurement made at 800 mm SAD, and a voxel at 15 mm depth on the central axis, in a uniform
water phantom with the beam in normal incidence. The fixed value chosen is the reference output
measurement geometry, i.e. Cbeam = 60 mm. It is calculated by running the Monte Carlo simulation
of this situation for each collimator, and dividing the results, that is:
D'   (d = 15, SAD = 800) 60  - (14)

d15(C beam) = ------------------------------------------------------------------------------
D'   (d = 15, SAD = 800) C beam 
OF is the measured output factor for each collimator. As always this is defined as
D beam   (d = 15, SAD = 800) C beam  (15)

OF(C beam) = --------------------------------------------------------------------------------------
-
D beam   (d = 15, SAD = 800) 60 
Where Dbeam is the dose per MU, as defined above.
Finally, fnormal is the calibration factor which converts D’ (average dose per simulated photon
history) to Dbeam (dose per MU) in the reference output geometry (d = 15 mm, SAD = 800 mm,
point on central axis of uniform water phantom, beam in normal incidence). This is defined by
D beam ( (d = 15 ,SAD = 800),60) (16)

fnormal = -------------------------------------------------------------------------------------------
-
D'

The denominator is calculated by Monte Carlo simulation, as with d15. The numerator is defined
as 1 cGy/MU by convention. Therefore, by combining Equation (11) through Equation (16) one can
rewrite Equation (10) as
D'   C beam 
-  D  (d =15, SAD=800) C beam  (17)
Dbeam ( Cbeam ) = -----------------------------------------------------------------------
D'((d =15, SAD=800) C beam) beam
The first term on the right-hand side of the equation is the average dose per history at the voxel of
interest relative to the average dose per history calculated at the output specification point for this
collimator. The second term is the measured dose per MU at the output specification point for this
collimator, so the complete right hand side of the equation gives the dose per MU at the point of
interest, as defined on the left hand side.
Note that both fnormal and d15 are calculated using an Monte Carlo simulation and the current
source model. Therefore, if any changes are made to the source model during commissioning,
these parameters must be recalculated. d15 affects only the calculated OF for each cone, so re-
commissioning is minimal. fnormal affects only the absolute output calculated for the machine.

The total absorbed dose delivered by all beams at each voxel, D(v), is then given simply by
D() = D beam   C beam  MU beam (18)

all beams
The above method is used, except that for the Multileaf Collimator, the reference field size used to
normalize the Monte Carlo calculation is the 53.8 mm x 53.9 mm rectangular field. So in the
equations above to define d15(Cbeam), OF(Cbeam) and fnormal, 53.8 mm x 53.9 mm should be
substituted for the 60 mm circular reference field. OF is calculated for each of the rectangular
commissioning field sizes using measured output factors, and d15 is calculated for the same field
sizes. When applied to a treatment plan dose calculation, OF and d15 are interpolated within this
dataset using aperture area projected at 800 mm SAD.
Calculating Statistical Uncertainty

The relative statistical uncertainty in total dose at each voxel, D/D, is calculated from
 E    –   E    
2
 N hist
D (-) = (19)
-------------- all histories all histories
---------------------------------------------------------------------------------------
-
D()  
2
 
E

all histories
where E(v) is the energy deposited at voxel v per photon history, and Nhist is the total number of
histories
(that is, N hist = n hist ).
all beams

Since generally Nhist is much greater than the energy deposited at each voxel, this term is
approximately equal to
 E 
2
D ()- (20)
--------------  -----------------------------------
all histories
-2
D()  
  E 
all histories
So the relative uncertainty is related to the variation in energy deposition per history.
Photon Sampling
Photons are generated one at a time as input to the photon/particle transport algorithm. The data
required in order to sample a photon is the complete source model, the secondary collimator size
(fixed collimators and the Iris Collimator only), and collimator specific correction factors for energy
and field size which are described below (for fixed collimators and the Iris Collimator only). The
output is the energy, position (defined in a plane normal to the beam at 800 mm distance),
direction, and weight factor of the resulting photon. The photon energy is obtained from the energy
spectrum, the position from simple geometric principles, the weight from the fluence distribution,
and the direction by the combination of the position and the source distribution.
NOTE: The ranges on the user-specified values for the Energy Correction
Factors (ECF) and Collimator Correction Factors (CCF) are 0.5 to 1.5.
Typically, though not always, the best fits with measured data have values
between 0.9 and 1.2.
Sampling Initial Photon Energy

The photon energy spectrum contained within the source model is converted into a discrete
cumulative probability distribution function (CPDF). A uniformly sampled random number is used
select an energy bin from this CPDF. A second uniformly sampled random number is used to select
a photon energy within this bin, assuming equal probabilities within this range.


The resulting photon energy, which is independent of the secondary collimator size, is multiplied
by a collimator specific correction factor. These are determined by the user during commissioning
of the Monte Carlo Dose Calculation algorithm on the basis of comparing TPR data from Monte
Carlo Dose Calculation procedures with measured data for each collimator. The default settings
for these correction factors are 0.96 for the 5 mm collimator and unity for all others.
There is no modification of the photon energy at this stage, although there is a subsequent
modification during the first stage of photon transport in the patient model as described later.
Sampling Source Position

The source distribution contained within the source model is converted into a discrete CPDF. A
uniformly sampled random number is used to generate a radial bin using the CPDF, and a second
uniformly sampled random number is used to generate a radius within this bin assuming radially
weighted probabilities within this range. A third uniformly sampled random number is used to
generate an angle within the source plane, assuming equal probability of angular positions, which
together with the radius gives the photon point of origin in polar coordinates. These are converted
to Cartesian coordinates.
Sampling Photon Position

First, a uniformly sampled random number is compared against a collimator specific constant
(0 - 1) to determine whether the photon position lies within the field defined by the secondary
collimator or outside it. In principle, each constant is determined by the collimator opening and the
collimator transmission (remembering that the position is defined in a plane at 800 mm distance,
i.e. beneath the secondary collimator). This constant determines the proportion of sampled
photons which lie outside the collimated field. The dose within the field is always normalized
according to the d15 and fnormal parameters, i.e., is independent of this constant, and therefore
the constant is effectively setting the level of the dose plateau outside the collimated field and
beyond the penumbral region. These collimator constants are pre-defined and are not editable by
the user.
If the photon is within the collimated field then a uniformly sampled random number is used to
select a radius between zero and R x CR, assuming radially weighted probabilities within this
range. Here R is the nominal collimator radius, and CR is a collimator specific correction factor set
by the user during commissioning of the Monte Carlo Dose Calculation algorithm on the basis of
comparing Monte Carlo calculated Off-Center Ratio data with measured data for each collimator.
These factors effectively adjust the radiation field width for each collimator. The default settings are
unity for the 10 mm and larger collimators (which are divergent), 0.97137 for the 5 mm collimator
and 0.94796 for the 7.5 mm collimator (both of which are non-divergent).

If the photon is outside the collimated field then the same approach is used, but the sampled radius
is within the range R x CR and (R x CR) + 50 mm. So photon positions for each beam are
contained within a circle of radius (R x CR) + 50 mm in this plane.
A third uniformly sampled random number is used to generate an angle within the position plane,
assuming equal probability of angular positions, which together with the radius gives the photon
position in polar coordinates. These are converted to Cartesian coordinates.
A position is randomly selected within an area 12.5 cm X by 10.5 m Y assuming equal probability
of all positions.
Photon Direction
The direction of each photon is defined by the direction of the vector linking the sampled source
position and the sampled photon position.
Photon Weight
The selection of photon positions assumes uniform photon fluence in the sampling plane, if the
secondary collimator were removed. The difference between this assumption and reality is given
by the fluence distribution within the source model, and this is used to define a weighting factor for
each photon, Wfluence, which is the relative probability of a photon at this radius within the
uncollimated beam profile. This weighting factor is applied to the energy deposited by the photon,
as described in the photon and particle transport section. For fixed collimators and the Iris
Collimator, the effect of secondary collimator transmission is included in the position calculation.
For the Multileaf Collimator, this is not the case, and so the weight factor is subsequently modified
to reflect transmission probability through the MLC leaves during the first stage of photon transport
in the patient model as described later.
Photon and Particle Transport

Primary photons, or histories, are provided to the photon and particle transport algorithm
individually, as explained in previous sections. The algorithm calculates and returns the energy
deposited at each voxel within the patient model resulting from this history.
The Monte Carlo Dose Calculation algorithm makes significant use of variance reduction
techniques, which are methods of improving the speed in which the Monte Carlo method achieves
a fixed level of statistical uncertainty. The variance reduction techniques employed in this algorithm
are photon interaction forcing, photon splitting, electron history repeating, Russian rouletting and
electron range rejection. An introduction to these techniques is provided by Kawrakow and
Fippel (2000). (See “References” on page 5-146.) The nomenclature used by Kawrakow and
Fippel has been used here, where possible.

Overview
1. If the beam is shaped using the Multileaf Collimator, the first step is to modify the photon
weight factor and energy to reflect attenuation through the collimator.
2. Multiple interaction sites are selected along the path of the primary photon, based on
density variations within patient, the photon energy, and pre-calculated photon mean free
paths (MFPs) in various materials.
3. An electron history record appropriate for the photon energy is sampled from a database
of such data. This record contains the pre-computed tracks of all particles (electrons and
positrons) resulting from a photon interaction, together with a description of any tertiary
photons also generated.
4. This record is overlaid at the first photon interaction site, and an energy deposition
algorithm follows each particle track, scaling each step according to local voxel density,
and depositing energy in the appropriate voxels along the track. Any tertiary photons
generated are added to the list of photons awaiting later calculation if they pass a
Russian roulette test.
5. When Step 4 is complete for all particle tracks within the record, the entire track is
overlaid again at the next photon interaction site and the process is repeated. (This is the
electron history repeating method.)
6. When Step 5 is complete for all photon interaction sites, the process repeats from Step 2
for each of the saved tertiary photons.
This larger process repeats until there are no more tertiary photons to calculate. At this point, the
total energy deposition per voxel is passed back.
The algorithm is summarized in Figure 7 on page 5-41 and the main steps are described in more
detail below.
Electron History Records and Mean Free Path Data

Electron history records were generated by simulation using the EGS4/PRESTA Monte Carlo code
in a uniform water phantom. Records correspond to 51 different initial photon energies ranging
from 25 keV to 7.7 MeV. These energy bin widths are unevenly set, ranging from 25 keV at the
lowest energies to 200 keV at the highest (particle tracks are most changeable in the lower photon
energy range). Records exist within each bin to simulate Photo-Electric, Compton Scattering, and
Pair Production interactions, with the relative number of each as calculated by the EGS4/PRESTA
simulations. The records are randomly distributed within each bin.
Each record contains the tracks and energy deposition pattern of all secondary and tertiary
particles (electrons and positrons) resulting from the initial interaction, together with the properties
(start location, direction, energy) of any tertiary photons generated within these tracks (e.g.
Compton photons, bremsstrahlung, annihilation photons). Each particle track is described by a
series of discrete steps. The parameters of each step are direction, length, energy deposited, and
the particle interaction at the end of the step. These interaction types are bremsstrahlung,
annihilation, Møller scattering, Bhaba scattering, or no interaction. Each step length corresponds
to an energy loss of  4% (step lengths are randomly sampled in the range 0 to 4%). The record
geometry assumes an initial photon traveling along a vertical track prior to interaction.

Photon MFP data was obtained from ICRU Report 46 (1992) from the International Commission
on Radiation Units and Measurements, which tabulates MFP as a function of photon energy and
tissue type for various body tissue types [Ref. 4].
Random Number Generation

The Monte Carlo Dose Calculation algorithm requires a high quality source of uniformly sampled
random numbers in the range 0 – 1. In this implementations two random number generators are
used. Photon sampling uses the RAN2 algorithm from Numeric Recipes in C, 2nd Edition. Particle
tracking uses a 64-bit linear congruential generator (LCG). The LCG random number generator is
seeded with an odd integer.
Photon Parameter Modification for Multileaf Collimator

Transmission
Photon directions are sampled uniformly over an area of 12.5 cm (X) x 10.5 cm (Y) at 800 mm
SAD and the weight factor only describes the probability of a primary photon being emitted in this
direction (based on the fluence distribution, which is measured with the Multileaf Collimator
removed). For each MLC beam, the first step of photon transport in the patient model is to modify
the weight factor and energy of the sampled photon to reflect attenuation through the MLC leaves
of the relevant aperture. To do this, the intersection of the photon trajectory with the MLC leaves
is classified into one of five categories using the following algorithm:
1. Define the MLC aperture at 800 mm SAD. Define a bounding rectangle that is 0.5 cm
larger than the maximum extent of this aperture in all four directions. If the sampled
photon is outside this rectangle, then categorize it as full leaf attenuation.
2. If the photon falls within this bounding rectangle, then backproject its position to
SAD = 310, 340, 370, and 400 mm (corresponding to the position of the leaves). At each
of those four distances, calculate whether the photon trajectory passes through a leaf
body, a leaf tip, or is in air (that is, inside the MLC aperture). The effect of the MLC tilt in
the Y-direction is included in this calculation. Based on these intersections, the photon is
categorized as being attenuated by the full leaf, leaf end, leaf end edge, leaf side edge, or
not attenuated. These possibilities are illustrated in Figure 6.
For all attenuated photons the photon weight factor is multiplied by the relevant partial transmission
factor that is defined during the beam model commissioning. Next a Russian roulette is performed
in which a random number (0 -1) is compared with the photon weight factor. If the number is greater
than the weight factor then the photon is rejected. Otherwise the weight factor is set to unity and
the photon is transported.
Finally, for each photon that intersected the Multileaf Collimator and passes the Russian roulette
test, the energy originally sampled (which was taken from an energy distribution optimized using
open beam measurements) is replaced with an energy sampled from a hardened photon energy
distribution, to model the beam hardening effect of MLC transmission. This distribution is
calculated from the original energy distribution, by multiplying the probability at each energy bin by
an exponential attenuation term e–µ(E)*t, where µ(E) is the linear attenuation coefficient of tungsten
at this bin energy (E), and t is the MLC leaf thickness.

(a)
(b) (c) (e) (c) (a) (d) (e) (d)
Figure 6 Illustration of the classifications of photon attenu-

ation by the MLC leaves seen in the XZ plane (left) and
YZ plane (right, with the leaf bank tilt exaggerated)
Based on the intersection of the photon trajectory with the leaves at SAD = 310 mm, 340 mm,
370 mm, and 400 mm, each photon is classified as undergoing either (a) full leaf attenuation (thick
black lines), (b) leaf end attenuation (dotted black lines), (c) leaf end edge attenuation (dashed
black lines), (d) leaf side edge attenuation (dot-dashed lines), or (e) not attenuated (thin black
lines), as shown in Figure 6.

Forced Photon Interaction and Photon Splitting

Algorithms
This part of the algorithm is used to define the interaction locations, and corresponding weights,
for each primary and tertiary photon.
Photon Interaction Forcing Without Splitting

In a simple forced interaction approach with no splitting, the total number of photon mean free
paths (MFPs) along the photon path within the patient, Λ, is calculated by tracing the path through
the patient model accounting for the density at each voxel. The probability of the photon interacting
somewhere along this path, Pint, is
(21)
An interaction can therefore be forced to occur somewhere on the path, and given a weight of Pint.
The interaction point occurs λ MFPs along the path, where λ is sampled from
(22)
and η is a uniformly sampled random value between 0 and 1. Since every history is forced to
interact within the patient, calculation time is not wasted in tracking photons that pass through the
patient without interaction.
Note that this approach involves tracing the photon path through the patient twice, once to
calculate Λ and again to find the interaction site. A potentially more efficient approach is to estimate
Λ by assuming some uniform water-equivalent thickness for the patient along the photon path, L
(i.e. Λest = L/MFPwater,), and then proceed as above. If the true number of MFPs along the photon
path, Λtrue, is smaller than Λest then over many repeated histories a proportion of the forced
interaction points given by
(23)
will lie outside of the patient, and no energy will be deposited by these histories. The total energy
deposition over all histories will therefore be correct. The efficiency trade-off is between reducing
the number of photon path tracings by a factor of 2 and increasing the number of histories required
to compensate for those which pass through the patient without interaction. This is determined by
the value of L. Note also that the possibility of photon interactions at equivalent depths > L is
ignored.

Photon Interaction Forcing Combined with Photon Splitting

In this implementation a water equivalent phantom estimation with L = 45 cm is employed. The
value of MFPwater appropriate to the photon energy is obtained from the stored reference data, and
is used to calculate Λest and then according to Equation (6).
In order to further improve the calculation efficiency, each photon is split into Nsplit identical
photons, where
(24)
Here, Nnominal is a constant (in this execution = 90). Each of these split photons is then forced to
undergo an interaction, and the energy deposited following each interaction is assigned a post-
splitting weighting factor, W of
(25)
So that the energy deposited over all Nsplit photons is weighted by as expected.
Each of these split photons is forced to interact within a fixed region along the photon path, with
each interaction occurring further along the path than the previous interaction. The distance to the
interaction point of the nth split photon from the interaction site of the (n-1)th split photon, ΔD(n), is
given as a multiple of MFPs by sampling
(26)
Here η is a uniformly sampled random value between 0 and 1, and the summation term gives the
total step lengths along the photon path for the (n-1)th split photon interaction. (Note that
1 n Nsplit, and D(a=0) = 0). It can be seen from Equation (26) that as the interaction point moves
further along the photon path, that is, as n increases, then the average step size between
interactions also increases. This is seen most clearly if the random value is set constant. In that
situation the step sizes as a function of n are illustrated in Equation (27). The corresponding photon
interaction density, given by 1/(step size), as a function of distance along the photon path is shown
in Figure 9 on page 5-43 and it is exponential as expected.
The furthest possible distance along the photon path at which the nth split interaction can occur,
Dmax(n), is given by
(27)

and so the maximum distance at which the final interaction (that is, when n = Nsplit) can occur is
shown by substituting Equation (21), Equation (24), and Equation (25) into Equation (27), giving
Dmax(Nsplit) = Λest, which shows that all split photon interactions are forced to occur within the
estimated water phantom geometry as intended.
As stated previously, if the actual number of mean free paths along the photon path within the
patient, Λtrue, is less than Λest then a proportion of the split photons given by Equation (23) will
interact outside the patient and deposit no energy. So the total energy deposition by the initial
photon history after splitting and forced interaction will be calculated with the correct weight:
This can also be shown using Equation (27) by substituting Dmax(n) = Λtrue, which gives the
number of split particles that interact within the patient as:
and therefore a total weighting factor per history of:
As also stated earlier, if Λtrue > Λest then photon interactions in the region corresponding to a water
equivalent depth > L (= 45 cm) will be ignored.
In the actual patient model the physical step length, ΔU(n), between each interaction is determined
from ΔD(n) calculated using Equation (26) and the actual MFP at the voxel location in which the
step starts, v, that is:
(28)
Where ρest and ρtrue are the estimated material density used in the MFP calculation (given by the
material type setting at each voxel) and the actual patient density taken from the CT calibration
respectively. If the photon path takes any interaction points outside of the patient model (i.e.
outside the entire CT field of view) then these points are ignored.

Electron History Selection and Rotation Algorithms

The input to this algorithm is the initial photon energy and direction. An electron history record is
selected from the energy bin closest to the photon energy. Records are selected sequentially from
each energy bin, and when the final record in any bin is reached the sequence repeats from the
first record.
The entire record is read into memory, including all of the particle steps and parameters describing
all of the tertiary photons generated within this history (the record contents are described more fully
elsewhere). Since the direction of the initial photons used to generate the records (vertically
downwards) is generally different to that of the initial photons in the patient dose calculation, every
particle step and tertiary photon direction is then rotated so that its direction relative to the patient
model is correct.
Finally, the photon weight is modified by 2 factors i) since the energy of the photon, Ephoton, will not
correspond exactly to that used to generate the interactions in the closest energy bin, Ebin, the
photon weight is modified according to ratio of actual to bin energy, and ii) the fluence weighting
factor Wfluence of the initial photon, as described in the photon sampling section (note that for the
Multileaf Collimator, the fluence weighting factor is unity, since fluence weighting is considered
together with MLC transmission in the Russian roulette step at the start of photon transport).
Therefore the final weight, W’, is given by
(29)
where the initial weight W is explained above. This weighting factor is applied to the energy
deposited by all particles within the record.
Electron History Repeating and Russian Roulette Algorithms

The input to this algorithm is the photon interaction site and the electron history record previously
selected (which is already rotated into the correct orientation relative to the photon path). An
overview of the algorithm is given in Figure 10 on page 5-44. The highlighted sections are
described in more detail below.

Compton Photon Processing

The photon resulting from a Compton scattering interaction is processed before the electron
transport calculation. If the scattered photon energy from the electron history record is lower than
Pcut (= 10 keV) then this energy multiplied by the weighting factor W’ is deposited in the current
voxel. Otherwise a Russian roulette procedure is performed, and the photon is deleted unless the
inequality
(30)
is satisfied, where η is a uniformly sampled random number between 0 and 1. In this case the
scattered photon is stored to the photon calculation stack, for later processing.
Voxel Particle Transport per Step

The energy lost in each step is deposited across 1 or more voxels. The step direction is read from
the Electron History Record, together with the total energy lost, Estep, and total step length, Lstep.
Starting from the initial interaction point, the distance to the voxel boundary along the direction of
the step, rb(v), is calculated. If rb(v) > Lstep/ρ(v), where ρ(v) is the voxel density, then the entire step
energy multiplied by the weighting factor W’ is deposited within this voxel, and the step is complete.
Otherwise, the energy deposited within this voxel, Edep(v), is given by
(31)
rb(v) is then recalculated as the distance between the points at which the step enters and leaves
the next voxel, and the process repeats until rb(v) > Lstep/ρ(v), at which point the remaining energy
is deposited in the current voxel and the step is complete.
1. If this is the final particle step in the record, as soon as the current particle energy is less
than a threshold Ecut (= 0.7 MeV, including rest mass energy) then
2. the remaining electron energy is deposited over multiple voxels using a simplified particle
transport in which the particle travels in a straight line following its current trajectory until
the remaining energy is fully deposited, and the energy deposited at each voxel along this
trajectory is given by
(32)

The first term on the right hand side of Equation (32) is the collision mass stopping power for the
relevant material (soft tissue or air). The product of the first three terms on the right-hand side is
the energy lost to low energy inelastic collisions according to the continuous slowing down
approximation, and the final term approximates additional energy deposited in the more
convoluted real electron trajectory. The purpose of this simplified transport method is to avoid
depositing all of the remaining energy erroneously in a very low density voxel which can cause very
high dose single voxel features in the final dose distribution.
NOTE: The simplified particle transport algorithm reduces the frequency and
magnitude of non-physical high dose sparkles in low-density regions.
Actions Following Particle Interactions at the End of Each Step

Several particle interactions are possible at the end of each step, and the resulting algorithm steps
are described below:
• No interaction, particle remains – continue tracking the particle.
• No interaction, particle track ends – finish tracking this particle, and deposit any
remaining energy in the current voxel.
• Bremsstrahlung – treat the resulting photon in the same manner as a Compton scattered
photon, i.e. deposit energy in current voxel (if energy < Pcut) or Russian roulette and store
to photon calculation stack if passed. Continue tracking the particle.
• Bhaba or Møller scattering. Finish tracking this particle and record details of the
2 resulting scattered electrons (Møller scattering) or electron and positron (Bhaba
scattering) in the particle stack for later transport.
• Annihilation – Finish tracking this particle. Treat each of the resulting annihilation photons
in the same manner as a Compton scattered photon, i.e. deposit energy in current voxel
(if energy < Pcut) or Russian roulette and store to photon calculation stack if passed.
Deposit any excess energy in this voxel.

Figure 7 Overview of the photon and particle transport

algorithm

A more complete description of the shaded boxes is given in the text. Pcut is set at 10 keV.
Figure 8 The step length between successive split photon

interactions increases with distance along the photon path

Figure 9 The photon interaction density (1/step length) as a

function of distance along the photon path for the step
length data presented in Figure 8 on page 5-42. The interac-
tion density decreases exponentially with distance (as
shown by the fitted exponential curve), as expected.

Figure 10 An overview of the particle transport algorithm.

The highlighted sections are described in greater detail in
the text. Ecut is set to 0.7 MeV including the particle rest
mass. EHR = Electron History Record.

Dose Display
As described in the dose summation section, the output of the Monte Carlo Dose Calculation
algorithm is the absorbed dose, and the associated statistical uncertainty in this value, at each
voxel of the patient model. In this section, details of the options for smoothing this data,
normalization, and display of this data are given.
Dose Filtering for Artificial Hot Spots

The raw dose volume given as the output of the Monte Carlo Dose Calculation algorithm may
contain isolated artificial hot spots in areas with very low CT numbers. The uncertainty in the dose
calculation for these voxels with low CT number is usually greater than the uncertainty for the
surrounding volume.
Before the smoothing algorithm is applied, a desparkling filter is applied to the raw dose volume to
remove these artificial hot spots. See Table 3 for a pseudo-code illustration of the algorithm for the
desparkling filter
Table 3 Illustration of the desparkling algorithms
Input Vraw original raw dose volume
Vunc uncertainty volume
fd desparkling factor for dose volume1
fu desparkling factor for uncertainty volume
Output Vdes desparkled raw dose volume
Algorithm Applied 3D Median filter to Vraw, to get Vmed_dose
Applied 3D Median filter to Vunc, to get Vmed_unc
For each voxel in Vraw,
If Vraw [i] – Vmed_dose [i] > Vmed_dose [i] * fd

or
If Vunc [i] – Vmed_unc [i] > Vmed_unc [i] * fu
Then, Vdes [i] = Vmed_dose [i]
Else, Vdes [i] = Vraw [i]
End
1. The desparkling factor for dose volume, fd, is set to 5. The desparkling factor for
uncertainty, fu, is set to 3. These values cannot be modified by the user.

Smoothing Algorithms
Monte Carlo Dose Calculation dose distributions exhibit noise due to the statistical uncertainty in
the dose calculation at each voxel. This can be minimized by increasing the number of histories
simulated, as described in the User Preferences section of the Treatment Planning Manual. In
addition, smoothing algorithms may be useful in reducing the level of noise and therefore aiding
clinical interpretation of the dose distribution. A review of this subject is given in De Smedt et
al (2006).
In this system the user can select from 5 smoothing algorithms. The selected smoothing algorithm
is applied to the 3D dose volume. Therefore, all representations of the dose distribution, including
isodose lines, dose-volume histograms, point doses, and plan quality parameters (conformality
index, new conformality index, homogeneity index, maximum and minimum doses per structure)
are affected.
The smoothing algorithms are:
1. Average: Equally weighted averaging of 27 voxels, that is, computing the average value
within a 3 x 3 x 3 voxel cube surrounding the calculation voxel.
2. Weighted: As in Step 1, but with weighting factors that decrease with distance from the
central voxel. The weighting factor matrix is:
3. Gaussian: Convolution of the dose distribution with a 3D Gaussian function, for which the
user can specify the standard deviation . The Gaussian kernel is a 3 x 3 x 3 voxel array.
This is the default smoothing method, with a configurable .
4. Clipped Gaussian: Convolution of the dose distribution with a 3D Gaussian function as
above, but the outcome of the Gaussian function is modified so that the delta between the
raw dose and the smoothed dose stays within the statistical uncertainty in dose
calculation at each voxel.
5. Desparkled Only: This filter eliminates artificial hot spots at voxels with high uncertainty.
The user can choose to display either the smoothed or unsmoothed (raw) dose distribution.
Dose Normalization
By default, a Monte Carlo Dose Calculation treatment plan is normalized to the maximum voxel
dose in the smoothed dose distribution. This means that doses greater than 100% are possible
when displaying the raw dose distribution. These can be visualized using the standard isodose line,
DVH, and point dose tools.

Display of Dose and Dose Uncertainty

The underlying 3D dose distribution is smoothed and normalized as described above. The
methods used to generate isodose lines, DVHs, point dose, and plan quality parameters from this
distribution are identical to those used with the Ray-Tracing dose calculation algorithm (i.e. they
are independent of the dose calculation model).
The user can display the statistical uncertainty at each voxel as a color wash overlay on the dose
distribution. This uncertainty distribution is not modified by the smoothing algorithm.
In addition, the user can display the statistical uncertainty at each voxel by using the point dose
tool with the smoothed and raw dose values at this point.

Checking Point Dose Calculations Using

Independent Algorithms
It is fairly common practice for a check to be made of the dose calculated at the reference point in
a treatment plan using an independent dose calculation algorithm. When applying this practice to
treatment plans generated using the Monte Carlo Dose Calculation algorithm, or comparing Monte
Carlo Dose Calculations with Ray-Tracing dose calculations at a reference point, several new
challenges are introduced:
1. The difference between a Monte Carlo Dose Calculation and an independent algorithm
result can be relatively large. This is because the dose calculation algorithm used to
perform the independent check is usually fairly simple, and therefore less accurate in
complex dose calculation situations. Therefore, in situations where systematic
differences exist between the more accurate Monte Carlo Dose Calculation algorithm and
a simpler algorithm, a relatively large difference between the treatment plan and the
independent check may exist. These differences will usually be larger than those
experienced when the treatment plan is generated using the Ray-Tracing dose
calculation algorithm because the Ray-Tracing dose calculation algorithm is fairly similar
to the simpler algorithms used for independent checking, and therefore the differences for
the Monte Carlo Dose Calculation algorithm may exceed tolerance levels established
based on comparing dose calculations using two simple algorithms.
2. The Monte Carlo Dose Calculation at any voxel is associated with a random uncertainty
(which is displayed as part of the treatment plan). This is the uncertainty in the total dose
deposition within the voxel. The random uncertainty in the contribution of each individual
beam to the dose within each voxel can be significantly larger than the uncertainty
associated with the total dose, and it increases with the number of beams used.
3. The Monte Carlo Dose Calculation is not performed exactly at the reference point, but
using a voxel resolution defined by the user. The total dose at the reference point as
displayed on the Evaluate step is extracted from this 3D dataset by interpolation. Since
an independent algorithm usually calculates dose exactly at the point this can cause
differences in regions of high dose gradient. Note that the reference point dose displayed
on the Evaluate step is based upon either the raw dose volume (if raw dose display,
Show raw, is selected) or smoothed dose (if smoothed display, Show smooth, or
smoothed and raw display, Show both, is selected). The exception to this behavior is if
Use max dose point is selected to define the reference point, in which case the
smoothed dose volume will always be used to calculate the reference point dose.

4. The Monte Carlo dose calculation at the reference point from each individual beam can
only be obtained from the treatment beam list. This is generated from the individual beam
maps which are used during plan optimization, not from the final 3D dose volume on
which all dose display and the treatment prescription is based. The use of these beam
maps to generate reference point doses introduces two further problems:
• Dose is not calculated specifically at the reference point. Instead, dose is obtained
directly from the Monte Carlo calculation voxel geometry. If the reference point does
not lie at the center of a dose calculation voxel, then the dose calculated at the
nearest neighboring voxel within the beam map is assigned to it. In addition, the dose
calculated within each voxel represents the total dose within the voxel, which can
differ by a very large degree from that delivered at a single point within the voxel in
regions of steep dose gradient (for example, near the beam edge).
• Very low dose values in each beam map are truncated to zero.
It is recommended that if the user wishes to check a Monte Carlo generated treatment plan by
independent dose calculation at a reference point then only the total dose delivered by all beams
at the reference point should be used as the checking method. This approach minimizes the impact
of points (2) and (3) above, and removes the impact of point (4) completely. Therefore a valid
comparison between two dose calculations on the basis of the physical differences between them
(point (1)) is possible. Advice on an appropriate method is included in “Checking Total Dose at a
Reference Point” on page 5-50.
Checking the treatment plan using the dose calculated per beam is not recommended because the
problems noted in points (2) and (4) above can make a decision about the physical accuracy of the
dose calculation shown in the treatment plan very difficult to reach. However, some advice on
minimizing these effects in this comparison is also given in “Checking Calculated Dose per Beam
at a Reference Point” on page 5-52.

Checking Total Dose at a Reference Point

Placing the Reference Point
The location of the reference point determines the accuracy of the simpler algorithm being used to
perform the independent check. Use the cross-hairs to place the reference point manually
according to the following guidelines.
• Do not use the maximum dose point.
• Do not place the reference point at an artificial hot spot. The uncertainty of an artificial hot
spot is significantly higher than that of neighboring voxels. See “Dose Display” on
page 5-45.
• Place the reference point in a region of density that is approximately equivalent to that of
water and that is not close to tissue interfaces such as bone in the case of lung.
• Place the reference point at a a Monte Carlo Dose Calculation voxel.
Use the axial view to position the cross-hairs. Display the uncertainty map and zoom in
around the target volume. Each uncertainty pixel corresponds to a Monte Carlo Dose
Calculation voxel. Place the cross-hairs at the center
 To check total dose at a reference point:
1. On the Accuray Precision System, perform the final Monte Carlo Dose Calculation using
high resolution and the lowest practical uncertainty level, typically 1 or 2%.
2. Prescribe the treatment plan.
3. Position the reference point manually in a region of relatively uniform dose within the
target volume. (See “Placing the Reference Point” on page 5-50.) Ensure that Use max
dose point is not selected. Click the Set to Cross-hair Point button.
4. Display the raw Monte Carlo Dose Calculation.
NOTE: Because the reference point is in a region of low uncertainty inside the
target volume, the use of smoothing algorithms could degrade the agreement
with the independent point dose calculation.
5. Record the raw Monte Carlo Dose Calculation at the reference point as reported on the
Evaluate step.
This reflects the value at that point in the total dose volume. Both the clinical evaluation of
the treatment plan and the prescription process are based on the smoothed dose of the
reference point and not the raw dose.
Do not sum the Monte Carlo dose values given per beam in the treatment beam list
because these values are obtained from the individual beam maps, which are truncated
and therefore less accurate than the values in the total dose volume. (The beam maps
are used only during optimization.)

6. Generate the independent dose calculation result at this same reference point in the
usual manner.
Typically, this is done by exporting the beam geometry from the treatment beam list to a
separate program or spreadsheet.
7. Compare the relative difference between the 2 values against your local investigation
level.
If the difference exceeds this level, then estimate the expected difference between a
Monte Carlo Dose Calculation and the simpler independent algorithm in this specific
treatment planning situation.
Evaluate the collimator size, tissue density near the reference point, tissue interfaces
near the interface point, and tissue obliquity.
Consider the differences in the handling of scattered radiation, obliquity correction, and
charged particle disequilibrium between the algorithms.
8. Choose the next step according to the results above:
• If the observed difference is consistent with the expected difference, given an
understanding of both algorithms and the treatment planning situation, record this
with the plan approval.
• If the difference is not expected, then consider possible further calculations as
described below. (See “Additional Dose Check Calculations” on page 5-51.)
Additional Dose Check Calculations

If the difference observed in the second dose check is not expected, the following calculations can
clarify the cause of the difference.
1. Review the position of the reference point.
If the reference point is within a region of very low or high density tissue, or is very close
to a tissue interface such as lung-to-tissue or bone-to-tissue, then move it away from
these interfaces and repeat the comparison. Moving the reference point in this way
improves the accuracy of secondary dose calculation algorithms that do not consider the
effects of tissue heterogeneity on the scatter dose contribution as realistically as does the
Monte Carlo Dose Calculation algorithm.
2. Compare the dose calculation at this point given by the Ray-Tracing algorithm (found in
the treatment beam list) with the result from the independent checking algorithm.
An acceptable result verifies that the reason for the difference lies in the Monte Carlo
Dose Calculation algorithm itself, not in the beam geometry or general patient model.

3. Change the mass-density model to Water/Air and recalculate the Monte Carlo Dose
Calculation distribution. Compare this result with the result of the independent checking
algorithm. (Ensure that the reference point is not moved during this process).
This simplifies the patient model to a uniform water equivalent phantom. If the
independent checking algorithm employs a simple 1-D heterogeneity correction method,
turn it off for this comparison.
An acceptable result verifies that patient density variations and/or surface obliquity are
the cause of the difference.
4. If the patient model has relatively uniform density but significant obliquity, use the plan
QA procedure to overlay the treatment plan onto a uniform cube type water phantom or
solid tissue equivalent slab phantom. Repeat the comparison and repeat the independent
dose calculation for this phantom.
An acceptable result indicates that the difference results from the obliquity correction that
is inherent to the Monte Carlo Dose Calculation algorithm but which is usually absent
from a simple checking algorithm.
Checking Calculated Dose per Beam at a Reference

Point
NOTE: This method is not recommended for a Monte Carlo Dose Calculation
treatment plan for the reasons stated above. However, if this is attempted, then
the following information should be considered.
1. Perform the final Monte Carlo Dose Calculation using high resolution and the lowest
practical uncertainty level (typically 1 - 2%).
2. Prescribe the dose to the treatment plan.
3. Position the reference point manually using the cross-hairs in a region of fairly uniform
dose within the target volume. (See “Placing the Reference Point” on page 5-50.)
4. Obtain the dose contribution to the reference point for each beam from the treatment
beam list.
5. Express the difference of each value to the equivalent value generated by the
independent algorithm as an absolute dose or relative to the total dose at the reference
point.
NOTE: Do not express the difference relative to the beam dose at the
reference point.

6. To minimize the random uncertainty in this calculation, perform the following procedure:
• Move the reference point to a different location within the target volume.
• Ensure that the differences in position correspond to at least one Monte Carlo Dose
Calculation, following the advice in Step 1 on page 5-51.
• Export the beam list, and compare the Monte Carlo Dose Calculation result with the
independent checking algorithm result for each beam.
• Repeat the tasks in this step for up to 8 individual locations within the target volume.
• Evaluate the average agreement between the 2 calculations across all of these
reference points, that is:
(33)
The average agreement between the 2 algorithms within the target volume is estimated
for each beam.
7. Beams that exceed the local investigation level for your site, based on this average
difference in dose calculation within the target volume should be investigated further.
• Save the plan.
• On the Finetune step, set MU = 0 for all beams except those being investigated.
• Visualize the dose calculation for these individual beams and evaluate the expected
difference between the 2 algorithms. Consider the position of the reference point(s)
relative to the beam and the effects of tissue density and patient obliquity on that
beam. See Figure 13 on page 5-56.
8. Based on the results from Step 7 above, choose the next step:
• If the observed difference is consistent with the expected difference, given an
understanding of both algorithms and the treatment planning situation, record this
explanation and the plan approval.
• If the observed difference is not consistent with the expected difference, it is due to a
large random uncertainty at the limited number of points chosen or to a systematic
difference between the 2 algorithms. To eliminate the former, recalculate all beams at
very low uncertainty (0.2%) overnight or a subset of beams selected on the
Finetune step at 1 – 2% uncertainty.
If this calculation shows good agreement, the reason for the difference was random
calculation uncertainty at the limited number of reference points. If this does not
explain the difference, consider the evaluation steps described in Step 7 on page 5-
51 for each of these beams.

Figure 11 Sample reference point placement
Sample Reference Point Placement

Figure 11 on page 5-54 depicts the results of a high resolution calculation performed at low
uncertainty (2%).
The position of the reference point is set using the green cross-hairs in an axial image. The position
is in an area of relatively low dose gradient and low uncertainty within the target volume, and is at
a position of water-equivalent density, close to the center of a Monte Carlo Dose Calculation voxel.
Alignment with the center of a Monte Carlo Dose Calculation voxel is determined using the
uncertainty map in the axial plane. The Z coordinate of the reference point also corresponds
exactly to a CT slice location as shown by the point dose tool.
In this example, dose was calculated using a simple correction-based independent checking
algorithm performed with effective depth heterogeneity correction. The result is within
approximately 1.5% of the Monte Carlo Dose Calculation reference point dose. The small
difference between the 2 algorithms is expected and results from the lack of significant tissue
heterogeneity and surface obliquity.

Figure 12 Sample reference point placement for a lung

treatment plan
Sample Comparison with Correction-based Model

Figure 12 on page 5-55 displays the reference point that was set according to the guidelines in
“Sample Reference Point Placement” on page 5-54.
The Monte Carlo Dose Calculation value at the reference point is 15% lower than the dose
calculated at the same point using a correction-based model with effective depth inhomogeneity
correction.
The difference is explained by the combination of low-density lung tissue around the reference
point and by the small collimator size (12.5 mm), which contributes to significant electronic
disequilibrium that is not accounted for by models that only account for primary heterogeneity
corrections. Dose at the reference point is almost always over-estimated in such models.

Figure 13 Sample visualization of single beam
Sample Visualization of Single Beam

Figure 13 on page 5-56 displays a portion of the Finetune Step with the reference point indicated
by the green cross hairs. The reference point is within the steep dose gradient at the edge of the
beam.
Although a treatment plan that has been computed with low or medium resolution cannot be saved
as deliverable if ray trace dose calculation has been used, plans that have been computed using
Monte Carlo Dose Calculation algorithm can be saved as deliverable when low or medium
resolution (coarse voxelization) has been used. Therefore, for deliverable plans that have been
computed using Monte Carlo Dose Calculation with a resolution lower than high, the dose assigned
to a reference point for a particular beam may actually be an average over a large range of isodose
lines which intersect that voxel.

Finite Size Pencil Beam Algorithm

This section contains the following topics:
• “Finite Size Pencil Beam” on page 5-57
• “Dose Deposition Kernel” on page 5-60
• “Field Size Calculation” on page 5-61
• “Align Dose Plane with CT Series” on page 5-63
• “Lateral Scatter Correction” on page 5-63
Finite Size Pencil Beam

Dose calculation for Multileaf Collimator plans is performed using a finite size pencil beam (FSPB).
The fundamental algorithm is described in [Ref. 14] and [Ref. 15]. The algorithms have been
adapted to handle some of the particulars of CyberKnife treatment, especially the lack of a
flattening filter, the smaller leaf widths, and smaller field sizes. Commissioning this algorithm is
described in a separate section.
.
Figure 14 A dose plane, P, for a beam with a beam-

let centered at point p(prime)
1075879-ENG A Finite Size Pencil Beam Algorithm |5-57

Figure 14 shows the setup geometry of the calculation with respect to the treatment beam. A set
of dose planes, P, are established normal to the central axis of the beam. The dose for point, p’,
along a beamlet is found by Ray-Tracing through the volume. A kernel spreads the dose at this
point across the plane, so that the dose per monitor unit at point p due to the beamlet passing
through p’ is given by:
2
800
D p  p  = A  p   TPR  F  p , d eff  p    K p  p   ------------------------2- (34)
SAD  p 
where:
• A (p’) models the attenuation of the Multileaf Collimator and the beam fluence. The value
will be 0, if the beamlet is blocked by a leaf. Note that the specification for intraleaf
transmission through the Multileaf Collimator is < 0.3% and therefore dose outside the
aperture is dominated by phantom scatter. As implemented, the edge of the Multileaf
Collimator aperture in the direction of leaf travel is assumed to be slightly larger than the
geometric leaf opening to account for partial transmission through the leaf tips. So, the
modulation factor, A (p’), is calculated from the open field Fluence, Fl(p’):
A  p  = Fl  p   1, point in Field of View (FOV) (35)
or
A  p  = Fl  p   0, blocked by Multileaf Collimator (36)
• F is the equivalent square field size, and
800 (37)
F  p  = F  ---------------------
SAD  p 
is the field size at the dose plane that crosses point p’.
• TPR (F(p’),d) is the tissue-phantom ratio at depth d for field size F(p’), normalized at
depth 15 mm. The value is stored in a lookup table based on depth and equivalent square
field size. The field size is projected to the dose plane. Bilinear interpolation is used to
determine values not at the storage points.
• deff (p’) is the equivalent path length depth at point p’.
5-58 | Finite Size Pencil Beam Algorithm 1075879 ENG A

• 8002/SAD (p’)2 is the inverse square law term. Like the circular collimator algorithms, the
beams are normalized to a distance of 800 mm SAD.
• Kp'(p) is the value of the deposition kernel contributing dose at point p due to the beamlet
centered at p’. The function represented by this term is called the Pencil Beam Kernel.
• SAD(p’) is the source-to-axis distance to p’. Its exact value is equal to the distance Isp’I,
however, the finite size pencil beam algorithm approximates it by using IscI.
• The total dose at point p is the sum of the contribution from all the kernels in the plane.
Dp=  D p  p  (38)
p  P
This term can be expanded as:
2
800
D  p  =  A  p   TPR  deff  F  p    -----------------------2- (39)
p  P SAD  p 
Combine all of the terms except the kernel into a fluence term:
2
800 (40)
  p  = A  p   TPR  deff  F  p    -----------------------2-
SAD  p 
Finally, the dose at point p can be expressed as the combination of the fluence and the kernel.
Dp =    p   K p  p  (41)
p  P

Dose Deposition Kernel

The kernel is derived as described in [Ref. 14]. Each component, x and y, of the kernel is
composed of a linear combination of the difference between two offset exponentials, one
dimension of which is illustrated in Figure 15.
Figure 15 The pencil kernel is formed from the

difference of two exponential functions
The equation for each exponential curve is:
1 ux (42)
su  x  = ---  e  if x < 0
2
and
–u x
e (43)
su  x  = 1 – --------- , if x  0
2
where u is a non-negative exponential decay parameter.

The simplest one-dimensional kernel profile (see Figure 15) of width t is formed by subtracting two
exponentials:
p u(x t) = s u(x – t  2) –  x + t  2  (44)

The deposition kernel used in formulas above is two-dimensional and models primary and
secondary penumbra by using a pair of p terms in each dimension. The pencil beam kernel of size
tx x ty is given by:
(45)
K(x, y, t x, t y) = w 0  P u 0x(x, t x)Pu 0y(y, t y) + w 1  Pu 1x(x, tx)P u 1y(y, t y)
where u0x, u0y, u1x, and u1y are exponential decay parameters, w’s are weights. [Ref. 14] requires
the sum w0 and w1 to be 1.0. The constraint, however, is not enforced in the Accuray Precision
implementation.
Six parameters (u0x,u0y,u1x,u1y,w0, and w1) need to be determined during commissioning to model
the kernel. These six parameters are stored as functions of field size and depth.
Field Size Calculation

The pencil beam kernel and the TPR are lookup tables that depend on the field size. The Field size
F is computed as the length of an equivalent square.
F is computed using a two step process. First, an equivalent rectangle (x, y) is calculated.
Figure 16 An Example that demonstrates how to calculate

equivalent rectangle from an irregular shape.

As shown in Figure 16, the x component is in the motion of leaf travel and the y component is
perpendicular to the x component. The x value for the equivalent rectangle is the average opening
of all the open leaves. So, if n leafs are open, then:
x = 1  n  xj (46)
j = 1n
The y dimension is the range of the open leaves.

In the second step, we denote the larger of two dimensions x or y as Mxy, and the lesser of two
dimensions as mxy and compute the length of the equivalent square as:
(47)
where:
(48)

Align Dose Plane with CT Series

The dose plane, in general, does not align with the CT series. So, once the dose has been
calculated across each plane for a segment, the resulting dose volume needs to be rotated and
interpolated so that the dose is stored with relation to the CT series.
Figure 17 A beam trajectory with sample dose

planes shown in relation to a CT volume
Figure 17 illustrates the relationship between the dose plane and the CT series for an example
beam.
Lateral Scatter Correction

The user has the option of incorporating a lateral scatter correction component that adjusts the
model parameters for the dose deposition kernel based on the local density, ρ, through which the
beam passes. Six terms are used to adapt the kernel parameters. Four are the penumbra
broadening factors: fu1(ρ'), fu2(ρ''), fw1(ρ'), fw2(ρ''), and two are weight-correction coefficients
bw1(ρ'), bw2(ρ''). These corrections depend on smoothed densities. Smoothing is done with 3D
spherical exponential filters. The filter used to smooth the density for u1 and w1 is:
(49)
where r is the radial distance .

The filter used to smooth the density for u2 and w2 is:
(50)
The filters are applied to the CT density map to create smoothed density maps by downsampling
the CT density by a factor of 4 in each direction and then convolving the down sampled density
with the appropriate spherical exponential filter.
(51)
The downsampling reduces memory requirements for the computation without affecting accuracy,
because the smoothed density map varies at a slower rate of change than the original CT.
Given the smoothed densities, P’(p) and P”(p) at point p, the corrected kernel parameters are
computed from the uncorrected kernel parameters using the equations and table lookups below.
(52)
fu1(Ρ'(p)), fu2(Ρ''(p)), fw1(Ρ'(p)), and fw2(Ρ''(p)) are stored in a table and looked up as functions of
field size and density.

Beam Targeting and Optimization Algorithms

This section provides a description of the major targeting, beam optimization, imaging, and dose
calculation algorithms.
Generation of treatment plans involves several fundamental steps:
• Collimator Selection
• Beam targeting
• Beam weighting
• Dose Calculation
Resolution of the Dose Calculation Grid

The optimization algorithms constrain only those portions of a VOI that are within the dose
calculation grid. Therefore, the algorithm must handle more constraints when the grid has a finer
resolution.
The user can set the dose grid to use low, medium, or high resolution. The resolution for low,
medium and high is based on the CT resolution downscaled factor.
Optimization is computationally intensive. Therefore, the low mode does not require as much
memory and CPU usage as the medium or high modes. Use the high mode for cases in which a
small, important VOI must be constrained. Dose grid resolutions are summarized in Table 4.
Dose Cut-Off for Ray-Tracing Dose Calculations

The Ray-Tracing dose volume displayed in the Sequential workspace (high, medium, and low
resolution) is calculated as the sum of individual beam maps. In each beam map, if the dose at any
point is less than 0.01 cGy/MU, then that dose is set to zero. This cut-off is applied to all
calculations within the Sequential workspace.
1075879-ENG A Beam Targeting and Optimization Algorithms |5-65

No threshold is applied (or, the threshold is 0.00 cGy/MU) to any calculations in the Evaluate
workspace. Therefore the calculation in the Evaluate workspace will tend to result in a higher dose
value at each voxel than calculation in optimization steps, even though the spatial resolution of the
calculations may be identical.
Table 4 Dose grid resolutions for dose calculation
Dose grid size
Low Medium High Volume

Resolution Purpose resolution resolution resolution in grid
Fine Dose Grid Calculate tar- CT Resolution CT Resolution CT resolution Bounds of the
Optimization get and OAR downscaled by downscaled by up to 512 x 512 user-defined
for Ray-Tracing doses, goals, 4 x 4 x 2 2x2x1 Fine Dose Grid
and finite size and con-
pencil beam straints during
optimization.
Fine Dose Grid Calculate tar- CT resolution Whole CT vol-

Optimization get and OAR 128 x 128 x 256 x 256 x up to 512 x 512 ume
for Monte Carlo doses, goals, Number of Number of
and con- axial CT slices axial CT slices
straints during for Monte Carlo for Monte Carlo
optimization
Fine Dose Grid Calculate and CT Resolution CT Resolution CT resolution Bounds of the
Evaluation for display the downscaled by downscaled by up to 512 x 512 user-defined
ray-tracing and dose distribu- 4x4x2 2x2x1 fine dose grid
finite size pen- tion of a treat-
cil beam ment plan.
Fine Dose Calculate and 128 x 128 x 256 x 256 x CT resolution Whole CT Vol-
Evaluation for display the Number of Number of up to 512 x 512 ume
Monte Carlo dose distribu- axial CT slices axial CT slices
tion of a treat- for Monte Carlo for Monte Carlo
ment plan.
Total Number of Beams in the Optimization

Solution Space
The Accuray Precision System limits the number of beams in the solution space based on several
factors, including targeting method, number of targets, node set, and optimization method.
For each isocentric target point, the number of beams can be as great as the number of nodes in
the selected path set. The maximum number of isocentric target points is 32. The number of nodes
for each template path set will depend on the configuration of your CyberKnife System.
Configuration variables that can affect the number of nodes in a template path set are as follows:
5-66 | Beam Targeting and Optimization Algorithms 1075879 ENG A

• Treatment Robot Location: Mirror or Normal

• Treatment Couch Type: RoboCouch or Standard Treatment Couch
Note that not all permutations of these configuration parameters are available together. Table 5
gives the number of nodes in the head path sets. Table 6 gives the number of nodes in the body
path sets, except those specific to prostate treatments. Table 7 gives the number of nodes in the
prostate-specific path sets.
Table 5 Nodes in the head path set for InLine configurations
Path Set
Configuration FullPath ShortPath InTempo_Short InTempo Even_Paths
InLine, Fixed/Iris 179 64 38 120 179
InLine, MLC 171 73 46 116 171
Table 6 Nodes in body path sets not specifically tailored

to prostate treatments for InLine configurations
Path Set
Configuration FullPath ShortPath InTempo_Short InTempo Even_Paths
InLine, Fixed/Iris 117 87 61 82 117
InLine, MLC 102 76 55 71 102
Table 7 Nodes in prostate path sets for InLine configurations
Path Set
Prostate Reduced
Prostate Prostate InTempo Reduced Prostate
Configuration Prostate InTempo short short Prostate InTempo
InLine, Fixed/Iris 101 70 73 49 24 21
InLine, MLC 91 61 69 50 24 23
Based on the above, the maximum number of isocentrically targeted beams is therefore 32 x 179
= 5728 beams.
for VSI systems


Although the Iris Collimator is designed for and capable of collimating beams as small as 5 mm
diameter at 800 mm SAD, it is advantageous to limit the use of 5 mm Iris collimator beams. The
Accuray Precision System limits the total Monitor Units (MU) which can be delivered to the target
from these 5 mm Iris collimator beams at the time of planning, decreasing the potential dose
uncertainty at delivery to no more than 2% of the prescription dose. The implementation of this
limitation in the planning system assumes that the Output Factor for the 5 mm aperture of the Iris
collimator could vary by up to 15%, based on a worst-case scenario analysis of mechanical
repeatability. This variability is used to calculate the maximum allowable MU contribution delivered
by beams from the 5 mm Iris collimator aperture, restricting the potential dose variation to no more
than 2% of the prescription. The absolute number of MU delivered by the 5 mm Iris aperture will
vary from plan to plan and depend on the relative contribution to the prescription dose compared
to other field sizes in the treatment plan.
Beam Targeting
After the collimator size has been selected, beams must be directed at the treatment target.
Treatment planning for the CyberKnife System includes these fundamental methods of targeting
beams:
• Isocentric Targeting
• Manual Beam Placement
Isocentric Targeting
The Accuray Precision System permits the user to target beams isocentrically. For each defined
isocenter, a single beam from each treatment robot node is directed toward the defined isocenter.
For multiple or single isocenter treatments, you can reduce the treatment time by only using beams
from 1 or 2 paths to treat a defined isocenter. This capability may be especially useful if the
isocenters do not have the same diameter.
On the Accuray Precision System, isocenters are displayed in 2D views as circles, and in the 3D
view as spheres, both corresponding to the diameter of the collimator used for the isocenter beam,
with an attached legend displaying size of the collimator.
For isocentric planning, the most common rule of thumb is to choose the smallest collimator that
fully covers the target volume or some large percentage of the target volume.
Because field size for a given collimator is defined at 800 mm SAD, the actual field size for body
treatments is larger than the nominal field size, since body path SADs are typically between 900
and 1000 mm.
The above field size convention overestimates the span of the beam for treatments to the
trigeminal nerve because the field size is actually smaller for these beams, since the trigeminal
path SAD is between 650 and 750 mm. The dose distribution, however, is accurately represented
because it is adjusted for changes in field size.

Segment Generation for the Multileaf Collimator

Before the optimization commences, but after the Multileaf Collimator is selected, a solution set of
segments is generated. The segments depend on the size and shape of the target volumes of
interest (VOI) and the user inputs.
Also, before optimization is started for the Multileaf Collimator plan, the user needs to open the
MLC dialog. In this dialog, the user sets the following parameters:
• The maximum number of nodes.
• Whether to use isocentric conformal targeting or conformal avoidance targeting.
• The maximum margin to apply around the target VOI when generating the segment.
• The leaf justification convention to use at the border of the target VOI.
If the user selects conformal avoidance targeting, additional heuristics may be used to generate
segments. There segments are referred to as perimeter segments, eroded segments, and random
segments. The user can also choose to create segments that conform to the target VOI while not
directly intersecting a specific critical VOI.
Target Point Selection

All the heuristics that create a solution set of segments use the projection of the target VOI from
the node. This target projection is centered on the volume center of the VOI. The projections are
pixilated at the same resolution as the primary CT series. If the user has disabled the critical VOI
in the Plan > Settings step, the projections of those critical VOIs are subtracted from the
projected target VOIs.
For target VOIs that have projections smaller than the projection of the MLC, the target point will
be the center of the volume center of the target VOI.
If the projection of the Target VOI is larger than the projection of the MLC, multiple target points
will be used from that node. The number of target points required depends on the size of the target
VOI. The number of divisions of the target VOI is first determined in the direction perpendicular
(y-direction) to leaf motion. For each of these divisions, the target may be further divided in the
direction of motion (x-direction) for the MLC.
When multiple target points are needed, the target VOI is divided into sections and the conformal
shapes are generated to match those divided shapes. Figure 18 shows a large target that is
divided into 2 divisions in the y-direction and 2 divisions in the x-direction.

Figure 18 A large target for which four target points are

determined, in order to assure that the InCise 2 collimator
can fully cover the projection of that target
Isocentric Conformal Targeting

The isocentric conformal method of targeting is an attempt to mimic 3D conformal treatments in
conventional radiotherapy systems. In this method, the central axis of the LINAC targets the same
point in the target VOI for all segments. Therefore, in order to assure that the MLC can cover the
whole target volume, this option is only available if the target VOI projection from at least 1 node
is smaller than the projection of the MLC.
This method only generates segments that conform to the shape of the target VOI (plus or minus
the user set margin) with the projections of all disabled VOIs subtracted. If the target VOI projection
is concave, multiple segments may be created to assure that the full target VOI is covered. The
exact size and shape of the conformal segment depends on the margin setting and the edge
justification.

Conformal Avoidance Targeting

The selection of conformal avoidance targeting introduces more possibilities for the segments
generated by the solution set. If this targeting method is chosen, the user has the option of applying
other heuristics: perimeter segments, eroded segments, negative margin, and random segments.
The user also has the option of selecting critical VOIs to be avoided.
For conformal avoidance, a set of conformal segments will be created. If the margin is positive, two
sets of conformal segments will be created. The first set has the user specified margin, M. The
second set applies a margin of M-3.85 mm. If the margin is greater than 3.85 mm, a third set of
conformal segments will be created. These segments have a margin of M-7.7 mm. If the margin is
negative, one set of conformal segments, with the user-specified margin, will be created.
If the user selects avoidance VOIs, additional conformal segments will be generated. These
segments subtract the projection of a critical VOIs to avoid, from the projection of the target VOI.
If more than one avoidance VOI is selected, segments are generated subtracting each avoidance
VOI individually and subtracting all avoidance VOI.
Segment Margins and Edge Justification

The user can set a margin around the target VOI that is used to shape the segments. Though the
user sets the margin in mm, the system applies the margin as a pixilated buffer. The number of
pixels in this buffer is determined by rounding the user input to the nearest number of pixels.
Three settings are available for edge justification: leading edge, trailing edge, and middle. For
leading edge justification, the edge of the leaves is outside the projection of the target VOI. For
trailing edge justification, the edge of the leaves is fully inside the projection of the target VOI.
Middle justification positions the leaves halfway between the setting for leading and trailing edge.
Figure 19 shows the conformal segments generated for target projection using the three edge
justifications.
If a disabled VOI is set and its projection intersects the target VOI and the margin is positive, the
segments will be generated with a trailing edge justification, regardless of the user input. This
variance is used to prevent the edges of the segments from intersecting the disabled VOI.
Leading edge Middle Trailing edge
Figure 19 Conformal segments for a Target VOI. Left to

right, these segments are generated with Leading Edge,
Middle, and Trailing Edge justification.

Perimeter, Eroded, and Random Shapes

If perimeter shapes are selected, up to four segments per node will be generated. These segments
are located at the boundary of the projected VOI. Left and right half-rings will be generated with the
nominal thicknesses of 7.7 mm and 11.55 mm.
If the user selects eroded shapes, up to two segments per node will be generated. The eroded
segments compliment the perimeter segments. They are the conformal shapes with the perimeter
shapes removed.
Random shapes are circular segments that are clipped at the boundary of the target VOI. The
center and radius of the circle are randomly selected. Then, the leaves are set, so that the segment
follows that circle or conforms to the boundary of the target VOI, whichever leads to the smaller
segment.
Number of Segments Generated

The total number of segments generated will depend on the number of nodes selected, the number
of avoidance VOI with projections that intersect the target VOI projection, and the types of
heuristics chosen. Nominally, 1 conformal segment, 2 eroded segments, 4 perimeter segments,
and 10 random segments will be generated if all those algorithms are selected. Additional
conformal segments will be generated if one or more avoidance VOI are selected and if the target
VOI has a concavity or is so large that multiple segments must be used to fully cover it.
If random segments are chosen, the number of segments in the solution will generally be between
600 and 3600, respectively.
Limitations on the Shapes of Segments

The segments used have to conform to the following criteria. For the most part, these criteria are
meant to assure that the shapes can be modeled with the finite size pencil beam dose calculation
algorithm.
• Only 1 continuous opening per segment is permitted.
• All segments have a minimum projected area of 57.75 mm2 at 800 mm SAD.
• The minimum width of an individual open leaf is 5.0 mm.
• Any opening along a line perpendicular to the direction of leaf motion must be at least 2
leaf widths wide.
• A limit on long narrow shapes is imposed by requiring that the ratio of the equivalent
square term used to generate the pencil (the equivalent square field size, F, in
Equation (47) on page 5-62) and the square root of the projected area is greater than
0.57.
The segment on the right is not valid because between 2.5 mm and 9.0 mm to the right of center
the opening is only 1 leaf wide, rather than 2 leafs wide.

Valid Segment Invalid Segment
Figure 20 Two segments for the same case. The segment

on the left is valid. The segment on the right is not valid,
because a short band is open only 2 leafs.

Sequential Optimization
• “Mathematical Basis for Sequential Optimization” on page 5-76
• “Constraints Applied to the Minimization of F(x)” on page 5-85
• “MU Limits, VOI Limits, and Objectives” on page 5-86
• “Constraints Established by Optimization Steps and Relaxation” on page 5-90
• “Ordering the Steps” on page 5-93
• “Clinical Examples” on page 5-95
• “Beam Reduction” on page 5-100
• “Time Reduction” on page 5-101
• “Automatic Collimator Selection” on page 5-107
The formulation of planning objectives in Sequential Optimization differs from more conventional
optimization approaches where multiple objectives are grouped in a single cost function and
optimized simultaneously. The Sequential Optimization algorithm is executed sequentially as a
series of individual optimization steps. Each step performs a linear programming optimization
applied to a single objective cost function, designed to correspond to a specific clinical objective.
The available objectives include maximization of target volume coverage by a defined dose level,
target volume dose homogeneity, conformality of the dose distribution around the target volume,
minimization of maximum or mean dose for critical structures, minimize the volume of critical
structures that exceed a dose, maximize the volume of target structures that exceed a dose, and
minimization of total monitor units.
The sequence of steps is defined by the user to match the overall clinical goals. This process
replaces the manual definition of numerical weighting factors needed to prioritize each objective of
a multiple objective cost function in many conventional optimization approaches. Therefore, the
user’s clinical knowledge is applied more directly to the treatment planning problem.
5-74 | Sequential Optimization 1075879 ENG A

The Sequential Optimization process proceeds as follows:

1. Limits (absolute constraints) are defined which cannot be violated during the optimization
steps. Available constraints are: Maximum MU for each beam, for each node, and for the
entire treatment plan, and specific maximum doses for each VOI in the optimization.
2. The first optimization step is required to act on the target volume. The step includes an
optimization type (optimize minimum dose, dose coverage, or dose homogeneity) and a
dose to act as a goal value for the optimization step. This first optimization step will
always act to increase the dose delivered to the target without violating any of the MU,
shell, or VOI maximum dose absolute constraints.
3. The result of each optimization step is retained as an additional constraint for all
subsequent optimization steps. Therefore, the sequence in which the steps are
performed is a key factor in determining the trade-offs between multiple clinical
objectives. The result of each step can be retained unchanged as a new constraint or the
result can be relaxed before being applied as a constraint. If no relaxation is applied, the
subsequent steps may have very little room for further optimization. On the other hand, a
reasonable relaxation of the limiting constraints generally has a small impact on the result
obtained by the current step and allows subsequent steps to explore a larger range of
variable values in their optimization.
4. The optimization proceeds sequentially through the optimization steps, to build up the
treatment plan one clinical objective at a time. Because the result of each step is applied
as a new constraint for all subsequent steps, any planning objective already optimized
(and used after relaxation to update a constraint) will not degrade as a result of later
optimization steps.
1075879-ENG A Sequential Optimization |5-75

Mathematical Basis for Sequential Optimization

Each step of the sequential optimization process involves minimizing the linear cost function F(x),
VOI
where x can be either a single explicit slack variable, like S maximize_min , a set of slack variables, like
voxel
the S maximize_mean , or the beam weights, W Beams :
VOI VOI
F(x) = c maximize_min S maximize_min or c minimize_max S minimize_max or
c maximize_mean S voxel
maximize_mean or c minimize_mean S voxel
minimize_mean or
voxels voxels (53)
Shell VOI
c minimize_DV S minimize_DV or c maximize_DV S maximize_DV or
W
Beams
c minimize_MU
Beams
such that
  RHS max
A  x
  RHS min
where A is the coefficient matrix and the RHS values are the voxel constraints.
The cost function minimization is performed using the Simplex method. In most cases, the c
coefficients are set to either unity or zero. For most step types, the c coefficients are set to either
unity or zero. When maximizing the volume at a specified dose for a target VOI, the c coefficients
are adapted during the sequential step. The sequential nature of the algorithm is achieved by
setting only one c coefficient to a non-zero value and all other coefficients to zero during the
optimization procedure. Therefore, the cost function is reduced to only one of the seven terms
described in Equation (53). The sequential nature of the algorithm is achieved by setting only one
c coefficient to unity and all other coefficients to zero during the minimization procedure. Therefore,
the cost function is reduced to only one of the five terms described in Equation (53), and also is
applied to only one VOI at a time (with the exception of the last term, which applies to the total
monitor units). The overall optimization procedure is implemented as a series of steps in which the
coefficients are varied at each step. The seven terms within the cost function are described below.

Each minimization process is constrained such that the solution cannot violate upper or lower
bounds, the RHSmax or RHSmin, representing clinical objectives. Only upper bounding constraints
can be defined prior to the optimization. All lower bound constraints are initially set to zero. This
means that the initial optimization problem is always feasible. Additional upper and lower bounding
constraints are added to the problem based on the results of each optimization step. Because the
lower bounding constraints can only be defined based on the results of an optimization step, the
problem is guaranteed to remain feasible during the minimization process. The upper and lower
bounding constraints are summarized in Table 8 on page 5-85.
When goals are set (by changing the RHS values in Equation (53) to the goal values) below current
maximum constraints (RHSmax), or above current minimum constraints (RHSmin) it is possible that
the new RHS values will result in an infeasible problem without any solutions. To avoid this, explicit
slack variables (as shown in the objective function in Equation (53) above) are subtracted or added
to the problem to prevent infeasibility. Initially, before the step has been optimized, these explicit
slack variables are a measure of how much tighter the goal constraint is than the current constraint
(for a given VOI's voxels). After the optimization has minimized the explicit slack variable, by
changing beam weights (which result in changing the dose to the voxels in the problem), the
optimized explicit slack variables are a measure of how far the voxel doses are from the goal
constraint, for the VOI whose goal is being optimized in the step.
For example; a VOI with a dose maximum constrained to be less than 3000 cGy may have an OMA
step goal to minimize the maximum dose to 2000 cGy. So before the OMA optimization
VOI
the S minimize_max explicit slack would be set to 3000 - 2000 = 1000 and the maximum dose constraint
VOI
(RHSmax) would be set to 2000 (the A matrix coefficient of the S minimize_max is -1 so the slack is
subtracted from each voxel's dose). Thus each dose, which was constrained to be  3000, now
has the relation dose - 1000  2000, and the problem remains feasible. After optimization the voxel
doses change and the minimum value that needs to be subtracted from the largest dose (in the
VOI
optimized VOI) to make it  2000 is 100, this is the optimized value of S minimize_max . The new
constraint for this VOI is then dose - 100  2000. Before proceeding to the next step we put this in
standard form and add the relaxation delta (say 50) to get the final constraint:
dose  2000 + 100 + 50 = 2150 cGy. So 2150 is set into the RHSmax as the updated maximum
constraint for this VOI and the S VOI is set = 0.
minimize_max

Maximize Minimal Dose
This term as described above measures both the initial feasibility gap between the RHSmax
constraint and the steps goal and the deviation of the VOI minimum dose ( ) beneath the user-
defined goal value ( ). These initial limits for the explicit slack variable are given by
RHS min
voxel
= min ( oldRHS min ) voxel  VOI
ClippedGoal maximize_min RHS min 
= max ( G VOI
(54)
VOI
S maximize_min  max  0 ClippedGoal – RHS min  voxel  VOI
currentRHS min
voxel
= ClippedGoal voxel  VOI
Therefore, minimizing this term within the cost function increases the minimum dose within the VOI
to be as close as achievable to the goal value without violating the existing constraints. This term
is implemented as the Optimize Minimum (OMI) step and is available only for targets. See Table 10
on page 5-88.
After the OMI step, the optimal minimum dose is retained as an additional dose constraint applied
to all voxels in the VOI. This additional dose constraint is given by
voxel
oldRHS min = min oldRHS min  voxels in the VOI ( from previous step )
VOI (55)
newRHS min
voxel
= max (oldRHS min,  currentRHS min
voxel
– F(x) – R maximize_min )
voxels in the VOI
voxel
where newRHS min is the same updated minimum constraint for each voxel and henceforth
D
voxel
 newRHS min
voxel
VOI
and where R maximize_min is a user-defined relaxation value. This additional dose constraint cannot
be set below the VOI minimum dose defined by a previous optimization step. This guarantees that
the minimal dose within the VOI can only increase as subsequent optimization steps are
performed.

Minimize Maximal Dose
constraint and the steps goal and the deviation of the VOI maximum dose ( ) above the user-
defined goal value ( ). These initial limits for the explicit slack variable are given by
RHS max
voxel
= max ( oldRHS max ) voxel  VOI
ClippedGoal minimize_max RHS max 
= min ( G VOI
(56)
VOI
S minimize_max  max  0 RHS max – ClippedGoal  voxel  VOI
currentRHS max
voxel
Therefore, minimizing this term within the cost function reduces the maximum dose within the VOI
to be as close as achievable to the goal value without violating the existing constraints. This term
is implemented as the Optimize Maximum (OMA) step when applied to a critical structure and as
the Optimize Conformality (OCI) step when applied to an auto-shell. See Table 10 on page 5-88.
After this optimization step, the optimal maximum dose is retained as an additional dose constraint
applied to all voxels in the VOI. This additional constraint is given by
voxel
oldRHS max = max oldRHS max  voxels in the VOI ( from previous step )
VOI
newRHS max
voxel
= min (oldRHS max,  currentRHS max
voxel
+ F(x) + R minimize_max ) (57)
voxel
wherenewRHS max is the same updated maximum constraint for each voxel and henceforth
D
voxel
 newRHS max
voxel
VOI
and where R minimize_max is a user-defined relaxation value. This new dose constraint cannot be set
above the VOI maximum dose defined prior to the optimization or by a previous optimization step.
This guarantees that the maximal dose within the VOI can only decrease as subsequent
optimization steps are performed.

Maximize Mean Dose
constraint and the steps goal and the summed deviation of the dose at each voxel ( )
beneath the user-defined goal value ( ). These initial limits for the explicit slack variable
are given by
RHS min
voxel
= min ( oldRHS min ) voxel  VOI
ClippedGoal maximize_mean RHS min 
= max ( G VOI
(58)
voxel
S maximize_mean  max  0 ClippedGoal – RHS min  voxel  VOI
currentRHS min
voxel
Therefore, minimizing this term within the cost function increases as much as possible the volume
receiving at least the goal value without violating the existing constraints. This term is implemented
as the Optimize Coverage (OCO) and Optimize Homogeneity (OHI) steps and is available only for
targets. The Optimize Coverage and Optimize Homogeneity steps differ only in their goals. See
Table 10 on page 5-88. After this optimization step, the optimal coverage or homogeneity is
retained as additional dose constraints applied to all voxels in the VOI. The additional constraints
are given by
voxel
oldRHS min = min oldRHS min  voxels in the VOI ( from previous step )
= max (oldRHS min, min  currentRHS min  D voxel – R VOI (59)

maximize_mean )
voxel voxel
newRHS min
voxel
where newRHS min is the updated minimum constraint for each voxel and henceforth
D
voxel
 newRHS min
voxel
where is a user-defined relaxation value. No voxels are constrained to dose values

above the goal; this would over-constrain the problem for the subsequent steps. These new
constraints cannot be relaxed below the VOI minimum dose defined by a previous optimization
step. And if the lowest dose within the VOI is larger than the previous VOI minimum dose, it
replaces it. This guarantees that the minimal dose within the VOI can only increase as subsequent

Minimize Mean Dose
The term as described above measures both the initial feasibility gap between the RHSmax
constraint and the steps goal and the summed deviation of the dose at each voxel ( ) above
the user-defined goal value ( ). These initial limits for the explicit slack variable are
given by
RHS max
voxel
= max ( oldRHS max ) voxel  VOI
ClippedGoal minimize_mean RHS max 
= min ( G VOI
(60)
voxel
S minimize_mean  max  0 RHS max – ClippedGoal  voxel  VOI
voxel
currentRHS max = ClippedGoal voxel  VOI
Therefore, minimizing this term within the cost function decreases as much as possible the volume
receiving more than the goal value without violating the existing constraints. This term is
implemented as the Optimize Mean (OME) step and is available only for critical structures. See
Table 10 on page 5-88. After this optimization step, the optimal mean dose is retained as an
additional dose constraint applied to all voxels in the VOI. The new constraints are given by
voxel
oldRHS max = max oldRHS max  voxels in the VOI ( from previous step )
= min (oldRHS max, max  currentRHS max  D voxel + R VOI (61)

minimize_mean )
voxel voxel
newRHS max
voxel
where newRHS max is the updated maximum constraint for each voxel and henceforth
D
voxel
 newRHS max
voxel
and where is a user-defined relaxation value. No voxels are constrained to dose

values below the goal; this would over-constraint the problem for the subsequent steps. These new
constraints cannot be set above the VOI maximum dose defined prior to the optimization or by a
previous optimization step. If the largest dose within the VOI is lower than the previous VOI
maximum dose, the new value is used. This guarantees that the maximal dose within the VOI can
only decrease as subsequent optimization steps are performed.

Minimize the Dose Volume Objective

Shell
c minimize_DV  S minimize_DV
This step is similar to the minimize maximal dose step. For minimization of a dose volume,
however, instead of minimizing the dose to the entire critical VOI, the dose is minimized to a shell
that partitions the VOI into two volumes. Thus, the explicit slack variables are formed similarly to
the minimize maximal dose goal of Equation (56).
This optimization shell is found from the user-specified volume that cannot exceed the given dose.
To find the shell, a mask is created from the voxels in the VOI that gives the distance from each
voxel to the nearest target VOI. The voxels are then sorted from closest to furthest from the target
VOI. The voxel that divides the VOI into two volumes is found and a band of voxels, based on the
voxel dimensions, is extracted as the thin shell optimized in this step. When the volume allowed to
exceed the specified dose is very small (4.9% of the total volume of the VOI), the shell includes
all the voxels that are closer than the voxel that partitions the critical VOI.
This method assumes a uniform gradient of the dose throughout the critical VOI. To allow some
variation a constrained set of slack variables is used to allow some variation of the dose within the
shell.
S
Shell Shell
c minimize_DV minimize_DV
- , where
Shell
(62)
 Shell
    N Shell  , where
Shell
NShell is the number of voxels in the shell and  is constant used to control the waviness of the
isodose line through the shell.
After the optimization step is completed the goal is converted into a constraint. For dose-volume
objectives relaxation is a volume relaxation. So, in this instance, a new shell is created and
constrained to the resultant dose of the optimization step. The shell is created by finding the pixel
that divides the VOI into two volumes given by the relaxation volume. The relaxation volume is the
sum of the user input optimization volume and the relaxation value. The constraint is formed
similarly to the minimize maximal dose constraint in Equation (57).

Maximize the Dose Volume Objective

VOI
c maximize_DV  S maximize_DV
This step is similar to the maximize minimal dose step. Note that the weight is applied to each voxel
in the target VOI. The implementation, however, has significant differences. First, this step is run
iteratively. Thus, Sequential Optimization repeats the maximize dose volume objective until one of
three conditions is met:
1. The dose volume objective is achieved.
2. The dose volume objective does not improve sufficiently between two iterations.
3. The maximum number of iterations is reached.
During each iteration, the value of the weighting factor, Cmaximize_DV, will change based on the
results of the previous iteration. Consider a goal dose, Dg, and a voxel dose, Dv. Then, if the dose
at a voxel is close to the goal dose, the penalty for violating the goal dose at that voxel will be large.
Alternatively, if the dose at a voxel is far from the goal dose, the penalty for violating the goal dose
at that voxel will be small.
if  D g  D v ,
 = max  0.5 D g – D v 
(63)
1
c maximize_DV = ------------------------------------
-
–   D g 
1 – e 
If a voxel achieves the goal dose then that voxel is constrained rather than included with the goal.
After the optimization step is complete the relaxation is done similarly to the relaxation for the
maximize minimal dose step and Equation (55).

Minimize Monitor Units
W
Beams
c minimize_MU
Beams
This term measures the total Monitor Units for the treatment plan and is constrained to be 0.
Minimizing this term within the cost function reduces the total MU as far as possible and therefore
also reduces the treatment time. This is implemented as the Optimize Monitor Units (OMU) step.
See Table 10.
After this optimization step, the optimal Monitor Units is retained as an additional constraint given
by
W
beam,opt opt w
W + R minimize_MU = W max (64)
Beams
where Wopt is the minimum value resulting from this optimization step, and RW is a user-defined
relaxation value. This guarantees that the total Monitor Units can only decrease as subsequent

Constraints Applied to the Minimization of F(x)

Prior to optimization, only upper bounding constraints can be defined. Therefore, the initial
optimization problem is always feasible. The problem is guaranteed to remain feasible during all
steps because the lower bounding constraints (see Table 8) can be defined only based on the
results of the optimization process.
Table 8 Constraints applied during minimization
Constraint Set at Start of Bound Can Be Updated by an

Bound Constrained Optimization? Optimization Step?
Maximum dose within Yes Yes, after Optimize Maximum

the VOI (OMA), Optimize Conformality
(OCI), and Optimize Mean (OME).
Maximum dose at each Yes, but the maximum dose for each Yes, after Optimize Mean (OME).
voxel voxel is always less than or equal to
May differ for each voxel.
the VOI maximum dose constraint.
Minimum dose within No Yes, after Optimize Minimum

the VOI (OMI), Optimize Coverage (OCO),
or Optimize Homogeneity (OHI).
Minimum dose at each No Yes, after Optimize Coverage

voxel (OCO) and Optimize Homogeneity
(OHI).
May differ for each voxel.
Maximum Dose to a Yes, for critical VOI Yes, after DVU

Volume within a VOI
Maximum total MU Yes, but the default value is very Yes, after Optimize Monitor Units
large if not specified by the user. (OMU).
Maximum MU per beam Yes, but the default value is very No

large if not specified by the user.
Maximum MU per node Yes, but the default value is very No

large if not specified by the user.

MU Limits, VOI Limits, and Objectives

Initial maximum constraints are inviolate throughout the optimization process. See Table 9. The
maximum MU for each beam, for each node, and for the entire treatment plan cannot be violated.
VOI maximum limits may be decreased by an optimized goal from a specific optimization step. In
practice, dose above the maximum limits or below the (optimized) minimum limits for a VOI may
be observed in the following situations:
• When the optimization sampling points (voxels) are sparse.
This occurs when the Skip Factor is larger than 1 or Importance Sampling is applied (to
reduce the optimization computation time). To compensate for not constraining all the
voxels, one can apply a smaller maximum value or upper dose limit goal than the
intended clinical maximal dose, or a larger lower dose limit goal than the intended
minimal dose.
• If Low Resolution is chosen for optimization and dose calculation.
The DVH and dose statistics are computed at CT voxel resolution and the dose values for
the CT voxels are computed by interpolation from the low resolution dose volume voxels
used in the optimization. Interpolation of dose points may result in the calculation of a
maximum dose which is higher than the VOI limit entered or a minimum dose which is
lower than the value set after target minimum dose optimization.
Note that no minimum MU constraint is available with Sequential Optimization. The addition of
such a constraint complicates the optimization equations. If such a constraint were added this
would result in significantly longer optimization times. Low MU beams below the MU lower limit
must be set to zero (or increased) after the optimization on the Finetune step, or they will be
rounded up so that they have a dose = 1 MU x Number of Fractions when the plan is prescribed.

Absolute Constraints
Table 9 Absolute constraints
Type Maximum Description
MUs Total MUs Limit the total MU to minimize overall treatment time. Note that
limiting the total MU can restrict the Sequential Optimization to use
fewer beams with small collimator size. Beams with small collimator
size are useful for generating sharp dose gradient to protect nearby
critical structures or to sculpt dose within a tumor.
MUs per Limit the MU per beam to minimize the occurrence of high dose
beam regions within the body or just below the skin surface that result from
a single beam or multiple beams from different nodes that pass
through a single volume.
MUs per Limit the MU per node to minimize the occurrence of high dose
node regions within the body that result from multiple beams from a node
passing through a single volume.
Target Maximum Limit the maximum dose delivered within a target to control dose
Dose homogeneity. If the desired uniformity of dose over the target volume
is 20% between minimum and maximum doses, then set this
constraint to be about 20% larger than the prescription dose.
Critical Maximum Limit the maximum dose delivered to a critical structure to minimize
structure Dose the complication probability and to maximize dose conformality.
Dose Volume Limit the maximum dose to a subvolume of a critical structure in order
Upper Limit to achieve a dose volume criterion.
Auto-shell Maximum Limit the maximum dose delivered to an auto-shell to maximize dose
Dose conformality.
Operation of Optimization Steps

Each step is designed to optimize a single objective. The input is a clinical objective with a
corresponding Goal value, which is not the same as a constraint. The program attempts to achieve
a result as close as possible to the goal, but this is not guaranteed. See Table 10.

Table 10 Optimization steps
Type Objective Description DVH
Target Optimize Maximizes and then constrains the

Minimum minimum dose delivered to the target. Set
Dose (OMI) the goal to the minimum dose level you
want to obtain everywhere within the
target.
Optimize Dose Maximizes the dose to a user specified

Volume Lower fraction of the total volume of a target. Set
Limit (DVL) the goal to the minimum dose and volume
that should be achieved in the target. The
result is constrained after relaxation of the
volume required to achieve the goal dose.
Optimize Minimizes and then constrains the

Maximum maximum dose delivered to the target
Dose (OMA) structure. Set the goal you want to obtain
everywhere within this target structure.
Optimize Maximizes and then constrains the voxels

Coverage that receive as close as possible to a
(OCO) specified dose. Set the goal to the dose
level whose volume you want to maximize
(e.g. a prescription dose)
Optimize Maximizes and then constrains the voxels

Homogeneity that receive as close as possible to the
(OHI) maximal dose. The goal is automatically
set to the maximal dose constraint, and
therefore the action is to maximize dose
homogeneity

Type Objective Description DVH
Critical Optimize Minimizes and then constrains the

structure Maximum maximum dose delivered to the critical
Dose (OMA) structure. Set the goal to the maximum
dose you want to obtain everywhere
within this critical structure.
Optimize Dose Minimizes the dose a user specified

Volume Upper fraction of the total volume of a critical
Limit (DVU) structure. Set the goal to the maximum
dose and volume that should be achieved
in the critical structure. The result is
constrained after relaxation of the volume
permitted to receive the goal dose.
Optimize Minimizes and then constrains the voxels

Mean Dose that receive as close to the specified dose
(OME) value as possible. Set the goal to the
dose level whose volume you want to
minimize.
Auto-shell Optimize Minimizes and then constrains the

Conformality maximum dose delivered to the auto-
(OCI) shell. Set the goal to the maximum dose
you want to obtain everywhere along the
auto-shell.
MUs Optimize Minimizes and then constrains the total N/A

Monitor Units MU. The goal is automatically set to zero.
(OMU)

Constraints Established by Optimization Steps and

Relaxation
The result of each optimization step is retained as an additional constraint for all subsequent
optimization steps. The result of each step can be retained unchanged as a new constraint or the
result can be relaxed before being applied as a constraint. Table 11 below describes for each
objective how the DVH are optimized, constrained without relaxation and constrained after a user-
defined relaxation. The blue line is the goal, the red line the constraint, and the red arrows the user-
defined relaxation.
For the optimization steps that apply to target volumes (OMI, OCO, OHI), the new constraint is
always clipped to the minimum of the goal or the (minimum) dose minus the relaxation value.
Constraining dose above the goal would retain undesirable high dose within the target volumes
and would also over-constrain the problem for the subsequent steps. The new constraint is also
always clipped above that minimal dose constraint establish by a previous step to guarantee that
constraint is retained. The minimal dose constraints can only increase as more step optimizations
are performed.
For the optimization steps that apply to critical structures or auto-shells (OMA, OME, OCI), the new
constraint is always clipped to the maximum of the goal or the (maximum) dose plus the relaxation
value. Constraining dose below the goal would over-constrain the problem for the subsequent
steps. The new constraint is also always clipped below the maximal dose constraint defined in the
VOI limits or established by a previous step to guarantee that maximal constraints are only
decreased as more step optimizations are performed.

Constraints and Relaxation

Table 11 Constraints and relaxation
Constrain Without Constrain After

Type Objective Optimization Relaxation Relaxation
Target Optimize
Minimum Dose
(OMI)
Optimize
Coverage (OCO)
Optimize
Homogeneity
(OHI)
Critical Optimize
Structure Maximum Dose
(OMA)
Optimize Mean
Dose (OME)

Constrain Without Constrain After

Type Objective Optimization Relaxation Relaxation
Auto-shell Optimize
Conformality
(OCI)
Relaxed Convergence
If the Relaxed Convergence checkbox is enabled, then convergence testing is performed. If
this checkbox is not enabled, convergence testing is not performed and feasible steps continue
running until interrupted by the user, or until they reach optimality (to within an absolute iteration
difference threshold of about 10-6).
Convergence testing uses the following parameters, whose values cannot be modified by the user:
• D, the update interval
• M, the minimum number of iterations
• A, the number of iterations over which the relative threshold is averaged
• R, the relative convergence threshold
The update interval D is used to set a timeout parameter so that the optimization is interrupted
every D seconds.
If convergence testing is performed, the first M iterations of the update cycles (a time period of
roughly M * D seconds) are ignored so that the optimization algorithms have a chance to either
converge on their own, or settle down.
The A parameter is used to average the relative changes (the change in objective value divided by
the objective value) over A updates cycles, so that a single pair of iterations where the optimization
algorithm does not make much improvement in the objective value will not cause the step to be
terminated. This parameter reduces the effects of noise or fluctuations in the rate of convergence.
Once the averaged relative change in the objective values decreases below R, the convergence
test indicates effective convergence, the optimization for that step then exits as if the result was
optimal, and in the normal course of processing, the next step, if any, is started.

Ordering the Steps

As noted, mapping the order of the clinical objectives into script steps is an important factor in the
optimization process. Table 12 details some important guidelines on each of the available
optimization objectives.
In addition, several approaches can be followed to define the Sequential Optimization set of
absolute limits and sequence of optimization steps depending on the clinical objectives. For
example:
• If the dose to the critical structures has priority over the tumor coverage, set the maximal
dose constraints to the critical structures at the clinical limits, then apply the optimization
steps to optimize dose to the tumor without compromising the dose to the critical
structures.
• If tumor coverage has priority over the critical structures, set the maximal dose
constraints to the critical structures at a reasonable but higher than the clinical limit value,
then optimize the tumor dose. Next, optimize the maximum dose or the mean dose to the
critical structures to reduce their maximal doses as far as possible without compromising
the target volume dose distribution.
• If minimizing treatment time is a key objective, set a limit on the total MU in the treatment
plan, and optimize the total MU during an early optimization step. However if optimizing
MU early in the sequence, it is important to use MU per beam/node constraints and/or
maximum dose constraints on shells in order to avoid the possibility of only a few beam
directions being selected.
Once an appropriate set of absolute limits and sequence of optimization steps is identified for a
typical clinical application, it can be stored as a script and applied to similar clinical cases in the
future. Each script is fully editable within the planning interface.

Table 12 Guidelines for ordering steps
Type Objective Guidelines
Target Optimize The minimum dose obtained with this step might be lower than the
Minimum prescription dose due to the constraints applied on the surrounding
Dose (OMI) dose-limiting structures. Therefore, this step by itself might not
achieve optimum coverage. Always follow up with optimize
coverage or optimize homogeneity.
If the minimum dose delivered to the tumor has a lower priority than
sparing an adjacent critical structure, set the OMI goal to the
maximum allowable dose to this critical structure. Or start directly
with optimize coverage or optimize homogeneity as the first
optimization step.
Optimize Setting the goal to the prescription dose would maximize and then
Coverage constrain the volume receiving at least the prescription. For
(OCO) example, setting the goal to 125% of the prescription, would
maximize and then constrain the volume that is receiving at least
125% of the prescription. This can be useful if the intention is to
define a non-uniform dose distribution within the target volume.
Optimize The maximum dose constraint defined for this target is the goal for
Homogeneity this step.
(OHI)
Dose Volume This is the lowest value for the dose volume.
Lower
Critical Optimize Setting the goal to zero would identify and then constrain the lowest
structure Maximum possible maximum dose within the current constraints, but this very
Dose (OMA) tight constraint might limit subsequent optimization steps unless
sufficient relaxation is applied. Setting the goal to a reasonable
clinical dose provides more room for the subsequent optimization
steps. In addition it requires less computation time.
Optimize Setting the goal to zero would identify and then constrain the lowest
Mean Dose possible mean and total dose within the current constraints, but this
(OME) very tight constraint might limit subsequent optimization steps
unless sufficient relaxation is applied. The goal can be set to a
specific clinical objective. For example, setting the goal to 75% of
the prescription would minimize and then constrain the V75 (volume
receiving more than 75% of the prescription).
Dose Volume This is the highest value for the dose volume.
UpperLimit

Type Objective Guidelines
Auto-shell Optimize Setting the goal to zero would identify and then constrain the lowest
Conformality possible maximum dose along the boundary auto-shell and this
(OCI) would achieve the optimum conformality at this point. However, this
tight constraint might limit subsequent optimization steps unless
sufficient relaxation is applied. Setting the goal to a reasonable
isodose level provides more room for the subsequent optimization
steps. In addition it requires less computation time.
MUs Optimize Optimizing the total MU tends to favor larger diameter beams, and
Monitor Units sometimes fewer beams. After minimizing and constraining the total
(OMU) MU, apply sufficient relaxation in order to leave room for subsequent
optimization steps.
Clinical Examples
The examples below illustrate the use of steps in Sequential Optimization in hypothetical clinical
settings. Each description is accompanied by a table that defines the steps.
• Prostate tumor case whose main objectives are dose homogeneity and low dose to the
surrounding critical structure. See “Sample Prostate Case” on page 5-95 and Table 13.
• Spine tumor case whose main objectives are dose coverage and low dose to the spine.
See “Sample Spine Case” on page 5-97 and Table 14.
• Lung tumor case whose main objectives are dose conformality and limiting the treatment
time. See “Sample Lung Case” on page 5-98 and Table 15.
Sample Prostate Case

In the example described in Table 13, the clinician wants to treat a prostate and deliver a dose as
uniform as possible within the PTV. The clinician wants at least 20% between minimum and
maximum doses, and therefore set PTV maximum to 20% larger than the prescription dose. The
maximal dose to the rectum and bladder are set to the known tolerated dose from each organ. The
clinician requires that the dose gradient in all directions away from the PTV is high in order to
reduce the dose delivered to the normal tissue. It is known from previously treated cases that
constraining the prescription dose close to the PTV and at 50% of the prescription dose at a further
distance provide good conformality without restraining the other clinical objectives. Two auto-shells
are generated at these distances and the prescription dose and the 50% of the prescription dose
are set as maximal doses. The maximum total MU, MU per beam and MU per node are set to
reasonable values that were demonstrated to achieve the desired dose distribution and entry dose
in previously treated similar cases.

Several critical structures surround the prostate. Of these, the rectum has the lowest dose
restriction -- the prescription dose should not touch the rectal wall. The OMI step goal is set to the
prescription dose, which will not conflict with the maximal dose to the rectal wall. It is followed by
an OHI step to maximize the tumor dose homogeneity. Then, the OME steps are added to further
reduce the dose to the rectum and bladder. The rectum step is performed first because the clinician
gives it priority over the bladder. The goal is set to 75% of the prescription dose in order to minimize
the V75 which is known to correlate with complication probability. It is followed by an OMU step to
achieve the lowest possible total MU while keeping the quality of the plan achieved from the
preceding optimization steps.
Table 13 Sample prostate case
Absolute Constraint
Step VOI Step Objective (Inputs) Step Goal Step Solution (Output)
1 PTV Optimize Maximum Total MU, Prescription Highest possible PTV

Minimum Dose MU per beam and MU dose minimum dose below or
(OMI) per node. equal to the prescription
dose
Maximum dose to
PTV, Rectum,
Bladder, Auto-shell 1
and Auto-shell 2.
2 PTV Optimize As in Step 1 + PTV Largest possible volume

Homogeneity PTV minimum dose maximum of the PTV receiving at
(OHI) (output of dose least the maximum
1 - Relaxation) dose, therefore the
maximum homogeneity.
3 Rectum Optimize Mean As in Step 2 + 75% of the Lowest possible volume

Dose (OME) PTV dose prescription of the Rectum receiving
homogeneity dose more than 75% of the
(output of prescription dose,
2 - Relaxation) therefore the minimum
V75.
4 Bladder Optimize Mean As in Step 3 + 75% of the Lowest possible volume

Dose (OME) Rectum minimum V75 prescription of the Bladder receiving
(output of dose more than 75% of the
3 + Relaxation) prescription dose,
therefore the minimum
V75.
5 MUs Optimize As in Step 4 + Zero Lowest possible total

Monitor Units Bladder minimum V75 MU
(OMU) (output of
4 + Relaxation)

Sample Spine Case

In this case, the clinician wants to get the best coverage to a spinal tumor while restraining the dose
delivered to the spine. Dose homogeneity is not critical and the PTV maximum dose is set to a large
value. The maximum dose to the spine is set to the known tolerated dose. See Table 14.
Constraining the 75% prescription dose line at a certain distance keeps the dose to the surrounding
normal tissue low without affecting the dose to the spine or tumor coverage. An auto-shell is
generated and 75% of the prescription dose is set as the maximum dose. The maximum total MU,
MU per beam, and MU per node are set to reasonable values that were demonstrated to achieve
the desired dose distribution and entry dose in previously treated similar cases.
The tumor is located close to the spine and the dose tolerated by the spine is lower than the
prescription dose. Therefore, the OMI step goal is set to the maximum dose tolerated to the spine.
It is followed by an OCO step to maximize the tumor dose coverage. Then, an OME step is added
to further reduce the dose to the spine. The goal is set to zero to minimize the mean dose to the
spine. It is followed by an OMU step to get the lowest possible total MU while keeping the quality
of the plans achieved the preceding optimization step.
Table 14 Sample spine case
Step Absolute Constraint

Step VOI Objective (Inputs) Step Goal Step Solution (Output)
1 PTV Optimize Maximum Total MU, Maximum Highest possible PTV

Minimum MU per beam and dose to the minimum dose below or
Dose (OMI) MU per node. spine equal to the maximum
dose to the spine.
Maximum dose to PTV,
Spine and Auto-shell 1
2 PTV Optimize As in Step 1 + Prescription Largest possible volume

Coverage PTV minimum dose dose of the PTV receiving at
(OCO) (output of 1 - Relaxation) least the prescription
dose, therefore the
maximum coverage.
3 Spine Optimize As in Step 2 + Zero Lowest possible mean

Mean Dose PTV dose coverage dose to the Spine.
(OME) (output of 2 - Relaxation)
4 MU Optimize As in Step 1 + Zero Lowest possible total

Monitor Spine mean dose (output MU
Units (OMU) of 1 + Relaxation)

Sample Lung Case

The clinician wants to treat a lesion in the left lung with a dose uniformity of about 20%. The PTV
maximum dose is set to 20% larger than the prescription dose. The maximum dose to the
esophagus and heart are set to the known tolerated dose for each organ. See Table 15 on
page 5-99.
The clinician is willing to allow a small volume of the surrounding lung tissue to receive the full
prescription dose in order to achieve good coverage of the PTV, so the left lung is excluded from
the optimization. However, the clinician requires a high dose gradient in all directions away from
the PTV in order to reduce the average dose within the normal lung.
Previous plans of similar cases have shown that the steepest dose gradient achievable can be
characterized by positioning the 75% prescription dose line and 50% prescription dose line at
specific distances from the PTV. Two auto-shells are generated at these distances and an initial
maximum dose is set to the prescription dose for both auto-shells. The maximum total MU, MU per
beam, and MU per node are set to values that have been demonstrated to achieve the desired
dose distribution and entry dose in previously treated similar cases.
No critical structure other than the lung is in close proximity to the lesion, so the OMI step goal is
set to the prescription dose. The OMI step is followed by an OCO step to maximize the tumor
coverage.
Then, because the principle objective in this case is to minimize treatment time, an OMU step is
placed next, very early in the sequential optimization process. The OMU step is followed by two
OCI steps to optimize the conformality of the dose distribution on the inner shell closer to the 75%
prescription dose line and the outer shell closer to the 50% prescription dose line.

Table 15 Sample lung case
Step Absolute Constraint

Step VOI Objective (Inputs) Step Goal Step Solution (Output)
1 PTV Optimize Maximum Total MU, Prescription Highest possible PTV

Minimum MU per beam and dose minimum dose below or
Dose (OMI) MU per node. equal to the prescription
dose.
Maximum dose to PTV,
heart, esophagus,
Auto-shell 1 and
Auto-shell 2.
2 PTV Optimize As in Step 1 + Prescription Largest possible volume

Coverage PTV minimum dose dose of the PTV receiving at
(OCO) (output of least the prescription
1 - Relaxation) dose, therefore the
maximum coverage.
3 MU Optimize As in Step 2 + Zero Lowest possible total

Monitor Units PTV dose coverage MU.
(OMU) (output of
2 - Relaxation)
4 Auto- Optimize As in Step 3 + 75% of the Lowest possible Auto-

shell 1 Conformality minimum total MU prescription shell 1 maximum dose
(OCI) (output of dose above or equal to 75%
3 + Relaxation) of the prescription.
5 Auto- Optimize As in Step 4 + 50% of the Lowest possible Auto-

shell 2 Conformality Auto-shell 1 maximal prescription shell 2 maximum dose
(OCI) dose (output of dose above or equal to 50%
4 + Relaxation) of the prescription.

Beam Reduction
Sequential Optimization targets 2000 to 6000 candidate beams (depending on the number of
collimators selected) toward the tumor(s). Typically, Sequential Optimization results in a treatment
plan with 100 - 300 non-zero beams. To reduce overall treatment time, you can perform beam
reduction to further reduce the number of beams. Beam reduction removes from the optimization
process those beams whose MU is below a user-specified cutoff and re-optimizes using only the
remaining beams. The reduction in candidate beams from thousands to hundreds results in
significantly shorter optimization and treatment times. Beam reduction effectively excludes those
beams that do not contribute significantly to the treatment plan and re-optimizes only those beams
that were found to be efficient for the current tumor volumes and critical structures. For a
reasonable MU cutoff value, this results in a treatment plan that uses fewer beams and which
usually has fewer total MU and negligible degradation of the dose distribution.
Considerations:
• Generally, the re-optimization is performed using the same absolute constraints and
optimization steps. However, assuming that the remaining beams are geometrically
efficient for the current tumor volumes and critical structures, the same beams should
also work well with slightly different optimization parameters (maximum dose limits, MU
limits, objective goals, and so on).
Again, for a reasonable MU cutoff value, it is possible to finetune the absolute constraints
and optimization steps and take advantage of the short optimization time that results with
a smaller set of candidate beams to perform a small adjustment to the dose distribution.
• If the MU cutoff is too large, beams that significantly contribute to the treatment plan may
be excluded from the optimization, which can result in significant loss of coverage or
increase in dose delivered to critical structures.
• The beam reduction operation cannot be undone. To optimize again with the full
beamset, you must delete the existing beamset and then generate a new one. Therefore,
it may be appropriate to save the current treatment plan before attempting a beam
reduction using a large MU cutoff.
• The beam reduction MU cutoff is not a minimal MU constraint and the re-optimization
may re-generate beams below the MU cutoff. When beams below the desired MU lower
limit remain after a beam reduction, those beams must be deleted on the Finetune step,
or they will be rounded up to 1 MU per faction during the prescription process.
• Beam reduction is fundamentally different than using Finetune to remove low MU beams,
because in the case of Finetune, if one subsequently performs reoptimization then all the
zero beams are put back in to the optimizer for consideration in the optimization process.
Only a beam reduction can exclude candidate beams from the optimization process.
• To avoid compromising plan quality one might want to use a small cutoff first, rerun the
optimization, and then increase the cutoff if the plan quality seems good. This incremental
approach takes a little longer, but may avoid pruning away too many beams (which
cannot be restored without resetting the beamset).

Time Reduction
• “Time Reduction Annealing Schedule for Fixed and Iris Collimators” on page 5-103
• “Beam Regeneration for Fixed and Iris Collimators” on page 5-105
• “Time Reduction Annealing Schedule for the Multileaf Collimator” on page 5-106.
The time reduction feature in Sequential Optimization is a method of iteratively reducing the
number of beams and nodes in a treatment plan until a desired treatment time per fraction is
achieved. The algorithm wraps node and reduction, as well as beam regeneration, around iterative
runs of the sequential optimization script.
Figure 21 is a flowchart that steps the process of time reduction. As can be seen, the algorithm
needs an existing treatment plan in order to be available. Once that is available, the user sets a
goal for estimated treatment time per fraction and starts the time reduction.
Figure 21 Flowchart of time reduction

The iterative algorithm then begins. The first step for each iteration is to remove nodes and/or
beams based on the annealing schedule that the iterative time reduction will follow (see “Time
Reduction Annealing Schedule for Fixed and Iris Collimators” on page 5-103). The Remove Nodes
and Beams module is shown in more detail in Figure 22. As can be seen the first step is to remove
beams that fall below a given MU threshold. That threshold depends on the number of fractions
and current number of nodes. Table 16 gives the MU threshold. In Table 16, the number of
fractions is Fx and the number of nodes in the solution set is N.
Figure 22 Beam and node removal flowchart
Table 16 Minimum MU threshold for beam removal
Beam Minimum Maximum Minimum

Number of Nodes MU Threshold MU Threshold
N > 60 6.0 * Fx 240.0
60  N > 30 4.0 * Fx 160.0
N  30 2.0 * Fx 80.0
After beams have been removed the algorithm checks if the current number of beams is less than
the number desired in the solution space. If it is, then beams are regenerated using the algorithm
described in the Beam Regeneration section below.

Once beams have been generated and the solution space is either the size dictated by the
annealing schedule or has slightly more beams, the Sequential Optimization script is run and the
optimal plan is found. Then the time for the new plan is estimated. If the goal time has been
achieved or if the minimum number of beams or nodes has been reached, time reduction exits.
Otherwise, the module runs another iteration.
Time Reduction Annealing Schedule for Fixed and Iris

Collimators
The annealing schedule is based on the template path set, the number of nodes and beams in the
current plan's solution space, and the goal treatment time. The algorithm chooses one of two
annealing schedules based on the template path set.
If the template path set is the Reduced_Prostate_Path, which has 23 nodes, the schedule will have
up to 12 iterations in which 1 or 2 nodes are reduced at each iteration until the minimum number
of nodes is reached. The minimum number of nodes is determined by the goal treatment time.
Table 17 gives minimum number of nodes and beams based on the goal treatment time if we
assume that the setup time for each fraction is 5 minutes.
Table 17 Minimum number of nodes and beams with

Reduced_Prostate_Path annealing schedule
Treatment Time Minimum Number of Minimum Number of

Treatment Time Without Setup Nodes Beams
15 10 14 45
20 15 21 85
25 20 22 125
30 25 23 180
The number of beams in the solution set is pared to 500 beams in the first iteration and is reduced
in subsequent iterations based on a hyperbolic tangent curve, similar to the one shown in
Figure 23. (The curve in Figure 23 assumes a goal treatment time of 20 minutes, including
5 minutes of setup.) The initial iterations have over 400 available beams so that the number of
beams stays relatively high while the majority of the nodes are being deleted. The final iterations
remove fewer beams than iterations 5 through 8 in order to gradually reach the final treatment time.
The goal is to maintain highly conformal and uniform plans while decreasing the delivery time.
Note that this annealing schedule is geared toward achieving 20 minute treatment times for a
standard fractionation prostate plan. Generally, the final treatment time will be higher than desired
when using the Reduced_Prostate_Path and time reduction for radiosurgery fractionation.

Figure 23 Reduced_Prostate_Path beam annealing

schedule for 20 minute goal treatment time
For plans created with template path sets other than the Reduced_Prostate_Path, the reduction of
beams and nodes is based on the current number of nodes in the solution space. The reduction is
a stepwise continuous and linear function. Table 18 describes how beams and nodes are reduced
at each level. Nc is the number of nodes in the current solution space.
Table 18 Alternative annealing schedule
Number Number of Nodes Number of Beams

Level of Nodes Removed Remaining
1 48  Nc Nc - 8 400
2 32  Nc < 48 Nc - 4 350
3 24  Nc < 32 Nc - 2 250 + (32 - Nc)/8 * 100
4 21  Nc < 24 Nc - 1 150 + (24 - Nc)/3 * 100
5 Nc < 21 Nc - 1 60 + (21 - Nc)/7 * 90

Beam Regeneration for Fixed and Iris Collimators

Frequently after node and beam removal the number of remaining beams in the solution space is
less than called for by the annealing schedule. If that occurs, beams are generated for the selected
collimator diameters and the remaining nodes in the solution space.
The process of beam regeneration for fixed collimators or the Iris Collimator is shown in Figure 24.
First, calculate the number of beams per node to generate. Then, enter a loop that generates
beams for each node. Project the target VOI (usually the PTV) onto a plane normal to the node
direction at a distance of 800 mm from the node. Create a map on this plane for each voxel that
stores the distance from that voxel to the nearest boundary of the target. Then, a loop is entered
that creates beams for each node.
Figure 24 Beam generation during time reduction

For each beam, a target point is randomly selected within the target. The collimator diameter for
the beam is selected so the beam has the largest available collimator that extends no more than
40% of its radius outside the projection of the tumor (see Figure 25). For example, a point 11 mm
from the boundary would use a 35 mm collimator, because it will extend 6.5 mm (or 37%) outside
the boundary of the projected target, whereas a 40 mm collimator would extend 9 mm (or 45%)
outside the boundary of the projected target. Each beam is checked to assure that it is valid and
then added to the list of available beams in the solution space.
For Multileaf Collimators, all regenerated beams are random shapes. For example, a circle is
randomly placed and sized over the target VOI. Then that circle is trimmed at the boundary of the
target VOI if it extends beyond that boundary.
Figure 25 Collimator selection for point in projected target
Time Reduction Annealing Schedule for the Multileaf

Collimator
As with the annealing schedule for fixed collimators and the Iris Collimator, the user sets a desired
estimated delivery time per fraction. Then, nodes and segments are removed from the
optimization’s solution space iteratively. Unlike the algorithm for fixed collimators and the Iris
Collimator, segment generation is not integrated into the time reduction for the Multileaf Collimator.
At each iteration of time reduction, segments are removed that deliver 2% of the total MU. The
lowest MU nodes are removed initially, in order from the smallest to largest, if those nodes deliver
0.5% or less of the total MU. If, after a node is removed, the total MU removed is greater than 2%
of the total MU, the node reduction ends.

If less than 2% of the total MU has been removed, individual segments are removed, from the
lowest to the highest MU, until 2% of the total MU of the current plan has been removed. After
nodes and beams have been removed, the plan is optimized and the estimated delivery time is
checked against the desired delivery time. If the estimated time is greater than the desired time, a
new iteration of time reduction is applied. Otherwise, the process ends. MLC Time Reduction will
also end if the minimum number of beams or segments has been reached. These minima are 3
nodes or 10 segments. (Note that fewer nodes and segments can be in the final plan, but once the
plan has 3 or fewer nodes or 10 or fewer segments, time reduction will cease.)
Automatic Collimator Selection

The automatic collimator selection algorithm selects two or three collimator sizes for use during
Sequential Optimization. This selection is performed using a geometric heuristic based on the
target volume dimensions. The user preference for homogeneity or conformality determines
whether the heuristic will select larger or smaller collimator sizes respectively.
In practice, the Conformality option is often useful when dose-limiting organs at risk are close to
the target volume. The tool is designed to provide a starting point in the collimator selection
process. No geometric heuristic can be guaranteed to result in the optimal planning solution (that
is, the lowest overall cost term achievable with any possible combination of two or three collimator
sizes). Therefore, this selection should always be carefully evaluated based on a clinical
understanding of the specific planning problem. The automatic selection can be adjusted manually
if necessary before clicking OK on the Collimators dialog box, or by re-entering the dialog.

Although the Iris Collimator is designed for and capable of collimating beams as small as 5 mm
diameter at 800 mm SAD, it is advantageous to limit the use of 5 mm Iris collimator beams. The
Accuray Precision System limits the total Monitor Units (MU) that can be delivered to the target
from these 5 mm Iris collimator beams at the time of planning, decreasing the potential dose
uncertainty at delivery to no more than 2% of the prescription dose. The implementation of this
limitation in the planning system assumes that the Output Factor for the 5 mm aperture of the Iris
collimator could vary by up to 15%, based on a worst-case scenario analysis of mechanical
repeatability. This variability is used to calculate the maximum allowable MU contribution delivered
by beams from the 5 mm Iris collimator aperture, restricting the potential dose variation to no more
than 2% of the prescription. The absolute number of MU for the Iris 5mm aperture will vary plan to
plan and depend on the relative contribution to the prescription dose compared to other field sizes
in the treatment plan.

VOLO Algorithms for CyberKnife

Introduction
In the current Sequential optimization (SO) framework for the CyberKnife System, a large number
of segments (MLC shapes) or beams (Fixed / Iris Collimator sizes) are initially targeted (aimed from
pre-selected robot node positions towards points within the tumor or target) using geometric
heuristics. The weights or monitor units (MUs) of these segments or beams are then optimized
according to a set of prioritized goals and constraints. Since heuristics are used, the sequential
optimizer can lead to sub-optimal plans. In a number of cases, a separate time reduction step may
also be needed to make the plan more efficient leading to longer plan optimization times.
Furthermore, the framework is not intuitive or interactive to quickly tweak or regenerate a plan
based on alternate input parameters. The VOLO™ algorithms for CyberKnife System treatment
plan optimization have been designed to overcome these deficiencies. This chapter provides a
high-level description of the different algorithms used in VOLO.
Approach
Treatment planning for intensity-modulated radiotherapy (IMRT) has traditionally used a two-step
approach: in the first stage, a fluence map (a grid of beamlet intensities from each beam direction)
is optimized, which, in the second stage, is sequenced into a set of segments that are deliverable
using a Multi-leaf collimator (MLC). An optional weight optimization of the segments is also
performed in many cases. The main goal of VOLO is to bring this traditional planning methodology
to the CyberKnife System with modifications that enable the rapid creation of efficient treatment
plans. The following are some of the modifications used in the VOLO algorithms:
• Smoothing based on the l1 norm of the fluence map gradients results in fewer and larger
candidate segments.
• During optimization, dose is used only at sample points yielding memory utilization
benefits.
• The total Monitor Units (MU) of the plan is added as a cost during segment or beam
weight optimization which produces more efficient plans.
• Minimum MU constraint is applied at the end of each segment or beam weight
optimization guaranteeing deliverability.
• A heuristic scaling factor is used to balance costs like fluence smoothness and total MU
with the dosimetric objectives.
• Segment shapes are fine-tuned after weight optimization so that the critical structures
near the target can be spared better.
• A quasi-Newton optimizer (L-BFGS-B) is used for rapid convergence.
• Implementation leverages the GPU for high performance.
5-108 | VOLO Algorithms for CyberKnife 1075879 ENG A

Limitations
In its current form, VOLO has some known limitations which will be addressed in future releases
of the Accuray Precision System. Some of them are as follows:
• Dosimetric hard constraints are not supported. All specified dose levels for targets and
organs at risk are used as objectives (or goals) that need not be met strictly.
• Dose distribution changes when going from the fluence space to segment space for the
following reasons:
 Since the shapes and sizes of segments are unknown before fluence optimization,
the dose contributions from each beamlet in the fluence map has to be based on
some approximations.
 Sequencing a fluence map with a small set of segments can decrease the number of
degrees of freedom for subsequent optimizations.
 The objective during segment optimization is just a weighted sum of the user-
specified dose volume objectives. The optimizer is not designed to match the 3-
dimensional dose distribution from the fluence optimization.
• A normal tissue or a dose fall-off objective has not been implemented. User-defined
shells may be needed to control conformality, especially far from the target.
• 3D dose distribution is not viewable until the end of the optimization sequence.
High-Level Description
The usual steps to set up a CyberKnife System plan for optimization, such as contouring VOIs,
selecting the robot path, choosing an align center, etc., are performed. Then the user specifies a
maximum number of nodes the final plan can use and the dose volume goals based on an
appropriate clinical protocol. The software then generates sample points within the objective VOIs
and performs targeting (selection of nodes and aim-directions for the beams). In the case of MLC
optimization, each beam is further sub-divided into a grid of beamlets. Then, the software
computes dose at sample points for each candidate beam or beamlet and then optimizes the
corresponding weights based on the chosen objectives. The user can control the relative weighting
between objectives. Several advanced parameters are also provided to control certain aspects of
the algorithms, such as delivery efficiency and beamlet weight smoothness. In the case of MLC,
candidate segments are derived from the optimized beamlet weights and further optimized.
1075879-ENG A VOLO Algorithms for CyberKnife |5-109

Figure 26 Major Steps in MLC Optimization
In the case of MLC, candidate segments are derived from the optimized beamlet weights and
further optimized.
Figure 27 Major steps in Iris/Fixed collimator optimi-

zation
Optimizer
L-BFGS-B (R. H. Byrd, 1995) is used as the optimizer. It is a limited-memory variant of a quasi-
Newton algorithm (BFGS) that has fast convergence characteristics and can handle bound
constraints on the variables. It uses an estimation to the inverse Hessian matrix to steer its search
through variable space, but where BFGS stores a dense n×n approximation to the inverse Hessian
(n being the number of variables in the problem), L-BFGS-B stores only a few vectors that
represent the approximation implicitly. Due to its resulting linear memory requirement, this method
is particularly well suited for optimization problems with a large number of variables.

VOI Sampling
Sample points are generated uniformly within each VOI for which an objective is specified based
on a sampling density chosen by the user. The sampling, and therefore the optimization, is not
constrained by the dose box selected by the user. The user may choose to set the dose box such
that it covers the entire CT image without affecting performance. A fractional volume is assigned
to each sample point such that the sum of the sample volumes is equal to the VOI volume. The
user can choose from the following options for sampling density: High, Medium, Low and
Boundary. All the CT voxel centers within the VOI are chosen for “High.” A skip factor of 2 (every
other voxel) is used in X and Y directions of the CT for “Medium.” For “Low” the skip factor is 4.
“Boundary” selects all CT voxels that are on the VOI boundary. In other words, every CT slice that
intersects the VOI will be sampled according to the chosen density.
Node Selection
The spatial diversity algorithm used with the Sequential Optimization algorithm is used for VOLO
as well.
• The user specifies the maximum number of nodes to be used for the plan.
• From the user selected robot path, all feasible nodes are first selected such that:
 the beams from those nodes do not enter the patient through the truncated CT slices
 the robot arm can be positioned without collisions while aiming at the target centroid.
(for multiple target volumes, the centroid of the combined volume is used as the aim
point)
• The first node is chosen arbitrarily from this feasible set.
• Compute the 3D aim vector that points at the target centroid from each node.
• Compute the angle between each pair of aim vectors.
• For the next node, choose the node with an aim vector that has the largest angle with the
first node selected.
• For each remaining feasible node, get the set of angles to each selected node and the
minimum angle in that set.
• Choose the next node that has the largest minimum angle.
• Repeat this process until the user-specified maximum number of nodes are selected.
This algorithm is used to cover the target from a wide variety of angles thereby reducing the risk of
hot streaks of dose in normal tissue from overlapping beams. When there are multiple target
volumes, the centroid of the union of those volumes will be used as the aim point. Figure 28 shows
an example where 20 nodes were selected from a head path containing more than a 100 nodes.

Figure 28 Example of a spatially diverse node set
MLC Optimization
The purpose of this optimization is to generate multiple MLC segment shapes at each selected
node and assign weights or Monitor Units (MUs) such that the specified dosimetric objectives are
achieved to the best extent possible while keeping the overall treatment efficient. Figure 26 shows
the major steps in VOLO for MLC optimization. The following sections describe these steps in
depth.

Beamport Selection
A “Beamport” defines the orientation (MLC up-vector and leaf travel direction, which define the IEC
61217 beam limiting device axes) and lateral extents of the field while pointing the robot at a
specific point in the patient volume. From a given node, the MLC can be aimed at a number of
points. For most tumors, aiming the robot at the tumor centroid from each node will provide
adequate coverage. However, for large targets, the target projection in the beam’s eye view may
be bigger than the MLC opening. For such cases, the target volume is split and the robot will be
aimed at each sub-volume’s centroid. If the sub-volume’s projection is still bigger than the MLC, it
will be split further and the process is repeated until each sub-volume can be completely covered
by the MLC while pointing at its centroid. Each aim point from the node corresponds to a beamport
geometry. The segments defined within a beamport will have the same node position and point at
the same location within the patient. When there are multiple target volumes, the union of these
volumes is used for beamport generation. If the target volume is split and target points are
modified, the robot reachability and collision checks are performed again and invalid beamports
are discarded. Figure 29 shows an example of a large target covered by multiple beamports.

Figure 29 Example of a large target covered by mul-

tiple beamports

Beamlet Selection
A fluence map is a grid of intensities that is defined within a beamport. Each element of the grid is
called a beamlet or bixel (beam element). For MLC26, the fluence map is a 23-by-26 grid (see
Figure 30). The 26 leaf pairs align with the rows of the fluence map. Along the leaf travel direction,
each beamlet is 5 mm wide projected at 800mm SAD. So, the left end of the fluence map
corresponds to a leaf position -57.5 mm and the right end corresponds to 57.5 mm. The beamlets
that intersect with the target projection in the beam’s eye view will be selected as active beamlets
that can have non-zero intensities (see Figure 30). If multiple target volumes are specified, the
projection of the union is used. A 6 mm margin is used to expand the target projection to identify
the active beamlets. By allowing the intensity of each beamlet to vary, the intensity from each
beamport can be modulated to shape the dose within the patient.
Figure 30 a) Beamlet grid; b) Active beamlets
Blocking of organs-at-risk (OARs) are done at the beamlet level by deactivating the beamlets that
intersect with the blocked OARs. For example, Figure 31 shows the active beamlets for the same
target but with a nearby OAR that is “Exit Only”. By allowing each active beamlet in the grid to have
different weights, the intensity profile of the beam-port can be modulated to shape the dose
deposited within the patient.
Figure 31 Active beamlets with an "Exit Only" OAR

Beamlet Dose Computation

FSPB (Finite Size Pencil Beam) is used to compute the dose per unit weight (dose coefficient) for
each beamlet. Since the segments that will be formed from these beamlets are not known a-priori,
the equivalent square for beamlet dose calculation is computed from the projected target area as
an approximation. The dose coefficients are computed only at the sample points identified in “The
purpose of this optimization is to generate multiple MLC segment shapes at each selected node
and assign weights or Monitor Units (MUs) such that the specified dosimetric objectives are
achieved to the best extent possible while keeping the overall treatment efficient. Figure 26 shows
the major steps in VOLO for MLC optimization. The following sections describe these steps in
depth.” on page 5-112. Values below 0.001 cGy/MU are discarded. The non-zero values are then
stored in a sparse matrix (dij) to save storage. The rows correspond to sample points and columns
correspond to beamlets. Let wj be the jth beamlet intensity and Di be the total dose deposited at
the ith sample point. Then, Di = ∑jwjdij. This summation can be done very efficiently on the GPU.
Fluence Map Optimization

Fluence map optimization is the process of finding the optimal set of beamlet intensities (wj) that
minimizes a dosimetric objective function F(Di). Figure 32 shows an example of intensity
modulation from six different angles to shape the dose within the target shown in Figure 29. Red
denotes a high intensity and blue denotes a low intensity.
Figure 32 Examples of optimized fluence maps

Treatment planning is traditionally done to achieve multiple dose volume levels within the tumor
and the OARs. Each desired dose volume level can be formulated as an objective function fk(Di)
defined within the corresponding volume of interest. All these individual functions are then
combined into a single objective function using user-defined weights (vk). Therefore, F(Di) = v1. f1
(Di) + v2. f2 (Di) + …+ vn. fn (Di), where n represents the number of dose volume objectives
specified. The composite objective function is positive and approaches zero as the dose
distribution gets close to satisfying all the requested dose levels. The beamlet intensities are
constrained to be between 0 and a user-defined maximum intensity during this stage of the
optimization.
Dose Volume Objectives

A quadratic single-sided penalty function formulation is used for each dose volume objective. For
example, consider an OAR that has a maximum dose objective. Only the sample points within the
OAR that has a total dose higher than the requested maximum dose level contribute to the
objective function and is proportional to the square of the dose difference. Similarly, minimum dose
objectives penalize only the sample points with dose below the requested level. This simple
formulation can be extended to objectives requested at different volume levels. For instance, in
order to compute a maximum dose volume objective, the dose at all sample points within the VOI
is first sorted in descending order. While traversing the sample points in this order, the sample
volumes are accumulated until the requested (or allowed) volume level that exceed the specified
dose is reached. Only the remaining sample points that violate the requested dose level are then
penalized. See Figure 33 for an illustration of the minimum and maximum dose volume objectives.
The solid line represents a feasible DVH that passes through the requested dose level of D1 at
volume level V1 and the dashed line represents the current DVH which has a dose level of D2 for
the requested volume level V1 and has a volume level of V2 for the requested dose level D1. Any
DVH curve that passes through the red region in the figure, violates the requested point (D1, V1).
Figure 33 An illustration of (a) maximum and (b)

minimum DV objectives
The sample points in the red region (hatched area in the figure) that fall between levels V1 and V2
are then penalized according to the deviation from D1.

Mean Dose Objective

In addition to dose volume objectives, planners may specify a mean dose objective for a critical
VOI. If the user specifies a mean dose goal for a critical volume i, Dimg, then during optimization,
the mean dose for the volume is calculated. If that mean dose exceeds the goal dose, the cost
function is appended with the cost calculated from the difference between the actual mean dose
and the goal mean dose. The mean dose penalty, like the penalty for the dose volume objectives,
is a weighted quadratic single-sided function.
Normal Tissue Objective

A normal tissue objective (NTO) for one critical VOI can be added to the total cost of the
optimization. The user selects the critical VOI for which NTO is specified.
An exponential falloff function is used to generate the goal dose within this VOI as a distance from
the target VOIs. To define this falloff function, the user sets three points that give the percent dose
falloff at three distances from the target VOIs. For an exponential falloff function these three points
define the amount of falloff, the falloff coefficient, and the additive constant.
For each target VOI with a minimum dose objective, the dose values for the falloff function are
calculated from the start distance to the end distance. The 100% dose of the falloff function for any
target VOI with at least one minimum dose objective is the minimum dose of all the minimum dose
objectives. For the NTO, the selected NTO VOI is sampled at low resolution, regardless of whether
it is sampled at a higher resolution for a dose volume objective or a mean dose objective. At every
sampled point, the goal dose is the maximum of the NTO goal values defined at that point.
The NTO dose penalty is a weighted quadratic single-sided function calculated from the difference
between the dose at a sample point and the goal NTO dose at that sample point. This penalty is
added to the total cost function for the optimization.
Smoothness Penalty
The fluence maps can be noisy if all the beamlet weights are allowed to be independent. Instead,
the fluence maps are smoothed during optimization in order to better represent a dose distribution
achievable by the combination of a few segments. This is done by adding a smoothness penalty
S(w) to the dosimetric objective function. In this implementation, S(w) is chosen to be the L1-norm
of the spatial gradient of beamlet intensities in a fluence map. When optimized with this additional
penalty, the fluence maps tend to have only a few levels of constant contiguous intensities (see
Figure 34).

Figure 34 Examples of noisy fluence maps (top row)

and smooth fluence maps (bottom row)
The user can control the relative weight of the smoothness penalty with the rest of the dosimetric
penalties. The following describes how the user-specified weight for smoothness penalty is used
in conjunction with a heuristic scaling factor in fluence optimization.
• Start with unit intensity for all beamlets
• Use the total weighted dose penalty F(D) as the objective function
• Run fluence optimization for 10 iterations
• Calculate the smoothness penalty S(w)
• Calculate a constant heuristic scale factor (g) as F/S at the 10th iteration
• Let wS be the user-specified smoothness weight
• Choose the new objective function as FTOTAL= F(D) + wS g S(w)
• Reinitialize the beamlet weights and optimize with this new objective
This heuristic scaling is done to bring the smoothness penalty to the same order of magnitude as
the dose penalty and the user-defined smoothness weight is effectively used as a weight to
increase or decrease importance of smoothness with respect to the dose objective.

Segment Generation
The process of converting fluence maps into deliverable segments is called sequencing. Segments
are MLC openings defined by leaf positions and are assigned Monitor Units (MU) representing the
duration for which the beam is on. There are different approaches to sequencing including some
optimization algorithms. For this implementation, we choose a reducing-level method (P Xia, 1998)
for its simplicity and tendency to generate larger segments (see Figure 35). Since the weights are
optimized and the segment shapes fine-tuned in the subsequent steps, this sequencing approach
has been shown to work well in practice.
Figure 35 Segments from a fluence map
The reducing-level method comprises of the following steps:

1. For the given fluence map, choose a threshold as maximum intensity divided by 2.
2. Select the fluence map region with intensities greater than the chosen threshold.
3. Extract the largest sub-region as a segment from the selected region such that:
 the sub-region is not dis-jointed
 each row in the sub-region is a contiguous set of active beamlets
 any part of the sub-region is at least two beamlets in height
 any part of the sub-region is at least one beamlet in width
 area of the sub-region is at least 58.52 mm2 (7.7 mm x 7.6 mm)
 the sub-region satisfies the CK MLC regularity condition
4. Associate the threshold intensity with the selected segment.
5. Reduce the intensities in the segment region of the fluence map by the threshold.
6. Repeat the previous steps with the reduced fluence map for the next segment.
7. Repeat until no further segments are possible.
8. Remove duplicate segments after accumulating their corresponding intensities.
9. Sort the candidate segments by intensity times area in descending order.
10. Select only the user-requested maximum number of segments per beam.

Segment Dose Computation

The default dose calculation algorithm used is FSPB. If the final dose calculation algorithm
requests lateral scaling correction (LS) or is Monte Carlo (MC), dose will be computed using
FSPB+LS (see ). Dose is computed per unit weight for each segment at each sample point and
stored as a sparse matrix. Values below 0.001 cGy/MU are not stored. This threshold is much
smaller than the cut-off (0.01 cGy/MU) used by Sequential Optimization. As a consequence, the
VOLO optimized result tends to be closer to the final dose calculation.
Table 19 Dose algorithm choice for MLC optimization phases based on the chosen final
dose algorithm
User chosen algorithm for final dose FSPB FSPB + LS MC
Fluence Optimization FSPB FSPB FSPB
Segment Optimization (Pre-Adaptation) FSPB FSPB + LS FSPB + LS
Segment Optimization (Post- FSPB FSPB + LS MC

Adaptation)
Final Dose Calculation FSPB FSPB + LS MC
Segment Weight Optimization

The dose objective function formulation is exactly the same as the one used in fluence
optimization. There is no smoothness penalty added during segment weight optimization. Instead,
a total MU penalty is added which helps the optimizer find efficient treatment plans. The total MU
penalty is just the sum of each segment’s MU. Computation of the heuristic scale factor for the total
MU penalty follows an approach that is similar to the process described in “Smoothness Penalty”
on page 5-118. So, choosing 0.5 for user-defined total MU weight means the total MU penalty will
be equal to half of the total weighted dose penalty after 10 iterations. During optimization, the
segment MUs are constrained to fall between 0 and the maximum segment MU chosen by the
user. At the end of optimization, the segments that have MUs below the requested minimum level
are pruned. If, subject to no more than 2% of the total MU being pruned, the number of segments
left is greater than the requested maximum number of segments for the plan, the segments are
sorted by MU times area and the segments with the lowest MU times area get pruned. The weights
of the remaining segments are optimized again followed by a pruning iteration. This is repeated
alternately until no segments with MUs have been pruned. L-BFGS-B is used as the optimizer.
Segment Shape Adaptation

In this implementation, segment shape adaptation is used as a fine-tuning step (A. Cassioli, 2013).
The segments generated by sequencing the fluence maps have segment leaf positions at the
beamlet boundaries (see Figure 36). There is scope for further improvement if these leaves are
allowed to be placed anywhere within the beamlet boundaries. This can lead to better target
conformity and better sparing of nearby OARs.

Figure 36 Example of a segment shape with leaves

at beamlet boundaries
However, formulating the dose objective as a function of leaf position and using it during
optimization would require the computation of the effect of modifying each leaf position on the dose
distribution. But, segment dose calculations for every such modification will be time-consuming. In
this implementation, the dose coefficients from the initial segment shape are adjusted with
fractional beamlet dose coefficients for a leaf positioned within the corresponding beamlet (see
Figure 37).

Figure 37 Leaf positions and beamlet open fractions
Since the beamlet dose coefficients are used to quantify the dose gradient, the leaf positions during
each round of shape adaptation is constrained to be within the boundaries of one beamlet. At the
end of each shape adaptation, if the leaf reaches one of the containing beamlet’s boundaries, the
adjacent beamlet is evaluated using the gradient information to check whether there will be a
benefit in choosing that beamlet as the bounds for the next round of optimization. Just a few rounds
of shape adaptation are sufficient to improve the results of aperture weight optimization further.
See Figure 38 for an example where the lower left corner of the target is made more conformal
through adaptation.
Figure 38 a) Segment shape from a fluence map; b)

Corresponding segment after adaptation

The objective function used is just the weighted sum of dose penalties and the beamlet open
fractions are bounded between 0 and 1. L-BFGS-B is used as the optimizer. At the end of the
requested number of adaptation rounds, a post-processing logic tweaks the shapes further to
satisfy the MLC shape conditions. As a result of this step, the maximum number of segments per
beam constraint set by the user and enforced at the end of “Segment Generation” on page 5-120
can be violated. If this is important to the user (e.g. because of patient specific QA issues) they
should set shape adaptation iterations to zero or review and edit the segment shapes in the
Evaluate > FineTune tab of the Accuray Precision System as needed.
Final Weight Optimization

The dose coefficients per unit weight at every sample point for each adapted segment is computed.
The dose calculation algorithm is switched to Monte Carlo if that is the selected final dose
calculation algorithm. Segment weight optimization with iterative pruning (“Segment Weight
Optimization” on page 5-121) is performed to get the final deliverable plan.
Iris/Fixed Collimator Optimization

The VOLO algorithms have been adapted to Iris or Fixed collimators as well. The logic is similar to
segment optimization and is illustrated at a high-level in Figure 27.
Candidate Beam Selection

Candidate beams are selected based on the selected collimator sizes. The beam targeting logic
used for Sequential Optimization is reused for VOLO.
Beam Dose Computation

The RayTrace (RT) algorithm is used for computing dose per unit weight at all the sample points
for each candidate beam. Since circular beams tend to have many more non-zero coefficients, in
order to save memory, a higher dose coefficient cut-off of 0.005 cGy/MU is used. Note that this
value is still smaller than that used in SO, resulting in a better correspondence between optimizer
dose and final dose.
Table 20 Dose algorithm choice for Iris/Fixed collimator optimization phases
User chosen algorithm for final RT MC
Beam Weight Optimization (Until Max Beams remain) RT RT
Beam Weight Optimization (Remaining Cycles) RT MC
Final Dose Calculation RT MC

Beam Weight Optimization

Treatment planning is traditionally done to achieve multiple dose volume levels within the tumor
and the OARs. Each desired dose volume level can be formulated as an objective function fk(Di)
defined within the corresponding volume of interest. All these individual functions are then
combined into a single objective function using user-defined weights (vk). Therefore, F(Di) = v1.
f1(Di) + v2. f2 (Di) + …+ vn. fn (Di), where n represents the number of dose volume objectives
specified. The composite objective function is positive and approaches zero as the dose
distribution gets close to satisfying all the requested dose levels. The beam MUs are constrained
to be between 0 and a user-defined maximum MU value during this stage of the optimization.
Dose Volume Objectives

A quadratic single-sided penalty function formulation is used for each dose volume objective. For
example, consider an OAR that has a maximum dose objective. Only the sample points within the
OAR that has a total dose higher than the requested maximum dose level contribute to the
objective function and is proportional to the square of the dose difference. Similarly, minimum dose
objectives penalize only the sample points with dose below the requested level. This simple
formulation can be extended to objectives requested at different volume levels. For instance, in
order to compute a maximum dose volume objective, the dose at all sample points within the VOI
is first sorted in descending order. While traversing the sample points in this order, the sample
volumes are accumulated until the requested (or allowed) volume level that exceed the specified
dose is reached. Only the remaining sample points that violate the requested dose level are then
penalized. See Figure 32 for an illustration of the minimum and maximum dose volume objectives.
The solid line represents a feasible DVH that passes through the requested dose level of D1 at
volume level V1 and the dashed line represents the current DVH which has a dose level of D2 for
the requested volume level V1 and has a volume level of V2 for the requested dose level D1. Any
DVH curve that passes through the red region in the figure, violates the requested point (D1, V1).
Figure 39 An illustration of (a) maximum and (b)

minimum DV objectives

The sample points in the red region (hatched area in the figure) that fall between levels V1 and V2
are then penalized according to the deviation from D1.
Mean Dose Objective

In addition to dose volume objectives, planners may specify a mean dose objective for a critical
VOI. If the user specifies a mean dose goal for a critical volume i, Dimg, then during optimization,
the mean dose for the volume is calculated. If that mean dose exceeds the goal dose, the cost
function is appended with the cost calculated from the difference between the actual mean dose
and the goal mean dose. The mean dose penalty, like the penalty for the dose volume objectives,
is a weighted quadratic single-sided function.
Normal Tissue Objective

A normal tissue objective (NTO) for one critical VOI can be added to the total cost of the
optimization. The user selects the critical VOI for which NTO is specified.
An exponential falloff function is used to generate the goal dose within this VOI as a distance from
the target VOIs. To define this falloff function, the user sets three points that give the percent dose
falloff at three distances from the target VOIs. For an exponential falloff function these three points
define the amount of falloff, the falloff coefficient, and the additive constant.
For each target VOI with a minimum dose objective, the dose values for the falloff function are
calculated from the start distance to the end distance. The 100% dose of the falloff function for any
target VOI with at least one minimum dose objective is the minimum dose of all the minimum dose
objectives. For the NTO, the selected NTO VOI is sampled at low resolution, regardless of whether
it is sampled at a higher resolution for a dose volume objective or a mean dose objective. At every
sampled point, the goal dose is the maximum of the NTO goal values defined at that point.
The NTO dose penalty is a weighted quadratic single-sided function calculated from the difference
between the dose at a sample point and the goal NTO dose at that sample point. This penalty is
added to the total cost function for the optimization.
A total MU penalty is added which helps the optimizer find efficient treatment plans. The total MU
penalty is the sum of each segment's MU.
During optimization, the beam MUs are constrained to fall between 0 and the maximum beam MU
chosen by the user. At the end of optimization, the beams that have MUs below the requested
minimum level are pruned. If, subject to no more than 2% of the total MU being pruned, the number
of beams left is greater than the requested maximum number of beams for the plan, the beams are
sorted by MU times area and the beams with the lowest MU times area get pruned. The weights
of the remaining beams are optimized again followed by a pruning iteration. This is repeated
alternately until no segments with MUs have been pruned. L-BFGS-B is used as the optimizer.
However, when Monte Carlo is the requested final dose calculation algorithm, pruning and beam
weight optimization is stopped when the user-specified maximum number of beams is reached.
Monte Carlo is used to compute dose per unit weight for all the remaining beams in the solution
and beam weight optimization restarted.

References
1. A. Cassioli, J. U., 2013. Aperture shape Optimization for IMRT treatment planning.
Physics in Medicine & Biology, 58(2), pp. 301-318.
2. P Xia, L. V., 1998. Multileaf collimator leaf sequencing algorithm for intensity modulated
beams with multiple static segments. Medical Physics, 25(8), pp. 1424-1434.
3. R. H. Byrd, P. L. a. J. N., 1995. A Limited Memory Algorithm for Bound Constrained
Optimization. SIAM Journal on Scientific and Statistical Computing, 16(5), pp. 1190-1208.

Treatment Planning Beam Data for Ray-

Tracing and FSPB Dose Calculations
This section describes the methods that are used to calculate the effective depth and the
equivalent field size of the OF, TPR and OCR terms for configurations of depth, SAD, and radius
that are different than those which have been measured. The terms are used in Ray-Tracing and
FSPB dose calculations.
The interpolation and extrapolation of the measured OF, TPR and OCR data is done in two
phases:
1. Stored tables are constructed, often called calculated beam data.
See “Construction of Beam Data Stored Tables” on page 5-128.
These tables are viewed and approved by the user in the Commissioning Tools.
2. Final values for dose calculation are determined by interpolation and extrapolation of
these stored tables.
Different interpolation and extrapolation methods are used for separate terms in each
phase. Treatment Planning Data Fitting. This section provides information on treatment
planning data fitting in the Accuray Precision System. It covers the following topics:
• “Range of Measurements” on page 5-128
• “Construction of Beam Data Stored Tables” on page 5-128
• “Interpolation and Extrapolation of the Stored Beam Data Tables” on page 5-138
• “Tissue Density and Dose Calculation Accuracy for Ray-Tracing and FSPB” on
page 5-140
• “Algorithms Used in Data Fitting” on page 5-141
Range of Measurements
The Ray-Tracing dose calculation algorithms look up and interpolate or extrapolate measured
data. Thus these calculation are more accurate when operating within the ranges of the measured
data.
Recommended measurement ranges are listed in Chapter 2 for both dose algorithms:
• “Beam Data Acquisition for the Ray-Tracing Dose Calculation” on page 2-24
• “Beam Data Acquisition for the Finite Size Pencil Beam Dose Calculation” on page 2-100
Construction of Beam Data Stored Tables

This section describes how the beam data stored tables are constructed. It covers the following
topics:
• “Output Factor (OF)” on page 5-130
• “Tissue Phantom Ratio (TPR) in Ray Tracing” on page 5-130
• “Algorithm for MLC TPR Field Size Extrapolation” on page 5-133
5-128 | Treatment Planning Beam Data for Ray-Tracing and FSPB Dose Calculations 1075879 ENG A
• “Off Center Ratio (OCR)” on page 5-134

Interpolation and extrapolation methods used to generate the calculated beam data tables in the
Accuray Precision System are summarized in Table 21. TPR values outside the calculated beam
data table (which may have been extended to a depth of 800 mm or more by extrapolation) are
calculated by bilinear extrapolation and Taylor Series expansion.
NOTE: Taylor Series interpolation and extrapolation are not available for new
commissioning in the Accuray Precision System. However, previously
commissioned systems will still load Taylor Series data until new beam data is
imported and recommissioning is performed.
Table 21 Interpolation and extrapolation methods used to construct the stored tables.
Beam Data Table (Parameter)
Interpolation Extrapolation
TPR (Field Size) Taylor Series Taylor Series
TPR (Depth) Taylor Series Taylor Series or Exponential
OCR (Radius) Taylor Series Constant or Exponential
OCR (Depth) Taylor Series Taylor Series or Linear Least

Squares
OF (SAD) Linear Interpolation Linear Extrapolation
The OCR extrapolation is one of the following combinations:

• Constant (in radius) and Taylor Series (in depth), or
• Exponential (in radius) and Linear Least Squares (in depth).
The above combinations cannot be mixed.
Two methods are available to extrapolate the OCR table: least squares and Taylor Series. The
least squares method models the physics of beam spread more accurately. The Taylor Series
method was the only method available before MultiPlan System version 1.6 and remains primarily
as a legacy setting.
NOTE: For fixed collimator beam data, the extrapolation depth for OCR and
TPR is shared. If the OCR extrapolation depth is changed, TPR beam data will
be disapproved. If the TPR extrapolation depth is changed, the OCR beam
data will be disapproved.
For Iris Collimator beam data, the above is also true. But extrapolation depth
is not shared between fixed collimator and Iris Collimator beam data.
1075879-ENG A Treatment Planning Beam Data for Ray-Tracing and FSPB Dose Calculations |5-129
Output Factor (OF)

The output factor is determined based on the collimator and the SAD. One or more SAD
measurements are provided for each collimator. Measurements at 650 mm, 800 mm, and
1000 mm are recommended for Ray-Tracing. The FSPB algorithm only requires a measurement
at 800 mm SAD. The table for each collimator is constructed by linear interpolation and
extrapolation along the SAD dimension.
Since the original points used to construct the table are included directly in the table, the difference
between the measured data and the tabulated data is 0 (or at most machine round-off precision of
10-7) at these points.
Tissue Phantom Ratio (TPR) in Ray Tracing

The input TPR beam data files for each collimator should cover depths from 0 to 300 mm in 1 mm
depth increments. Usually the data is acquired at about 15 depths, and fit to a cubic spline to
generate a table at 1 mm intervals. Sometimes the site Physicist makes detailed measurements at
1 mm increments. In either case the quality of the input data is subject to approval by site
personnel, before being uploaded to the iDMS Data Management System as TPR data files.
For creating TPR tables with depths greater than the last entered depth point (beyond 300 mm),
the user may select either Taylor Series extrapolation (not recommended but retained for
compatibility with previous MultiPlan System versions) or exponential extrapolation
(recommended). These algorithms extrapolate the measured collimator depth profiles to 450 mm
or to a user-selected maximum depth up to 800 mm.
Accuray recommends using exponential extrapolation because it is performed by fitting a least
squares line to the log of the TPR values and is thus more robust to measurement noise, as shown
in the curve in Figure 40. For reference, the Taylor Series extrapolation is shown in Figure 41. In
Figure 41 the last two points (used in Taylor extrapolation) for some of the collimators caused the
extrapolation to be too low. Since MultiPlan System version 2.0, the extrapolated TPR values have
clipped to 1.17 if they are larger than 1.17 and to 0.0 if they are smaller than 0.0.
Figure 40 Exponential TPR depth extrapolations
Figure 41 Unpredictable TPR depth extrapolations with Tay-

lor Series algorithm
After the depth extrapolation (if any) is done for each of the collimators, the measured and
extrapolated collimator data is used to interpolate and extrapolate the TPR table to field sizes from
0 to 99.5 mm. The interpolation and extrapolation below the measured depth is much smoother
than the similar functions using measured data, because the extrapolation is very smooth (to within
machine precision). This can be seen in Figure 42 by looking at the noise difference in the 99.5 mm
extrapolated TPR data.
The interpolation and extrapolation are performed by using the Taylor Series method, which works
fairly well for interpolation. For extrapolation this method introduces a slight wobble in the data at
the larger field size. This wobble and the slight discontinuity in the depth extrapolation at 300 mm
can be seen in Figure 42. The depth discontinuity is on the order of 0.002 (so the dose error would
be a maximum of approximately 0.002% at this point) while the wobble (above the extrapolation
depth) is on the order of 0.01 (along the entire measured range). Since our usual treatment path
sets position the isocenter at between 800 and 1000 mm SAD (with the majority of the cases
around 900 mm SAD) the 60 mm collimator dose calculation will only need TPR field sizes out to
about 75 - 80 mm (1000/800 = 1.25; 1.25 * 60 mm = 75 mm). These field sizes usually occur
between effective depth values of 50 to 300 mm, so they use the measured data to created the
field size extrapolations. For the Taylor Series extrapolation the wobble increases linearly from
60 mm to 99.5 mm so we may assume the wobble is about 0.005 at 80 mm. This would produce
about a 0.5% calculation error in the TPR until the effective depth reaches 300 mm (or the end of
the measured data).
Figure 42 TPR measured and extrapolated data values as a

function of effective depth
Since the input values of the TPR data are used for all the TPR table values lying at the collimator
field sizes, and above the input data depth cut-off, the error between the measured data and the
tabulated data is on the order of machine round off error (10-7) at these points.
Algorithm for MLC TPR Field Size Extrapolation

Inherently, TPR measures have uncertainties that will be magnified when the data is extrapolated
to regions outside the limits of measurement. For the MLC, we anticipate the field size can be as
much as 195 mm square and down to 1400 mm of depth. But data is only collected up to a
115 x 100.1 mm field size (which converts to a roughly 107.0 mm equivalent square) and down to
300 mm in depth. To reduce the noise in the extrapolated data, FSPB uses an extrapolation
algorithm that differs from the Ray Tracing beam data extrapolation. The new extrapolation method
is more immune to noise in the input depth dose measures; and, thus produces generally smoother
curves. The new method is described below.
1. The input data for the extrapolation are:
• The number of field sizes and depths in the TPR table.
• The values of the field sizes and depths.
• The input TPR table mapped to the field sizes and depths. The depths are generally
stored at 1 mm of spacing.
• Depth from 300 mm to 450 mm is found using the existing exponential extrapolation
algorithm.
2. Linearly interpolate the beginning and end (5 points) of each of the TPR depth profiles at
0.2 mm spacing.
3. Spline fit this 0.2 mm spaced data using a Catmull-Rom spline with a tension of 0.5.
4. Use the same spline fitting to interpolate the original points spaced at 1 mm intervals.
5. Smooth each TPR profile with a 9 point wide Gaussian kernel with a sigma value of 1.7.
6. Bilinearly interpolate the last 5 TPR depth profiles so that it has 0.05 mm spacing in depth
and 1.0 mm spacing in field size.
7. Optimally fit the data with a linear 3D least squares plane at each 0.05 mm of depth to
find the optimum parameters A, B, and C to a parametric form of the TPR data:
(65)
TPR (depth,fieldsize) = A + B  depth + C  field  depthsize 
This form is not used between 0 mm and 5 mm of depth. At these shallow depths, the
extrapolated data in depth is the measurement data for the nearest field size.
8. Apply a median filter to the 3D least squares extrapolated depth profiles to limit the noise
in this data and then smooth the data with a 50 point Gaussian filter (with sigma = 100).
9. Finally, sample the extrapolated data to depths values spaced at 1 mm like the original
input data and combine this data with the rest of the TPR data for use by the FSPB
algorithm.
This least squares approach with median and Gaussian filters produces very stable results despite
observed and predictable uncertainties in the TPR measurements.
Off Center Ratio (OCR)

MultiPlan System versions 1.5 and earlier:
• Because the radial sampling for the OCR beam data tables is small (< 1 mm), the
interpolation for OCR depths less than the first measurement or between measurements
is done by linearly extrapolating along the depth coordinate and using the nearest radial
value.
• For OCR depths greater than the last entered data point: Linear extrapolation using the
last 2 values out to 300 mm then constant thereafter.
• For OCR radii greater than last entered value: The average of the last 3 entered radius
values, extended to infinite radius.
Accuray Precision System and MultiPlan System versions 1.6 to 1.7 and 2.0 to 3.5:
The OCR table for each collimator runs from 0 to 59.9 mm radius in 0.1 mm increments and from
a depth of 0 mm to the table end (450 mm or a user-selected maximum depth up to 800 mm) in
1.0 mm increments. The linear least squares algorithm performs both radial and depth
extrapolation such that:
• If the range of the radial measurements for a given depth is < 59.5 mm then:
 Select all the measurements for which the OCR values satisfy
 OCR  0.051 and 0.002 < OCR < 0.2 (66)

r
 If there are less than 3 points satisfying these criteria then just extend the last OCR
value to fill all the radial values out to 59.9 mm.
 Otherwise use exponential extrapolation to compute the OCR value along this depth
out to a radial value of 59.9 mm.
 Linearly Interpolate all the data at this depth to 0.1 mm spacing.
• If the range of the radial measurements for a given depth is  59.9 mm, but the radial
spacing differs from 0.1 mm, then linearly interpolate to 0.1 mm.
• If the samples span the desired range at the desired spacing, just copy them.
• Perform Gaussian smoothing of the 0.1 mm samples for this depth.
• Use all the (smoothed) measurements to fit a linear least squares line at each radial value
to all the depth measurements. Then use this line to interpolate and extrapolate the OCR
value from 0 to a depth of 50 mm at 1.0 mm for off-axis. At the depth of 50 mm or more
the increment is 50. The last depth may not be an increment of 50, as it depends on what
the user-selected maximum depth is. If the user-selected max depth of 790 mm, the last
depth has an increment of 40.
The error between the input OCR data measurements and the interpolated and smoothed table
values may be computed along each radial direction for each of the input values. To evaluate the
importance of these errors, statistical descriptors (maximum, mean, and standard deviation) are
tabulated below in Table 22 for the absolute OCR errors (Delta) and the distance to agreement
values (DistToAgree) for penumbral samples with 0.8 > OCR  0.2. The statistics are averages for
each collimator/depth combination from 15 different sites. The differences are small so they have
been multiplied by 1000 to make the table more readable. For some site/collimator combinations
additional depth measurements were present. The number of samples indicates how many total
radial measurements were made at each collimator/depth combination.
The sample weighted averages for each of the statistics are listed in the bottom row of Table 22,
and the small values (also x1000) of the standard deviation statistics indicate that approximately
99.7% of the calculated table OCR values are within 0.0018 of the input data values and that
approximately 99.7% of the calculated table OCR values in the penumbral region are within
0.015 mm of the input data.
Table 22 Example absolute interpolation errors and

distance-to-agreement for the OCR values
Delta (x 1000) DistToAgree (mm)(x1000)

Collimator Depth Number
(mm) (mm) Samples Max Mean Std dev Max Mean Std dev
5 15 4492 8.2 0.2 0.5 23 4.6 3.8
5 50 4492 10.4 0.3 0.6 31.8 5.5 6.1
5 100 4401 11.2 0.3 0.7 52.4 6.3 8.9
5 150 132 19.3 1.1 2.3 14.2 3.4 3.7
5 200 4492 21.5 0.3 0.6 48 4.2 4.3
5 300 163 6.1 1.2 1.3 19.8 5.5 4.2
7.5 15 4552 7.3 0.5 0.4 27.8 4.7 4.1
7.5 50 4552 8.9 0.2 0.5 38.3 5.2 5.3
7.5 100 4421 8 0.2 0.4 30.8 4.4 2.6
7.5 150 131 15.1 0.8 2 13.4 2 3.1
7.5 200 4552 21.5 0.3 0.5 36.3 4.6 3.7
7.5 300 183 3.2 0.8 0.8 9 5.1 3.6
10 15 4577 5.7 0.4 0.4 22.8 3.6 1.8
10 50 4577 5.3 0.2 0.3 23.7 3.7 2.2
10 100 4421 6.9 0.2 0.4 31.3 4 2.6
10 150 156 12.9 0.6 1.5 12.9 1.9 3.1
10 200 4577 17.8 0.3 0.6 52.2 5.7 8.8
10 300 183 2.7 0.6 0.7 12.3 6.5 4
12.5 15 4599 5.4 0.3 0.5 30.6 4.5 3.8
12.5 50 4599 7.1 0.2 0.4 30.3 4.8 4.9
12.5 100 4428 7.1 0.3 0.5 31.8 4.9 5.2
12.5 150 171 10.9 0.6 1.5 15.8 2.2 3.7
12.5 200 4599 16.5 0.3 0.7 35.4 4.8 5.9
12.5 300 165 3.6 0.7 0.9 13.9 9.5 4

distance-to-agreement for the OCR values (continued)

15 15 4574 9.2 0.4 0.7 44.9 5.3 7
15 50 4574 7.2 0.2 0.4 25.6 4.2 3.7
15 100 4403 6.5 0.3 0.5 30.7 4.4 5.3
15 150 171 13.8 0.5 1.5 12.9 2.3 3.6
15 200 4574 15.6 0.3 0.5 27.3 4.1 3.6
15 300 165 2.6 0.6 0.8 16.8 12.8 3.4
20 15 4659 7.8 0.2 0.4 38.4 4.3 3
20 50 4659 8.5 0.2 0.4 48.1 4.1 3.2
20 100 4428 6.5 0.3 0.5 32.1 4.6 5
20 150 231 14.8 0.6 1.8 22.6 1.8 4.6
20 200 4659 16.2 0.3 0.6 24.4 3.7 2.6
20 300 165 4.9 0.7 1 21.9 12.6 8.2
25 15 4689 5.9 0.2 0.4 27.2 3.8 2.5
25 50 4689 7.6 0.2 0.4 25.3 4.1 3
25 100 4428 8.5 0.3 0.6 51.6 4.8 6.2
25 150 261 17.2 0.7 2.1 27.2 2.7 6.4
25 200 4689 18.9 0.4 0.7 53.8 4.6 6.3
25 300 165 9.8 0.8 1.7 19.8 10.8 8.6
30 15 4742 5.2 0.6 0.6 40.3 4 2.3
30 50 4742 9.4 0.3 0.6 50.5 5.4 7.3
30 100 4461 7.6 0.3 0.7 40.7 5.1 6.6
30 150 281 9.1 0.4 1.1 24.4 2 4.9
30 200 4742 24.7 0.4 0.8 51 4.2 4.6
30 300 165 16.2 1 2.7 18.5 14.1 4.1
35 15 5027 7.2 0.2 0.4 36.4 4.8 5.8
35 50 5027 8.2 0.2 0.5 45.5 5.1 6.6
35 100 4486 7.2 0.3 0.6 43.5 4.1 3
35 150 541 9.1 0.2 0.7 13.9 1.3 2.8
35 200 5027 11.2 0.3 0.8 50.4 4.4 5.5
35 300 165 21.7 1.1 3.5 22.4 14.3 6.2
40 15 5097 6.7 0.5 0.6 32.1 4.7 4.9
40 20 201 7.8 0.6 1.3 6.7 2.1 2
40 50 5097 8.5 0.2 0.5 51 4.8 6.1
40 100 4536 8.1 0.3 0.7 50 5.2 7
40 150 561 11 0.3 0.9 12.4 1 2.1
40 200 4896 13.7 0.3 0.7 40.3 3.8 3.7
40 300 165 2.9 0.6 0.8 22.8 15.6 9.4
50 15 5197 6.1 0.2 0.4 40 4.8 5.1

distance-to-agreement for the OCR values (continued)

50 50 5197 8.3 0.3 0.7 51.4 5 6.8
50 100 4586 8 0.3 0.7 40.9 5.2 5.9
50 150 611 13.8 0.3 1.1 21.1 1.3 3.3
50 200 5197 17.2 0.4 1 63 4.9 7.3
50 300 165 2.9 0.5 0.8 36.7 16.9 15
60 15 5247 12.6 0.2 0.6 65 6 7.7
60 50 5247 12.4 0.3 0.9 68.6 5.7 7.8
60 100 4586 12.4 0.5 1.2 69.6 5.6 7
60 150 661 1.2 0 0.1 21.5 1.6 3.6
60 200 5247 22.2 0.5 1.2 45.1 4.4 5.1
60 300 165 5 0.6 1.1 30 22.1 7.5
Weighted Average Values = 10.5 0.3 0.6 40.4 4.7 5
The OCR and TPR values used in the dose calculation are multiplied together, so it is only their
combined product that enters into the calculation. Figure 43 shows the decreasing OCR * TPR
product as a function of depth and off-center radius and indicates why (the small) values at large
radii and large depths are relatively insensitive to the algorithms used to create them. Note that
Figure 43 indicates the OCR * TPR product at effective depths of 15, 50, 100, 200, and 300 mm.
Figure 43 OCR * TPR table for 20 mm collimator
Interpolation and Extrapolation of the Stored Beam

Data Tables
The previous section (“Construction of Beam Data Stored Tables” on page 5-128) describes the
methods used to interpolate and extrapolate the measured data when generating the look-up
tables for the output factor, TPR, and OCR. This section gives the methods for determining the
values of these parameters for input values that are not the stored values in the table.
The majority of the error associated with conversion of the measured output factor, TPR, and OCR
values is incurred in the creation of the table, because the values are stored at relatively fine
intervals in comparison to the magnitudes of the interpolations required after the tables have been
constructed.
• “Effective Depth Calculation” on page 5-139
• “Output Factor Look-ups” on page 5-139
• “TPR Look-ups” on page 5-139
• “OCR Look-ups” on page 5-140
Effective Depth Calculation

There are two methods of effective depth calculation:
• Method 1 (Contour Correction option not selected): Approximate the dose at a point by
projecting it onto the beam’s central axis.
• Method 2 (Contour Correction option selected): Compute the dose at a point using tri-
linear interpolation from points along 4 surrounding rays that form a prism encompassing
the point.
Each beam has a set of effective depths calculated and stored at 1 mm depth increments along
the beam central axis. In addition, each beam also has a set of 120 additional depth rays calculated
and stored, again at 1 mm depth increments. These additional rays are arranged in a set of 10
concentric cones covering the beam cross section, with each cone containing twelve rays spaced
at 30 degree intervals, and the largest cone having radius at 800 mm SAD equal to the nominal
collimator size. If the Contour Correction option is not selected, the effective depth at each point is
set to the depth of that point projected onto the beam central axis, calculated by linear interpolation
between the two depth values at the nearest 1 mm intervals. If the Contour Correction option is
selected, the effective depth at each point is calculated by means of tri-linear interpolation of the
effective depth values of the 4 nearest rays, using the points that intersect the plane perpendicular
to the central axis and containing the point being calculated (see “Contour Correction” on
page 5-13). The effective depth for all rays (central and off-axis) is determined from the CT volume
in 1 mm depth increments.
Output Factor Look-ups

Output factor values are stored for each collimator based on the SAD of the beam. For a given
point, the SAD is calculated for the nearest point along the central axis of the beam. SAD values
between stored table entries are linearly interpolated. SAD values beyond stored table entries are
linearly extrapolated in the same fashion as the table values are generated when the look-up table
is created from the measured data. The table stores the values at 50 mm increments of SAD
between 500 mm and 1100 mm SAD.
TPR Look-ups
TPR values are stored based on effective depth and field size. For a given point, the effective depth
of the beam and field size are calculated for the nearest point along the central axis of the beam.
Points that fall between stored table values are bilinearly interpolated. Points that fall beyond the
stored values created in the table are bilinearly extrapolated. As with the OCR table, depth values
are stored at 1 mm increments to the maximum depth (450 mm to 800 mm) entered by the user.
Field sizes are stored from 0 mm to105 mm at 0.5 mm depths. For more information on depth
calculation, see “Effective Depth Calculation” on page 5-139.
OCR Look-ups
OCR values are stored based on collimator diameter, effective depth, and distance from the central
axis (or off-axis radius). For each collimator diameter, a table is created that stores the OCR value
based on the effective depth and off-axis radius. For a given point and collimator, we determine
the effective depth of the beam at the nearest point along the central axis and the off-axis radius
of that point. We scale the off-axis radius to the plane normal to the beam that is 800 mm from the
source. The off-axis radius is stored in 0.1 mm increments. The look-up table uses value of the
nearest 0.1 mm increment.
The maximum accessed off-axis radius is 60 mm. For radii greater than that, the value at 60 mm
is used. So, in general, the algorithm slightly overestimates the dose contribution of each beam at
points 60 mm or greater distant from the central axis of the beam.
The look-up table uses a Taylor Series expansion to interpolate between the stored depths of the
table and extrapolate beyond the maximum depth of the table. 1 mm increment is use to the depth
of 15 mm. At the depth of 50 mm or more the increment is 50. The last depth may not be an
increment of 50 mm, as it depends on what the user-selected maximum depth is. If the user-
selected max depth is 790 mm, the last depth has an increment of 40.
For more information on depth calculation, see “Effective Depth Calculation” on page 5-139.
Tissue Density and Dose Calculation Accuracy for

Ray-Tracing and FSPB
The Ray-Tracing and the FSPB dose calculation algorithms are more accurate the nearer tissue
densities are to the density of water, as all data is measured in water.
The Ray-Tracing and the FSPB algorithms assumes lateral scatter equilibrium within the beam.
This assumption breaks down when low density tissue is traversed. Examples of clinical cases in
which this assumption is not physically accurate are lesions in or near lung tissue or near the sinus
cavities. The amount of error will depend on multiple factors and is thus case specific. Elements
that are likely to increase the overall error are:
• Tumor size: A smaller tumor will generally result in larger errors because the dose build-
up region in the tumor is smaller.
• Collimator size: Smaller collimators generally have larger errors because the effects of
lateral scatter disequilibrium are more pronounced.
• Location of tumor: A tumor in the middle of a low density region will generally have
larger errors than tumors at the edge of low density regions.
Expected treatment errors are for 33 Ray-Tracing clinical cases are published in Ref. 13. FSPB
results are expected to be the same.
The Ray-Tracing and the FSPB algorithms accuracy also decreases when traversing through large
metal objects, such as hip prosthesis. These regions create two problems: a large density
differential and the presence of CT artifacts which make it difficult to accurately evaluate the actual
material properties through which the beams pass. Users should consider disabling beams that
pass directly through large metal objects.
Algorithms Used in Data Fitting

This section describes algorithms used in treatment planning data fitting. It covers the following
topics:
• “Linear Interpolation and Extrapolation” on page 5-141
• “Taylor Series Interpolation and Extrapolation” on page 5-142
• “Bilinear Interpolation and Extrapolation” on page 5-143
• “Linear Least Squares Interpolation and Extrapolation” on page 5-144
• “Exponential Interpolation and Extrapolation” on page 5-145
• “Gaussian Smoothing” on page 5-145
Linear Interpolation and Extrapolation

Given a function, f, of a single variable, x, the interpolated value of this function at a value of x in
between two variable values x0 and x1 is given by Equation (67):
 f(x 1) – f(x 0)  (67)

f(x) = f(x 0) + ---------------------------------   x – x 0 
 x1 – x0 
If the function value is desired at a value of x less than the smallest tabulated variable value (x0)
then the function value is extrapolated using Equation (68):
 f(x 1) – f(x 0)  (68)

f(x) = f(x 0) + ---------------------------------   x 0 – x 
 x1 – x0 
Whereas the extrapolation to a value of x greater than the largest tabulated variable value (xN) is
given by Equation (69):
 f(x N) – f(x N – 1) 
f(x) = f(x N) + ------------------------------------------   x – x N  (69)
 xN – xN – 1 
Taylor Series Interpolation and Extrapolation

For a function, f, of two variables, x and y, a Taylor Series interpolated table may be created
between the data extremes by using the Taylor Series approximation about the point (x0, y0) for a
functions for two variables, as in Equation (70):
f(x y) = f(x 0 y 0) +  x – x 0    f(x y) x = x0 +  y – y 0    f(x y) x = x0

(70)
x y
y = y0 y = y0
This differential equation is used to create the following finite difference equation for interpolating
the function, f, at a point (x, y) between two tabulated values in Equation (71):
 f(x 1 y 0) – f(x 0 y 0)   f(x 0 y 1) – f(x 0 y 0)  (71)

f(x y) = f(x 0 y 0) +  x – x 0   --------------------------------------------------- +  y – y 0   ---------------------------------------------------
 x1 – x0   y1 – y0 
There are six variants of this equation used to extrapolate beyond the limits of the measured (or
tabulated) data when either x or y or both are either less than or greater than the available data.
For example when both x and y are greater than the available measured (or tabulated) data the
backward difference equation in Equation (72) is used:
 f (x N  y M ) – f( x N – 1  y M )   f( x N  y M ) – f( x N  y M – 1 ) 
f(x y) = f(x N y N) +  x – x N   --------------------------------------------------------------- +  y – y M   --------------------------------------------------------------- (72)
 xN – xN – 1   yM – yM – 1 
Bilinear Interpolation and Extrapolation

The bilinear interpolation/extrapolation algorithm is, in general, more accurate than the Taylor
Series algorithm, but with a higher computational cost. The equation for the TPR function of field
size, f, and effective depth, d, is given in Equation (73) for the case where x is in the range (x1, x2)
and y is in the range (y1, y2):
f(x1 y1)
f(x y) = ------------------------------------------------   x 2 – x    y 2 – y  +
 x2 – x1    y2 – y1 
f(x 2 y 1)
-   x – x1    y2 – y  +
-----------------------------------------------
 x2 – x1    y2 – y1 
(73)
f(x 1 y 2)
-   x2 – x    y – y1  +
-----------------------------------------------
 x2 – x1    y2 – y1 
f(x 2 y 2)
-   x – x1    y – y1  +
-----------------------------------------------
 x2 – x1    y2 – y1 
In Figure 44 this corresponds to Equation (74):
Q 11
P = ------------------------------------------------   x 2 – x    y 2 – y  +
 x2 – x1    y2 – y1 
Q 21
-   x – x1    y2 – y  +
-----------------------------------------------
 x2 – x1    y2 – y1 
(74)
Q 12
-   x2 – x    y – y1  +
-----------------------------------------------
 x2 – x1    y2 – y1 
Q 22
-   x – x1    y – y1  +
-----------------------------------------------
 x2 – x1    y2 – y1 
Figure 44 Bilinear interpolation parameters
For the case where x or y or both are outside the range of the measured data, there are forward
and backward extrapolation formulae similar in nature to the Taylor Series forward and backward
extrapolation formulae.
Linear Least Squares Interpolation and Extrapolation

The least squares algorithm for determining  and  in the linear equation given by
y = +x (75)
given a set of x and y measurements is given by Equation (76):
2
y  x – x  x  y-  x  y – y  x-
 = ---------------------------------------------------
2 2
  = n--------------------------------------------- (76)
2 2
n  x –  x  n  x –  x 
Once the line is fit through a set of points (usually 5 - 20) the value of y can be evaluated for any
desired x (interpolation or extrapolation).
Exponential Interpolation and Extrapolation

By taking the logarithm of the function values (Y) as a function of data values x, an exponential
distribution can be modelled by a linear equation as follows:
y = log  Y  =  +   x (77)
This linear equation can then be inserted into the least squares fitting algorithm above to determine
 and . Then the data, Y, can be interpolated or extrapolated as a function of x using the equation:
(78)
Y = exp   +   x  = e   +   x 
Gaussian Smoothing
The OCR data frequently has truncation and measurement noise that needs to be smoothed out
before being used for (Taylor Series or least squares) interpolation or extrapolation. This is done
by convolving the interpolated (to 0.1 mm spacing) radial data with a 7-point Gaussian filter (array)
with a width (sigma) of the square root of (1.2) mm ( 1.2 ). The filter is normalized to have unit
response by dividing each of the 7 original Gaussian array values by the sum of the array values.
Aside from the normalization coefficient, , each term at array value x has the form given in
Equation (79) and Equation (80):
6
2
i – 3
N =  e –  ------------------- (79)
  2  1.2 
i=0
6
2
1 i – 3
GaussianSmooth  X j  = ----  X j + i – 3. e –  ------------------- (80)
N   2  1.2 
i=0
References
A Monte Carlo Dose Calculation bibliography is provided below.
Monte Carlo References:
1. Kawrakow I, Fippel M, Friedrich K. 3D electron dose calculation using a Voxel based
Monte Carlo algorithm (VMC). Medical Physics 1996;23(4):445-457.
2. Kawrakow I, Fippel M. Investigation of variance reduction techniques for Monte Carlo
photon dose calculation using XVMC. Phys Med Biol 2000;45(8):2163-2183.
3. De Smedt B, Fippel M, Reynaert N, Thierens H. Denoising of Monte Carlo dose
calculations: smoothing capabilities versus introduction of systematic bias. Medical
Physics 2006;33(6):1678-1687.
4. ICRU Report 46D (1992) Photon, electron, proton, and neutron interaction data for body
tissues. ICRU Publications, Bethesda, MD.
5. AAPM Report 85 (2004) Report of the AAPM Task Group No. 65: Tissue Inhomogeneity
Corrections for Megavoltage Photon Beams. Madison, WI: Medical Physics Publishing.
6. AAPM Report 97 (2007) Report of the AAPM Task Group No. 105: Issues Associated
with Clinical Implementation of Monte Carlo-based Photon and Electron External Beam
Treatment Planning. Medical Physics;34(12):4818-4853.
Monte Carlo Background:
1. Deng J, Jiang SB, Li J, Pawlicki T, Ma CM. Photon beam characterization and modeling
for Monte Carlo treatment planning. Phys Med Biol. 2000;45(2):411-427.
2. Deng J, Jiang SB, Pawlicki T, Li JS, Ma CM. Electron beam commissioning for Monte
Carlo dose calculation. In: Schlegel W, Bortfeld T, eds. Proceedings of the XIIIth
International Conference on the Use of Computers in Radiation Therapy (ICCR).
Heidelberg, Germany: Springer-Verlag; 2000;431-433.
3. Deng J, Jiang SB, Pawlicki T, Li J, Ma CM. Derivation of electron and photon energy
spectra from electron central axis depth dose curves. Phys Med Biol. 2001;46(5):429-
449.
4. Jiang SB, Deng J, Li JS, Pawlicki T, Boyer AL, Ma CM. Modeling and commissioning of
clinical photon beams for Monte Carlo treatment planning. In: Schlegel W, Bortfeld T,
eds. Proceedings of the XIIIth International Conference on the Use of Computers in
Radiation Therapy (ICCR). Heidelberg, Germany: Springer-Verlag; 2000;434-436.
5. Jiang SB, Kapur A, Ma CM. Electron beam modeling and commissioning for Monte Carlo
treatment planning. Medical Physics 2000;27(1):1801-91.
6. Keall PJ, Hoban PW. Superposition dose calculation incorporating Monte Carlo
generated electron track kernels. Medical Physics 1996;23(4):479-485.

7. Li JS, Pawlicki T, Deng J, Jiang SB, Mok E, Ma CM. Validation of a Monte Carlo dose
calculation tool for radiotherapy treatment planning. Phys Med Biol. 2000;45(10):2969-
2985.
8. Ma CM, Faddegon BA, Rogers DW, Mackie TR. Accurate characterization of the Monte
Carlo calculated electron beams for radiotherapy. Medical Physics 1997;24(3):401-416.
9. Ma CM, Li JS, Pawlicki T, Jiang SB, Deng J. MCDOSE – A Monte Carlo dose calculation
tool for radiation therapy treatment planning. In: Schlegel W, Bortfeld T, eds. Proceedings
of the XIIIth International Conference on the Use of Computers in Radiation Therapy
(ICCR). Heidelberg, Germany: Springer-Verlag; 2000:123-125.
10. Ma CM, Li J-S, Pawlicki T et al. A Monte Carlo dose calculation tool for radiotherapy
treatment planning. Phys Med Biol. 2002;47(10):1671-1689.
11. Ma CM, Mok E, Kapur A, Findley D, Brain S, Forster K, Boyer AL. Clinical implementation
of a Monte Carlo treatment planning system. Medical Physics 1999;26(10):2133-2143.
12. Ma CM, Nahum AE. Calculation of absorbed dose ratios using correlated Monte Carlo
sampling. Medical Physics 1993;20(4):1189-1199.
Additional references
13. Wilcox, Daskalov et al. Comparison of Planned Dose Distributions Calculated by Monte
Carlo and Ray-Trace Algorithms for the Treatment of Lung Tumors with CyberKnife: A
Preliminary Study in 33 Patients. Int. J. Rad Onc Biol Phys. 2010.
14. U. Jelen, M. Sohn and M. Alber, "A finite size pencil beam for IMRT dose optimization”,
Phys. Med. Biol. 50 (2005) 1747-1766
15. U. Jelen, M. Sohn and M. Alber, "A finite size pencil beam for IMRT dose optimization:
density corrections”, Phys. Med. Biol. 50 (2005) 617-633


Appendix 2A: Beam Data
Validation Rules
Introduction
This appendix to Chapter 2, "Commissioning", lists beam data validation rules, beam data
filenames for each collimator type, collimator size, and beam data value limits.
The Beam Data Import application of the iDMS Data Management System validates beam data
files during the import process using the Beam Data Validation rules. If the data in a file violates
any of these rules, the import option for that file is disabled, and the Beam Data Import application
displays an error or Warning message.
NOTE: Beam data files must be generated in plain text format (ASCII or ANSI).
Otherwise, they cannot be imported into the iDMS Data Management System.
The iDMS Data Management System recognizes beam data filenames with
both .dat and .txt file extensions.
This appendix covers the following topics:

• “Beam Data Validation Rules” on page 2A-2
• “Beam Data Filenames and Collimator Sizes for Fixed and Iris Collimators” on
page 2A-10
• “Beam Data Value Limits for Fixed and Iris Collimators” on page 2A-14
• “Beam Data Filenames, Field Sizes, and Value Limits for the Multileaf Collimator” on
page 2A-16
1075879-ENG A |2A-1
Beam Data Validation Rules

Table 1 lists beam data validation rules for Fixed and Iris beam data imported with the Beam Data
Import application. The first column of Table 1 gives the text of the error or Warning message that
is displayed.
Table 2 lists beam data validation rules for Multileaf Collimator beam data imported with the Beam
Data Import application. The first column of Table 2 lists the error messages displayed for a
particular type of file data and the second column lists a more detailed description of the errors.
The procedure for importing beam data files using the Beam Data Import application is described
in Chapter 2, "Commissioning". For detailed information on the Beam Data Import application, see
the Data Management Manual.
NOTE: In the file headers of beam data files, the words "version" and "sample"
must be lowercase.
Table 1 Beam data validation rules for beam data files (Fixed and Iris)
Message Type
DMtable.txt
Data for all collimator sizes must be included Error
The number of collimators must equal the number of columns Error
Values must be separated by either a space or a tab Error
Output Factor values exceed allowable range Error

(See Table 4 on page 2A-14.)
File must not include blank lines Error
File header must include version number, sample value and file description Error
A minimum of 3 SAD measurements are required Error
Values for each collimator must increase monotonically Error
Data must be formatted to a precision of 3 decimal places Error
Data for 800 SAD must be included Error
The number of SADs must equal the number of rows of data Error
2A-2 | 1075879-ENG A
Table 1 Beam data validation rules for beam data files (Fixed and Iris) (continued)
Message Type
SAD values must be in the range of 300 to 1500 mm Error
iris_mc_centralpdd.txt
The number of depths must equal the number of rows Error
The maximum number of depth measurements allowed is 500 Error
The maximum depth increment is 3 mm Error
The maximum value allowed is 100.00 Error
The minimum depth must be greater than 0 mm Error
The minimum number of depth measurements required is 100 Error
The minimum value allowed is 0.00 Error
Depths must increase monotonically Error
The SSD must be 800 Error
iris_mc_doseprofile.txt
The depth of the measurements must be included Error
Depth must be in the range of 10 to 30 mm Error
The maximum value at 0 mm must equal 1.0000 Error
Values for each radius must increase monotonically Error
The value for a radius of 0 mm must be included Error
1075879-ENG A |2A-3
Message Type
The number of radii measured must equal the number of rows Error
Radius must be in the range of -80 to 80 mm Error
The number of radii measured must be 161 Error
SSD must be in the range of 700 to 900 mm Error
Values must be in the range of 0.0000 to 1.0900 Error
iris_mc_outputfactor.txt
The value for the 5 mm collimator must be greater than or equal to 0.400 Error
The value for the 60 mm collimator must be 1.000 Error
The number of collimators must equal the number of rows Error
The depth of the measurements must be included in the file header Error
Values must increase monotonically Error
A row must be present for each collimator Error
The SAD must be 800 mm Error
irisOCRtableN.txt (where N is from 0 to 11)
The number of depths must equal the number of columns Error
The file name must include the collimator size Error
There must be a fixed distance between radial measurements Error
Values are outside of expected range of Full Width Half Max check Warning
File header must include version number, sample value and collimator size Error
2A-4 | 1075879-ENG A
Message Type
Values are expected to decrease monotonically with increasing radius Warning
Off Axis Ratio (OAR) values are out of allowable range Error
At least one depth measurement must be greater than 150 mm Error
At least one depth measurement must be less than 50 mm Error
Distance between measurements exceeds 1 mm Warning
The number of radial measurements must equal the number of rows Error
irisOFtable.txt
The number of collimators must equal the number of columns Error
Output Factor values exceed allowable range Error

A minimum of 3 SAD measurements are required Error
Values for each collimator must increase monotonically Error
Data for 800 SAD must be included Error
The number of SADs must equal the number of rows of data Error
SAD values must be in the range of 300 to 1500 mm Error
irisTPRtable.txt
1075879-ENG A |2A-5
Message Type
The 15 mm depth measurement must be included for all field sizes. The value must Error
be 1.000
Number of depth measurements is less than 150 Error
Number of depth measurements must be equal or greater than 50 Error
Depths measured must increase monotonically by exactly 1.000 mm Error
The number of field sizes must equal the number of columns Error
TPR100 must increase monotonically with field size Error
TPR values exceed allowable range Error

mc_centralpdd.txt
The maximum number of depth measurements allowed is 500 Error
The maximum depth increment is 3 mm Error
The maximum value allowed is 100.00 Error
The minimum depth must be greater than 0 mm Error
The minimum number of depth measurements required is 100 Error
The minimum value allowed is 0.00 Error
Depths must increase monotonically Error
2A-6 | 1075879-ENG A
Message Type
The SSD must be 800 Error
mc_doseprofile.txt
The depth of the measurements must be included Error
Depth must be in the range of 10 to 30 mm Error
The maximum value at 0 mm must equal 1.0000 Error
The value for a radius of 0 mm must be included Error
The number of radii measured must equal the number of rows Error
Values for each radius must increase monotonically Error
Radius must be in the range of -80 to 80 mm Error
The number of radii measured must be 161 Error
SSD must be in the range of 700 to 900 mm Error
Values must be in the range of 0.0000 to 1.0900 Error
mc_outputfactor.txt
The value for the 5 mm collimator must be greater than or equal to 0.400 Error
The value for the 60 mm collimator must be 1.000 Error
The number of collimators must equal the number of rows Error
The depth of the measurements must be included in the file header Error
Values must increase monotonically Error
1075879-ENG A |2A-7
Message Type
A row must be present for each collimator Error
The SAD must be 800 mm Error
OCRtableN.txt (where N is from 0 to 11)
The number of depths must equal the number of columns Error
The file must contain the correct collimator size Error

There must be a fixed distance between radial measurements Error
Values are outside of expected range of Full Width Half Max check Warning
File header must include version number, sample value and collimator size Error
Values are expected to decrease monotonically with increasing radius Warning
Off Axis Ratio (OAR) values are out of allowable range Error
At least one depth measurement must be greater than 150 mm Error
At least one depth measurement must be less than 50 mm Error
Distance between measurements exceeds 1 mm Warning
The number of radial measurements must equal the number of rows Error
TMRtable.txt
The 15 mm depth measurement must be included for all field sizes. The value must Error
be 1.000
Number of depth measurements is less than 150 Warning
2A-8 | 1075879-ENG A
Message Type
Number of depth measurements must be greater than 50 Error
Depths measured must increase monotonically by exactly 1.000 mm Error
The number of field sizes must equal the number of columns Error
TPR100 must increase monotonically with field size Error
TPR values exceed allowable range Error

Table 2 Beam data validation rules for beam data files (Multileaf Collimator)
Displayed Error Message Description
mlc_doseprofileN.txt (Where N is 45, 135, X, or Y)
Invalid MLC file header information The MLC Dose Profile does not conform to the required
file structure. See the required structure in Chapter 2,
"Commissioning".
The MLC dose profile value exceeds The MLC dose profile value exceeds the maximum
the maximum allowable value of 1.03 allowable value of 1.03
mlc_OCRFieldSize.txt (must be in the customer data folder when

importing the data)
The field size for this file does not The field size for this file does not match one of the
match one of the necessary field sizes required field sizes for import. Refer to Chapter 2,
for import. Refer to the Physics "Commissioning" for required field sizes.
Essentials Guide for allowable field
sizes
1075879-ENG A |2A-9
Table 2 Beam data validation rules for beam data files (Multileaf Collimator) (continued)
Invalid MLC OCR field size file The file does not conform to the required file structure.
structure See the required structure in Chapter 2,
"Commissioning".
mlc_OCRtableN.txt (Where N is from X0 to X13 or Y0 to Y13)
Invalid MLC OCR table field size; field The field size stated in the file does not match the one
sizes in this file must match the field required by the file name. Check the file name and field
sizes listed in the Physics Essentials size within the file match as stated in Chapter 2,
Guide "Commissioning".
Invalid MLC OCR table file name The file name is not a valid MLC OCR file name.
Invalid MLC OCR table file structure The file does not conform to the required file structure.
See the required structure in Chapter 2,
"Commissioning".
MLC OCR table value exceeds One or more of the OCR values exceeds the maximum
maximum value of 1.03
MLC OCR table value less than One or more of the OCR values is less than the minimum
minimum value of 0
mlc_OFtable.txt
Invalid MLC OF table field size One or more of the field sizes listed in the MLC OF table
is not listed in Chapter 2, "Commissioning" or one of the
field sizes listed is not contained in the MLC OF table.
Invalid MLC OF table file structure The MLC OF Table does not conform to the required file
structure. See the required structure in Chapter 2,
"Commissioning".
MLC OF table value exceeds One or more of the OF values exceeds the maximum
MLC OF table value below minimum OF values for field sizes larger than 80 mm square must
upper bound be greater than 1.0
MLC OF table value less than One or more of the OF values is less than the minimum
minimum value of .7
MLC OF table X and Y values must The OF values must increase monotonically as the field
increase monotonically sizes increase.
MLC OF table SAD value must match The MLC OF table SAD value must equal 800 mm.
SAD value in declaration Please make sure your measurements are taken at 800
mm SAD.
2A-10 | 1075879-ENG A
Table 2 Beam data validation rules for beam data files (Multileaf Collimator) (continued)
mlc_TPRtable.txt
Invalid MLC TPR table field size The field size for this file does not match one of the
required field sizes for import. Refer to Chapter 2,
"Commissioning" for required field sizes.
Invalid MLC TPR table file structure The file does not conform to the required file structure.
See the required structure in Chapter 2,
"Commissioning".
MLC TPR table value exceeds One or more of the TPR values exceeds the maximum
MLC TPR table value less than One or more of the TPR values is less than the minimum
minimum value of 0
1075879-ENG A |2A-11
Beam Data Filenames and Collimator Sizes

for Fixed and Iris Collimators
Table 3 lists the OCR beam data filename that corresponds to each collimator size for both fixed
collimators and the optional Iris Collimator.
Table 3 OCR beam data filenames for each collimator size
Filename Collimator size (mm)
Fixed collimators
OCRtable0.txt 5
OCRtable1.txt 7.5
OCRtable2.txt 10
OCRtable3.txt 12.5
OCRtable4.txt 15
OCRtable5.txt 20
OCRtable6.txt 25
OCRtable7.txt 30
OCRtable8.txt 35
OCRtable9.txt 40
OCRtable10.txt 50
OCRtable11.txt 60
Iris Collimator
irisOCRtable0.txt 5
irisOCRtable1.txt 7.5
irisOCRtable2.txt 10
irisOCRtable3.txt 12.5
2A-12 | 1075879-ENG A
Table 3 OCR beam data filenames for each collimator size (continued)
Filename Collimator size (mm)
1075879-ENG A |2A-13
Beam Data Value Limits for Fixed and Iris

Collimators
Table 4 lists the allowed maximum (_MAX) and minimum (_MIN) values for certain measured
beam data values for fixed and Iris collimators. The Beam Data Import application will disable the
import option for a file if it contains values that are outside these limits.
Table 4 Beam data value maximum and minimum limits
Beam data value Value limit Description
OCRtableN.txt and irisOCRtableN.txt (N = 0 to 11)
OAR_MAX 1.02 Maximum value allowed.
OAR_MIN -0.0001 Minimum value allowed.
TMRtable.txt and irisTPRtable.txt
TMR_MAX 1.17 Maximum value allowed.
DMtable.txt and irisOFtable.txt
DM5_MIN 0.45 Minimum value for 5 mm collimator allowed.
DM5_MAX 0.80 Maximum value for 5 mm collimator allowed.
DM7_MIN 0.55 Minimum value for 7.5 mm collimator allowed.
DM7_MAX 0.95 Maximum value for 7.5 mm collimator allowed.
DM12_MIN 0.75 Minimum value for 12.5 mm collimator allowed.
DM12_MAX 1.00 Maximum value for 12.5 mm collimator allowed.
2A-14 | 1075879-ENG A
Table 4 Beam data value maximum and minimum limits (continued)
Beam data value Value limit Description
1075879-ENG A |2A-15
Beam Data Filenames, Field Sizes, and

Value Limits for the Multileaf Collimator
Table 4 lists the beam data filename that corresponds to each file required for the Multileaf
collimator. The table also lists the allowed maximum (_MAX) and minimum (_MIN) values for
certain measured beam data values. The Beam Data Import application will disable the import
option for a file if it contains values that are outside these limits.
Filename Field Size (mm x mm) MAX Value MIN Value
mlc_OCRtableX0.txt/ 7.6 x 7.7 1.03 0.00

mlc_OCRtableY0.txt

mlc_OCRtableY1.txt

mlc_OCRtableY2.txt

mlc_OCRtableY3.txt

mlc_OCRtableY4.txt

mlc_OCRtableY5.txt

mlc_OCRtableY6.txt

mlc_OCRtableY7.txt

mlc_OCRtableY8.txt
mlc_OCRtableX9.txt/ 100 x 100.1 1.03 0.00

mlc_OCRtableY9.txt
mlc_OCRtableX10.txt/ 115 x 100.1 1.03 0.00

mlc_OCRtableY10.txt
mlc_TPRtable.txt All 11 field sizes 1.03 0.00
2A-16 | 1075879-ENG A
Filename Field Size (mm x mm) MAX Value MIN Value
mlc_OFtable.txt all 11 field sizes 1.05 0.70
mlc_doseprofileX.txt Primary Collimator 1.03 No Check
mlc_doseprofileY.txt Primary Collimator 1.03 No Check
mlc_doseprofile45.txt Primary Collimator 1.03 No Check
mlc_doseprofile135.txt Primary Collimator 1.03 No Check
1075879-ENG A |2A-17
2A-18 | 1075879-ENG A
Appendix 2B: Processing OCR
Beam Data (Fixed and
Iris Collimators)
Introduction
This appendix to Chapter 2, "Commissioning", gives examples of processing OCR beam data for
fixed collimators and the Iris Collimator only. The examples apply to the PTW MEPHYSTO mc2
and the IBA OmniPro software applications.
• “Processing OCR Data in PTW MEPHYSTO mc2 (Example)” on page 2B-2
• “Processing OCR Beam Data in IBA OmniPro Version 6.4a (Examples)” on page 2B-9
NOTE: The example procedures in this appendix describe the use of software
and/or hardware products that are not developed by Accuray and which do not
have a specific relationship to the CyberKnife System. These procedures
describe particular methods for performing OCR beam data processing.
Other, equally effective, methods might exist. The Medical Physicist is
responsible for determining which product and methodology to use for this
task.
Accuray assumes no responsibility for the accuracy of these procedures with

1075879-ENG A |2B-1
Processing OCR Data in PTW MEPHYSTO mc2

(Example)
This section gives examples of processing OCR beam data for fixed collimators and the Iris
Collimator only, using the PTW MEPHYSTO mc2 software application.
 To process OCR beam data for fixed collimators and the Iris Collimator in PTW MEPHYSTO
mc2:
1. Open the file containing the profile data (see Figure 1 on page 2B-2).
Figure 1 Multiple depth in-plane and cross-plane scans
2. Delete all curves except for the in-plane and cross-plane curves for the depth to be
processed and save the file with a new filename.
• Press and hold the SHIFT key, and select the curves to be deleted on the table.
• Right-click and select Delete Selected Scans.
There should be 2 curves remaining: a single in-plane scan and a single cross-plane
scan for the depth to be processed. (See Figure 2 on page 2B-3.)
2B-2 | 1075879-ENG A
Figure 2 Single depth in-plane and cross-plane scans

selected for processing
3. Highlight the in-plane and cross-plane curves in the left window.

4. Select PROCESS.
5. Smooth and shift curves to CAX. Accept the changes.
6. Right-click and select CREATE > AVERAGE SCAN.
7. Do not apply a weighting factor.
8. Click OK.
1075879-ENG A |2B-3
Figure 3 Average scan
A third curve is created, which is the average of the in-plane and cross-plane curves.
9. Delete the in-plane and cross-plane curves so only the averaged curve remains.
10. Save this as a new file.
11. Highlight the averaged curve and select PROCESS.
12. Smooth the curve as required.
13. Click ACCEPT and save the file.
Example file name: 5 mm cone_15 mm depth_averaged_smoothed.
14. Open the file containing the averaged curve.
15. Select the curve and click PROCESS.
16. Under the TOOLS menu, click OPTIONS.
17. Select USE RIGHT HALF and click OK.
2B-4 | 1075879-ENG A
Figure 4 Options to select half scan
18. Click HALVE > ACCEPT.

The curve should resemble the curve in Figure 5 on page 2B-5.
Figure 5 Radial beam profile
19. Save the file as the right half.

Example file name: 5 mm cone_15 mm depth_right half.
20. Close the file.
1075879-ENG A |2B-5
21. Reopen the averaged curve.

22. Click TOOLS > OPTIONS > USE LEFT HALF.
23. Click HALVE > MIRROR > ACCEPT.
24. Save the file as the left half.
Example file name: 5 mm cone_15 mm depth_left half.
25. Close the file.
26. To open the right and left files in the same window, click OPEN, highlight both files, and
click OK.
The left half was mirrored (using MIRROR), therefore, the 2 curves will appear in the
same quadrant. See Figure 6 on page 2B-6.
Figure 6 Average half profile
27. Highlight the left and right curves and then right-click.
28. Click CREATE > AVERAGE SCAN > OK.
(See Figure 3 on page 2B-4.)
The Average Scan is displayed as a new curve.
29. Do not apply a weighting factor.
30. Delete the left and right half-curves and save the files.
Example file name: 5 mm cone_15 mm depth_OCR.
The finished curve should resemble the curve in Figure 7 on page 2B-7.
2B-6 | 1075879-ENG A
Figure 7 Averaged half beam profiles
 To export the data:

You can use the following procedure to export the data to Excel. Upon data import into Excel, if the
dose values have only one decimal digit, non-physical discretization in the profile tails can result.
If dose values have only one decimal digit, two alternative export options are given below.
1. Highlight the curve and select PROCESS.
2. Click the EDIT button.
3. Right-click in the data columns and click SELECT ALL.
4. With all of the data highlighted, right-click and select COPY SELECTED POINTS.
(See Figure 8 on page 2B-8.)
5. Paste the data into an Excel spreadsheet.
If the imported dose values have only one decimal digit, dose values with two decimal digits need
to be extracted from the Mephysto software. You can use one of the following options for this
extraction:
• The first option is to set up the PTW-DataAnalyze software such that the menu item
GRAPHICS > NORMALIZE GRAPHICS reads TO ABSOLUTE UNIT. In this
case, the window for dose values extraction will show two decimal digits and a proper
CAX dose normalization will need to be done in Excel.
• The second option (which can also be used if your version of the MEPHYSTO software
does not have the functionality described above) is to open the corresponding MCC file in
a text editor or Excel, manually extract the primary channel dose values with the needed
precision, and then normalize to the CAX dose in Excel.
1075879-ENG A |2B-7
Figure 8 Profile data points extraction with two

decimal digits using Absolute Values settings
2B-8 | 1075879-ENG A
Processing OCR Beam Data in IBA OmniPro

Version 6.4a (Examples)
This section gives examples of processing OCR beam data for fixed collimators and the Iris
Collimator only, using the IBA OmniPro version 6.4a software application.
• “IBA OmniPro with Fixed Collimator OCR Beam Data” on page 2B-9
• “IBA OmniPro with Iris Collimator OCR Beam Data” on page 2B-19
NOTE: These procedures apply only to OmniPro software

version 6.x
IBA OmniPro with Fixed Collimator OCR Beam

Data
 To process OCR data for fixed collimators in IBA OmniPro:
1. Make a copy of the raw data folder to use while working.
Figure 9 Copy of raw data folder
2. Place all profiles for a given collimator into one file by selecting OPEN >FILE > ADD,
then click SAVE AS.
1075879-ENG A |2B-9
Figure 10 Adding collimator profiles
3. Repeat the procedure for all collimators.

 For each collimator open the new file that has all of the profiles:
1. Click the Inline button.
2. Press CTRL-A to select all.
3. Select TOOLS > ROTATE. On the Transform from inline profile to dialog
box, select CROSSLINE PROFILE, then check Replace Source Curve/s. Click
OK to continue.
2B-10 | 1075879-ENG A
Figure 11 Transform from Inline Profile to dialog

box
4. Press CTRL + A to select all.

5. Select TOOLS > CENTRE. Select Centre at 50% of CAX value, then click OK.
Figure 12 Centre step
1075879-ENG A |2B-11
6. Save your work by selecting FILE > SAVE. Save your work often during this procedure.
7. Select TOOLS > MAKE SYMMETRIC. Select Mean value of both sides, resolution =
step size for scan acquisition (0.2 mm for 5 – 15 collimator or 0.5 mm for 20 – 60
collimator). Check Replace Source Curve/s, then click OK to continue.
Figure 13 Make Symmetric step
8. This step is optional. Use it to verify that the step width is exact. Sometimes the previous
procedure causes the step width to be inexact.
Select TOOLS > FILTER/SMOOTH.
2B-12 | 1075879-ENG A
Figure 14 Filter / Smooth step
For Interpolation, select LINEAR. The Inter. Step Width field should equal step
size for scan acquisition (0.2 mm for 5 – 20 collimator or 0.5 mm for 25 – 60 collimator).
Select SMOOTHING = NONE. Check Replace Source Curve/s, then click OK
to continue.
Figure 15 Interpolation/Smoothing dialog box
1075879-ENG A |2B-13
9. Select TOOLS > RENORMALIZE.
Figure 16 Renormalize step
The Position field = 0 mm and Dose field = 100%. Click OK to continue.
Figure 17 Renormalize dialog box
The RENORMALIZE step may be done at anytime in the process.
2B-14 | 1075879-ENG A
10. Save your work by selecting FILE > SAVE. Save your work often during this procedure.
You should now have 10 crossline profiles, 2 at each profile depth.
11. Select the PROFILE DEPTH drop down box. Select each depth in sequence - with both
profiles selected (press CTRL + A).
Figure 18 Profile depth selector
Select TOOLS > MATHEMATICS. Select AVERAGE. Check Replace Source

Curve/s, then click OK to continue.
1075879-ENG A |2B-15
Figure 19 Mathematics dialog box
12. The software requires all scans to have the same SSD. Edit the header information to set
the SSD to 800 mm for all of the scans and the table function listed below will work.
Define the tables you wish to create: Select OPTIONS > TABLE
CALCULATIONS > OCR VS DEPTH TABLE SETUP. Enter the resolution,
normalization to CAX, and profile depths as needed by collimator size.
2B-16 | 1075879-ENG A
Figure 20 OCR vs. Depth Table Setup dialog box
1075879-ENG A |2B-17
13. Select the table you wish to create: Select OPTIONS > TABLE CALCULATIONS >
OCR VS DEPTH. To setup the table, click OK to continue.
Figure 21 OCR vs. Depth dropdown
14. Select all by pressing CTRL + A. Select TOOLS > CREATE TABLE (table format has
been pre-selected). Save the table with an appropriate name.
Figure 22 Create table
2B-18 | 1075879-ENG A
15. If the original scans were taken as SAD geometry:

• Import the table into an Excel spreadsheet.
• Normalize to 1.000 at CAX.
• Extract the "bottom half" of the table.
• Add the appropriate header.
• Save as a tab delimited .txt file.
You have a completed OCRtablexx.txt file.
16. If the original scans were taken as SSD geometry:
• Import the table into a blank worksheet.
• Correct the off axis distance for the SSD to SAD conversion.
• Save as a tab delimited .txt file.
You have a completed OCRtablexx.txt file.
IBA OmniPro with Iris Collimator OCR Beam Data

This section contains additional steps used to process OCR beam data for the Iris Collimator.
Make a copy of your data before you start. You need to take all four profiles and combine them into
one rotated, smoothed and normalized profile.
 To perform this procedure for the Iris Collimator:
1. If all the scans are in one rtb file - create new files of the normal scans (0°, 90°) and the
rotated scans (15°, 105°):
a. Open the file with all the scans.
b. Display all the 15° scans. Press CTRL + A to select all. Press CTRL + X to cut.
c. Repeat for the 105° scans. You now have a file with just the 0° and 90° scans.
d. SAVE AS normal scans.
e. Repeat steps a and b substituting 0°, and Step c, substituting 90°. You now have a file
with just the 15° and 105° scans.
f. SAVE AS rotated scans.
Do this for all 12 collimator sizes.
2. Open one of the normal scans file.
1075879-ENG A |2B-19
Figure 23 Open normal scans file
3. Follow the direction as for the fixed collimators (starting at step 1) except don't center the
beams (you already did this when you carefully set up the scanner).
4. Select each depth in turn and average the 2 scans by selecting TOOLS>
MATHEMATICS > AVERAGE. Check Replace Source Curve/s, then click OK
to continue.
2B-20 | 1075879-ENG A
Figure 24 Replace Source Curve/s
The software may assign either 0° or 90° to the averaged scan.

5. SAVE AS normal averaged scans
6. Repeat with the rotated scans. SAVE AS rotated averaged scans.
7. With the rotated averaged scans in the workspace, Select FILE > ADD to add the
normal averaged set
You should now have 10 crossline profiles - 2 at each profile depth
8. Using the Profile depth drop down selector, select each depth in sequence. Select both
profiles by pressing CTRL + A. Select TOOLS > MATHEMATICS. Select AVERAGE
and check Replace Source Curve/s, the click OK to continue.
1075879-ENG A |2B-21
Figure 25 Profile depth drop down
9. Select all by pressing CTRL + A. Select TOOLS > CREATE TABLE (table format has
been pre-selected), then save the file with an appropriate name.
2B-22 | 1075879-ENG A
Figure 26 Create table
10. If the original scans were taken as SAD geometry:

• Import the table into an Excel spreadsheet.
• Save as a tab delimited txt file.
You have a completed IRISOCRtablexx.txt file.
11. If the original scans were taken as SSD geometry:
• Import the table into a blank worksheet.
• Correct the off axis distance for the SSD to SAD conversion.
• Extract the “bottom half” of the table.
• Save as a tab delimited txt file.
You have a completed IRISOCRtablexx.txt file
1075879-ENG A |2B-23
2B-24 | 1075879-ENG A
Appendix 2C: Imaging Dose
Calculation
Introduction
This appendix to Chapter 2, "Commissioning," describes how X-ray alignment imaging dose is
calculated during treatment delivery.
• “Entrance Skin Dose” on page 2C-2
• “References” on page 2C-3
1075879-ENG A |2C-1
Entrance Skin Dose

The patient dose delivered by X-ray images acquired for tracking and alignment during treatment
is estimated and reported by the treatment delivery system. The dose that is reported is entrance
skin dose, defined as air kerma measured at the imaging center (point in space where the central
axes of the two imaging beams intersect), in the absence of backscatter. It is important not to
mistake this quantity for effective dose or to compare the entrance skin dose directly with any other
dose parameter reported by the treatment delivery or planning systems (for a detailed description
of this parameter, and methods of estimating effective dose from entrance skin dose, see AAPM
Task Group 75 [Ref. 1]).
The entrance skin dose is estimated using reference datasets that contain this dose parameter as
a function of X-ray technique (kV and mAs) per image, for the nominal X-ray system geometry (see
Table 1). The reference dataset is based on measurements performed on several X-ray systems.
Values include the full range of kV and mAs settings supported by the generator, even those which
are highly unlikely to be used clinically. An inverse square law correction is applied to account for
the difference between the nominal X-ray source-to-isocenter distance and the actual distance
which is recorded during system installation. For imaging dose calculation we include the extra 7cm
distance to the source, so 227cm is used for the nominal distance for the purpose of imaging dose
calculation.
Table 1 Entrance surface dose (in mGy) as a function of kV and mAs, averaged over both
X-ray tubes and generators on multiple CyberKnife Systems
kV
mAs 40 60 80 100 120 140 150
0.4 0.0004 0.002 0.003 0.005 0.007 0.010 0.010
2.5 0.003 0.008 0.020 0.031 0.044 0.057 0.062
10.0 0.011 0.040 0.079 0.126 0.181 0.236 0.262
16.0 0.018 0.064 0.126 0.201 0.289 0.377 0.415
20.0 0.022 0.081 0.160 0.256 0.369 0.482 0.537
32.0 0.033 0.126 0.251 0.402 0.581 0.759 0.818
40.0 0.040 0.152 0.311 0.499 0.719 0.951 1.038
50.0 0.046 0.188 0.380 0.612 0.905 1.189 1.297
64.0 0.063 0.233 0.495 0.795 1.158 1.522 1.660
160.0 0.158 0.600 1.236 1.987 2.896 3.805 4.150
200.0 0.198 0.750 1.545 2.484 3.620 4.757 N/A
250.0 0.247 0.938 1.932 3.105 N/A N/A N/A
320.0 0.316 1.201 2.470 N/A N/A N/A N/A
2C-2 | 1075879-ENG A
References
1. Murphy MJ et al. The management of imaging dose during image-guided radiotherapy:
Report of the AAPM Task Group 75. Med Phys 2007; 34(10): 4041-4063.
1075879-ENG A |2C-3
2C-4 | 1075879-ENG A
Appendix 2D: Robot Positioning
Introduction
This appendix to Chapter 2, "Commissioning," describes methods to more efficiently position the
robot for commissioning and routine QA procedures.
• “Storing the Robot Position” on page 2D-1
• “Initializing Robot Tool Frame” on page 2D-5
• “Monitoring the A5 Joint Angle” on page 2D-6
Storing the Robot Position

Storing the robot position can improve setup efficiency for beam commissioning or routine QA.
The following instructions describe how to store a robot position as a program. This program can
be run to move the robot back to the stored position. As long as the robot has not lost mastering
or been recalibrated, the robot returns to the stored position with a high degree of precision.
However, test setups should always be verified with an independent tool (when possible), such as
the front pointer and/or the pinhole collimator.
CAUTION: When moving the robot to a stored position, the robot will take the most direct path.
Collisions with other equipment, including the robot itself, are possible. Before commanding the
robot to move to a stored position, evaluate the path to that location, and if necessary, move the
robot manually to a position that will allow for a safe and direct path to the stored position. When
running a new program to move the robot to a stored position for the first time, use a low speed to
ensure there are no collisions.
When moving the robot, carefully monitor the robot position with respect to itself and other items
or persons in the treatment room.
1. In T1 mode, set the robot to the position you want to store in a program.
2. Navigate to the CKuser directory and highlight the template program. See Figure 1.
1075879-ENG A Introduction |2D-1

Figure 1 Finding the Template Program
3. Press Duplicate.
4. Enter a unique name for the program. See Figure 2.
2D-2 | Storing the Robot Position 1075879-ENG A

Figure 2 Duplicating the Template Program
5. Press OK.
6. Highlight the newly named program and press Select.
7. Press the Change button. See Figure 3.
1075879-ENG A Storing the Robot Position |2D-3

Figure 3 Changing the Template Program
8. Press the Touch Up button and press Yes in response to any messages that appear.
See Figure 4.
2D-4 | Storing the Robot Position 1075879-ENG A

Figure 4 Touch Up New Program
9. Press Cmd OK. Then you can exit the program by pressing the R box at the top of the
screen and then pressing Cancel.
10. The robot position is now stored. Be very cautious when moving the robot to and from this
stored position.
Initializing Robot Tool Frame

During commissioning, it is convenient to move the robot in the Tool frame and leave the robot
setup over the water phantom over night in order to maintain the position of the collimator for
1075879-ENG A Initializing Robot Tool Frame |2D-5

subsequent measurements the following day. This is recommended, however when the system is
powered up the Tool Mode coordinate system is not initialized directly. If the user then needs to
adjust the robot position, say to account for water evaporation in the water phantom, moving in
Tool Mode may not give the expected results and may be surprising to the user. To avoid this, a
program can be run via the Teach Pendant that will initialize the Tool Frame and will subsequently
produce consistent movements in Tool Mode day after day.
Procedure:
1. Switch the Teach Pendant to T1 or T2 mode
2. Navigate to CKmain and select the InitFrames program
3. Run the InitFrames program just as you would for running the prch or PathStart
programs.
The program is very quick and you will know that it has completed when the R status window on
the Teach Pendant shows a black background.
Figure 5 Location of R status (circled in red) on the

Teach Pendant status bar
Monitoring the A5 Joint Angle

During beam commissioning or QA measurements on the treatment couch, it is often useful to
move the robot in Tool mode, particularly along the Z axis.
However, due to a singularity in the A5 joint positions (where the angle equals 0), user initiated
motion along the Z axis can deviate from the true Z axis to allow the robot to pass the singularity
point without overdriving the joint velocity. This could introduce setup errors which would not be
obvious unless checked.
Monitoring the A5 joint angle to prevent the angle from falling below 10 degrees ensures that the
motion in the Z direction remains true. Although the A5 axis is allowed to be less than 10 degrees,
and often is, it can cause problems when precise motion in Tool mode is required. Use the
following steps to monitor the A5 joint angle during commissioning and QA tests.
1. On the Teach Pendant, open the position display screen. Open the main menu and
navigate to Display > Actual Position.
2D-6 | Monitoring the A5 Joint Angle 1075879-ENG A

Figure 6 Teach Pendant Display Menu
2. Choose Axis-Specific monitoring. Monitor the A5 joint angle as needed throughout the
test procedure.
Figure 7 Axis-specific monitoring of the A5 joint
1075879-ENG A Monitoring the A5 Joint Angle |2D-7

RoboCouch Teach Pendant Sharing

The RoboCouch Teach Pendant and robot Teach Pendant functions are consolidated into a single
system Teach Pendant with the release of the second generation RoboCouch with the couch-
mounted Hand Controller. If you have custom programs on the Teach Pendant for the
RoboCouch, want to move the couch discrete distances for couch QA, or want to move the couch
back into treatment or load positions, you can disconnect the system Teach Pendant from the
Robot and connect it to the RoboCouch by following these steps:
1. Press the disconnect button on the Teach Pendant. You have 30 seconds to reconnect it.
Disconnect button
Location of RoboCouch
Teach Pendant cable
2. Disconnect the Teach Pendant from the robot.

3. Connect the Teach Pendant to the RoboCouch.
2D-8 | RoboCouch Teach Pendant Sharing 1075879-ENG A

Appendix 3A: Using the Iris QA
Tool
Introduction
This appendix to Chapter 3, "Quality Assurance Recommendations and Tests", describes how to
use the Iris QA tool and Iris QA software application.
• “Overview of the Iris QA Tool” on page 3A-2
• “Summary of Procedures” on page 3A-3
• “Prerequisites” on page 3A-5
• “Initializing the Iris QA Software” on page 3A-8
• “Acquiring Baseline Iris QA Measurements” on page 3A-10
• “Performing Iris QA Spot Checks” on page 3A-12
• “Iris QA User Interface” on page 3A-13
• “Troubleshooting” on page 3A-21
1075879-ENG A |3A-1
Overview of the Iris QA Tool

This document describes the Iris Quality Assurance (QA) tool. This tool is designed to provide a
convenient means of spot checking the reproducibility of Iris Variable Aperture Collimator field
sizes. This is a film-based tool that offers an alternative to the use of a water phantom for this
check. The specification for Iris QA is within 0.2 mm change from the baseline value.
NOTE: The Iris QA tool does not replace the water phantom for Iris
Collimator commissioning or calibration.
The Iris QA tool consists of the following components:

• Hardware accessory that fits into the birdcage assembly.
• Film analysis software.
NOTE: The Iris QA tool requires EBT type film, which must be provided by the
Physicist. The Iris QA tool has not been validated for use with film other than
EBT type film. Use only EBT type film with the Iris QA tool.
3A-2 | 1075879-ENG A
Summary of Procedures
This section provides a brief summary of procedures for using the Iris QA tool:
• “Install the Iris QA Software” on page 3A-3
• “Initialize Iris QA Software” on page 3A-3
• “Acquire Baseline Measurements” on page 3A-3
• “Spot Check” on page 3A-4
Install the Iris QA Software

The Iris QA software can be installed on a PC or laptop (see “Prerequisites” on page 3A-5 and
“Installing the Iris QA Software” on page 3A-6).
Initialize Iris QA Software

The Iris QA software must be initialized prior to first use. Initialization of the software consists of
the following tasks (see “Initializing the Iris QA Software” on page 3A-8):
1. Set the Blank Pixel Value
2. Set the optical density (OD) threshold
Acquire Baseline Measurements

Baseline measurements should be acquired when a new Iris Collimator is installed, when there is
a change in film batch, or when there is a change in film scanner.
1. Insert the fixed 15 mm collimator (used to normalize the results).
2. Install the birdcage assembly.
3. Insert 2 in x 2 in (5.1 cm x 5.1 cm) cut EBT type film into the Iris QA hardware accessory
and mount it on the birdcage assembly.
4. Irradiate the film.
5. Wait at least 15 minutes and then scan and import the film into the Iris QA film analysis
software.
NOTE: The time elapsed between film irradiation and scanning should be kept
consistent for all baseline measurements and subsequent spot-checks.
6. Install the Iris Collimator, the birdcage assembly, and the Iris QA hardware accessory.
1075879-ENG A |3A-3
7. Irradiate four films for each Iris aperture size (resize the Iris Collimator between each film
irradiation).
NOTE: Since there can be slight variations in each irradiated film, using 4 films
for each aperture size provides the ability to review trends and use averages.
Using this technique, the random error from shot to shot for EBT type film
measurement of field size is approximately 0.1 mm.
8. Scan and import each film into the Iris QA film analysis software.
NOTE: Be sure to scan the film in a consistent orientation (preferably in

landscape orientation, as recommended by the film manufacturer).
Spot Check
Spot checks should be performed any time service is performed on the Iris Collimator, any time the
Iris Collimator is recalibrated, and when there is a change in Iris Collimator firmware. In addition,
regular spot checking of Iris Collimator field size reproducibility is recommended for routine QA.
1. Install the Iris Collimator.
2. Install the birdcage assembly.
3. Insert EBT type film into the Iris QA hardware accessory and mount it on the birdcage
assembly. Use 2 in x 2 in (5.1 cm x 5.1 cm) cut film for 20 mm and smaller field sizes, and
4 in x 4 in (10.2 cm x 10.2 cm) cut film for larger field sizes.
4. Irradiate one or more films for each selected aperture size.
5. Scan and import each film into the Iris QA film analysis software.
6. Run software analysis to compare spot check data against baseline data.
NOTE: In order to detect changes of 0.2 mm, it is important to look at trends

and averages over 4 or more film shots.
Results are exportable in text format and are available as a printable report.
3A-4 | 1075879-ENG A
Prerequisites
In addition to the Iris QA software installed on your computer, as specified in “Customer Site QA
Equipment” on page 21-6 the following accessories are required:
• A flatbed scanner suitable for film dosimetry, for example, Epson 10000XL or similar (as
recommended by the film manufacturer)
• EBT type film cut to the appropriate size
NOTE: Because baseline measurements should be repeated for the Iris

Collimator each time there is a change in film batch number, ordering more
than one box of the same film batch at a time is recommended, depending on
your QA needs. A box of EBT type film typically contains 25 sheets of size 8 in
x 10 in (20.3 cm x 25.4 cm). One sheet can be cut into 16 squares of 2 in x 2 in
(5.1 cm x 5.1 cm), suitable for 20 mm or smaller field sizes, and 4 squares of
4 in x 4 in (10.2 cm x 10.2 cm), suitable for 25 mm and larger field sizes.
1075879-ENG A |3A-5
Installing the Iris QA Software

 To install the Iris QA software:
1. Close all programs and insert the Iris QA Installation Disk PN 031583 into the CD-ROM
drive.
2. Follow the instructions in IrisQA_Install_Readme.txt
3. Launch MCRInstaller.exe with Administrator privileges.
This step will first install the Matlab Runtime Environment v7.8 on your system.
4. Compiler Runtime 7.8 will tell you if you need .net Framework.
Click Okay.
The .net Framework will be installed while running the setup.exe program.
5. Follow the prompts.
This step of the installation may take several minutes. The Matlab runtime environment is
installed in the following directory: C:\Program Files\MATLAB\MATLAB Compiler
Runtime\v78.
6. After the Matlab Runtime installation is complete, launch setup.exe to install the Iris QA
v1.0 software. Follow the prompts.
At the end of the installation procedure an Iris QA icon should be displayed on your
desktop and in your Start menu.
7. Browse to the installation directory, which is set by default as: C:\Program Files\
Accuray Inc\IrisQAv0100. Verify that the following directories exist: config,
distrib, logs, and src.
3A-6 | 1075879-ENG A
Using the Iris QA Film Mount

The Iris QA film mount fixture consists of a base plate of 50 mm (or greater) thickness and a 15 mm
thick build-up plate (see Figure 1). The film mount fixture is designed to fit onto the birdcage
assembly. It can be used when the treatment robot is in the perch position.
The base plate is screwed onto the bottom ring of the birdcage as shown in Figure 1. Film is placed
on the base plate. A build-up plate is then placed on top of the base plate. Screws are provided to
secure the build-up plate to the base plate. The film mount fixture is designed to hold the film at
800 mm SAD when it is properly attached to the birdcage assembly.
Figure 1 Iris QA tool, with the base plate mounted on the
birdcage assembly with film (left), and fully assembled with

the build-up plate on top of the film (right)
1075879-ENG A |3A-7
Initializing the Iris QA Software

When the Iris QA software is first launched, it loads default parameter values. Before using the
software, the user must set the Blank Pixel Value and OD Threshold values. These values depend
on the film batch and film scanner. Once calculated, these values are saved so that the user does
not have to re-enter them for each analysis, except as necessary when there is a change in film
batch or film scanner.
 To initialize the Iris QA software:
1. Cut EBT type film to obtain four square pieces of size 2 in x 2 in (5.1 cm x 5.1 cm). Mark
the film orientation as recommended by the film manufacturer.
NOTE: The Iris QA software has not been validated for use with films other
than EBT type film. Do not use the Iris QA tool and software in any way other
than as described in these instructions.
2. Scan a blank piece of film.
NOTE: The film scans must be in uncompressed TIFF format using 48-bit
color at 300 dpi resolution with no color corrections or any other post
processing.
3. Install the 15 mm fixed collimator and attach the birdcage assembly. The treatment robot
can be in the perch position.
4. Mount the Iris QA tool base plate onto the birdcage assembly and use the thumbscrews
to secure it (see Figure 1).
5. Place the first piece of film at the center of the base plate using the 2 in x 2 in (5.1 cm x
5.1 cm) line drawing to align the film (see Figure 1).
6. Place the build-up plate on top of the film, taking care to ensure that it is flush with the film
(see Figure 1). The thumbscrews can be used to secure the build-up plate to the base
plate.
7. Irradiate the film with 600 MU using the Calibration Check window in Physics mode on
the treatment delivery computer. Remove the irradiated film and repeat this step for the
other three pieces of film.
8. Wait for at least 15 minutes after film irradiation, and then scan the film.
NOTE: Label each film with the date it was scanned using a permanent marker
directly on the film itself (write only along the outer edge) or by including the
date in the image filename when the film is scanned. Labeling the film helps
ensure that you are importing the correct scanned image file.
9. Launch the Iris QA software.
Default parameter values are displayed.
3A-8 | 1075879-ENG A
10. In the User Inputs panel, enter the Iris Serial Number in the Iris S/N textbox to
uniquely identify your Iris Collimator (enter the Iris serial number or any text up to 32
characters).
11. Enter the film scanner serial number in the Scanner S/N textbox and the film batch
number in the Film Batch # textbox (enter any text up to 32 characters for each).
NOTE: If there is a change in the film batch or film scanner, you must repeat
the Iris QA software initialization procedure by entering a new value for Film
Batch # or Scanner S/N and setting new Blank Pixel Value and OD
Threshold values for that film batch or film scanner. Then you must repeat the
baseline measurements for your Iris Collimator.
12. Enter the film scanner dpi value in the Scanner dpi textbox (set by default to 300).
13. Select the film orientation used to scan the film from the Film Orientation dropdown
list.
NOTE: EBT type film must be scanned in a consistent manner, preferably in

the landscape orientation with the long axis of the original (uncut) film
perpendicular to the scan direction (or as recommended by the film
manufacturer). Scanning the film using different orientations can give
inconsistent results. Use a permanent marker to label the film orientation of
smaller pieces of film that are cut from larger film sheets.
14. Edit other textboxes such as Notes and Physicist as necessary.
15. In the Film Import panel select Blank Film from the Select Film Type dropdown
list. Then click the Import Film… button and browse to the location of the scanned
image file of blank film.
16. Follow the instructions displayed in the Status panel. Select a Region of Interest (ROI)
so that film edges, handwriting, and other markings are excluded. Right-click and select
Crop Image to crop the image.
17. Click the Run Analysis button. In the Update Blank PV dialog box, click Yes to
update the Blank Pixel Value.
18. In the Film Import panel select Fixed 15 mm from the dropdown list and import one
of the 15 mm fixed collimator scanned film files. Crop the image as described above.
19. Click the Auto Threshold… button. In the Update OD Threshold dialog box, then
select Yes.
20. When the Import Fixed 15 mm film #2? message is displayed, select Yes. Repeat
this step for the remaining three films.
21. In the Accept OD Threshold = (value) dialog box, select Yes. Selecting No or
Cancel reverts to the previous value.
The Iris QA software is now initialized and can be used for film analysis.
Run the analysis on each 15 mm fixed collimator film, by re-importing each film scan,
cropping the image, and then clicking the Run Analysis button. Save the reports for
future reference.
1075879-ENG A |3A-9
Acquiring Baseline Iris QA Measurements

After the Iris QA software has been initialized for the first time, it is recommended that you perform
baseline measurements for your Iris Collimator by taking 4 film shots of each Iris aperture, resizing
the Iris aperture between each film shot.
 To acquire baseline Iris QA measurements:
1. Cut EBT type film, taking care to mark the film orientation as recommended by the film
manufacturer, to obtain the following pieces:
• 24 pieces of size 2 in x 2 in (5.1 cm x 5.1 cm): 4 for each Iris aperture from 5 mm
through 20 mm.
• 24 pieces of size 4 in x 4 in (10.2 cm x 10.2 cm): 4 for each Iris aperture from 25 mm
through 60 mm.
2. Install the Iris Collimator and set the Iris aperture to 5 mm.
3. Mount the base plate of the Iris QA tool on the birdcage assembly and use the
thumbscrews to secure it.
4. Align a piece of film at the center of the base plate using the 2 in x 2 in (5.1 cm x 5.1 cm)
line drawing on the base plate.
5. Place the build-up plate on top of the film, taking care to ensure that it is flush with the film
(the thumbscrews can be used to secure it to the base plate).
6. Irradiate the film with 600 MU using the Calibration Check screen in Physics mode
on the treatment delivery computer. Remove the irradiated film.
7. Resize the Iris aperture by switching to another aperture size (for example, 30 mm) and
then switching back to 5 mm.
8. Repeat Step 4 through Step 7 for the other three pieces of film.
9. Set the Iris aperture to other aperture sizes from 7.5 mm through 60 mm and repeat
Step 4 through Step 8. Use the 4 in x 4 in (10.2 cm x 10.2 cm) pieces of film for Iris
apertures 25 mm and larger.
10. After waiting at least 15 minutes after film exposure, scan the film.
11. In the Film Import panel on the Iris QA software screen, select the appropriate Iris
aperture from the dropdown list and click the Import Film… button. Select the
scanned film image corresponding to that aperture.
NOTE: It is important to select the correct film from the dropdown menu. For
example, selecting Iris 10 mm when the film shot is from a 5 mm Iris
aperture can give incorrect results due to a large difference in output factor
(OF).
12. Select a Region of Interest (ROI) so that film edges, handwriting, and other features are
excluded. Right-click and select Crop Image to crop the image. Then click the Run
Analysis button.
13. When the analysis is complete, the Status panel will display the text Result ready
for export. Save the results in an appropriate format as desired.
3A-10 | 1075879-ENG A
14. Use a spreadsheet to generate a table of Iris apertures (including an entry for the 15 mm
fixed collimator) as reported by the Iris QA software. This data is the Iris baseline data
which later spot checks can be compared with.
While performing baseline measurements of your Iris Collimator, the following optional procedure
is recommended, in addition to taking film shots of each Iris aperture and the 15 mm fixed
collimator:
1. Use the same irradiation process described above to take baseline measurements for
one or two additional fixed collimators, using four pieces of film for each fixed collimator.
2. When analyzing each of these films, from the dropdown list on the Iris QA software
screen, select the Iris aperture that matches the fixed collimator size used.
You can refer to these additional fixed collimator baseline measurements when you perform future
routine Iris QA. If you experience Iris measurements that fail during future spot checks, you can
irradiate films for the same fixed collimator(s). Since the fixed collimators do not change in size,
measurement results for the fixed collimators should be consistent with their baseline values. If
results for the fixed collimators are different from their baseline values, there is likely a problem with
the QA measurement process, and not necessarily the Iris Collimator. For more information, see
“Troubleshooting” on page 3A-21.
1075879-ENG A |3A-11
Performing Iris QA Spot Checks

After acquiring baseline Iris QA measurements, you can subsequently repeat film shots of an
appropriate set of Iris apertures as part of a QA procedure or as necessary after an Iris upgrade,
recalibration, major service, or software upgrade.
Although you can take a single film shot, variations from film shot to film shot are possible due to
film variations and resizing of the Iris aperture. In order to detect changes of 0.2 mm, it is important
to look at trends and averages over 4 or more film shots.
3A-12 | 1075879-ENG A
Iris QA User Interface

The Iris QA user interface includes 6 panels which display the following controls:
• “User Inputs Panel” on page 3A-14
• “Film Import Panel” on page 3A-14
• “Status Panel” on page 3A-15
• “Scan Processing Pad Panel” on page 3A-15
• “Analysis Results Section” on page 3A-17
• “Export Results Panel” on page 3A-20
When the Iris QA software is launched for the first time, the screen displays default parameter
values (see Figure 2).
Figure 2 Default parameter values when Iris QA software is

first launched
1075879-ENG A |3A-13
User Inputs Panel

The User Inputs panel includes the following user-editable fields:
• Iris S/N textbox: Enter the Iris Serial Number or any text up to 32 characters to
uniquely identify your Iris Collimator.
• Scanner S/N textbox: Enter the film scanner Serial Number or any text up to 32
characters to uniquely identify your film scanner.
• Scanner dpi textbox: The film scanner dpi setting. The default value is 300 dpi.
• Film Batch # textbox: The film batch number. Enter any text up to 32 characters to
uniquely identify the film batch.
• Film Orientation dropdown list: The orientation used to scan the film. Includes
3 options (Unknown, Landscape, and Portrait).
• Notes textbox: Notes or comments. Enter any text up to 32 characters.
• Physicist textbox: Physicist name. Enter any text up to 32 characters.
Film Import Panel

The Film Import panel displays the Select Film Type dropdown list with the following
options (see Figure 3):
• Blank Film: Scanned image of blank film.
• Fixed 15 mm: Scanned image of 15 mm fixed collimator.
• Iris 5 mm through Iris 60 mm: Scanned images of Iris Collimator with apertures
5 mm to 60 mm.
Figure 3 Select Film Type dropdown list
3A-14 | 1075879-ENG A
Status Panel
The Status panel displays the current status of the Iris QA software (see Figure 4). Displayed text
that is followed by an ellipsis (…) indicates that the software is waiting for user action.
Figure 4 Status panel
Scan Processing Pad Panel

The Scan Processing Pad panel includes an upper and lower panel. The upper panel displays
the scanned film image after it is imported and allows the user to crop the image. To crop an image,
use the mouse to select an ROI that maximizes the film shot area while excluding the film edges,
handwriting, or other markings. Then right-click and select Crop Image to crop the image.
Figure 5 shows an example of a correctly selected Region of Interest (ROI).
Figure 5 ROI selected correctly in the Scan Processing Pad
1075879-ENG A |3A-15
Figure 6 shows an example of an incorrectly selected ROI that includes handwriting on the film.
Figure 6 Selected ROI includes handwriting on the film. Do

not include handwriting or other markings.
Figure 7 shows an example of an incorrectly selected ROI which is too small.
Figure 7 Selected ROI too small. Maximize the film shot

area while excluding the film edges and other markings.
After the image is cropped, it is displayed in the lower panel (see Figure 8).
3A-16 | 1075879-ENG A
Figure 8 Correctly cropped image displayed in lower panel
When you are satisfied with the cropped image, click the Run Analysis button to calculate the
field size of the beam spot on the film.
Analysis Results Section

The Analysis Results section displays the results of film analysis (see Figure 9).
1075879-ENG A |3A-17
Figure 9 Analysis Results panel and Export Results drop-

down menu
The top panel shows the thresholded image and the bottom panel shows 4 OD contours (30%,
50%, 70%, and 90%) along with the measured equivalent diameter. It also displays the following
information:
• Date: From the system clock.
• Iris S/N: From the User Inputs panel.
• Scanner S/N: From the User Inputs panel.
• Scanner dpi: From the User Inputs panel.
• Film Batch #: From the User Inputs panel.
• Blank Pixel Value: Based on the mean pixel value of blank film imported by the user
during initialization of the Iris QA software. This value is used to convert the pixel values
in an exposed film to optical density (OD) values using the following formula:
3A-18 | 1075879-ENG A
OD = log  PV blank  PV  (1)
where OD is the optical density, PV blank is the Blank Pixel Value (from unexposed film),
and PV is Pixel Value of the irradiated film.
• OD Threshold: The OD Threshold value determined by the Iris QA software. This
value corresponds to a computed field size for the 15 mm fixed collimator scanned film
that matches the nominal field size of 15 mm. This threshold is determined during
initialization of the Iris QA software.
• Scan orientation: From the User Inputs panel.
• Image File: Name of the image file selected by the user after clicking the Import
Film... button.
• Modification Date: Date the image file was last modified.
• Collimator Type: Set to Fixed or Iris, depending on the option that was selected in
the Select Film Type dropdown list in the Film Import panel.
• Nominal Size (mm): The nominal field size (in millimeters) based on the option that
was selected in the Select Film Type dropdown list in the Film Import panel.
• Equivalent Diameter (mm): The field size determined by the Iris QA software
using the equivalent diameter method. The field size is the diameter of a circle with the
same area as the thresholded region, calculated as follows:
(2)
field size = 4  Area  
where Area is the area of the threshold region.

• Profile Diameter (mm): The field size (in millimeters) determined by the Iris QA
software based on the average of 12 profiles taken at equally spaced angles around the
centroid of the thresholded image.
NOTE: If the Profile Diameter differs from the Equivalent Diameter by 0.5 mm
or more, a warning message is displayed: “Equivalent diameter:
(value) mm is different from Profile diameter: (value) mm”,
indicating that the results may not be reliable (for example, incorrect
thresholding or multiple blobs).
• Std. Dev. Of Profile Diameter (mm): The standard deviation of the Profile
Diameter.
1075879-ENG A |3A-19
• Central PV: The Pixel Value at the center of the irradiated area.
• Notes: From the User Inputs panel.
• Physicist: From the User Inputs panel.
Export Results Panel

The Export Results panel includes a dropdown list allowing export of results in the following
formats (see Figure 9):
• .txt: tab-separated text (suitable for import into third party software such as Microsoft
Excel).
• .pdf: Portable Document Format (suitable for printing).
• .png: Portable Network Graphics (an image file).
When the user clicks the Save… button, the File Save As dialog box is displayed. The dialog
box is prepopulated with the filename ImageFileName_Report with the appropriate file
extension as selected by the user.
3A-20 | 1075879-ENG A
Troubleshooting
A log of all software events such as startup, user selections, and warnings, as well as diagnostic
quantities such as Area, Eccentricity, Euler number, and Isoperimetric ratio, are stored in the
following log file: C:\Program Files\Accuray Inc\IrisQAv0100\logs\IQA_Log_dd-
mmm-yyyy.log.
where dd-mmm-yyyy is the date the event occurred.
If any unexplained change in the Iris aperture occurs compared to the Iris baseline data, perform
the following steps:
1. First check the Iris QA report to ensure that the correct scanned film was imported and
that it was cropped correctly. Then check the film scan technique (confirm that it is 48-bit
color and 300 dpi with consistent film orientation).
2. Then check that the Blank Pixel Value and the OD Threshold values are the same as
those used during the baseline Iris QA measurements (assuming that the film batch or
film scanner has not changed).
3. If all settings are the same as those used during the baseline Iris QA measurements, then
retake a film shot of the 15 mm fixed collimator and run an analysis to determine if it is
consistent with the baseline value (corresponding to the nominal field size of 15 mm and
determined during OD Threshold initialization).
4. If the Equivalent Diameter determined by the Iris QA software for the 15 mm fixed
collimator is close enough to the baseline value, then use the water phantom to perform
an Iris QA spot check.
Iris QA measurements are very sensitive to any changes in measurement process. The following
process changes could cause measurement failures:
• Setup and/or irradiation differences. For example, 600 MU per film was not used, or the
build-up plate was not used.
• A different time period between irradiation and scanning of the films than was used for the
baseline films.
• A new film lot or batch than was used for baseline measurements.
• The film batch has degraded due to heat and/or light exposure.
• The film scan settings are not correct.
• The film scan orientation does not match that used for baseline measurements.
1075879-ENG A |3A-21
3A-22 | 1075879-ENG A
Appendix 5A:
Electron Transport in the
MC Dose Calculation Algorithm
Introduction
This appendix describes electron transport in the Monte Carlo (MC) Dose Calculation algorithm. It
covers the following topics:
• “Electron Interactions in a General MC Algorithm” on page 5A-1
• “Electron Transport in a MC Algorithm” on page 5A-3
• “Pre-generated Electron Histories in Fast MC Algorithms” on page 5A-4
• “Pre-generated Electron Histories in the Accuray Precision MC Algorithm” on page 5A-5
• “Validation of the Accuray Precision MC Electron Transport Algorithm” on page 5A-6
• “Summary” on page 5A-18
Electron Interactions in a General MC

Algorithm
This section describes electron interaction processes included in a general Monte Carlo electron
transport algorithm. The number of individual interactions occurring along the track of a single
primary electron within matter is too large to simulate directly. Both inelastic and elastic collisions
occur. The Monte Carlo electron transport method simplifies the interaction processes into three
types:
1. Inelastic collisions, in which the energy of any secondary particle produced is lower than
a cut-off value. All secondary particle energy is deposited very close to the interaction
site; therefore, these particles need not be transported separately. These low-energy
inelastic collisions are modeled as a continual slowing down of the primary electron, and
characterized by energy loss per unit path length, or stopping power.
Total energy loss is described by collisional stopping power, Sc, and radiative stopping
power, Sr, which are the energy lost per unit path length to electron producing and photon
producing interactions respectively. These stopping powers include energy lost in the
production of both high and low energy particles. Interactions that produce high energy
particles are considered separately; therefore, the energy lost by continual slowing down
1075879-ENG A |5A-1
is described by the restricted stopping power. The restricted stopping power is defined as
the energy lost per unit length in the production of particles with energy lower than the
cut-off:
This energy is deposited uniformly along the electron step.

2. Inelastic collisions, in which the energy of any secondary particle produced is greater
than the cut-off value described above. These secondary particles deposit energy at large
distance from the interaction site, and therefore must be transported separately. Because
of this, the primary electron track is calculated as a series of steps. Within each step the
electron loses energy by continual slowing down, and at the end of each step a discrete
interaction may occur at which a high-energy secondary particle is generated. The
probability of these interactions is defined by the interaction cross sections for Møller
scattering, Bremsstrahlung, Bhaba scattering, and annihilation. Differential cross section
data give the relative probability of each interaction as a function of emitted particle
energy.
3. Elastic collisions, in which no energy is lost. The effect of these is modelled as a change
in the electron direction at the end of each step. The change of electron direction at the
end of each step is a function of the number of single elastic scattering events within the
step length, and the angular distribution of single scattering events. This combination is
described by the linear scattering power, Ts, which is defined by
(1)
where t is the step length, and is the mean square scattering angle at the end of the
step.
5A-2 | 1075879-ENG A
Electron Transport in a MC Algorithm

This section describes the implementation of these processes for electron transport within
homogenous media in a general Monte Carlo approach.
1. At the start of each step the electron energy, Ei, electron position, and electron direction
are known.
2. Sample the step length to the next inelastic high energy interaction point, based on
interaction cross section data. This defines the step length ti. If this length exceeds a
predefined limit, then truncate the step length at this limit and end the step without any
high energy interaction.
3. At the end of this step the energy lost through continual slowing down is:
(2)
4. Sample the scattering angle through which the electron is scattered at the end of this
step, using a probability distribution based on .
5. If necessary, calculate which high energy inelastic interaction occurs at the end of the
step (using relative interaction cross sections). Sample the energy of the emitted particle
using differential cross section data. Transport this particle separately.
6. The electron energy at the start of the next step is given by subtracting that lost through
continual slowing down (see Step 3) and discrete interaction (see Step 5) from Ei.
7. The electron position at the start of the next step is given by the position and direction at
the start of this step (see Step 1) and the step length (see Step 2).
8. The electron direction at the start of the next step is given by its direction at the start of
this step (see Step 1) and the scattering angle at the end of the step (see Step 4).
9. Repeat from Step 1 above until the electron energy is beneath a cut-off, then deposit its
remaining energy at the current location.
The entire record of initial energy, energy lost through continual slowing down, step length, step
direction, end of step high-energy interaction type and description of resulting particle(s) and
energy loss, for all steps along a single electron track forms the electron history.
In fast Monte Carlo algorithms these histories can be pre-calculated in a homogeneous water
equivalent phantom before being applied in the patient dose calculation (e.g. [Ref. 1, Ref. 2,
Ref. 3]), and that is the approach used in the CyberKnife System Monte Carlo Dose Calculation
algorithm, as described below.
1075879-ENG A |5A-3
Pre-generated Electron Histories in Fast MC

Algorithms
This section describes applying an electron history pre-generated in a homogeneous medium to a
dose calculation within inhomogeneous media. Assume that the reference material, in which the
history is pre-generated, is water. Starting with the first electron step within the history, the
following adjustments to the processes described in the previous section are required in order to
calculate the absorbed dose to medium [Ref. 1].
High Energy Inelastic Interaction Modification

The number of high energy secondary particles emitted within this step length in any medium will
be different to that in water. The end of step interaction data can be modified using interaction cross
section data for the appropriate medium and for water. These modified particles (instead of the
original particles in the water based history) are transported.
Step Length Scaling

The step length in medium, ti`, is given by
(3)
where is mass density. So the total energy lost within the step by continual slowing down is
constant across media, but the length of the step across which energy is deposited, and therefore
the energy deposited per unit length (or per voxel) along the step is modified.
Scattering Angle Modification

The scattering angle applied at the end of the step is modified by sampling a new probability
distribution. This new distribution differs from the original scattering angle distribution in water
through addition of a weighting factor which is determined by the difference in mean square
scattering angle in the medium and in water.
5A-4 | 1075879-ENG A
Pre-generated Electron Histories in the

Accuray Precision MC Algorithm
This section describes applying an electron history pre-generated in a homogeneous medium to a
dose calculation within inhomogeneous media using the Accuray Precision System Monte Carlo
Dose Calculation algorithm. The variance reduction methods used in this algorithm to improve the
calculation efficiency include the following modifications of the general approach described in the
previous section.

No modification is made to the pre-generated high energy inelastic interaction data. The same
modification as made by Keall and Hoban [Ref. 2] and Kawrakow et.al. [Ref. 1]
Step Length Scaling

Equation (3) on page 5A-4 is simplified to
(4)
The same modification is used by Keall and Hoban [Ref. 2]
Scattering Angle Modification

The scattering angle is not modified from the pre-generated data. The same modification is used
by Keall and Hoban [Ref. 2]
Considering these three modifications together, the CyberKnife System Monte Carlo electron
transport algorithm can be considered as calculating the dose to variable density water at all points
within the patient. The difference between this calculation and a calculation of absorbed dose to
medium is very small in biological materials, as is demonstrated in “Validation of the Accuray
Precision MC Electron Transport Algorithm” on page 5A-6.
1075879-ENG A |5A-5
Validation of the Accuray Precision MC

Electron Transport Algorithm
This section describes validation of the electron transport algorithm modifications employed in the
Accuray Precision System Monte Carlo Dose Calculation algorithm.

(Soft Tissue, Lung, and Bone)
Using interaction cross section data, Kawrakow et.al. [Ref. 1] have estimated that omitting this
modification causes a maximum error in the absorbed dose calculation at any point of 0.5% in bone
(lower in soft tissue and lung) over the full range of electron energies relevant in radiation oncology
and radiosurgery.
Step Length Scaling in Soft Tissue and Lung

Biological tissues other than bone have an effective atomic number which is very similar to that of
water. Note that this includes soft tissues within bone (e.g. non bone-cell derived tumors, such as
most metastatic tumors found in bone, and bone marrow). As a result, their stopping and scattering
powers are very close to those of water.
Table 1 shows the unrestricted total mass stopping power evaluated for a range of biological
tissues, excluding bone, with 1.5 MeV electrons. This energy is chosen as the approximate mean
photon energy within the beam spectrum of the CyberKnife System. The stopping power ratio
variation across the relevant range of electron energies is small. For example, in average male soft
tissue, the stopping power ratio varies between 1.000 at 0.1 MeV and 1.010 at 6 MeV [Ref. 5]
The approximation made in Equation (4) on page 5A-5 leads to an uncertainty of 0.5% in the
energy deposited per unit step length in average soft tissue, and 1.6% in all tissues. The stated
uncertainty in total stopping power for each material is 1 - 2% (at energies > 0.1 MeV) [Ref. 5]
which gives an uncertainty in the stopping power ratio of 1.4 – 2.8%. These uncertainties are
comparable to, and in most cases larger than, the variations in stopping power in all soft tissues.
Ignoring these uncertainties, Siebers et.al. [Ref. 4] have used the MCNP Monte Carlo code1 to
demonstrate that, when averaged over a 6 MV beam spectrum, the difference between
unrestricted mass collision stopping powers for medium and water is at most 0.6% within lung
(including at lung:bone interfaces) and 1.0% in ICRU soft tissue. The collision stopping power is
> 99% of the total stopping power in this range of tissues and this beam energy [Ref. 5]
Therefore, within soft tissue and lung, scaling electron step lengths by relative mass density only
results in a difference between absorbed dose to medium and the absorbed dose to variable
density water calculated by the Accuray Precision System Monte Carlo Dose Calculation
algorithm, which is comparable to or smaller than the stated uncertainty in the stopping power data.
1. A general purpose Monte Carlo calculation software application developed at Los Alamos
National Laboratory for the simulation of electron, neutron and photon transport through
matter.
5A-6 | 1075879-ENG A
Table 1 Total unrestricted stopping power ratio data in soft tissue

obtained for 1.5 MeV electron energy [Ref. 5]
Material
(MeV-m2/kg)
Water 0.184 1.000
Average soft tissue (ICRU44 formulation) 0.183 1.005
Lung (adult inflated, ICRU44 formulation) 0.187 0.984
Lung (adult congested, ICRU44 formulation) 0.183 1.005
Muscle (adult skeletal, ICRU44 formulation) 0.182 1.011
Step Length Scaling in Bone

Bone has a significantly higher effective atomic number than water and therefore, both the stopping
and scattering power of bone differ from those of water. Table 2 shows the unrestricted total mass
stopping power evaluated for a range of bone materials with 1.5 MeV electrons. In cortical bone,
the absence of a stopping power ratio term in Equation (4) leads to an underestimation of step
length by approximately 12% and therefore to an overestimation of absorbed dose to cortical bone
by approximately 12% because the electron step energy is deposited over too short a distance. In
other bones the effect is less pronounced, but the same systematic trend is observed. The
magnitude of the effect is larger than the calculation uncertainty in the stopping power data.
Siebers et.al. [Ref. 4] demonstrated that the unrestricted mass collision stopping power of cortical
bone is 11.6 – 12.7% lower than in water, when averaged over a 6 MV beam spectrum.
Table 2 Total unrestricted stopping power ratio data in bone

Material
(MeV-m2/kg)
Water 0.184 1.000
Cortical bone (adult, ICRU44 formulation) 0.164 1.122
Cranium (adult) 0.168 1.095
Femur (adult 30 year) 0.174 1.057
1075879-ENG A |5A-7
Ribs (average, adult) 0.171 1.076
Sacrum (average, adult) 0.174 1.057
Vertebral body (average) 0.173 1.064
Scattering Angle Modification in Soft Tissue, Lung,

and Bone
The ratio of mean square scattering angles at the end of each electron step in water and in medium
can be shown by combining Equation (1) on page 5A-2 and Equation (4) on page 5A-5 to be given
by
(5)
Table 3 shows the mass scattering power for a full range of biological tissues for 1.5 MeV
electrons.
It can be seen that in soft tissue the variation is within 5.7%. The scattering power ratio variation
across the relevant range of electron energies is small. For example, in average male soft tissue,
the scattering power ratio varies between 1.041 at 0.1 MeV and 1.054 at 6 MeV). The uncertainty
in the scattering power data is not given [Ref. 5] The scattering powers of bone are significantly
higher than of water (by 26.5% in cortical bone). This difference is greater than is observed for any
soft tissue.
The implication of this difference is that the electron track is more convoluted in bone than in water
or soft tissue, and therefore by omitting any scattering angle correction the absorbed dose to bone
is underestimated due to underestimating the number of electron steps crossing each voxel. This
gives an error opposing the overestimation of dose to bone resulting from the stopping power
modification described in “Step Length Scaling” on page 5A-5 above. The result of these two
opposing effects can be demonstrated experimentally using Monte Carlo simulation (with and
without the modifications applied) and by comparison of Monte Carlo calculation (with the
modifications applied) against measurement.
5A-8 | 1075879-ENG A
Table 3 Mass scattering power ratio data in soft tissues

Material
(radian2m2/kg)
Water 0.186 1.000
Average soft tissue (ICRU 44 formulation) 0.176 1.057
Lung (adult inflated, ICRU 44 formulation) 0.184 1.011
Lung (adult congested, ICRU 44 formulation) 0.185 1.005
Muscle (adult skeletal, ICRU 44 formulation) 0.182 1.022
Cortical bone (adult, ICRU 44 formulation) 0.253 0.735
Cranium (adult) 0.235 0.791
Ribs (average, adult) 0.224 0.830
Sacrum (average, adult) 0.212 0.877
Vertebral body (average) 0.215 0.865
Figure 1 on page 5A-10 shows a comparison of central axis dose calculations for the 60 mm
collimator performed in a simulated phantom containing water and cortical bone ( = 1.8 g/cc) at
the Fox Chase Cancer Center. The phantom contains layers of water and bone material. The bone
is sandwiched between the pairs of colored lines shown (i.e. bone at 2.9 – 3.1 cm, 4.9 – 5.5 cm,
6.9 – 7.9 cm, 8.9 – 10.9 cm, 12.9 – 17.9 cm).
1075879-ENG A |5A-9
Figure 1 MCSIM and Monte Carlo central axis dose calcula-

tions
One calculation is performed using the MCSIM Monte Carlo algorithm, which includes stopping
power step length correction and scattering angle correction to calculate absorbed dose to
medium. The other is performed using the Accuray Precision System Monte Carlo Dose
Calculation algorithm, which calculates dose to variable density water. Both calculations are
performed using the same uncertainty (< 0.2% at all depths beyond Dmax) and voxel size. Perfect
registration between the two calculations is guaranteed. The average difference between the
absorbed dose to medium at each point calculated by MCSIM, and the absorbed dose to variable
density water calculated by the Accuray Precision System Monte Carlo Dose Calculation algorithm
is 0.6% (of maximum dose) across all materials.
There is a slightly larger difference ( 3.2%) within a 1 - 2 mm region immediately ‘upstream’ of
each water:bone and bone:water interface. This is caused by differences in electron
backscattering, which are not currently modeled in the variable density water calculation. Even
when including these interface regions, the average difference between the two calculations within
bone is only 0.4% greater than the difference within water (0.5% in water, 0.9% in bone).
5A-10 | 1075879-ENG A
Figure 2 on page 5A-11 through Figure 5 on page 5A-13 show a comparison of absorbed dose
calculation along the beam central axis performed using the Accuray Precision System Monte
Carlo Dose Calculation algorithm, and measurements performed using radiochromic film in a solid
water phantom with a layer of bone substitute material ( = 1.42 g/cc). The requested calculation
uncertainty was 1% in the maximum dose. In comparison with the Monte Carlo-based experiment
described previously, significant additional uncertainty is introduced in any measurement based
experiment. These include i) Inaccuracy in the CT number based density calibration on which the
Monte Carlo calculation is based (including the effects of image artifact), ii) Very large differences
in calculation and measurement resolutions (i.e. voxel size versus film spatial resolution), and iii)
Error in the alignment of the film result and Monte Carlo data.
Figure 2 Monte Carlo Central Axis Dose Calculation com-

pared with radiochromic film measurement in a solid water–
bone–solid water phantom (5 mm)
1075879-ENG A |5A-11


5A-12 | 1075879-ENG A

Figure 6 on page 5A-14 through Figure 9 on page 5A-15 show the results of a similar experiment
using a polystyrene phantom containing a layer of cortical bone equivalent material ( = 1.84 g/cc).
The radiochromic film is essentially water equivalent, and is calibrated to measure absorbed dose
to water. It therefore provides a measurement of absorbed dose to water in medium at all points
[4]. It is apparent that within bone, the calculated absorbed dose to variable density water is
significantly lower than the measured absorbed dose to water in medium. Absorbed dose to water
in medium can be converted to absorbed dose to medium by multiplying the result by the
unrestricted mass collision stopping power ratio medium:water [Ref. 4, Ref. 6] This correction
factor was calculated (see Table 4) and applied. The results are included in Figure 2 on
page 5A-11 and Figure 3 on page 5A-12.
1075879-ENG A |5A-13
Figure 6 Monte Carlo Dose Calculation algorithm as com-

pared with radiochromic film measurements in a polysty-
rene–cortical bone–polystyrene phantom (7.5 mm)

rene–cortical bone–polystyrene phantom (10 mm)
5A-14 | 1075879-ENG A

rene–cortical bone–polystyrene phantom (20.0 mm)

rene–cortical bone–polystyrene phantom (40 mm)
1075879-ENG A |5A-15
In all cases, the corrected measurement, representing absorbed dose to medium, is in much better
agreement with the calculated dose than the (uncorrected) absorbed dose to water in medium film
measurement. In the solid water-bone phantom (see Figure 2 on page 5A-11 to Figure 5 on
page 5A-13) the average agreement within bone between the corrected measurement and
calculated dose is 1.0% which is very similar to the average agreement of 0.8% within solid water
(excluding the build-up region) and is smaller than both the measurement and calculation
uncertainties. In the polystyrene-bone phantom the average agreement within bone is slightly
worse (1.6%), but again is very similar to the average agreement of 1.2% within polystyrene
(excluding the build-up region). It can be seen that the difference between measurement and
calculation at bone:tissue interfaces is larger in these results than expected from the Monte Carlo
results presented in Figure 1 on page 5A-10. This is at least in part due to the additional
uncertainties involved in a measurement versus calculation experiment which are described
above. This is exemplified by the fact that the trend in the data (for example, whether the film
measurement is slightly larger or smaller than the calculation) is not consistent between the various
experiments.
Table 4 Unrestricted mass collision stopping powers for 5 - 30 MeV

electrons [Ref. 6] and electrons generated in a 6 MV 10 x 10 cm
LINAC photon beam [Ref. 4] in two bone materials
medium medium medium

Material  Sc   Sc   Sc 
     
   water    water    water
[Ref. 6] (derived [Ref. 4] (used in this
from [Ref. 1]) work)
bone equivalent material 0.942 0.9401 0.941

(= 1.42 g/cc)
Cortical bone equivalent material 0.902 0.895 0.899

(= 1.84 g/cc)
1. This data point is calculated by linear interpolation between data presented by the
authors for bone materials of density 1.18 g/cc and 1.85 g/cc.
Application of These Modifications to Non-

Biological Materials
“Pre-generated Electron Histories in the Accuray Precision MC Algorithm” on page 5A-5 describes
modifications to the step length scaling, end of step scattering angle calculation, and end of step
high energy inelastic interaction calculation which are employed within the Accuray Precision
Monte Carlo Dose Calculation algorithm.
5A-16 | 1075879-ENG A
“Step Length Scaling in Soft Tissue and Lung” on page 5A-6 through “Scattering Angle
Modification in Soft Tissue, Lung, and Bone” on page 5A-8 present data to validate these electron
transport modifications when applied to biological materials including soft tissue, lung, and bone.
Note, however, that the validity of these modifications deteriorates in non-biological materials,
particularly in metals that have a high atomic number. Therefore, the difference between the
absorbed dose to variable density water calculation performed by this algorithm, and the absorbed
dose to medium, may be substantial in non-biological materials. For example, Kawrakow et. al.
[Ref. 1] estimate that the modification discussed in section “High Energy Inelastic Interaction
Modification” on page 5A-5 causes a 5% systematic error in an absorbed dose to medium
calculation within lead for 10 MeV electrons.
1075879-ENG A |5A-17
Summary
A full electron transport method for calculation of absorbed dose to inhomogenous media in a
general Monte Carlo Dose Calculation algorithm is described in “Electron Interactions in a General
MC Algorithm” on page 5A-1 through “Pre-generated Electron Histories in Fast MC Algorithms” on
page 5A-4.
The simplified, and therefore faster, electron transport method described in “Pre-generated
Electron Histories in the Accuray Precision MC Algorithm” on page 5A-5 results in the Monte Carlo
Dose Calculation algorithm calculating absorbed dose to variable density water. It is shown in
“Validation of the Accuray Precision MC Electron Transport Algorithm” on page 5A-6 that this
calculation is essentially equivalent to the conventional Monte Carlo absorbed dose to medium
calculation as described in AAPM TG105 [Ref. 6]. The difference between the two calculations is
largest within bone owing to the significant stopping and scattering power differences relative to
water. A Monte Carlo experiment demonstrates that the average agreement of the Accuray
Precision System Monte Carlo algorithm and a full Monte Carlo algorithm is 1.0% within cortical
bone ( = 1.8 g/cc). Radiochromic film measurements demonstrate an average agreement with
calculation within bone of 1.0% ( = 1.42 g/cc) and 1.6% ( = 1.84 g/cc) across all field sizes. This
should be compared against the stated uncertainty in the basic stopping and scattering power data
used in the absorbed dose to medium calculations (1 - 2% in stopping power for each material
[Ref. 5]) and the typical patient dose calculation random uncertainty of approximately 2% at the
maximum dose point.
This level of agreement between absorbed dose to variable density water and absorbed dose to
medium is applicable only to biological tissues. Within inorganic materials with much higher
effective atomic number such as metal prosthetic implants, the agreement will be degraded.
5A-18 | 1075879-ENG A
References
1. Kawrakow I, Fippel M, Friedrich K. 3D electron dose calculation using a voxel based
Monte Carlo algorithm. Medical Physics 1996;23(4):445-457.
2. Keall PJ, Hoban PW. Superposition dose calculation incorporating Monte Carlo
generated electron track kernels. Medical Physics 1996;23(4):479-485.
3. Li JS, Pawlicki T, Deng J, Jiang SB, Mok E, Ma CM. Validation of a Monte Carlo dose
calculation tool for radiotherapy treatment planning. Phys Med Biol. 2000;45:2969-2985.
4. Siebers JV, Keall PJ, Nahum AE, Mohan R. Converting absorbed dose to medium to
absorbed dose to water for Monte Carlo based photon beam dose calculations. Phys
Med Biol. 2000;45:983-995.
5. ICRU Report 46 (1992) Photon, electron, proton, and neutron interaction data for body
tissues. ICRU Publications, Bethesda, MD.
6. Chetty II, Curran B, Cygler JE, et.al. Report of the AAPM Task Group No. 105: Issues
associated with clinical implementation of Monte Carlo-based photon and electron
external beam treatment planning. Medical Physics 2007;34(12) 4818-4853.
1075879-ENG A |5A-19
5A-20 | 1075879-ENG A
Appendix 5B:
Dose Calculation Results for
Typical CyberKnife Treatments
Introduction
This appendix to Chapter 5, describes dose calculation results for typical treatments using the
CyberKnife System. Three types of treatment cases are provided to illustrate typical results from
the Ray Tracing Dose Calculation (RT) algorithm, the Monte Carlo Dose Calculation (MC)
algorithm, and the Finite Size Pencil Beam Dose Calculation (FSPB) algorithm. For each case,
plans have been generated : one with the Iris collimator, which is evaluated using both RT and MC.,
and one with the MLC, which is evaluated using FSPB, with and without lateral scaling enabled,
and MC. These examples illustrate the similarities of and the differences between the three dose
calculation algorithms.
The three cases are:
• “A Homogeneous Phantom with a Single Beam” on page 5B-2
• “An Intracranial Case: Vestibular Schwannoma” on page 5B-9
• “A Treatment Plan for the Lung” on page 5B-15
1075879-ENG A |5B-1
A Homogeneous Phantom with a Single Beam

This case shows the typical dose distribution for a single beam. A collimator beam is targeted near
the center of a rectangular phantom. The beam is configured so that it is perpendicular to the
phantom surface. The dose was set to 1000 cGy (based on the Ray Tracing algorithm) such that
the dose passes through the target. For this case, the maximum dose will be approximately 15 mm
under the surface of the phantom.
Iris Collimator Plan

The dose distribution for the 30 mm Iris plan is calculated three times.
Figure 1 shows the dose distribution for the Iris plan using Ray Tracing dose calculation. This figure
and the other two for this plan show isodose lines at 300, 600, 800, 1000, and 1200 cGy. Note the
red contour is 1000 cGy and passes through the target, as expected.
Figure 2 shows the result of a medium resolution Monte Carlo dose calculation at 2.0% uncertainty
at the maximum dose. The 1000 cGy line passes through the targeted, so the absolute dose is
consistent with the Ray Tracing calculation. As can be seen, the isodose curves appear noisy. This
noise is caused by the stochastic nature of the Monte Carlo algorithm.
Figure 3 shows the result of a medium resolution Monte Carlo dose calculation at 1.0% uncertainty
at the maximum dose. The noise, though less prominent, still appears in the isodose lines.
Multileaf Collimator (MLC) Plan

A similar single beam phantom plan was generated with the Multileaf Collimator. The beam is
stepwise cylindrical with an equivalent square of 31.2 mm at 800 mm of depth. This dimension is
comparable to a circle with a 36 mm diameter. The dose distribution is calculated assuming the
beam has 1200 MU.
Figure 4 shows the dose distribution for the baseline finite size pencil beam (FSPB). Figure 5
shows the dose distribution for the finite size pencil beam algorithm with lateral scaling applied.
Note that the two distributions are identical. This outcome is expected because the materials in the
phantom have relative electron densities that are the same as water or higher. The lateral scaling
corrections are only applied to densities less than water.
Figure 6 shows the dose distribution for the Monte Carlo dose calculation algorithm. Two
differences are apparent. One, the isodose lines are noisier. This difference is expected because
of the stochastic nature of the MC algorithm. The second difference is that the dose is generally
lower for the Monte Carlo algorithm. The mean dose to the center sphere is 11.01 gray for the
FSPB algorithm, with and without lateral scaling. The mean dose is 10.74 (or 2.5% lower) when
evaluated with Monte Carlo. This difference highlights a limitation of the Monte Carlo model. The
Monte Carlo model assumes that the effective atomic number to mass ratio for all materials
traversed is the same as effective atomic number to mass ratio for water. For all biological tissues
this assumption is stable within 1%. For synthetic phantom materials, however, this assumption is
systematically lower by 1.5-3.2%. Therefore, the algorithm models higher photon attenuation than
actually occurs and that is seen through a lower dose deposition than the FSPB algorithm as depth
increases.
5B-2 | 1075879-ENG A
Figure 1 Example single beam treatment plan calculated

using a high resolution Ray-Tracing dose calculation for the
Iris Collimator
1075879-ENG A |5B-3

using a medium resolution Monte Carlo dose calculation for
the Iris Collimator (2.0% uncertainty)
5B-4 | 1075879-ENG A

using a medium resolution Monte Carlo dose calculation for
the Iris Collimator (1.0% uncertainty)
1075879-ENG A |5B-5
Figure 4 Example single beam treatment plan dose distribu-

tion for the baseline finite size pencil beam (FSPB) for the
MLC
5B-6 | 1075879-ENG A

tion for the finite size pencil beam algorithm for the MLC
with lateral scaling applied
1075879-ENG A |5B-7

tion for the Monte Carlo dose calculation algorithm for the
MLC
5B-8 | 1075879-ENG A
An Intracranial Case: Vestibular

Schwannoma
A vestibular schwannoma case serves as an extra-cranial example to compare the dose
calculations. In this case, the treatment protocol is 600 cGy per fraction for 3 fractions.

Figure 7 shows axial and coronal slices and the DVH for the high resolution RT dose calculation
for this problem. Isodose curves are shown for 1800, 1500, 1200, 800, and 400 cGy. 1800 cGy
covers over 95% of the tumor.
Figure 8 shows the same axial and coronal slices and the DVH for a high resolution MC dose
calculation with 1.0% uncertainty. As can be seen 1800 cGy does not fully cover the tumor, but
does cover over 85% of the tumor. The shape and size of the isodose lines are similar for Monte
Carlo and Ray Trace, but the dose is slightly lower for the MC algorithm. The reduced dose is likely
due to the effects of the bone surrounding the cochlea near the tumor. As can be seen, the Monte
Carlo isodose curves for this 79 beam plan are not as noisy as the similarly uncertain beams were
for the single beam plan.

A one fraction plan was created using the Multileaf Collimator. The plan goal was to treat 100% of
the vestibular schwannoma to 13.25 Gray. The brainstem dose should be less than 5.0 Gray.
Figure 9 shows the dose distribution and volume of interest statistics for the baseline FSPB
calculation. The dose to the tumor ranges from 13.37 Gy to 18.66 Gy. The maximum dose to the
brain stem is 4.13 Gy.
Figure 10 shows the dose distribution and volume of interest statistics for the FSPB calculation with
lateral scaling. The dose to the tumor ranges from 13.33 Gy to 18.65 Gy. The maximum dose to
the brain stem is 4.14 Gy. The small differences are easily accounted for by the fact that this
implementation attempts to model the low density pockets of the aural cavity.
Figure 11 shows the dose distribution and volume of interest statistics for the Monte Carlo
calculation. The plan was calculated at high resolution with 1.0% uncertainty. The dose to the
tumor ranges from 13.59 Gy to 18.59 Gy. The maximum dose to the brain stem is 4.59 Gy. This
algorithm models the physical interactions more precisely and should give a more accurate
representation of the impact of the low density pockets near the aural cavity as well as the bony
anatomy around the tumor.
1075879-ENG A |5B-9
Figure 7 Example Ray-Tracing dose calculation for

a vestibular schwannoma case
5B-10 | 1075879-ENG A
Figure 8 Example Monte Carlo Dose Calculation for

a vestibular schwannoma
1075879-ENG A |5B-11
Figure 9 Dose distribution and volume of interest statistics

for baseline FSPB calculation with the MLC for a vestibular
schwannoma case
5B-12 | 1075879-ENG A
Figure 10 Dose distribution and volume of interest statis-

tics for FSPB calculation with lateral scaling applied with
the MLC for a vestibular schwannoma case
1075879-ENG A |5B-13

tics for Monte Carlo calculation with the MLC for a
vestibular schwannoma case
5B-14 | 1075879-ENG A
A Treatment Plan for the Lung

Dose calculations for a CyberKnife Stereotactic Body Radiotherapy (SBRT) treatment are shown
in Figure 12 and Figure 13through Figure 16. This plan is a centrally located Stage 1 non-small cell
lung cancer. The first two figures show an Iris plan. The third is an MLC plan. In this case the
prescription dose is 5000 cGy and the dose is to be delivered over 5 fractions.

Figure 12 displays the high resolution RT dose calculation. The 5000 (red), 4000 (yellow), 3000
(magenta), 2000 (purple), and 1000 (cyan) cGy isodose lines are shown in axial and coronal slices.
These views shows that 5000 cGy sufficiently covers the tumor (white). The maximum dose is
6100 cGy.
Figure 13 displays the 1% uncertain medium resolution MC dose calculation. The same isodose
lines as the RT figure are shown. Note, from the two views, that the 5000 cGy curve is very small.
In fact, the calculated maximum dose to the plan has been reduced to 5150 cGy. This example
illustrates the weakness of the lateral scatter equilibrium assumption of the RT dose calculation
algorithm and is typical of the different results one might see when comparing RT and MC for a
tumor in the lung.

A central lung treatment was also planned for the Multileaf Collimator. The treatment goal is to
deliver 50 Gray in 5 fractions. At least 95% of the PTV should receive the prescription dose and
100% of the GTV should receive the prescription dose. The plan was created based on dose maps
created with the FSPB algorithm with lateral scaling enabled. The dose distributions for the plan
were compared to the baseline FSPB algorithm and the Monte Carlo dose calculation algorithm.
Figure 14 shows the dose distribution for the plan calculated by FSPB with lateral scaling. Note
that 95.3% of the PTV receives the prescription dose, which at 50.0 Gy is 83% of the maximum
dose.
Figure 15 shows the dose distribution for this plan if lateral scaling is disabled. Using this version
of the algorithm, the prescription dose is expected to cover 100% of the PTV. 50.0 Gy though is
now only 75.4% of the maximum dose. So, the maximum dose to the plan has increased from
60.2 Gy to 66.3 Gy or roughly 10%.
Figure 16 has the Monte Carlo dose calculation. Here the PTV coverage at 50.0 Gy has gone down
to 83.0%. The maximum dose, however, has not changed as dramatically. It is 61.0 Gy. Monte
Carlo is expected to more accurately calculate the dose distribution for this case. So, a plan
created with the FSPB algorithm with lateral scaling often will need to be adapted to meet criteria
evaluated with the Monte Carlo algorithm. The expected degree of change, however, is much less
than the change that would be required if the plan had been initially created with the baseline FSPB
algorithm.
1075879-ENG A |5B-15
Figure 12 Example Ray-Tracing dose calculation for a lung

SBRT treatment
5B-16 | 1075879-ENG A
Figure 13 Example Monte Carlo Dose Calculation for a lung

SBRT treatment
1075879-ENG A |5B-17
Figure 14 Dose distribution for plan calculated by FSPB

with lateral scaling applied with the MLC for a lung SBRT
treatment
5B-18 | 1075879-ENG A
Figure 15 Dose distribution for plan calculated by FSPB

with lateral scaling disabled with the MLC for a lung SBRT
treatment
1075879-ENG A |5B-19

tics for Monte Carlo calculation with the MLC for a lung
SBRT treatment
5B-20 | 1075879-ENG A
Figure 17 Example Monte Carlo Dose Calculation with MLC

Optimization for a lung SBRT treatment
1075879-ENG A |5B-21
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Physics Essentials

CyberKnife® S7™ System

Hardware and Software Maintenance

Use of Third-Party Software

Instructions for Use of the Accuray System

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Data Management Manual

Treatment Planning Manual

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Physics Essentials Guide

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Open Double-click the name of a window to open it.

Chapter 1: CyberKnife Treatment Delivery System Overview1-1

Equipment Components .................................................................. 1-4

Dosimetry System.......................................................................... 1-35

Power Modes and Interruptions .....................................................1-35

Commissioning and QA Equipment .................................................2-4

Diode Detectors and Diode Test ......................................................2-8

Laser and Radiation Coincidence Check .......................................2-10

Beam Commissioning ....................................................................2-16

for Fixed and Iris Collimators............................................................................ 2-19

Absolute LINAC Dose Calibration................................................ 2-155

Determining the Equivalent Square Field Size............................................... 2-157

Import Phantom CT Image Studies ..............................................2-178

CT Geometric Accuracy Check ....................................................2-183

Dose Delivery Verification Check .................................................2-198

References .................................................................................. 2-215

Chapter 3: Quality Assurance Recommendations and

Monthly QA Tests .......................................................................... 3-15

Quality Assurance of the Multileaf Collimator ....................................... 3-19

Annual Testing Requirements ........................................................3-21

Chapter 4: AQA, E2E, MLC, and Plan QA Tests ....................4-1

Setup Task > Fiducials Step .............................................................................. 4-9

Equipment and Materials for E2E Tests ........................................ 4-23

Using the Ball-cube in E2E Tests .................................................. 4-36

Treatment Plans for E2E Tests...................................................... 4-41

E2E Planning with Isocentric Sequential Optimization ......................... 4-41

E2E Dose Delivery for Stationary Tracking Modes ........................4-55

Using the Motion Controller.............................................................................. 4-69

Film Analysis.................................................................................. 4-80

Creating Multileaf Collimator Test Patterns ................................... 4-93

TG-50 Picket Fence ....................................................................................... 4-104

Plan QA for Treatment Plans .......................................................4-127

Chapter 5: Algorithms for Dose Calculation and Display ....5-1

DRR Generation for Treatment Planning......................................... 5-8

Monte Carlo Dose Calculation Algorithm (Option)......................... 5-15

Dose Display.............................................................................................. 5-45

Finite Size Pencil Beam Algorithm .................................................5-57

Beam Targeting and Optimization Algorithms................................5-65

Sequential Optimization .................................................................5-74

Minimize Mean Dose........................................................................................ 5-81

VOLO Algorithms for CyberKnife................................................. 5-108