Eclipse v18.

0 and Enhanced Leaf Modeling (ELM)

Upgrade Experience and Early Impressions at Clatterbridge
Rhydian Caines and Varian respond to Q&A asked during the June 26, 2023 webinar.

Can you skip v16 for ARIA® oncology information system to go from v15.0 to v18.0
Q directly for ARIA?
Varian: For Eclipse™ treatment planning system v18.0, you can upgrade from v15 to
A v18.0. Please contact your local Varian staff for interoperability requirements.
You mentioned that you got v18.0 on your T‐box 3 weeks before the upgrade.
Would it have been useful if you had been able to have access to v18.0 earlier to
Q prepare your physics checks?
Yes, there were parts of the process that were a little pressed for time! As we were
working within the agreed timescales of the limited launch with Varian, it was one of
the known project constraints and we were able to provide enough resources locally
to work with this. We have had several follow up projects going on to further
characterize aspects of the system, but nothing which we had judged would be a
barrier to clinical handover after the essential dosimetric and workflow verifications
A had been completed.
How did ELM affect evaluation of IMRT results, for SRS and SBRT cases in
Q particular?
In general, I would say we have not seen a big step change in PSQA results. In many
clinical cases, the impact of ELM appears to be quite small, and our patient QA
devices are not of sufficient precision to discriminate between two very similar
predictions. For example, Sun Nuclear ArcCHECK performed well with both systems
during commissioning at 3% 3mm for H&N, prostate and two breast cases, and two
other VMAT plans we looked at showed almost identical gamma passing rates on
ArcCHECK down to 1% 1mm). One breast IMRT field scored 94% at 3% 2 mm. The
largest difference we have found is within SRS HyperArc® high‐definition
radiotherapy multi‐met cases with very small off‐axis beam apertures and here the
PTV doses seem to be around 4% higher in Eclipse v18.0 vs v15.6 when calculated
with the same MU. Even in these cases our independent dose calculation has
remained within an acceptable variation (Sun Nuclear SunCHECK), and our clinical
PDIP tolerances have remained unchanged (3% 2mm for SRS I believe, so it's possible
the steep dose gradients help us here). The PDIP measurements for the SRS case I
A presented in the webinar were particularly challenging (both in v15.6 and v18 ‐ our
 best‐case result here was a field average of 94.9%) and we suspect some
improvements can be made to our PDIP models in particular so this is an area of
ongoing inquiry for us.
Q Can you have dosimetrically equivalent machines with different ELM values?
I will let Varian confirm but I believe within a dosimetrically equivalent machine
group, each machine needs to refer to a common set of beam data and common ELM
add‐on. We are currently carrying out some investigatory work looking at the
feasibility of a 'machine‐averaged' ELM as we have adopted a common beam model
and ELM across our eight TrueBeam® systems to permit patient transfers in the event
of breakdowns, etc., as well as to simplify any TPS QA. Please also see the other
A related questions on this!
How did the new MLC modeling agree with clinical measurements for static IMRT
QA vs. Rapid Arc® treatment technology VMAT QA plans? Did you correct the DLG
Q for clinical measurements in IMRT QA?
In many clinical cases, there appears to be only small differences between ELM and
the legacy DLG approach. Several of the clinical plans we measured during
commissioning (e.g. 3% 3mm with Sun Nuclear ArcCHECK) verified well with both
Eclipse v15.6 and Eclipse v18.0. Measurements include fixed‐field IMRT breast
tangent fields, and VMAT for prostate and head & neck, but I would not say we saw
substantial differences between the two techniques. To answer the 2nd part of your
question, we have not 'tuned' our DLGs beyond the values determined using the
sweeping gap measurements recommended by Varian; we have usually found our
PSQA measurements are not of sufficient precision to provide this level of
A discrimination at the level of beam model fine tuning. Hope that helps!
Q What routine PSQA are you doing?
All patients get a full 3D independent dose calculation with Sun Nuclear DoseCHECK.
Tolerances are site‐specific but range from 3% 3mm for general techniques down to
3% 1mm for SRS. Most SABR and SRS patients additionally get a pre‐treatment
measurement using Portal Dosimetry/PDIP (analyzed typically around 3% 3 mm or 3%
2 mm 2D local gamma). Most patients also get a #1 in‐vivo dosimetry measurement
using the EPID (subject to some local inclusion/exclusion criteria) with a wide
tolerance to guard against any gross errors, and these are analyzed in Sun Nuclear
PerFRACTION. Additionally, all patients get some form of daily IGRT with online
A correction to verify set‐up.
 For the comparison of v15 vs 18 SRS, did you use Acuros ®advanced dose calculation
Q for both? SRS in lung? Brain?

Yes both v15.6 and v18.0 were AcurosXB with dose‐to‐medium for all sites and
phantom situations considered.
A
For a given photon energy, do you have one model for all your TrueBeams or one
Q model per LINAC?
Yes, we have one open field beam model and one ELM add‐on for all our TrueBeams.
The open‐field beam model is based on the TrueBeam representative beam data
available on the MyVarian website, and our ELM add‐on is derived as an average set
of measurements from two of our TrueBeams after a review and audit of legacy
transmission and DLG measurements. Our two Edge® radiosurgergy sysyems use the
same open‐field beam model and again have their own shared ELM add‐on which is
an average of the two machines, which we found in any case to be very close to each
other. We are currently carrying out some investigatory work looking at the
continued feasibility of a 'machine‐averaged' ELM approach as we favor a common
beam model and ELM across our eight TrueBeams to permit patient transfers in the
A event of breakdowns, etc., and also to simplify and streamline our TPS QA tests.
Are differences with ELM between 15 and 18 of clinical significance? Looks like
Q outcomes should not be clinically significance
I agree I think in most clinical cases we are looking at only very small differences. Even
within the SRS context I included in the presentation I don't think we would expect a
4% change to be clinically significant within an ablative regime (20 Gy in 1 # for
example), and as noted in some of the other questions here we have not detected a
A step change in any of our PSQA measurements.
Q On the "Biggest Chances for SRS" slide, what were the field sizes?
The field sizes were dynamically varying with jaw‐tracking enabled, but they were
very small target volumes. (The example I showed had a PTV volume of 0.57 cc).
Locally, we will increase the PTV margin on very small GTVs until the equivalent
spherical diameter reaches 1 cm, so as to avoid running into dosimetric errors in very
A tiny fields which are difficult to measure!
Q Did you check a static IMRT case?
 We looked at two fixed‐field breast plans which are sliding window rather than step
and shoot, but yes, they checked out OK in both Sun Nuclear DoseCHECK and
ArcCHECK (3% 3 mm). One breast only reached 94% at 3% 2mm. PDIP is also often
more challenging with breast for us, I think due to the relatively open, flat fields and
some variation in panel response off‐axis, but this is not a new issue as such, and we
A are currently looking into whether we can improve our PDIP model performance.
Q What experience with Halcyon is there?
Varian: For use of ELM in conjunction with Halcyon, and TrueBeam, please see the
following publication:
A https://aapm.onlinelibrary.wiley.com/doi/abs/10.1002/mp.16019
Q Can you comment on the using MCO?
We have not evaulated MCO in any detail currently and it is not in routine use at
Clatterbridge I'm afraid! I believe the direct isodose line dragging in v18.0 is meant to
provide a more intuitive way of navigating the pareto space. We have a colleague
looking at this in some more detail as part of her doctoral research so perhaps we will
A be able to share more on this in the future.
You mentioned that DLG is related to the MLC calibration. How large is the
Q variation of DLG between your machines?
Yes, I believe the 'DLG' now reported in the ELM configuration is mostly related the
mechanical calibration of the leaves rather than dosimetric + mechanical effects
(even if there are smaller residual dosimetric effects still present). We are currently
carrying out a more thorough study to characterize the linac‐dependence of ELM and
the extent to which a machine‐averaged ELM is acceptable. I hope we will have more
to share on this in the future. To give you an idea though, our 'legacy' DLG
measurements across our eight TrueBeams typically ranged from 0.07 to 0.11 cm,
A with transmission ranging from ~1.3% to ~1.5%.
What is optimization time improvement factor expected to be when going from
GPU‐based opt in v16.1 to GPU‐based opt in v18? I think the improvement factor
Q you quoted (2.5‐3x) is for going from 15.6 to 18?
Varian: Internal testing has revealed speed improvements of 50% (or 2 times faster)
A when upgrading from 16.1 to 18.0. Note, your results may vary.
Does v18.0 ELM solve the problem for large fields with carriage shifts for eComp
plans that show a perturbation of dose in the section where the carriage shift
Q occurs?
 I'm not sure I can comment here as I don't think that's something we have run into.
However, if the dose perturbation you see is a result of the MLC penumbra, you may
see some changes here as a result of changes in the differential leaf tip transmission
which is now more explicitly modelled. Varian have additionally updated their
example spot size values in the v18.0 document which can also affect penumbral
A dose.
Q How does the new ELM model affect Portal Dosimetry calculations?
My understanding that PDIP_18.0 will calculate the dose to the panel using the
fluence generated in the ELM source plan. In general practice, we have not seen a
step change in PDIP performance. We are currently reviewing our PDIP models to see
whether any optimizations can be made here.
Varian: PDIP algorithm does not use ELM directly, but PDIP obtains the actual fluence
from the selected dose calculation algorithm, if v18.0 calculation algorithms are used
A then the actual fluence is calculated with ELM.
Q Do you use a separate beam model for HyperArc?
We use a separate MLC ELM for our HD120 machines than our Millenniums.
However, both the HD120 and Millenium machines basically share the same
underlying open field beam data. Even within our HD120 machines, we have not
created a separate 'small field' model optimized for SRS ‐ i.e. we have one universal
A model for all field sizes.
Q What type of radiochromic film was used for the MLC tests?
The gafchromic measurements were actually acquired a few years ago. The
comparison I presented was a retrospective one using the new calculation. I believe
the film would have been GAFCHROMIC EBT3 from Ashland (or possibly EBTXD which
A is specified for a higher dose range >10 Gy.)
It seemed to me during your presentation that you have developed this improved
MLC model for the true beam linac. However according to some publications, the
MLC model of the Halcyon in eclipse is quite improvable, is the ray tracing model
Q available for the halcyon?
Varian: For use of ELM in conjunction with Halcyon, and TrueBeam, please see the
A following publication: https://aapm.onlinelibrary.wiley.com/doi/abs/10.1002/mp.16019
Q Any specific hardware upgrade as well?
Varian: For hardware interoperabilities, please contact your local Varian
A representative.
Q Does the model separate inter‐ and intra‐ leaf leakage?
 While leaf tip, leaf thickness and drive screw are now all more explicitly modelled,
inter‐leaf leakage and 'tongue‐and‐groove' effects are not yet incorporated in ELM. I
A have suggested to Varian this might be an area for focus for future versions.
Q Currently is ELM on a per machine basis and not generic for matched machines?
We have had lots of questions about this! We are using an 'average' ELM based on
measurements made on two machines, following an audit we completed of legacy
DLG measurements made across all eight TrueBeams. We have found this works OK,
but we are currently carrying out a more detailed study to quantify the acceptability
(or otherwise) of this approach. We hope to have more detailed analysis on this that
we can share in the future. Matched and equivalent machines are an important
practical consideration for transfer of patients in the event of machine breakdowns,
as well as simplifying TPS QA. So this seems like an important question for many
A centers looking to implement ELM.
Will this propagate changes in your measurements of DLG by your team, or is this
Q more just a separation of planning‐DLG and dosimetric DLG?
The traditional sweeping gap measurements used for DLG in v16 and prior are
actually very similar to those used for ELM in v18.0. We have not yet made any
changes to our routine DLG measurements (which we check typically around every six
months as a constancy check on the machines.) I suspect these will remain a good
constancy check if you wish to keep them. We will probably update this test in time
to use the new sweeping gap fields for ELM so that it aligns more directly to our TPS,
but the set‐up is very similar. The Van Esch paper on ELM measured the new ELM
fields at 10 cm deep (and 90 cm SSD), rather than 5 cm deep, which is the main
A difference for us.
Q Since PDIP can be configured with AAA, does this mean PDIP 18 has ELM as well?
Varian: See above, and AAA requires ELM in v18.0, when the v18.0 AAA algorithm is
A used it always uses ELM.
Are these measurements required for a Halcyon or are they hard‐entered by Varian
Q as is all other machine data?
Varian: For ELM configuration guide, please navigate to the MyVarian webpage
where you can find the document titled Enhanced Leaf Modeling Measurement
A Procedure guide.
These FAQs are a helpful guide. Please consult the Instructions for Use, user manuals, and MyVarian for
labeling and additional product information.

Recommendations shared are the speakers' personal opinion and/or are based on the experience of the
speaker, and not necessarily those of Varian.

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