DICOM RT Mode Reference Guide

DICOM RT Mode
Reference Guide
ARIA® Radiation Therapy Management
13485 P1005177A MARCH 2014

Document ID P1005177A
Document Title DICOM RT Mode Reference Guide
Abstract This document provides basic information and procedures for using DICOM RT
Mode, version 13.5, with ARIA 8.0 - 11 / ARIA RTM 13.0 and 4D Integrated
Treatment Console.
This publication is the English-language original.
Manufacturer Varian Medical Systems, Inc.
3100 Hansen Way
Palo Alto, CA 94304-1038
United States of America
Authorized Varian Medical Systems Nederland B.V.

Representative in Kokermolen 2
the EU 3994 DH Houten
The Netherlands
Notice Information in this user guide is subject to change without notice and does not
represent a commitment on the part of Varian. Varian is not liable for errors
contained in this user guide or for incidental or consequential damages in
connection with furnishing or use of this material.
This document contains proprietary information protected by copyright. No part
of this document may be reproduced, translated, or transmitted without the
express written permission of Varian Medical Systems, Inc.
FDA 21 CFR 820 Varian Medical Systems, Oncology Systems products are designed and
Quality System manufactured in accordance with the requirements specified within this federal
Regulations regulation.
(CGMPs)
ISO 13485 Varian Medical Systems, Oncology Systems products are designed and
manufactured in accordance with the requirements specified within the ISO
13485 quality standard.
EU REACH SVHC The link to the current EU REACH SVHC disclosure statement can be found at
Disclosure http://www.varian.com/us/corporate/legal/reach.html
WHO ICD-O codes and terms used by permission of WHO, from:

■ International Classification of Diseases for Oncology, (ICD-O) 3rd edition,
Geneva, World Health Organization, 2000.
ICD-10 codes and terms used by permission of WHO, from:
2 DICOM RT Mode Reference Guide

■ International Statistical Classification of Diseases and Related Health
Problems, Tenth Revision (ICD-10). Vols 1–3, Geneva, World Health
Organization, 1992.
CAUTION: US Federal law restricts this device to sale by or on the order of a physician.
Trademarks ARIA® oncology information system, Clinac® iX linear accelerator, On-Board Imager® kV
imaging system and VARiS® practice management solution are registered trademarks of
Varian Medical Systems, Inc. Inspiration™ integrated oncology environment, Millenium™
MLC, VARiS Vision™ oncology information system, Vision™ image management solution,
and TrueBeam™ are trademarks of Varian Medical Systems, Inc.
Microsoft® and Windows® are registered trademarks of Microsoft Corporation.
All other trademarks or registered trademarks are the property of their respective owners.
Copyright © 2008–2014 Varian Medical Systems, Inc.
All rights reserved. Produced in Switzerland.
3
Contents
CHAPTER 1 INTRODUCTION .............................................................................................................. 6

About this Guide ............................................................................................................................................... 6
Visual Cues ......................................................................................................................................................... 6
Contacting Varian Customer Support ......................................................................................................... 7
Abbreviations and Definitions .......................................................................................................................8
Related Publications ........................................................................................................................................ 9
CHAPTER 2 SAFETY ............................................................................................................................. 11

General ................................................................................................................................................................11
Always Handle with Care ............................................................................................................................... 11
Site and Personnel Requirements ................................................................................................................ 11
Conditions Invalidating Varian Responsibility .........................................................................................12
CHAPTER 3 DICOM RT MODE OVERVIEW .....................................................................................13

What is DICOM RT Mode? ..............................................................................................................................13
What is new in DICOM RT Mode? ................................................................................................................13
Prerequisites for Using DICOM RT Mode ........................................................................................... 14
Planned Downtime of OIS .............................................................................................................. 14
Unplanned Downtime of OIS .........................................................................................................14
Use Cases for DICOM RT Mode ...................................................................................................... 15
Advantages of Using DICOM RT Mode ............................................................................................... 15
About DICOM RT Files .....................................................................................................................................17
CT Image ..................................................................................................................................................... 17
RT Plan ......................................................................................................................................................... 17
RT ION Plan ................................................................................................................................................ 18
RT Image .....................................................................................................................................................18
RT Spatial Registration ........................................................................................................................... 18
RT Structure ............................................................................................................................................... 18
RT Treatment History ..............................................................................................................................18
RT ION Treatment History ..................................................................................................................... 19
CHAPTER 4 OPERATING PROCEDURES ........................................................................................ 20

Overview ...........................................................................................................................................................20
File Storage Preparation ............................................................................................................................... 20
Storage Space ...........................................................................................................................................20
Read and Write Access ...........................................................................................................................20
Set Default Folders for 4DITC ............................................................................................................... 22
Check that Treatment Approvals are Enforced ................................................................................ 23
Prepare the Machine and Imaging Environment for OBI 1.4, 1.5, and 1.6 ..........................................23
Check User Rights for DICOM RT Mode .....................................................................................................24
Configure Import and Export Filters .......................................................................................................... 25
Configure an Export Filter for ARIA 8.0 to 10.0 ................................................................................ 25
Configure an Export Filter for ARIA 11 or ARIA RTM 13 ....................................................................26

Configure an Import Filter for ARIA 11 or ARIA RTM 13 ................................................................... 26
DICOM RT Mode Workflow ...........................................................................................................................27
Export DICOM Data in ARIA 8.0 to 10.0 .....................................................................................................27
Export RT Plan, Image and Structure Data from RT Chart ............................................................ 28
Use Case .....................................................................................................................................................29
Settings for the Export Wizard (RT Chart / ARIA 8.8) ......................................................................32
Export DICOM Data in ARIA 11 or ARIA RTM 13 ......................................................................................... 33
Modify the ARIA OIS Database Plan after Initial Plan Export .............................................................. 36
DICOM RT Data on 4DITC ............................................................................................................................. 36
Open RT Plan Data from the File Storage System ...........................................................................36
Start Treatment Using DICOM RT Mode ........................................................................................... 38
Limitations for Treatments Using DICOM RT Mode .......................................................................38
Troubleshoot DICOM RT Data on 4DITC ............................................................................................39
Close the Patient Data and Create DICOM History Records ......................................................... 41
DICOM History Files from 4DITC ..........................................................................................................42
Exit DICOM RT Mode in 4DITC ..............................................................................................................43
Import DICOM Records to the ARIA 11 or ARIA RTM 13 Database ........................................................43
Import RT Records ................................................................................................................................... 45
Verify and Complete the Import ..........................................................................................................47
Assign Fraction Numbers ...................................................................................................................... 50
Verify the Scheduling in Treatment Preparation ............................................................................. 51
INDEX .........................................................................................................................................................53
Contents 5
Chapter 1 Introduction
About this Guide

This guide describes the features of DICOM RT Mode when used in conjunction with
ARIA (v8.0 - 11 / ARIA RTM 13), 4D Integrated Treatment Console (4DITC),
TrueBeam (TXA), and On-Board Imager (v1.4, v1.5, and v1.6) Advanced Imaging.
This reference guide contains a workflow-oriented description of the DICOM RT
functions for ARIA 11 and ARIA RTM 13 in addition to the workspaces in ARIA 8.0
to 10.0. Access to DICOM RT Mode has changed from the ARIA versions 8.0 to 10.0.
Chapter 2 Safety on page 11 provides essential information on hazards related to
the use of DICOM RT Mode.
Visual Cues
This publication uses the following visual cues to help you find information:
WARNING: A warning describes actions or conditions that can result in serious injury or
death.
CAUTION: A caution describes hazardous actions or conditions that can result in minor or
moderate injury.
NOTICE: A notice describes actions or conditions that can result in damage to equipment
or loss of data.
Note: A note describes information that may pertain to only some conditions, readers, or sites.
Tip: A tip describes useful but optional information such as a shortcut, reminder, or suggestion,
to help get optimal performance from the equipment or software.

Contacting Varian Customer Support
Varian Customer Support is available on the internet, by e-mail, and by telephone.
Support services are available without charge during the initial warranty period.
The my.varian.com website provides contact information, product documentation,
and other resources for all Varian products.
Get Online Customer Support

You can browse the my.varian.com site without having a Varian account or logging
in. However, you must have a Varian account to get online customer support and to
access product information for products at your institution or clinic.
1. Go to http://my.varian.com.
2. Click Contact Us at the top of the window to display customer support and
training options, and international e-mail addresses and telephone numbers.
3. Choose an option:
■ If you do not already have an account, click Create New Account and follow
the instructions. Establishing an account may take a few days.
■ If you have an account, go to the next step.
4. Enter your user name and password.
5. Browse the information and then click the link that corresponds to what you
want to do:
■ Fill out and submit a support request.
■ Find documents. Online documents in PDF format include customer technical
bulletins (CTBs,) manuals, and customer release notes (CRNs).
■ Send an e-mail to Varian support. You can browse for international e-mail
addresses and telephone numbers by geographic area, and for oncology-
specific contacts such as for brachytherapy.
■ Find parts and services by geographical area.
E-Mailing Varian
Send e-mail inquiries through the my.varian.com website.
Alternatively, you can use a support e-mail address that corresponds to your location
or interest:
Location E-mail Address
North America support-americas@varian.com
Latin America soporte.al@varian.com
Europe support-emea@varian.com
Chapter 1 Introduction 7
Location E-mail Address
Australia and New Zealand support-anz@varian.com
China support-china@varian.com
Japan support-japan@varian.com
South East Asia support-sea@varian.com
Brachytherapy Systems brachyhelp@varian.com
Ordering Documents by Phone

You can order documents by phone by calling Varian Medical Systems support.
Location Telephone Number
North America + 1 888 827 4265 (Press 2 for parts)
Global Call your local Varian office.
Abbreviations and Definitions

4DITC 4D Integrated Treatment Console
ARIA RTM ARIA Radiation Therapy Management
ARIA OIS ARIA Oncology Information System for Radiation Oncology
CT Computerized Tomography
DB Database
.dcm File extension of DICOM files
DICOM Digital Imaging and Communications in Medicine
DAEMON A computer service that runs in the background.
DRR Digitally Reconstructed Radiograph
ID Identifier. The alphanumeric code that identifies a patient in the
Varian system database.
kV Kilovolt or Kilovoltage
LVI Linac Verification Interface
MLC Multileaf Collimator
MU Monitor Unit. In a dose monitoring system, an arbitrary unit in which
a quantity of dose is displayed and from which the absorbed dose
can be calculated. A table for the conversion of monitor units into
units of absorbed dose (gray or rad) can be generated by a dose cali-
bration of the machine by a qualified physicist.
MV Megavolt or Megavoltage

OBI On-Board Imager
OIS Oncology Information System
OSP Oncology Systems Platform
QA Quality Assurance
RE Prefix of DICOM RT Spatial Registration files
RI Prefix of DICOM RT Image files
RP Prefix of DICOM RT Plan files
RN Prefix of DICOM RT Ion Plan files
RS Prefix of DICOM RT Structure files
RT Prefix of DICOM History Files, created after treatment for each treat-
ment field
RTM Prefix of Radiation Therapy Management
RX Prefix of DICOM RT Ion Treatment History files
RV Record and Verify
UID Unique Identifier
VARiS The first Varian information platform designed for clinical informa-
tion and practice management.
Vision Trade name of the Varian imaging products family.
Related Publications
Varian recommends also referring to the following user documentation on the
specifics of system operation, or for background information depending on system
version:
■ ARIA RTM DICOM Import and Export Reference Guide
■ ARIA RTM Workflow Management Reference Guide
■ ARIA RTM Workflow Management Online Help
■ ARIA RTM RT Chart Reference Guide
■ ARIA RTM RT Summary Reference Guide
■ ARIA RTM Dosimetric Review Reference Guide
■ ARIA RTM Treatment Preparation Reference Guide
■ Treatment Delivery Instructions For Use
■ 4D Integrated Treatment Console Reference Guide
■ 4D Integrated Treatment Console Customer Release Note
■ 4D Integrated Treatment Console Administration Reference Guide
■ On-Board Imager Reference Guide
Chapter 1 Introduction 9
■ On-Board Imager Customer Release Note
■ TrueBeam Technical Reference Guide—Volume 2: Imaging
Varian has also made many items of documentation available on the MyVarian
website.
ARIA users may freely register for access at:
http://my.varian.com/

Chapter 2 Safety
General
Your hospital is responsible for establishing emergency and safety procedures to
ensure safe operation and maintenance conditions.
The process of delivering radiation therapy contains potentially life-threatening risks
to patients, operators and bystanders. Be sure to read and understand all safety
information before operating machinery and delivering treatment.
Varian hardware and software are designed to meet current international safety
standards, including IEC, for the protection of patients and operators.
However, hazards and risks cannot be ruled out completely. You must follow the
instructions and procedures described in the manuals.
Any use of the system and software which does not comply with the agreed use
described in this manual or other related Varian manuals is prohibited.
Modifications to the software are prohibited.
Always Handle with Care

Careless handling or operating can result in unsuccessful treatment or loss of data.
WARNING: Incorrect use of a radiotherapy linear accelerator can cause serious injury or
death. Only trained personnel under the supervision of a licensed physician should be
authorized by the hospital or owner to operate a clinical accelerator. The emergency
and safety procedures are described in the corresponding Instructions for Use.
Site and Personnel Requirements

■ Only qualified and trained personnel are permitted to operate the system and its
parts.
■ All persons who handle, use or operate the system must read and understand the
chapters dealing with safety regulations and emergency procedures.
■ Before operating the system, all personnel must be trained in the emergency and
safety procedures established by the hospital.
■ The system must be operated only with its original and unmodified fittings and
replacement parts.
Chapter 2 Safety 11
■ No modifications to the system are permitted without prior review and approval
from Varian.
Conditions Invalidating Varian Responsibility

Varian cannot be held responsible for personal injury or equipment damage in the
following cases:
In cases of noncompliance with instructions.
■ Changes or repairs carried out that are not in accordance with the instructions
contained in any Varian manual for the system, or if spare parts, standards and
procedures not authorized in writing by Varian are used.
■ Updates, modification or repair instructions occasionally issued by Varian are not
complied with.
In case of improper use or changes:
■ Removal of or changes to safety devices.
■ Unintended use of equipment.
■ Unauthorized software changes made to the workstation
In cases of noncompliance with personnel:
■ Unqualified persons perform operations or maintenance work.
■ Personnel does not immediately report to Varian anomalies during operation and
maintenance.
■ Operators are not familiar with the operating system or service manuals before
performing service or maintenance or ignore instructions in the manuals.
In cases of nonconformance with regulations, where operators, maintenance staff or
other personnel do not comply
■ with instructions and safety regulations.
■ local laws and regulations.
■ legal or government regulations or both.
These instructions do not render any further hospital or local, state or county
regulations or laws invalid. Such regulations must be complied with at all times.

Chapter 3 DICOM RT Mode Overview
What is DICOM RT Mode?

DICOM RT Mode is a file-based import/export interface. Its primary function is to
provide the possibility of opening a specific plan file along with its related 2D or 3D
reference image data from a previously prepared file storage system.
In DICOM RT Mode plan data is loaded to 4DITC. Most of the normal treatment
functions, MLC and imaging data remain available during downtime, when the main
Oncology Information System (OIS) database is not accessible. For example, if the
ARIA or VARiS Vision database goes off-line.
At the end of the treatment session history file data is automatically created using the
DICOM RT format. History data contains a record of delivered beams along with 2D
or 3D images acquired from the session. Plan modifications made on 4DITC during
the session are also recorded as new files.
When the OIS database is accessible again, you can manually import DICOM history
file information from the Import Export workspace.
CAUTION: Careless handling or operating can result in unsuccessful treatment or loss of

data. The hospital is responsible for establishing proper operation procedures to ensure
safe usage.
What is new in DICOM RT Mode?

Changes have been made to the DICOM workspace architecture. In previous
versions of ARIA (8.0 - 10.0) access to the import/export functions was obtained
through RT Chart. Starting with ARIA 11, the RT Chart application is divided into
distinct workspaces. The Import/Export workspace is accessed directly via the
Quicklinks drop-down box in User Home.
Chapter 3 DICOM RT Mode Overview 13

Figure 1 User Home Workspace
Prerequisites for Using DICOM RT Mode

The DICOM RT Mode file-based approach is used during planned and unplanned
downtime of the OIS, during which the OIS database is not accessible.
Alternatively, you can use DICOM RT Mode for plan testing, troubleshooting or QA
purposes.
Planned Downtime of OIS

Planned downtime of OIS is the result of one of the following factors:
■ Scheduled database upgrade or maintenance
■ Scheduled server maintenance, replacement or upgrade
■ Scheduled network maintenance, replacement or upgrade
Because the timing of such work is known in advance, it is possible to prepare the
relevant RT plan and RT image files ready for DICOM RT Mode treatments.
Note: It is vitally important that the export preparation of the DICOM RT data occurs before
the downtime.
Unplanned Downtime of OIS

Preparing for unplanned OIS downtime means a systematic and routine export
approach, because it cannot be predicted when the system will be unavailable. Some
sites routinely export RT plan and RT image data to mitigate against any unexpected
server or network problems.

Use Cases for DICOM RT Mode
Two main scenarios are considered here:
■ Temporary system downtime with ARIA, see Figure 2 System Downtime with
ARIA on page 15.
DICOM
ARIA .dcm
Export
DB
4D Console
DICOM
DICOM RT Mode
Import
.dcm
Figure 2 System Downtime with ARIA
■ System upgrade from VARiS Vision to ARIA, see Figure 3 Upgrade from VARiS
Vision to ARIA on page 15.
DICOM .dcm
V7.x Export
DB
4D Console
DICOM RT Mode
DICOM ARIA
.dcm Import DB
Figure 3 Upgrade from VARiS Vision to ARIA
Advantages of Using DICOM RT Mode

Historically, with VARiS 1.x and Generation 6.x, patients had to be treated with the
Clinac and MLC running in standalone mode when the main OIS database was
offline. This entailed disabling the RV interface on the Clinac and manually running
the MLC workstation application. Although it was still possible to treat patients
using this approach, the normal capabilities of the system were significantly reduced.

Because of the architecture used by 4DITC, DICOM RT Mode allows for most of the
normal treatment functions to still be available, even if the OIS database is
temporarily unavailable.
It is important to remember that when the initial RT plan and RT image data are
prepared and exported to the file storage system, the data can be used for treatments
over multiple sessions or days.
Table 1 DICOM RT Mode Compared with Standalone Mode on page 16 compares
DICOM RT Mode with conventional standalone mode.
Note: Some additional limitations apply to imaging on an OBI system in an ARIA

environment. These points are mentioned in section Overview on page 20
Table 1 DICOM RT Mode Compared with Standalone Mode
Capability DICOM RT Standalone

Mode Mode
Availability of electronic plan and 2D or 3D reference Yes No
image data for viewing and checking
RV Mode Up on Clinac Yes No
Display of planned and actual parameters, or field Yes No
photos on an in-room monitor (LVI) screen
Automatic load of MLC and dynamic MLC data Yes No
Automatic parameter verification of tolerance tables Yes No
(planned compared with actuals)
Override sign-off (recorded) of parameters outside of Yes No
tolerance
Machine and parameter override functions Yes No
Plan parameter acquire and edit actions Yes No
History data from treatment and imaging events re- Yes No
corded to file (including sign-offs)
Auto setup capability from Clinac pendant Yes No
Remote setup capability from Clinac console Yes Yes
Performing pre-defined MV imaging Yes No
Performing ad-hoc MV imaging Yes No
Online matching of MV images Yes No
Offline matching of acquired images No No
kV-kV online imaging and matching, for OBI 1.4, 1.5, Yes No
and 1.6 (Advanced Imaging)

MV-kV online imaging and matching, for OBI 1.4, 1.5, Yes No
CBCT online imaging and matching, for OBI 1.4, 1.5, Yes No
Marker Match online imaging and matching, for OBI Yes No
1.4, 1.5, and 1.6 (Advanced Imaging)
About DICOM RT Files

The ARIA OIS database supports the following DICOM objects, relevant to 4DITC /
OBI:
CT Image on page 17
RT Plan on page 17
RT ION Plan on page 18
RT Image on page 18
RT Spatial Registration on page 18
RT Structure on page 18
RT Treatment History on page 18
RT ION Treatment History on page 19
Exported DICOM files are automatically labeled with a file name corresponding to
the unique identifier (UID) used internally by the DICOM standard. All DICOM files
end with a .dcm extension.
CT Image
These files have the prefix CT. A single image (CT slice) is around 0.5 MB in size. A
CT volume containing 100 slices would therefore be around 50 MB in size. A single
planning volume image consists of many individual slices. In this context, CT images
are only needed by OBI for either Marker Match or the 3D-3D use cases.
RT Plan
These files have the prefix RP. A single plan file is typically a few kB in size, but can
increase to around 1 MB if all fields use dynamic MLC. Plan files contain information
on the relevant fields, MU and reference points. The field data within the plan also
have information on beam accessories, such as MLC (static or dynamic), wedges and
blocks. An example of a DICOM RT plan file name is:

RP.1.2.246.352.71.5.413.484.20051018160201.dcm
RT ION Plan
These files have the prefix RN. A single plan file is typically a few kB in size. Plan files
contain information on the relevant fields, MU and reference points. The field data
within the plan also have information on beam accessories, such as snouts, wedges
and blocks. An example of a DICOM RT ION plan file name is:
RN.1.2.246.352.71.5.330622248013.132.20110120155231.dcm
RT Image
These files have the prefix RI. A single DRR image file is typically around 0.5 MB in
size, a single fluoroscopy or kV image is typically between 1.5 MB and 6 MB,
depending on imaging system resolution. 2D or 3D image files contain the pixel
information of the image, as well as the drawing layer and contour information.
Examples are DRR or simulator fluoroscopy images. RT images can also be the 2D or
3D images acquired from a treatment session (for example, individual MV portal
images).
RT Spatial Registration
These files have the prefix RE. A spatial registration file is typically around 35
kilobytes in size. The spatial registration file contains positional information and is
used internally for pairing images together for subsequent off-line review.
RT Structure
These files are related to CT volume images and have the prefix RS. The size of the
file depends on the number and complexity of structures in the original image. A
structure file can therefore easily end up being more than 1 MB in size. In this
context, CT images are only needed by OBI for either Marker Match or the 3D-3D use
case. During 3D-3D use cases, a further RS file is created by the system that contains
the CBCT isocenter information (~10 kilobytes).
RT Treatment History
These record files have the prefix RT. Each treatment history file is typically around 3
kB in size. A single history record represents a single field exposure made at the
accelerator. The RT Treatment History File is created after the patient is treated in
DICOM RT Mode. One file exists for each field treated.

RT ION Treatment History
These record files have the prefix RX. Each treatment history file is typically around 3
kB in size. A single history record represents a single field exposure made at the
accelerator. The RT ION Treatment History File is created after the patient is treated
in DICOM RT Mode. One file exists for each field treated.

Chapter 4 Operating Procedures
Overview
The basic steps when using DICOM RT Mode are:
■ File Storage Preparation on page 20
■ Prepare the Machine and Imaging Environment for OBI 1.4, 1.5, and 1.6 on
page 23
■ Configure Import and Export Filters on page 25
■ Export DICOM Data in ARIA 8.0 to 10.0 on page 27
■ Export DICOM Data in ARIA 11 or ARIA RTM 13 on page 33
■ DICOM RT Data on 4DITC on page 36
■ Import DICOM Records to the ARIA 11 or ARIA RTM 13 Database on page 43
CAUTION: Careless handling or operating can result in unsuccessful treatment or loss of

data. The hospital is responsible for establishing proper operation procedures to ensure
safe usage.
File Storage Preparation

Start file storage preparation by manually exporting the file data from the OIS
database to a robust and reliable file storage system, free from viruses or any
malicious software and independent of the database server or network, to ensure
treatment delivery.
Storage Space
Ensure that you have sufficient storage space for the initial DICOM data.
Read and Write Access

Read and write access is required for the history and session image files created.
Note: Ensure that the file is organized logically around each patient. Create suitably named
folders before performing the DICOM RT export using Windows Explorer.

Figure 4 Example of a patient's data and file organization
Where several plans exist for treatment or imaging, allocate them to individual
subfolders, along with any reference images.
For export to OBI 1.4 and 1.5 (Advanced Imaging), use a shared folder on the 4DITC
workstation. The shared folder will be used by the DICOM Stream Service of the OBI
workstation to transfer the relevant data into and out of OBI.
Figure 5 Shared Folder on 4DITC workstation on page 21 shows an example of
such a shared folder on the 4DITC workstation. In this example, the shared folder is
called: D:\DICOM RT
Figure 5 Shared Folder on 4DITC workstation
Chapter 4 Operating Procedures 21

Use additional subfolders within the shared DICOM RT folder for each patient or
plan set. In the example below both patients have multiple plans to be used with
DICOM RT Mode:
Figure 6 Example for Additional Subfolders
Set Default Folders for 4DITC

For convenience, define a default location for the open and save folder location for use
with DICOM RT Mode. It can be set in the Treatment Administration application on
the Setup tab of the Component Manager. An example is shown in Figure 7 Setting
Default Folders for 4DITC on page 22:
Figure 7 Setting Default Folders for 4DITC

Check that Treatment Approvals are Enforced
Prior to any DICOM RT Mode treatment, the system administrator should verify that
the option for Treatment Approvals Enforced is enabled in the treatment
administration application. This setting must be checked for each accelerator. It
prohibits using plans for treatment that are not already Treatment Approved. For an
example, see Figure 8 Treatment Approvals Enforced on page 23.
Figure 8 Treatment Approvals Enforced
Prepare the Machine and Imaging Environment for OBI

1.4, 1.5, and 1.6
OBI makes use of a small database on the Oncology Systems Platform (OSP) to store
information about persistent parameters such as kV settings, mA, blade positioning
and match parameters. The database cannot be accessed, if the OSP service is not
running on the ARIA RTM server. OBI will appear to be performing slowly, or will
appear to have 'hung'.
During downtime, imaging from an OBI Clinac may still be required. Varian service
staff should temporarily set up a local OSP service just prior to ARIA RTM/OSP
going off-line. OBI can then use the database on the local OSP to temporarily store
the persistent parameter values.
Note: Discuss this possibility with Varian Service staff in advance of downtime during an
upgrade.
kV imaging is made possible by applying the correct sequence template before

exporting. At present, this template type cannot be applied from 4DITC. This may
prove to be an important consideration when swapping between non-OBI and OBI
Clinacs during the OIS downtime period.

The spatial registration of acquired 2D or 3D images is saved to the file storage
system (along with the beam records and acquired images) and can be imported back
into ARIA (versions 8.8 or later). The spatial registration object is used internally by
the system to pair images in Offline Review.
For 3D-3D Match cases, temporarily configure OBI Administration to use a local
folder path for saving the CBCT slices. Ensure that this option on the CBCT/Tube/
Pat.Supply tab in the OBI Administration Tool is enabled.
1. Select the Save CBCT to File System check box to enable.

2. Click Browse of CBCT Img Path to set the local save folder location for the CBCT
data.
Note: Note that the CBCT data is saved separately to the main file store for the DICOM RT
Plan/Ref Images/Structures.
Figure 9 CBCT Image Path in OBI Administration
Check User Rights for DICOM RT Mode

Assign the following access rights to users working with DICOM RT Mode (in
addition to their normal user activities):

Table 2 User Rights in ARIA
Action in ARIA User Right

Configure import and export filters Configure Task
Import or export DICOM RT file data Import and export data
Table 3 User Rights in 4DITC
Action in 4DITC User Right

Open a patient in DICOM RT mode in 4DITC (in- Treatment administration: Can open
stead of from the Queue) DICOM RT plan from file.
Configure Import and Export Filters

DICOM RT Mode on 4DITC uses a manually prepared file system to open RT plan
and 2D or 3D RT (reference) image data. To make the plan and image files available,
you must first export them manually from the Oncology Information System (OIS)
database.
Configure an Export Filter for ARIA 8.0 to 10.0

To export plan and image data to a file, the OIS system administrator needs to
configure an export filter in RT Chart. The following steps apply to ARIA 8.8
versions of RT Chart.
To configure an export filter in RT Chart (typically administrators only):
1. Ensure that the device is inserted and recognized by Windows, when using an
external storage device for the file storage system.
2. Log into RT Chart.
3. Select the Import Export workspace.
4. Choose Tools > Import Export Configuration.
5. Click Add in the Export Filter area.
6. Select DICOM Media File Export Filter.
7. Select the Make The Filter Available For The Entire Site check box to make the
export filter accessible from all workstations.
If you leave this unchecked the export filter is only available from that individual
workstation.
8. Click Add .
9. Change the ID of the filter from the default as needed; for example, DICOM RT
Export For 4DITC.
10. Click Browse.

11. Set the desired location path of where file data will be saved (exported) to.
This does not necessarily have to be the final destination; folders and files can
always be moved later from Windows Explorer.
Note: Use individual patient-based folders in the file storage system, rather than saving all
files to a single folder. Such folders can be identified using the ID1 +/- Patient Name labels.
12. Always use the Object UID for the default file name creation, otherwise users will
encounter problems with the loading of file data to 4DITC.
13. Click OK.
14. Click Close after the filter is configured.
Configure an Export Filter for ARIA 11 or ARIA RTM 13

To export plan and image data to a file, the OIS system administrator must configure
an export filter in the Import Export workspace. The following steps apply to ARIA
11 or ARIA RTM 13.
To configure an export filter (typically administrators only):
1. Ensure that the device is inserted and recognized by Windows when using an
external storage device for file storage.
2. Choose User Home > Quicklinks > DICOM > Import Export.
3. Click Manage in the Filter Selection panel.
4. Click Add in the Export Filter area.
5. Select DICOM Media File Export Filter.
6. Select the Shared check box to make the export filter accessible from all
workstations.
workstation.
7. Click Add.
8. Change the Name of the filter from the default as required; for example, DICOM
RT Export For 4DITC.
9. Click Browse.
Configure an Import Filter for ARIA 11 or ARIA RTM 13

To configure an import filter (administrator only):
1. User Home > Quicklinks > DICOM > Import Export.

2. In the Filter Selection panel click Manage.
3. In the Import Filter area, click Add.

4. Select DICOM Media File Import Filter.
5. To make the import filter accessible from all workstations, select the Shared
check box.
workstation.
6. Click Add.
7. Change the Name of the filter from the default as required; for example, DICOM
RT Mode Import Filter.
8. Click Browse.
9. Set the desired default working directory.
10. Click on Options. Ensure that the User ID Mapping check box is cleared.
11. Click OK.
12. Click OK in Manage Filters, after the filter is configured.
DICOM RT Mode Workflow

DICOM RT Mode utilizes several workspaces:
■ Start by navigating to DICOM Import Export from the Home Screen or the
Quicklinks menu.
Figure 10 Quicklink Drop-down Box
Note: Note: For further information on the DICOM Import Export application, refer to the
DICOM Import and Export Reference Guide, as well as the ARIA RTM Workflow
Management Reference Guide and the ARIA RTM Workflow Management Online Help.
Export DICOM Data in ARIA 8.0 to 10.0

Prior to treatment delivery you are expected to export Data from RT Chart to the file
storage system. The steps described below are based on ARIA 8.8.

Note: Users must be familiar with the general use of RT Chart and Windows. For more
detailed instructions on RT Chart operation, refer to the RT Chart Reference Guide.
Export RT Plan, Image and Structure Data from RT Chart

To perform DICOM RT treatments on 4DITC when the OIS database is offline, you
first have to export the RT plan (minimum requirement) along with any relevant data
required by OBI. The following table lists the various data items required for export
prior to performing the use cases in DICOM RT Mode.
Table 4 Export Data for DICOM RT Mode
Purpose Export Data Required

Treatment of plan (no RT plan, including any setup fields.
imaging)
■ The RT (reference) images are optional, but recommended
for general visualization of the treatment area.
Treatment of plan with MV RT plan, including any setup fields. Relevant RT (reference)
imaging (either 2D, 2D/2D, images.
3D or 3D-3D Match)
■ This also covers for Imaging Only attendances, where no
actual treatment is delivered.
Treatment of plan with kV RT plan, including any setup fields. Relevant RT (reference)
imaging (either 2D, 2D-2D, images.
3D or 3D/3D Match)
Treatment of plan for OBI RT plan, including any setup fields. Relevant RT (reference)
Marker Matching images. RT structures from original planning volume image.
CT slices of original planning volume image.
For OBI 1.4 and 1.5 (Advanced Imaging) imaging, place the DICOM data into the
shared folder on the 4DITC workstation in the file storage system, see Figure 5
Shared Folder on 4DITC workstation on page 21.

Use Case
OIS database, servers and network are online and accessible.
To export RT plan and RT image data to files:
1. Ensure that the device is inserted and recognized by Windows, when using an
external storage device for the file storage system.
2. Start RT Chart workspace.
3. Select the Scheduling workspace.
4. Open the desired patient and select a course context.
5. Verify that the desired sequence image template information has been applied to
the next active session for the plan. This also applies for OBI imaging.
Note: Only the image template information for the next active session is exported.
Note: If you plan to use multiple or varying plans during OIS downtime, make a manual
note of the plan scheduling and ordering.
6. Select the Parameters workspace.

7. Verify that the approval status of the plan is set to Treatment Approved.
Note: In ARIA versions of RT Chart you can set treatment approval only in the Reference
Point workspace.
8. Click Validate Plan to verify that there are no outstanding warnings.

9. Visually check on the 2D or 3D reference images to ensure that there are no more
than 16 individual drawing contours per image (for example, anatomical lines or
points).
For online match or other match with OBI first pre-mark the reference anatomy
on the reference images. Ensure that a field aperture contour is present on the
relevant reference images for a non-OBI 4DITC, in case of online matching.
10. Select the Import Export workspace in RT Chart.
Note: The previous step applies only to ARIA versions 8.6 - 10.0.
11. With the plan context selected, choose File > Export > Wizard.
12. Verify that the Plan check box is selected.
13. Click Next.

14. The next step depends on the version of RT Chart being used to export and on
the field types present in the plan. Do one of the following:
a. If there are only treatment fields in plan (no imaging), choose the settings as
shown in Figure 11 Treatment Fields Only in Plan / No Imaging - MV
Imaging on page 32.
b. If there are only treatment fields in plan (MV imaging), choose the settings as
shown in Figure 11 Treatment Fields Only in Plan / No Imaging - MV
Imaging on page 32.
c. If there are only setup fields in plan (MV or kV imaging), choose the settings
as shown in Figure 12 Mix of Treatment and Setup Fields in Plan (No
Imaging / MV imaging / MV or kV imaging on page 32.
d. If there is a mix of treatment and setup fields in plan (no imaging), choose the
settings as shown in Figure 12 Mix of Treatment and Setup Fields in Plan
(No Imaging / MV imaging / MV or kV imaging on page 32.
e. If there is a mix of treatment and setup fields in plan (MV or kV imaging),
choose the settings as shown in Figure 12 Mix of Treatment and Setup
Fields in Plan (No Imaging / MV imaging / MV or kV imaging on page 32.
f. If there is a treatment plan with marker match or 3D-3D (OBI imaging),
choose the settings as shown in Figure 13 Treatment of Plan with Marker
Match or 3D-3D (OBI Imaging) on page 32.
Note:
■ If exporting from ARIA 8.8 for use with an 8.8 (or higher) version of 4DITC, always
enable the option for Compatible To Varian Treatment Consoles 6.5 – 8.6
■ If exporting from ARIA 8.5 or 8.6, always enable the option for Compatible To Varian
Treatment Console.
■ If exporting from earlier versions of ARIA (8.0, 8.1, or 8.2), or from VARiS Vision 7.x,
the same option is named Compatible to Release 6.5. Always enable this option.
15. Click Next.

16. From the list of available filters, select the desired export method.
17. Click Next.
A list of the objects for export is shown.
CAUTION: At this point, the data is converted to DICOM format. You are notified if
there are any errors or warnings associated with the conversion. Errors always stop the
export process, where as warnings may be less serious.

Note: If the Administration option for Enable Plan Integrity Checking is disabled on the
system, a warning message at Plan export is displayed. Example: if exporting a Plan with
ID= PELVIS, the following is displayed:
Plan 'PELVIS' is treatment-approved but lacks plan
integrity checksum.
For this configuration, the warning can be acknowledged by the user (click YES to continue).
Note: Except for this case, always consult with the system administrator, if either errors or
warnings are encountered!
18. In the wizard, click Change For All Objects.

19. Use the Windows browser to select the desired export folder.
20. If the corresponding folders are not in the file storage system, click Create New
Folder in the browser. For more information, see File Storage Preparation on
page 20.
21. Click Open, after the required export folder is selected.
22. Verify that the correct export path is displayed in the list of files to be exported.
23. Ensure that the desired entries are selected (highlighted) in the list of files to be
exported.
To select entries use the mouse or the Ctrl+left-click or Shift+left-click functions.
24. To export the data, click Finish.
Note: Any failures in export must be reported to the system administrator before the OIS
database goes offline, otherwise data will not be available for treatment. If the export is
successful, a message box opens, stating
All Objects Saved Successfully
.
25. Repeat this procedure for any additional plans which also need to be made
available during the downtime period.
Note: For OBI 1.4 and 1.5 the export can initially be carried out to a portable file system (for
convenience). The data must then be loaded to the shared 'DICOM RT' folder on the 4DITC
workstation, before imaging and treatment starts.

Settings for the Export Wizard (RT Chart / ARIA 8.8)
Figure 11 Treatment Fields Only in Plan / No Imaging - MV Imaging
Figure 12 Mix of Treatment and Setup Fields in Plan (No Imaging / MV imaging / MV or kV
imaging
Figure 13 Treatment of Plan with Marker Match or 3D-3D (OBI Imaging)

Export DICOM Data in ARIA 11 or ARIA RTM 13
Note: Users must be familiar with the general use of the Scheduling and Import Export
workspaces as well as Windows. For more detailed instructions on the Import Export
function, refer to the DICOM Import and Export Reference Guide. For more detailed
information on Scheduling Workspace refer to the RT Summary Reference Guide.
OIS database, servers and network must be online and accessible.

The following section provides information on how to export the initial DICOM data
from the Import Export workspace to the file storage system before treatment
delivery in DICOM RT Mode. The steps below describe an export in ARIA 11 or
ARIA RTM 13.
To export RT plan and RT image data to files:
1. If using an external storage device for the file storage system, ensure that the
device is inserted and recognized by Windows.
2. Navigate using Quicklinks to Plan Scheduling workspace.
3. Open the desired patient and select a course context.
4. Verify that the desired sequence image template information has been applied to
the next active session for the plan. This also applies for OBI imaging.
Note: Only the image template information for the next active session is exported.
Note: Make a manual note of the plan scheduling and ordering where either individual or
multiple plans are used during downtime.
5. Verify that the desired approval status of the plan is set to Treatment Approved.
If not already set, go to Reference Point workspace and change plan status to
treatment approved.
6. Navigate to Plan Parameters workspace to verify that there are no other
outstanding warnings. Click Validate.
7. Visually check on the 2D or 3D reference images to ensure that there are no more
than 16 individual drawing contours per image (for example, anatomical lines or
points).
For online match or other match with OBI first pre-mark the reference anatomy
on the reference images. Ensure that a field aperture contour is present on the
relevant reference images for a non-OBI 4DITC, in case of online matching.
8. Select the Import Export workspace.

9. Select the Export tab in the Filter Selection panel.
10. Choose the appropriate DICOM Media File Export Filter.
11. Click NEXT to proceed.
If you have not selected a patient, the Patient Explorer application opens. For
detailed information, refer to the Patient Explorer online help.
12. Select the patient.
Figure 14 Selection Panel—DICOM Media File Export in ARIA 11

Figure 15 Selection Panel—DICOM Media File Export in ARIA RTM 13
The Selection panel opens.

13. In the Selection panel choose the objects you want to export and select the
destination folder.
Note: By default you start in the working directory folder which is defined as default for this
filter.
14. Click NEXT.
CAUTION: At this point, the data is converted to DICOM format. You are notified if
there are any errors or warnings associated with the conversion. Errors always stop the
export process, where as warnings may be less serious.
Note: If the Administration option for Enable Plan Integrity Checking is disabled on the
system, a warning message at Plan export is displayed. Example: if exporting a Plan with
ID= PELVIS, this warning would be seen as:
Plan 'PELVIS' is treatment-approved but lacks plan
integrity checksum.
For this configuration the warning can be acknowledged by the user (click YES to
continue). Except for this case, always consult with the system administrator, if you
encounter any errors or warnings!
15. Check the export summary table in the Summary panel.

16. Optionally, click View Detailed Log to check the detailed log.
Note: Report any export failures to the system administrator before the OIS database goes
offline, otherwise data will not be available for treatment.
17. Repeat this procedure for any additional plans which also need to be made
available during the downtime period.
Note: If plan changes are done in ARIA after the plan had been exported, the changes might
result in a different Plan UID. In this case the plan must be reexported to avoid confusion
with different plan UIDs for the same plan.
Note: For OBI 1.4 and 1.5 the export could initially be carried out to a portable file system
(for convenience). The data must then be loaded to the shared 'DICOM RT' folder on the
4DITC workstation, before imaging and treatment starts.
Modify the ARIA OIS Database Plan after Initial Plan

Export
Changes made to the exported RT plan in the OIS are not recorded automatically.
The following steps describe how the information is updated in the file storage
system used for DICOM RT Mode.
To update the RT plan information in the file storage system:
1. Modify the plan in the OIS database.

2. Delete the previously exported (RP.) plan, (RI.) images, (CT.) images and (RS.)
structure files for the relevant patient or plan from the file storage system.
3. Re-export the modified plan (along with any relevant images or structures).
DICOM RT Data on 4DITC

To enter DICOM RT mode and open RT plan from the file system:
1. Choose Tools > DICOM RT Mode in the treatment application on 4DITC.

2. Enter a user name and password. The system checks whether the user has the
appropriate user rights.
Open RT Plan Data from the File Storage System

From DICOM RT Mode, the next step is to open a patient's DICOM RT plan file.

Note: You can open only one plan at a time using in DICOM RT Mode.
To open an RT plan file from the file storage system:
1. Click on Open Patient in Treatment Application.

A Windows file browser dialog box opens. You can navigate to the desired drive
and folder.
2. Select the desired RP plan file.
For an example, see Figure 16 Open RT Plan File on page 37.
Figure 16 Open RT Plan File

3. Click Open.
Plan data is automatically validated by the Treatment application on 4DITC.
After successful validation, the fields and imaging templates are displayed in the
Session pane. The associated RT image file (2D or 3D reference) is automatically
loaded to 4DITC when the plan is opened. Ensure that the images reside in the
same folder as the related plan and that the image files are labeled with the object
UID from export.
CAUTION: Always verify that the correct patient and plan data are loaded to 4DITC. The
Patient Identification pane in 4DITC should be displayed whenever plan data is loaded.
Although patient photos are not supported in DICOM RT Mode, the patient's
name, ID1, ID2, DOB and Oncologist information is still displayed.

Start Treatment Using DICOM RT Mode
The treatment Process starts as soon as the appropriate plan data is loaded to 4DITC,
for example Mode Up field. However, there are some important limitations to be
aware of when using DICOM RT Mode. These limitations are explored in the next
two sections.
CAUTION: Each clinic is responsible for ensuring that users of DICOM RT Mode are aware
of these limitations, before delivering any treatments.
For specific information on the usage of 4DITC or OBI, refer to the following Varian
manuals and documentation:
■ Treatment Delivery Instructions For Use
■ 4D Integrated Treatment Console Reference Guide
■ On-Board Imager Reference Guide
Limitations for Treatments Using DICOM RT Mode

DICOM RT Mode does not support all of the capabilities normally associated with
4DITC and OBI.
The limitations of DICOM RT Mode currently include:
■ It is possible to manually select a different plan file other than intended for
treatment. Patient identification data is shown within 4DITC. Care must be taken
to always verify that the correct patient and plan are selected for the required
session.
■ For sessions where multiple plans have been scheduled simultaneously in the
Import Export workspace, only one plan can be loaded at a time to 4DITC using
DICOM RT Mode. Take care in to identify the correct plans due to be used in a
specific session and the order in which they are to be treated.
■ Dose limit checks are not supported (for example Session or Daily or Total Dose
Limits).
■ Breakpoints are not supported.
■ The use of patient selection from bar code is not supported.
■ Patient photos and patient notes or alerts are not supported.
■ There is no incremental fraction count displayed. Fraction 1 is always
displayed in 4DITC, because the system has no way of knowing how many
treatments have occurred previously.
■ There is no previous history data loaded. For example, it is therefore not possible
to see the previous cumulative dose to the primary reference point.

■ Previously acquired portal images are not loaded to 4DITC. Only each field’s
reference image is loaded.
■ Loading of the 2D or 3D reference images only occurs if the images exist in the
same folder as the corresponding RT plan. The images are linked to the plan by
reference to the DICOM object UID label.
■ Partial sessions are not recorded. A partially treated plan, closed in 4DITC, will
create a history record. However, if the same plan is reopened, no reference is
made to the previous history record. All the fields within the plan will be
available for treatment again. The Inactivate Field control in 4DITC may be of use
to temporarily disable whole fields for treatment in that session.
■ Resuming partial dynamic MLC fields between sessions (Open/Close Patient
actions) is not supported in DICOM RT Mode. To avoid partial MLC treatment
scenarios export the MLC file data (per field) separately from the appropriate
workspace (Import Export or RT Chart).
Note: If it becomes necessary to resume a partial dynamic MLC, you can use the Clinac and
MLC Workstation in conventional standalone mode (RV interface off) to set up a
corresponding partial beam.
CAUTION: Care must be taken to ensure that the operators manually select the correct
partial treatment parameters.
■ Plan modifications made in 4DITC result in a new session plan file being created in
the file storage system when the patient data is closed. This session plan does not
automatically overwrite the existing occurrence of the original (RP.) plan file. The
use of plan modifications is not generally recommended with DICOM RT Mode.
■ Continuous acquisition (cine) imaging is only possible by having the correct
sequence template applied before exporting from RT Chart. This template cannot
currently be applied directly from 4DITC.
Troubleshoot DICOM RT Data on 4DITC

This section outlines a few scenarios that could be encountered if some of the
previous steps are missed.
■ If you attempt to open an unknown data file type in 4DITC, a message box
displays a Management System Error. Click Details <<. In the example
shown, an attempt was made to open an image file (RI.). Solution: Open RP (RT
plan) data files from the browser in 4DITC.

Figure 17 Management System Error Box
■ To export 2D or 3D reference images from the Import Export workspace, use the
object UID option in the export filter. Do not use the Patient ID + Object Suffix
export option. If the image file names are not set with the Object UID, the images
do not load to 4DITC (although treatment delivery and image acquisition are still
possible). Similarly, images do not load to 4DITC if they are manually renamed
from the object UID to some other user-defined file name (for example, if the file
name is manually changed to ANT PELVIS IMAGE.dcm). 2D or 3D reference
images must always reside in the same folder (directory) as the related RT plan
RP file. Otherwise, 4DITC will not be able to locate them. Solution: Re-export the
RT plan and 2D or 3D reference image data from the Import Export workspace
using the option for the Object UID in the export filter. Do not manually change
the automatically created filenames. Both the plan and images must be saved to
the same folder (directory). Ensure that the OIS database is still online and
accessible.
Note: For VarisVision Version 6.5 - ARIA 10: RT plan file data exported from the Import
Export workspace must be set to Compatible To Varian Treatment Console. Otherwise, a
message box stating Session Load Error opens in 4DITC whenever you attempt to
open an RT plan file. Click Details << to view details. For an example, see Figure 18
Session Load Error on page 41.

Figure 18 Session Load Error
Solution: Ensure that the option for Compatible To Varian Treatment Console is
selected and re-export the RT plan and 2D or 3D reference image data from the
Import Export workspace.
Close the Patient Data and Create DICOM History Records

To close the patient's data at the end of the treatment session:
1. If the plan contains only treatment fields, a message box opens, stating Do you
want to close the patient? after completing the last treatment field. To
close the session, click Yes.
2. If the plan contains one or more setup fields: In 4DITC, click Clear Mode Up.
3. Click Close Patient.
4. To confirm, click Yes.
Depending on the local configuration of the 4DITC application, a Treatment
Complete sign-off box opens.
5. To complete the treatment, enter at least one valid user name and password
combination, with the option to include the user names of an additional two
extra staff who were also present during the session.
6. Click OK.
A Save To dialog box opens. This determines which folder in the file storage
system the DICOM history records are written to, and also how the files are

labeled. This aspect is described in more detail in section DICOM History Files
from 4DITC on page 42.
History records should be written back to the same folder that contains the
original plan (RP.) file data. This has advantages when importing the data back
into the OIS (especially if there are beam history records from multiple sessions).
DICOM History Files from 4DITC

Use a standardized approach for determining the file names of DICOM history
records from 4DITC.
Examples of data to be included in the history file names might include the fraction
number for the plan, date and Patient ID1. An example format could therefore be:
■ Fraction{Number}_{Day}-{Month}_{PatientID1}
The user-defined file name for Fraction 12 treated on 15th June for Patient ID1=
A123456 would be:
■ Fraction12_15-06_A123456
The user-defined file name is appended automatically with the plan ID and also with
information as to whether the file is a Beam Record, Portal Image, kV Image, and so on.
A further example: Patient ID= A123456 had Fraction 12 of their PELVIS plan treated
(two fields) using DICOM RT Mode. One pre-scheduled portal image was also
acquired during the session. This would create three DICOM (.dcm) files on saving:
■ Fraction12_15-06_A123456_PELVIS_BeamRecord1.dcm
■ Fraction12_15-06_A123456_PELVIS_BeamRecord2.dcm
■ Fraction12_15-06_A123456_PELVIS_PortalImage1.dcm
This example shows that when the two beam records are subsequently imported to
the OIS database, they are regarded as imported treatment events in the RT
Summary workspace.
Acquiring any MV portal images before or after treatment also creates additional
beam record files. When such data is subsequently imported to the OIS database, it is
regarded as a portal imaging event in RT Summary.
Modifications made to a plan during a DICOM RT session are also recorded as a new
session plan DICOM file. Examples of modifications which invoke the creation of a
session plan file include changes on 4DITC such as:
■ Editing or acquiring of any plan parameter.
■ Modifying of setup note information.
■ Modifying of image sequence templates.
■ Re-ordering of fields (by drag and drop).

Note: The Session plan file acts as a potential record of what was done during the session.
Session plan changes are not reflected in the original RT plan (RP.) file however.
CAUTION: To minimize confusion, do not make plan changes during DICOM RT sessions.
Avoid opening a Session plan file using DICOM RT Mode for future treatment. Stick to
using the original RP plan file.
Exit DICOM RT Mode in 4DITC

1. Choose one of the following options to close DICOM RT Mode:
Leaving DICOM RT Mode opens patient data from the queue.
Option Description
Option 1: 1. In the Tools menu, clear the DICOM RT Mode check mark.
2. Click Open Patient to access the queue.
Option 2: ■ Exit from 4DITC and reopen the application.
The normal function to open patients from the queue is restored by
default when 4DITC is restarted.
Import DICOM Records to the ARIA 11 or ARIA RTM 13

Database
For DICOM RT Mode Import, choose the folder where the objects are located and
then the objects you want to import.

Figure 19 Selection Panel—DICOM Media File Import in ARIA 11
Figure 20 Selection Panel—DICOM Media File Import ARIA RTM 13

Importing DICOM records to the ARIA 11 or ARIA 13 RTM database is done
following DICOM RT Mode treatments (with or without imaging) after the ARIA
database is online again.
Note: Ensure that the import of patient DICOM RT history and imaging data to the ARIA
database is done before any subsequent treatments are delivered.
Import RT Records
There are several possibilities to perform actions or generate data in DICOM RT
Mode. The following example follows the import of a pelvis treatment plan. Use it as
a guide.
Prerequisites:
■ System upgrade. ARIA database is shutdown.
■ Required filters and user rights are defined by the system administrator.
■ A treatment plan including Setup Fields has been scheduled for a total of 30
sessions.
■ The plan was applied in DICOM RT Mode and Images were acquired respectively
during each DICOM RT session.
To import treatment records:
1. Navigate from User Home > Quicklinks > DICOM to the Import Export
workspace.
2. Click on the Import tab.
3. From the list of available filters, select the required DICOM Media File Import
Filter.
4. Click Next.
To browse to the desired patient folder that holds the DICOM history data in the
file storage system, click the browser button.
Figure 21 Import Wizard

5. Ensure that all RT Records listed for this patient are selected in the DICOM Tree
on the Navigation panel.
6. Click Next.
The incoming DICOM data is validated automatically.
Note: Inform the system administrator of any errors or warnings before proceeding!
The wizard matches up the patient defined in the DICOM files against the
corresponding patient in the ARIA database.
After successful patient matching, patient data is listed in the Patient Selection
Panel
Figure 22 Import Wizard: Select Patient

7. In the Patient Selection panel, select the patient by doing one of the following:
a. Choose one entry in the Existing Patients list on the left side.
b. If the patient matching fails, click New Patient or Browse Patients.
The Patient Explorer application opens and you can search for patients or
create a new patient record. For detailed information, refer to the Patient
Explorer online help. A new patient is listed in the Existing Patients list.
c. Highlight the patient.
8. Click Next.
After the import is completed, you need to verify the import and verify the
scheduling in Treatment Preparation, see Verify and Complete the Import on
page 47 and Verify the Scheduling in Treatment Preparation on page 51.

Verify and Complete the Import
Figure 23 Connection Page in ARIA 11

Figure 24 Connection Page in ARIA RTM 13
The Import Export Log displays the alerts to problems that occurred during import.
An overview of the objects imported to the selected target patient is displayed in the
Connection panel.
1. The Import Export Log displays

■ Objects already present and flagged with a yellow warning icon. These objects
will not be overwritten.
■ Objects with missing data (for example, image creation date or patient
position) flagged with a red clock. These objects will not be imported.
2. In the Connection Page
a. Review the general status:

■ New and properly connected objects are displayed with a green check
mark.
■ New unconnected objects are flagged with a green up/down icon
indicating they can be reconnected to other series.

■ Targets for reconnection are displayed with a green basket.
b. Assign the unconnected object data.
During connection RT plans can be reconnected to courses. New courses can
be created by clicking Create Course, reconnecting is done by drag-and-drop
of plan objects, see Figure 25 Import Summary on page 49.
Note: If there are no error or warning messages, proceed with the next step.
Figure 25 Import Summary

3. Click Next.
The Summary page opens.
4. At this point the import is complete. Click Start New Session to start a new
import or export of DICOM RT data.
Note: For verifying the scheduling, see Verify the Scheduling in Treatment Preparation
on page 51.

Assign Fraction Numbers
1. Navigate via Quicklinks to the RT Summary workspace.
Figure 26 Imported Record Details

2. Select the patient, if not already selected.
3. Select the imported fraction.
The Dose Information panel opens where you can verify the recorded dose.
Figure 27 Dose Information Panel

4. Click Session Detail on the Dose Information panel.
The Session Details panel opens, showing the session timeline.

5. Select one of the treatment records on the session timeline.
The Treatment Details for that record opens.
6. Click Edit Fraction Number in the Treatment Details panel.
Figure 28 Edit Fraction Numbers Dialog
A display for editing fraction numbers opens. Under Select the treatment
records to be updated check the treatment records which share the same fraction
number. The Type column indicates, that the treatment record is imported.
7. Enter a new value for the fraction number in the Change to field.
CAUTION: Take care to assign fraction numbers in the proper order. Otherwise you may
end up with confusing names and with wrong predictions about the numbering of
future fractions.
8. Click Save.
The course timeline displays the updated fraction number.
Note: Note: For more detailed information on the RT Summary Workspace, please refer to
the ARIA RTM RT Summary Reference Guide.
Verify the Scheduling in Treatment Preparation

After import of treatment records, you will get a message that you need to verify the
scheduling in the Treatment Preparation application.

To verify scheduling after treatment records import:
1. Navigate using Quicklinks to Plan Scheduling workspace.

2. A message is shown that informs about the locked course. Read the message
carefully and acknowledge it.
3. In the Scheduling Overview panel click Edit > Unlock Scheduling.
4. Verify the scheduled number of fractions.
5. Select the added fractions and click Remove.
Note: For more detailed information refer to ARIA RTM Treatment Preparation Reference
Guide.

Index
2D reference image 39 RT image 18
4D Integrated Treatment Console (4DITC) 8 RT Ion Plan 18
4DITC (4D Integrated Treatment Console) 8 RT plan 17
DICOM RT data on 36 RT spatial registration 18
history file 42 RT structure 18
RT treatment history 18
RT treatment ion history 19
A DICOM media file
abbreviations 8 import 43
access right 24 DICOM RT files
Advanced Imaging for OBI 1.4 and 1.5 23 about 17
approval of treatment 23 DICOM RT Ion
ARIA OIS 8 plan file 9
ARIA RTM 8 DICOM RT Ion Treatment
history file 9
DICOM RT Mode
B advantages of using 15
careless handling 11
beam record file 42
conditions invalidating Varian
additional 42
responsibility 12
data on 4DITC 36
C troubleshooting 39
enter 36
closing general 11
patient data 41 history file 9
Computerized Tomography (CT) 8 image file 9
configure import and export filters 25 limitation for treatment 38
configuring operating procedures 20
export filter 25, 26 personnel requirements 11
Connection panel 47 plan file 9
CT (Computerized Tomography) 8 related publications 9
file 17 site requirements 11
customer support 7 spatial registration file 9
structure file 9
D use cases 14, 15
what is it 13
DAEMON 8 what is new 13
data organization 21 Digitally Reconstructed Radiograph (DRR) 8
DB (Dynamic Beam) 8 DRR (Digitally Reconstructed Radiograph) 8
dcm 8 Dynamic Beam (DB) 8
default folders for 4DITC, set 22
definitions 8
DICOM 8 E
history file 41 emailing Varian customer support 7
history file from 4DITC 42 exit DICOM RT Mode in 4DITC 43
DICOM files export
CT image 17 RT image data 28
Index 53
RT plan 28 Linac Verification Interface (LVI) 8
Export DICOM Data in ARIA 11 / ARIA RTM LVI (Linac Verification Interface) 8
13 33
export DICOM data in ARIA 8.0 to 10.0 27
export filter M
configuring 25, 26 Megavolt (MV) 8
Export Filter for ARIA 11 / ARIA RTM 13 26 message box
do you want to close the patient 41
management system error 39
F MLC (Multileaf Collimator) 8
file storage system modal mode
preparing 20 DICOM RT Mode Workflow 27
filter 25, 26 modification 42
fraction 42 modify the OIS database plan after initial plan
number 50 export 36
Monitor Unit (MU) 8
MU (Monitor Unit) 8
G Multileaf Collimator (MLC) 8
guide MV (Megavolt) 8
intent 6 my.varian.com 7
purpose 6
target group 6
N
number
H session 50
history file 41
from 4DITC 42
O
OBI (On-Board Imager) 9
I OIS
ID (Identifier) 8 planned downtime 14
Identifier (ID) 8 unplanned downtime 14
image file 9 OIS (Oncology Information System) 9
2D 39 On-Board Imager (OBI) 9
import Oncology Information System (OIS) 9
RT treatment record 45 online customer support 7
wizard (figure) 45 open patient plan 36
Import / Export workspace 13 open RT plan 36
Import Filter for ARIA 11 / ARIA RTM 13 26 open RT plan data from the file storage system
information update 36 36
intent of guide 6 operating procedure 20
ordering product documents by phone 7
organization of patient data 21
K OSP 9
kV (kilovolt) 8
P
L patient data
limitation closing 41
for treatment 38 Patient Explorer application 46

patient plan structure file 9
open 36 support e-mail addresses 7
plan file 9
planned downtime of OIS 14
prepare the imaging environment 23 T
prepare the machine environment 23 target group of guide 6
preparing the file storage system 20 technical support 7
procedure treatment
operating 20 approval 23
purpose of guide 6 limitation 38
starting 38
troubleshooting DICOM RT data on 4DITC 39
Q
QA (Quality Assurance) 9
Quality Assurance (QA) 9 U
UID (Unique Identifier) 9
Unique Identifier (UID) 9
R update information 36
Radiation Therapy Management 9 use case 29
RE 9, 18 use of plan modifications 39
read access 20 user right 24
RI 9, 18
right 24
RN 9, 18 V
RN (Radiation Therapy) Varian customer support 7
files 18 VARiS 9
RP 9, 17 verify scheduling 51
RS 9, 18 VISION 9
RT 9, 18 visual cues 6
RT (Radiation Therapy)
files 18
image W
export 28 wizard
plan import 45
export 28 write access 20
open 36
treatment record
import 45
RT plan 29
RTM 9
RV interface 9
RX 9, 19
RX (Radiation Therapy)
files 19
S
settings for the Export Wizard (RT Chart /
ARIA 8.8) 32
starting treatment 38
storage space 20
Index 55

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DICOM RT Mode

ARIA® Radiation Therapy Management

13485 P1005177A MARCH 2014

Authorized Varian Medical Systems Nederland B.V.

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

2 DICOM RT Mode Reference Guide

All rights reserved. Produced in Switzerland.

CHAPTER 1 INTRODUCTION .............................................................................................................. 6

CHAPTER 2 SAFETY ............................................................................................................................. 11

CHAPTER 3 DICOM RT MODE OVERVIEW .....................................................................................13

CHAPTER 4 OPERATING PROCEDURES ........................................................................................ 20

4 DICOM RT Mode Reference Guide

About this Guide

6 DICOM RT Mode Reference Guide

Get Online Customer Support

Ordering Documents by Phone

Abbreviations and Definitions

8 DICOM RT Mode Reference Guide

10 DICOM RT Mode Reference Guide

Always Handle with Care

Site and Personnel Requirements

Conditions Invalidating Varian Responsibility

12 DICOM RT Mode Reference Guide

What is DICOM RT Mode?

CAUTION: Careless handling or operating can result in unsuccessful treatment or loss of

What is new in DICOM RT Mode?

Chapter 3 DICOM RT Mode Overview 13

Prerequisites for Using DICOM RT Mode

Planned Downtime of OIS

Unplanned Downtime of OIS

14 DICOM RT Mode Reference Guide

Figure 2 System Downtime with ARIA

Figure 3 Upgrade from VARiS Vision to ARIA

Advantages of Using DICOM RT Mode

Chapter 3 DICOM RT Mode Overview 15

Note: Some additional limitations apply to imaging on an OBI system in an ARIA

Table 1 DICOM RT Mode Compared with Standalone Mode

Capability DICOM RT Standalone

16 DICOM RT Mode Reference Guide

About DICOM RT Files

Chapter 3 DICOM RT Mode Overview 17

18 DICOM RT Mode Reference Guide

Chapter 3 DICOM RT Mode Overview 19

CAUTION: Careless handling or operating can result in unsuccessful treatment or loss of

File Storage Preparation

Read and Write Access

20 DICOM RT Mode Reference Guide

Figure 5 Shared Folder on 4DITC workstation

Chapter 4 Operating Procedures 21

Figure 6 Example for Additional Subfolders

Set Default Folders for 4DITC

Figure 7 Setting Default Folders for 4DITC

22 DICOM RT Mode Reference Guide

Figure 8 Treatment Approvals Enforced

Prepare the Machine and Imaging Environment for OBI

kV imaging is made possible by applying the correct sequence template before

Chapter 4 Operating Procedures 23

1. Select the Save CBCT to File System check box to enable.

Figure 9 CBCT Image Path in OBI Administration