OBI-IGRT Clinical School Manual - ENG - Secured

OBI Physicist Operations
OBI/IGRT – Clinical
School Rev. 1.0
© Varian Medical Systems iii

FOR TRAINING PURPOSES ONLY!
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© Varian Medical Systems iv

Introduction
The OBI/IGRT clinical school course provide initial training for physicist, therapist and
doctors. The four-day course provides an overview of how the On-Board Imager
system communicates with the Clinac and the verification system, basic On-Board
Imager maintenance procedures, hands-on training on how to prepare the plan for
treatment utilizing the On-Board Imager system, how to acquire kV and MV images,
how to perform marker match, how to utilize the RPM software with the On-Board
Imager system, and CBCT.The clinical perspective will also be presented.
This document uses the following visual cues to help you locate and find information:
CAUTION: A caution describes actions or conditions that can

result in minor or moderate injury to personnel or can result in
damage to equipment.
WARNING: A warning describes actions or conditions that can

result in serious injury or death to personnel.
NOTE: A note describes actions or conditions that can help the

user obtain optimum performance from the equipment or
software
QUESTION: Lists a question.
© Varian Medical Systems v

Introduction Módulo 1
 Course Introduction
OBI Clinical Rationale and Help Resources Módulo 2
 OBI Clinical Rationale and Help Resources

 OBI system components
 Interfraction and intrafraction motion
 Image guidance radiation therapy
 OBI clinical process
 Help and information resources
 MyVarian Web Site and CTBs
 Overview of MyVarian web site
Treatment Preparation Módulo 3
 Plan Preparation
 Creating setup fields and reference images in Eclipse
 Adding markers in Eclipse
 Plan verification for OBI
 Plan approval
 Treatment Preparation
 Plan verification
 Adding graticule, layers, and field aperture
 Changing field order
 Plan Scheduling and Adding imaging
 Treatment approval
 Plan Preparation Exercise
© Varian Medical Systems

System Components Módulo 4
 Department components
 Server
 Control console components
 Alphanumeric keyboard and mouse
 Clinac console
 Console electronics cabinet
 4DITC
 MLC controller and LVI
 OBI workstation (IGMA)
 OBI console
 KVM Switch
 PaxScan Unit
 RPM respiratory gating computer
 RPM system control
 Treatment room
 Clinac
 Gating camera
 kVS
 kVD
 MVD
 BMC
 ICP and Supervisor
 Hand pendants
 System Components Exercise

2D/2D Match (kV/kV) Verification Módulo 5
 Plan Preparation
 2D/2D match (kV/kV) Verification
 4DITC
 On Board Imager Graphical User Interface
 Acquire Images
 Imaging and Verification Tools
 OBI Tools
 2D/2D match (kV/kV) Verification Exercise
2D/2D Match (MV/kV) Verification Módulo 6
 2D/2D match (MV/kV) and 2D Match (Portal Image) Verification

 4DITC
 Acquire Images
 2D/2D Match (MV/kV) and 2D Match (Portal Image) Verification
Exercise

CBCT Módulo 7
 Cone Beam CT Verification

 Load Session on 4DITC
 Acquire Images
 Reconstruction of an existing exam
 Cone Beam CT Verification Exercise
Imaging Modalities and Theory Módulo 9
 Imaging Modalities
 Optimizing Image Quality
Marker Match Módulo 11
 Marker Match
 4DITC
 Acquire Images
 Marker Match Exercise

Gated Matching and Fluoro Módulo 13
 RPM Overview
 Gated kV/kV and Pre Treatment Fluoro Verification
 4DITC
 RPM
 OBI
 Gated kV/kV and Pre Treatment Fluoro Verification Exercise
Morning Preparation Módulo 15
 Morning Preparation, Warm Up, Shutdown, and Interlocks

 Power up OBI and Clinac with PaxScan Unit on
 Power up OBI and Clinac following complete shutdown
 X-ray tube warm up
 Shutdown sequence for OBI and Clinac
 Troubleshoot Interlocks
 Operator Tips
 Morning Preparation, Warm Up, Shutdown, and Interlocks
(Exercise)

Calibrations Módulo 16
 ExactArm Indexing
 ExactArm Indexing Exercise
 OBI Morning QA and Blade Calibration
 Maintenance workspace
 Blade calibration
 Daily maintenance checks
 OBI Morning QA and Blade Calibration Exercise
 IAS3 Calibration
 Common Terms
 IAS 3 Hardware and Software Components
 Maintenance Workspace Icons
 IAS 3 Calibration
 IAS3 Calibration Exercise
 IsoCal

Administration Módulo 17
 OBI, CBCT, Reconstructor, and Treatment Administration

 Clinac Administration
 Remote auto motions
 Auto setup
 Auto goto
 Large remote auto motions
 Small remote auto motions
 Beam time
 RPM
 Small motions
 ARIA RT Administration
 Administration task startup manager
 Multi-user administration
 External cached plans
 Adding an imager
 Tolerance tables
 Sequence templates
 OSP
 Couch locking
 Administration Exercise

CBCT/Emergency Imaging Módulo 18
 Cone Beam CT Attach CBCT Template at Treat

 Cone Beam CT Image Review After Treatment
 Load Session on 4DITC
 Review previously acquired CBCT Images
 Local Load Procedure
CBCT Calibration Módulo 19
 Cone Beam CT Existing Calibration Procedure

 Calibration and Maintenance Workspace
 Dual Gain Calibration
 I0 (zero) Calibration Mode
 Norm Scan
 Cone Beam CT Existing Calibration Exercise
QA
 Dose in CT/CBCT
 CBCT Primer
 QA
 Quality assurance for IGRT
 A quality assurance program for the OBI

Appendix
 Appendix
 OBI Filters Appendix A
 HU Calibration Appendix B
 OBI Generator Numerical Codes Appendix C
 Persistent Parameters Appendix D
 OBI Status Messages Appendix E
 Keyboard Shortcuts Appendix F
 QA Plan Import
 OBI Plan Preparation
Homework
 OBI Homework Exercise

 ARIA RT Administration
 Treatment Administration
 OBI Administration
 CBCT Administration
 Clinac Administration
 Test patient
 Departmental QC and QA program
OBI Publications/OBI Bibliography

OBI-IGRT CLINICAL SCHOOL
VARIAN February 2014

ONCOLOGY
SYSTEMS
1 | VARIAN ONCOLOGY SYSTEMS
Instructors
Varian/Grupo COI

Course Goal
• OBI/IGRT clinical school course provide

initial training for physicist, therapist and
doctors to operate the Varian On-Board
Imaging system safely and effectively in the
clinical environment.

Course Components
• Target Audience
• Doctors/Physicists/Therapists
• Prerequisites
• None

Building Map

Building Map

Emergency Contact
• If you are going to be late, or not coming in

for the day please contact us at:
• +5521998743051 – Kamilla
• Leave a message. Include your name, and

phone number where we can reach you.

Course Paper Work
• Customer Agreement
• Emergency contact
• Name
• Radiation Badge Form
• Course evaluation
• Electronic survey

Course Do’s and Don’ts
• Cell phones on silent or vibrate mode

• Walk out into the hall to talk
• No laptops out or exploring the internet
during lecture and lab
• No audio or video recording is permitted
• Have fun!

Introductions
• Your Name and Position

• Equipment
• R&V
• Clinacs
• CT/Sim
• Treatment Planning
• Previous Experience
• Hobbies

Varian Resources
Varian Resources
Varian Resources
Varian Resources
Varian Resources
To view Webinars, you do not have to be a member of myvarian.com

• No myvarian.com login is required.
These are presented for free.
Varian Resources
Myvarian.com > select Product Documentation > under Search for Product
Information > select the Product from the dropdown > select the Document Type
from the dropdown > select the Version from the dropdown > add any Refine
using keyboard words > Apply.
Reference Guides and Instructions for Use are located under the Manuals
Document Type.
Varian Resources
Customer Technical Bulletins are located under the CTBs Document Type. If you
are not the one in your department that receives direct information from Varian,
check for new CTBs.
Product Notification Letters are located under Product Notification Letters
Document Type. If you are not the one in your department that receives direct
information from Varian, check for new Product Notification Letters.
Product Safety Notifications are located under Safety Notifications Document
Type. If you are not the one in your department that receives direct information
from Varian, check for new Safety Notifications.
Customer Release Notes are located under Release Notes Document Type. If you
are not the one in your department that receives direct information from Varian,
check for new Safety Notifications.
Varian Resources
For urgent issues, dial 1.888.VARIAN5.

If the issue does not require immediate attention or a document needs to be
attached, send an e-mail to Help Desk address.
Help Desk may use SmartConnect to remotely view the customer’s screen display.
SmartConnect uses internet connection to remotely connect to a workstation.
Varian Resources
Varian Resources
OBI Clinical Rationale and
Resources
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Resources
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Resources
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Resources
• The OBI consists of a kV X-ray source and an amorphous silicon kV panel.

• The OBI employs robotically controlled arms that operate with three axes of
motion, optimizing positioning of the imaging system for the best possible view of
the target.
• The Portal Vision MV imaging system and the OBI allows for filmless acquisition of
MV and kV radiographic pairs without gantry rotation.
• Amorphous silicon MV panel 500-II
• Amorphous silicon MV panel 1000
• The OBI workstation enables you to reposition a patient and the Clinac console
allows you to control the Clinac.
• The OBI Control Console enables you to remotely move the robotically controlled
arms.
Resources
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Resources
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Resources
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Resources
• Our treatment goals are to be able to manage both kinds of organ motion.
• If we succeed, we can minimize tumor margins, spare healthy tissue, and as a
result, possibly increase the dose to the target improving the results of therapy.
Resources
• Prior to treatment, we image the patient in the treatment position.

Resources
• The reference image contains the planned isocenter position.

• By aligning the reference image isocenter with the isocenter of the acquired image
(which should coincide with machine isocenter) the OBI displays the position of
the patient in relation to the correct treatment position. Alignment of the images
is translated into couch shifts by the OBI, which can then be sent to the Clinac
console for accurate patient positioning.
• IGRT lets you obtain high-resolution, three-dimensional images to pinpoint tumor
sites, adjust patient positioning when necessary, and complete a treatment – all
within the standard treatment time slot.
Resources
• Matching modes become active based on what type of field is selected on the
4DITC.
• For example, a CBCT setup field will activate the 3D Match button whereas a kV
setup field will activate the other three.
Resources
• Use 2D Match with kV or MV images.

Resources
• An orthogonal pair, AP and Right Lateral, is generally used with 2D/2D match.
However, any orthogonal pair as well as non-orthogonal pair can be used.
• Example: Hip prosthesis may require an AP and anterior lateral oblique to view
necessary anatomy.
• 2D/2D can be used with kV/kV, MV/kV, or MV/MV.
Resources
• Markers can also be aligned using 2D/2D Match by contouring the markers in
treatment planning and adding them as a layer to the DRR.
Resources
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Resources
The OBI offers a convenient clinical process:

Patient setup
• The therapist positions the patient as usual.
Image acquisition
• The therapist selects the appropriate setup field and chooses to acquire either a pair of radiographs
(kV/kV or MV/kV pair) with or without gating, fluoro, or a cone-beam CT scan.
• When the OBI is used in conjunction with the Real-Time Position Management (RPM) respiratory
gating system this also enables fluoroscopic pre-treatment gating verification and gated
radiographic anatomy image matching.
• Setup fields are image only fields utilized in the verification process.
Image analysis
• The therapist can select from manual or automated image registration tools to register the OBI
images with the reference image (kV radiographs, DRRs, or planning CT scans).
• Verification can be done utilizing bony anatomy or radiopaque markers in paired images, or by
visualizing soft-tissue and bony anatomy in cone-beam CT images.
Remote patient positioning
• The couch is moved remotely with the press of a motion-enable button.
Treatment delivery
• The robotic arms can be retracted/parked remotely, and the treatment can commence.
Review of images
• The acquired images are sent via DICOM to the image server, where they can be accessed later on
during the review process.
• With OBI AI images can also be reviewed in Offline Review prior to applying shifts.
Resources
• OBI is delivered with course operations manuals, Instructions for Use (IFUs), and
reference guides in electronic format.
• There are also customer release notes (CRNs) delivered with each software version
or upgrade.
• Help Desk agents can be contacted via phone or e-mail.
• CTBs (Customer Technical Bulletins) are available through MyVarian.
• PNLs (Product Notification Letter) are mailed to one person at each site.
• FDA 510 (k) clearance numbers for OBI:
• Radiographic 510(k): K040192
• Cone beam CT 510(k): K042720
• Fluoro 510(k): K041519
• To get a copy of the documents go to the FDA web site
(http://www.fda.gov) and enter the appropriate number.
Resources
• Varian documentation can be found on myvarian.com

• Only the above listed independent MU calculation programs are validated to be
installed on Varian workstations.
• Installing unapproved software on Varian workstation may invalidate the warranty
support.
Resources
• Antivirus software can be installed but it cannot run in real-time mode.

• Scanning the incoming/outgoing data with an antivirus software may:
• Slow down the system.
• False alarms.
• Misinterpretation of data.
• Daily backup procedure slow down or failure.
Resources
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Plan Preparation
PROCEDURE
Objective:
 After completing this module, using the OBI/IGRT Clinical School Manual as a
resource, the student will be able to:
 Create setup fields
 Define couch and imager positions
 Assign reference images
 Add layers
 Schedule sequence templates
A. Exercise Key
1. Right mouse click denoted as RMC.

2. Brackets denote additional selection options.
3. The ‘>’ symbol denotes drill down from menus.
B. Procedure Content
1. Creating setup fields and reference images in Eclipse

2. Adding Markers in Eclipse
3. Adding Setup Fields to Already Treated or Imaged Plans using Eclipse
4. Plan verification for OBI
5. Plan approval
6. Treatment Preparation
 Plan verification
 Adding graticule, layers, and field aperture
 Changing field order
 Plan Scheduling and Adding Imaging
 Treatment approval
© Varian Medical Systems Módulo 3

Plan Preparation
NOTE: This exercise was designed for training purposes only and
is not to be followed directly in the clinical process. Any changes to
the plan that will be used for the treatment of the patient have to be
verified and approved by qualified personnel.
C. Setup Field general Information
1. Setup Fields are fields that are utilized for moving the treatment unit to the correct
treatment position or for aligning the patient correctly for treatment.
2. Setup Fields are typically orthogonal fields, generally an AP and a right lateral.
NOTE: Customers who have the On Board Imager (OBI) on their

accelerator generally utilize a right lateral field as a Setup Field. It
requires less gantry rotation to move the accelerator from one field
to another than it would if using a left lateral field.
3. Setup Fields are created in the plan and do not contribute to the dose of the plan.
4. DRR’s attached to Setup Fields are used by the OBI as reference images for 2D
and 2D/2D matching.
5. Setup fields intended for use with CBCT do not require a DRR.
6. Setup Fields are designated with the icon in the Focus window.
D. Create and Modify a Setup Field
1. Setup Fields can be created from the original (treatment) fields in External Beam
Planning > Fields workspace.
 The original field remains intact, while the created setup field is an exact copy
of the original, excluding dose and including the DRR and field accessories.
 When the field is modified, the DRR of the setup field will recalculate.
 If an MLC is attached to the field, it must be updated following field
modification.
 RMC on the selected treatment field in the Focus window > New Setup Field
from Selected Treatment Field (Figure 1).

Plan Preparation
Figure 1: New Setup Field from Selected Field
2. Insert new setup fields in a plan using the default field settings.
 Select the plan requiring the Setup Fields in the Context window: Insert >
New Setup Field... (Figure 2).
 The field will appear in the vertical gantry (0° IEC) position without a DRR.
This is with respect to the default geometry entered in RT Administration.

Plan Preparation
Figure 2: Insert New Setup Field
3. Adjust gantry rotation and field size in the Info window.

 If using a portal imager for imaging, ensure the field size set is smaller than or
equal to the active area (at the defined SSD) of the portal imager to avoid
damage to the hardware. The maximum field size is 26.7cmx20cm with the
imager at 50cm from isocenter.
4. Add a DRR to a setup field.
 RMC on the Setup Field > New DRR.
 DRR options dialog box appears. Please refer to the Appendix for DRR editing
options.
 Select options; then Apply.
5. Repeat steps 1-4 for additional setup fields.

Plan Preparation
E. Add Markers to the 3D image:
1. Markers can be pre-defined in Eclipse in an Inspiration environment. The system

will save the Markers so that they can be used on a daily basis to perform Marker
Match verification in OBI.
2. If the Markers are not pre-defined in Eclipse, they can be detected and saved in
the OBI software application. This will also enable the user to perform daily
Marker Match verification.
 This functionality is not supported with some 3rd party R/V systems. The
Markers will have to be detected in the OBI software application on a daily
basis.
3. To add Markers in Eclipse, select the Contouring or External Beam Planning >
Field workspace.
4. Select Insert> New Marker.
5. Define Marker properties and select OK. Error! Reference source not found.
6. Select the Move Marker icon .

7. Click on the Marker in any of the views and adjust its location.
F. Adding Setup Fields to Already Treated or Imaged Plans using Eclipse
1. If a patient is transferred to an OBI machine from a non-OBI machine, it may be

advantageous to update the patient’s plan with setup fields for kV imaging.
2. Create a Plan Revision:
 RMC on the Plan> Create Plan Revision (Figure 3).

Plan Preparation
Figure 3: Create Plan Revision
3. The original Plan will be Retired .

4. The revised plan is displayed with a [plan name]:1.
5. The new plan, Plan: 1 is unapproved and ready for editing.

6. Add setup fields per section D.
G. Plan Verification for OBI
1. Plan needs to have at least one treatment field with MUs. Plans can be created
with only set up fields (ex. Morning QA patient).
2. The plan's patient orientation needs to be defined.
3. If necessary, define marker locations.
4. Create appropriate setup fields.
5. Create reference images.
6. The couch and imager parameters are defined.
7. All fields in the plan should to have the same couch positions (excluding couch
rotation).

Plan Preparation
H. Plan Approval process in Eclipse:
1. Once the above parameters have been verified, select F4 on the keyboard and
the planning approval wizard will be displayed. Alternatively, you may also RMC
on the plan in the context window > plan approval > planning approved.
2. If the plan is incomplete, the planning approval wizard will display the invalid
parameters in the planning approval – verification dialog box (Figure 4).
Figure 4: Planning Approval warnings and errors
3. In the projected structures in reference images list box, select the structures
whose outlines need to be added to the reference images (Figure 5).
4. To create a DRR image for each field, select the generate DRRs into fields
check box (Figure 5).
 DRR’s will be created for each field that does not already have one.
 The system will use the default DRR template.
5. To calculate the treatment time for the fields, select the calculate treatment
times check box and define the treatment time factor in the multiply with
factor box (Figure 5).
 The treatment time of a plan is calculated from the MUs and the dose rate of
the plan, using a treatment time factor:
treatment time = treatment time factor x MU/dose rate
 The range of the factor is 1.00 to 5.00.
6. The actual SSD can be defined for each of the fields in the actual SSD window
(Figure 5).

Plan Preparation
7. After verifying the parameters in the planning approval wizard dialog box, click
next (Figure 5).
Figure 5: Planning Approval dialog box
8. The authentication dialog box will be displayed. (Figure 6)

 Type the appropriate User name and Password and click Finish.

Plan Preparation
Figure 6: Authentication
9. The status of the plan is changed to planning approved .
I. Treatment Preparation – Plan Parameters Workspace:
1. Navigate to Plan Parameters by selecting Quicklinks > EMR > Plan Parameters
(Figure 7). Manipulations of set up fields can also be done in Treatment
Preparation prior to treatment approval.
Figure 7: Quicklinks: Plan Parameters
2. To turn on and off the context window, select on the toolbar.

3. In the view, select the appropriate plan in the dropdown (Error! Reference
source not found.8).
4. In the view, select field graphics and treatment unit checkboxes to display the
reference images and gantry position.
5. Verify the individual field parameters: ID, name, time, tolerance table, SSD,
couch position, imager position.

Plan Preparation
 Verify that the setup fields have the appropriate tolerance table.
Figure 8: Plan Parameters workspace
6. To add a graticule, click on the Setup Field in the scope pane and select the
graticule on the toolbar.

 This will display a yellow graticule on the active image in the view (Figure 9).
 To convert the Graticule to a contour, RMC on the setup field > convert
graticule to contour.
 The displayed graticule will change from yellow to green on the active image in
the view and the icon will be added to the focus pane (Figure 10).
 Repeat the process as necessary for the remaining fields.

Plan Preparation
Figure 9: Display graticule
Figure 10: Convert graticule to contour
NOTE: Treatment field apertures are automatically created for all

fields at the 4DITC and in Off Line Review. To add a field aperture
contour to a set up field of the same gantry angle, the user can add
it in Plan Parameters or Treatment Preparation.

Plan Preparation
7. To create a layer, first verify that the Setup field is active.
 Click on top of the Setup field in the scope pane.
 RMC on the image in the focus pane > New Layer (Figure 11).
Figure 11: New layer
8. The layer properties dialog box will be displayed (Figure 12).

 Fill in the ID, name, appropriate Type and Color and Style. Select User for
Type and click OK.
 A new layer will be added to the focus pane .
Figure 12: Layer Properties

Plan Preparation
9. To activate the graphic toolbar, click on the Layer icon in the focus pane.
The graphic toolbar will become active within the toolbar (Error! Reference
source not found.3).
 For a detailed description of the individual graphic tools view Table 1.
Figure 13: Graphic toolbar
Graphic Toolbar
Icon Name Description
Select Selects an object.
Rotate Rotates a selected layer by clicking and dragging anchor

points.
Mirror L/R Mirrors selected contours left/right. Flips vertically.
Mirror U/D Mirrors selected contours up/down. Flips horizontally.
Point Places points that can be used for anatomy matching, or

user-defined labeling.
Rectangle Draws a square or rectangle that can be stretched and
adjusted.
Ellipse Draws a circle or oval that can be stretched and adjusted.
Freehand To draw with the mouse on the selected layer.
Annotation To type a text label that appears at the point you clicked.
Rubber Automatically creates points along a selected outline. To

Band change the outline of the shape, pull on the points by using
the mouse.
Correction To extract or extend a contour.
Auto To automatically draw a margin of a designated size around

Margin a selected layer.
Table 1: Graphic toolbar

Plan Preparation
10. To enlarge the image, select maximize in the field graphics window.
11. Select the Freehand icon on the toolbar.

 On the active image in the field graphics window, click point by point, or draw
a continuous line to define the contour.
 RMC and select Finish Open or Finish Closed (Error! Reference source
not found.4).
 Repeat the process as necessary for the remaining fields.
Figure 14: Freehand tool
NOTE: The FAC contour is added automatically by a DICOM

Daemon running on the 4DITC. Steps 13-15 are no longer
necessary but may be useful for troubleshooting purposes.
12. For the RPM use cases, a treatment field aperture will need to be added. The
treatment field aperture outlines the area being treated.
13. The treatment field aperture overlay is displayed on the fluoroscopic image on the
OBI workstation. The overlay is green or blue when the MV treatment beam is
‘On’ or red or yellow when the MV treatment beam is ‘Off’. The respective colors
are determined in the OBI Administration.

Plan Preparation
14. To add a treatment field aperture RMC > setup field > create field aperture
contour (Error! Reference source not found.5).
 The aperture is automatically created.
Figure 15: Field aperture
15. To change the field order, select field > field order (Error! Reference source
not found.6).
 The field ordering dialog box appears, listing all the treatment and setup fields
(Error! Reference source not found.7).
 The fields can be moved up or down in the priority list or can be arranged for
clockwise or counterclockwise by gantry rotation.
 To move a field up or down, click on the required field in the field ordering
dialog box and click move field up or down.
 When finished click OK.
Figure 16: Field > Field Order

Plan Preparation
Figure 17: Field ordering
16. Click save all on the toolbar.
J. Treatment Preparation – Plan Scheduling workspace:
1. It is necessary to schedule the plan. Select the Plan Scheduling workspace

Figure 18: Plan Scheduling Workspace

Plan Preparation
2. A list of plans and their status display in the Plan Scheduling pane.
 Select the checkbox to the left of the plan to be scheduled. This allows the
plan details to display in the Manual Scheduling pane (Figure 19).
 Select the Schedule button to schedule daily fractions (5fx/week)
automatically. If the Fraction Pattern needs to be altered (say, for BID
treatments), adjust the pattern using the up or down arrows under the plan's
fraction pattern then select Schedule (Figure 19).
 If scheduling a plan that requires a Delay (ex. a boost plan), type in the
number of fractions the plan needs to be delayed before use (Figure 19).
Figure 19: Plan Scheduling and Manual Scheduling
3. Once the Schedule button is selected, verify the correct number of treatment
fractions is scheduled in the Manual Scheduling workspace (Figure 19). Available
scheduled fractions appear as numbered green bubbles. Once a fraction is
delivered, the green bubble changes to gray.
4. To pre-schedule port films, MV, kV, or CBCT images, in the Manual Scheduling
workspace, select the to expand the treatment plan. Select the again to
expand Imaging (Error! Reference source not found.0).
Figure 20: Image Scheduling

Plan Preparation
5. Highlight the boxes that correspond to the field for each treatment fraction that
requires prescheduled images (Figure 21). Click and drag your mouse over rows
and columns of images for bulk scheduling. Use the control key with the mouse
to highlight specific fractions for imaging. Highlighting the row titled Imaging is not
used for scheduling, but is a quick reference placeholder for images scheduled if
not expanded.
Figure 21: Fields selected for image scheduling
6. Select Add Imaging. Select the correct image type (Figure 22).
Figure 22: Add Imaging
7. The icon representing the image type scheduled is displayed. The icon
indicates that images are scheduled for that fraction (Figure 23).

Plan Preparation
Figure 23: Images Scheduled
8. Repeat steps 5-6 to preschedule images for other fields in the plan if required.
9. Click Save Patient on the toolbar.
K. Treatment approval process in Treatment Preparation:
1. Select the Treatment Preparation workspace (Error! Reference source not

found.4).
Figure 24: Treatment Preparation
2. In the Treatment Setup section, select the plan to be treatment approved


Plan Preparation
Figure 25: Select plan for treatment approval
3. In the Validation and Approval section, ensure “Plan is ready for approval” is
displayed (Figure 26).
Figure 26: Validation and Approval
NOTE: Errors will be displayed as in the Validation and

Approval section. These errors must be resolved prior to treatment
approval.

Plan Preparation
4. In the Treatment Approval section, enter your Username and Password (Figure
27).
Figure 27: Treatment Approval
5. The status of the plan is changed to treatment approved (Figure 28).
Figure 28: Treatment Approved Plan

Plan Preparation
Information Disclaimer
Abstract
The On-Board Imager® Training material is an educational aid for Varian On-Board Imager® System.
Worldwide Headquarters
Varian Medical Systems, Inc.
3100 Hansen Way, Bldg. 4A
Palo Alto, CA 94304-1030, U.S.A.
Notice
This information is an educational aid only and is intended solely as a supplemental document. This information
provides information concerning the use of the On-Board Imager® System. For complete information concerning
components, safety instructions, installation, maintenance, troubleshooting, etc., refer to the applicable Varian
product Operator’s Manual. This document does not replace the Varian Operator’s Manual.
Carefully read all instructions prior to use. Observe all contraindications, warnings and precautions noted in these
instructions. Failure to do so may result in patient and/or user complications.
Information within the manual 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 information or for incidental or consequential
damages in connection with furnishing or use of this material. This contains proprietary information protected by
copyright. No part of this information may be reproduced, translated, or transmitted without the express written
permission of Varian Medical Systems, Inc.
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
Varian Medical Systems, Oncology Systems products are designed and manufactured in accordance with the
requirements specified within this federal regulation.
ISO 13485
requirements specified within ISO 13485 quality standards.
HIPAA
Varian’s products and services are specifically designed to include features that help our customers comply with
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The ARIA and VARiS Vision systems
use a secure login process, requiring a user name and password that supports role-based access. Users are
assigned to groups, each with certain access rights, which may include the ability to edit and add data or may limit
access to data. When a user adds or modifies data within the database, a record is maintained of the data that
was changed, the users ID and the date and time the changes were made. This establishes an audit trail that can
be examined by authorized system administrators.
CE
Varian Medical Systems, Oncology Systems products meet the requirements of Council Directive MDD
93/42/EEC.
Trademarks
Argus Software®, Clinac®, On-Board Imager®, SonArray®, Trilogy® and VARiS® are registered trademarks of
Varian Medical Systems, Inc. 4D Integrated Treatment Console™, Acuity™, ARIA™, Eclipse™, FastPlan™,
Millennium™ MLC, PortalVision™, Real-Time Position Management™ and SmartBeam™ are trademarks of
All other trademarks or registered trademarks are the property of their respective owners.
© 2013 Varian Medical Systems, Inc.

All rights reserved.

OBI Plan Preparation
PROCEDURE
Objective:
 After completing this module, using the OBI/IGRT Clinical School Manual
as a resource, the student be able to verify the prepared On Board Image
(OBI) plan.
A. Exercise Key

2. Left mouse click denoted as LMC.
3. Bracket () denotes additional options.
4. The > symbol denotes drill down from menus.
1. Plan Preparation and Plan Scheduling

2. Treatment Approval
3. Alternatives
C. Plan Preparation and Plan Scheduling
1. Create treatment plan with one set up field using Eclipse or 3rd party Treatment
Planning System (TPS). Refer to Tab 06-05 in this manual for more details on
Plan requirements.
2. Include DRR’s, digital images from Acuity or scanned images as reference
images.
3. Change the plan status to “Planning Approved” by right clicking on the plan in the
context window of Plan Parameters > Plan Approval > Planning Approved. If
the plan is created in Eclipse, Planning Approval (F4) is suggested to be done n

Eclipse.
4. It is necessary to schedule the plan. Select the Plan Scheduling workspace
(Error! Reference source not found.).
Figure 1: Plan Scheduling Workspace
5. Manipulations of set up fields can also be done in Treatment Preparation prior to

treatment approval.
6. A list of plans and their status display in the Plan Scheduling pane.
 Select the checkbox to the left of the plan to be scheduled. This allows the
plan details to display in the Manual Scheduling pane (Figure 2).
 Select the Schedule button to schedule daily fractions (5fx/week)
automatically. If the Fraction Pattern needs to be altered (say, for BID
treatments), adjust the pattern using the up or down arrows under the plan's
fraction pattern then select Schedule (Figure 2).
 If scheduling a plan that requires a Delay (ex. a boost plan), type in the
number of fractions the plan needs to be delayed before use (Figure 2).
Figure 2: Plan Scheduling and Manual Scheduling
7. Once the Schedule button is selected, verify the correct number of treatment
fractions is scheduled in the Manual Scheduling workspace (Figure 2). Available
scheduled fractions appear as numbered green bubbles. Once a fraction is
delivered, the green bubble changes to gray.

8. To pre-schedule port films, MV, kV, or CBCT images, in the Manual Scheduling
workspace, select the to expand the treatment plan. Select the again to
expand Imaging (Error! Reference source not found.).
Figure 3: Image Scheduling
9. Highlight the boxes that correspond to the field for each treatment fraction that
requires prescheduled images (Figure 4). Click and drag your mouse over rows
and columns of images for bulk scheduling. Use the control key with the mouse
to highlight specific fractions for imaging. Highlighting the row titled Imaging is not
used for scheduling, but is a quick reference placeholder for images scheduled if
not expanded.
Figure 4: Fields selected for image scheduling

10. Select Add Imaging. Select the correct image type (Figure 5).
Figure 5: Add Imaging
11. The icon representing the image type scheduled is displayed. The icon
indicates that images are scheduled for that faction (Figure 6).
Figure 6: Images Scheduled
12. Repeat steps 9-11 to preschedule images for other fields in the plan if required.
13. Click Save Patient on the toolbar.

D. Treatment Approval
1. Select the Treatment Preparation workspace (Error! Reference source not

found.7).
Figure 7: Treatment Preparation
2. In the Treatment Setup section, select the plan to be treatment approved

Figure 8: Select plan for treatment approval

3. In the Validation and Approval section, ensure “Plan is ready for approval” is
displayed (Figure 9 and Figure 10).
Figure 9: Errors and Warnings
Figure 10: Validation and Approval

4. In the Treatment Approval section, enter your Username and Password (Figure
11).
Figure 11: Treatment Approval
5. The status of the plan is changed to treatment approved (Figure 12).
Figure 2: Treatment Approved Plan
E. Alternatives
1. As an alternative to Treatment Approval in the Treatment Preparation workspace,

this can also be done:
 in Plan Parameters – RMC on the plan in the Context window for Approval
options.
 in Reference Points – RMC on the plan in the Context window for Approval
options or click on the Signature button for Treatment approval dialog box.
2. As an alternative to creating DRRs in Eclipse, this can also be done in the
Treatment Preparation workspace.
 To create DRRs in Treatment Prep, this must be done before the plan is
approved and a reference CT must be available.
 Highlight the field.
 In the Field Images area, click Edit > Create DRR > Parameter Set and
choose the appropriate parameter set (Figure 13).

Figure 13: Creating DRRs in Treatment Preparation
 You can perform other tasks to adjust the appearance of your newly created
DRR or any image that is attached to a field using the View, Edit and Expand
window features (Figure 14).
Figure 14: DRR in Treatment Preparation

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Plan Preparation
EXERCISE
Objectives:
 Using the OBI/IGRT clinical School Manual as a reference, the student will be
able to:
 Create an orthogonal pair setup fields either in Eclipse or ARIA Plan
Parameters workspace.
 Assign a reference image to each setup field.
 Add a bone layer and treatment field aperture.
 Schedule a kV sequence template and CBCT sequence template to the
appropriate setup field for each treatment session.
 Verify the plan parameters needed to perform the OBI use cases.
A. The participants will complete the following exercise:
1. Open the patient Plan Preparation IGRT Clinical School (ID1:

IGRT01/IGRT02/IGRT/03) and the plan Plan Preparation (found in Course 1).
2. Create two kV setup fields, one pre-fluoro gating setup field, and one CBCT setup
field. This can be done in either Eclipse or ARIA Plan Parameters workspace.
3. Verify that each of the setup fields has a reference image.
4. Add a bone layer to each of the kV setup fields.
5. Add a treatment field aperture to the pre-fluoro gating setup field.
6. Schedule the appropriate sequence template for each of the setup fields.

System Components
PROCEDURE
Objectives:
 After completing this module, the student will be able to perform the following
tasks using the OBI/IGRT Clinical School Manual as a resource:
 List the major components of the OBI
 Record the properties of the individual OBI arms
A. Exercise Key:
1. Right mouse click denoted as RMC

2. Brackets () denote additional selection options
3. The ‘>’ symbol denotes drill down from menus
1. Department components
 Server
2. Control console components
 Alphanumeric keyboard and mouse
 Clinac console
 Console electronics cabinet
 4DITC workstation
 MLC controller and LVI
 OBI workstation (or IGMA computer)
 OBI console
 KVM switch box

System Components
 PaxScan Unit
 RPM respiratory gating computer
 RPM system control
3. Treatment room
 Clinac
 Gating camera
 kV Source (kVS)
 kV Detector (kVD) panel
 MV Detector (MVD) panel
 Backup Motion Control (BMC)
 Inter-Connect Panel (ICP) with Supervisor
 Hand pendants
C. Department Components
1. Server
 In an Inspiration environment, the server stores all of the patient data.
 Patient information is sent via DICOM to the 4DITC by the IT DICOM Daemon.
 The server can also communicate with 3D party treatment planning software.

System Components
D. Control console components

1. Clinac
2. 4DITC
2
3
1 . 4 3. OBI
. . .
4. RPM
Dedicated Alphanumeric KVM OBI control RPM control

keyboard keyboard switch console
Figure 1: Control console area
1. Alphanumeric keyboard and mouse (Figure 1):

 The multipurpose keyboard and mouse enables the user to work with
treatment delivery and other software components.
 Multiplicity Software installed on the 4DITC and the OBI workstations (RPM
workstation optional) allows the user to drag the mouse between monitors
without the use of a KVM switch.
 A KVM switch (keyboard, video, and mouse) is installed for backup purposes.

System Components
2. Clinac console:
 Displays accelerator operations (Figure 2).
Figure 2: Clinac Console
3. The dedicated keyboard controls the Clinac console. The dedicated keyboard
provides function and motion keys that enable the user to enter data and carry out
commands. The dedicated keyboard is divided into motion keys, beam-control
buttons, and control keys.
4. The console electronics cabinet is the interface between the Clinac and the rest of
the system (Figure 3).
 The Clinac console has its own workstation.
 The LVI could be housed inside or outside of this cabinet.
Figure 3: Console electronics cabinet

System Components
 The console electronics cabinet enables interlock communication for the OBI
and RPM through the I/F board (interface) (Figure 4).
 The console electronics cabinet also looks at interlock communication for the
MV beam, kV system, MLC controller, and RPM computer.
Figure 4: I/F board in console electronics cabinet

System Components
5. 4DITC (4D Integrated Treatment Console) (Figure 5)

 Displays treatment delivery software.
 Operated by the alphanumeric keyboard and mouse.
 Has its own workstation. The MV imaging calibration software and MLC
software is installed on this same workstation.
 Has its own administration: Treatment Administration.
 In an Inspiration environment, communicates directly with the department
server. Transfers information back and forth via the IT DICOM Daemon.
 Communicates directly with IMPAC via DICOM.
 During verification, transfers the plan and setup fields to the OBI workstation,
and transfers the couch shifts to the Clinac. The OBI sends requests via the
4DITC to the LVI to the Clinac. The 4DITC records the Clinac position via the
LVI and sends the position to the OBI.
 The IAS3 image reconstruction boards are also housed in the 4DITC
workstation.
 Transfers acquired MV images to the OBI (Figure 6).
 Has interlock communication with the OBI and Clinac.
Figure 5: 4DITC

System Components
Figure 6: MV Overview
6. MLC Controller (Figure 7)

 Communicates with the 4DITC and MLC.
Figure 7: MLC controller

System Components
7. LVI (Linac Verification Interface) (Figure 8)

 Communicates with the 4DITC and the Clinac.
 Has its own workstation, which could be located in the Clinac control cabinet
or as a separate stand alone computer box outside of the cabinet.
 Communicates directly to the Clinac and indirectly with the OBI via the 4DITC.
 Connects to In-room Monitor.
Figure 8: Console electronics cabinet

System Components
8. OBI workstation (Figure 9)

 The graphical user interface is similar to the 4DITC.
 Two different workspaces: Verification and Maintenance. Service engineers
use Maintenance for calibration.
 Supports acquisition and evaluation of kV and MV images (MV Images are
processed on the 4DITC) (Figure 10).
 Graphics window displays reference images and acquired images, pair of
orthogonal images for image match, CT images for marker match and CBCT,
and reference images and field aperture for gated acquisition.
 The dynamic window displays the Plan Tree and Image Gallery. The user
can change the active field by selecting the appropriate field from the
hierarchy tree, and dragging and dropping it to the active area. The Image
Gallery displays the reference, historical (past 4), and current acquired
images.
 The toolbar has advanced verification tools (i.e. blending, filters, match
algorithm, split window, moving window, etc.).
 The dashboard displays the kV imager position, kV exposure settings, X-ray
tube parameters, mode selection, and interlocks.
 During Marker Match and 3D Match (CBCT) verification, the OBI downloads
the planning CT from the server.
Figure 9: OBI graphical user interface

System Components
Figure 10: kV Overview
9. CBCT Reconstructor Workstation

 A Windows background service “CTreconstructor” reconstructs the raw
projections acquired during a CBCT into a 3D dataset.
 The “CTreconstructor” service is installed on the OBI workstation for installs
with Dell T7500 and others.
 For IGMA (Industrial Grade Medical Appliance) installations, the OBI and
Reconstructor workstations are combined into one device.
10. OBI Console (Figure 11)

 The OBI control console is a dedicated control panel that enables the user to
control the motion and function of the kV imaging system.
 The OBI workstation downloads the source and imager arm position to the
supervisor via the OBI console.
 The hand switch or foot switch can be used to acquire kV radiographic and
CBCT images.

System Components
kV
controls MV
controls
Figure 11: OBI console
11. PaxScan Unit (Figure 12 and Figure 13) :

 Image processor and power supply.
 Transfers kV images for display on the OBI. The X-rays enter the PaxScan
detector and are converted into electrons. The charges stored in the pixel
matrix are then read out and digitized in the detector. The command
processor converts the pixel data into video data and sends it to the UCB.
 Be careful of the fiber optic cable.
 Power should be on at all times.
 Only turn off to reboot the system for troubleshooting purposes.
 If turned off for more than a few minutes, it will take approximately 2 hours to
warm up.
Figure 12: PaxScan Unit Figure 13: PaxScan Unit on/off switch on back of
the box

System Components
12. RPM respiratory gating system computer (Figure 14)

 Dedicated computer for the RPM respiratory gating system.
 Video tracking software.
 Breathing Trace display.
 The OBI workstation receives the gating signal and displays the gated fluoro
field outline in green or red on the acquired image.
 Common patient database located on the network.
 Not connected to any Record and Verify system.
Figure 14: RPM graphics window

System Components
RPM system control (
13. Figure 15)

 Enables the operator to disable gating or manually hold the beam.
 Two gating controls: disabled or enabled.
 Beam hold button: press to manually put the beam on hold.
 Key can be removed when in the gating disabled position.
Figure 15: RPM system control
14. OBI Network Architecture (Figure 16)
Figure 16: OBI Network Architecture

System Components
E. Treatment Room
1. High Energy Clinac (Figure 17)
Figure 17: High Energy Clinac OBI
 In-room monitor: displays the moded-up treatment field (Figure 18).

 Large In-room monitors may interfere with the hand pendant infrared signal
and receiver.
Figure 18: In-room monitor

System Components
F. kVS Anatomy (Figure 19)
2. Enclosed by a protective plastic cover, which acts as its collision detector.

3. X-ray tube with 140 target angle.
4. Two focal spots: 0.4mm (small) and 0.8mm (large).
5. The kV Blades:
 Defines the size of the kV image.
 Can be symmetrical or asymmetrical.
 Minimum field size is 2x2. Maximum field size is 50x50.
 Defaults to Track position. When Track is enabled, the kV blades
automatically open the field size to the maximum size of the imager’s active
area. When Track is disabled, the user can set a specific blade position. This
function minimizes unnecessary radiation exposure and may improve image
quality.
 The mechanical parameters of the blades are (Error! Reference source not
found.):
Table 1: Blade Mechanical Limits

System Components
Figure 19: kV Source Geometry – NOTE: 147.90 mm = Focal Spot to distal side of Interface
Plate

System Components
6. A bow tie filter can be mounted to the kVS during the acquisition process.
WARNING: Always handle the bow tie filter carefully. An

improperly fitted bow tie filter can fall off and cause serious bodily
harm. Rotate the gantry so that the X-ray source is below the
patient and then fit the bow tie filter (Figure 20). Pull on the handle
to verify a secure fit.
7. A bow tie filter is a mechanical device that is mounted to the face of the kV
Source in order to filter the X-ray beam. The OBI bow tie filter is made of
aluminum. This device improves the quality of CBCT projections which are
reconstructed into 3D CBCT images. The use of a bow tie filter for acquiring
CBCT scans offers the following advantages:
 Reduces skin dose.
 Reduces X-ray scatter improving image quality.
 Reduces charge trapping in the detector. Refer to the abstract for more
information on charge trapping “Temporal artifacts in flat dynamic x-ray
detector”. Proc. SPIE Vol. 4320, p. 47-58, Medical Imaging 2001: Physics of
Medical Imaging, Larry E. Antonuk; Martin J. Yaffe; Eds. ©2006 SPIE.
 Allows higher X-ray techniques to be used without saturating the detector.
NOTE: The bow tie filter can improve radiographic image quality.
We recommend that the bow tie filter be left in place for 2D/2D
acquisition. This allows for 2D/2D and 3D acquisition to be
performed one after the other without going into the treatment
room.

System Components
Lock
Latch Accessory Light (LED)
Handle
Notch
Stops
Figure 20: Bow Tie Filter Fitted
G. kVD Anatomy
1. Enclosed by a protective plastic cover, which attaches to a collision detection

system.
2. Maximum image size ~ 40 x 30 cm2
3. Three modes of operation:
 2x2 binned mode (Single Gain) = Pulsed fluoro, 1024 x 768 resolution, 15 fps.
 Un-binned mode (Single Gain) = Full resolution, 2048 x 1536 resolution, 7.5
fps.
 Dual Gain* = 1536 x 1024 resolution, 11 fps with electronic gain adjustments
between each readout line is the factory pre-set. Used for Radiograph and
CBCT acquisitions.
 For more information on Dual Gain with flat panel radiography, please refer to
the abstract, “Multiple Gain ranging readout method to extend the
dynamic range of amorphous silicon flat panel imagers.” Proc. of SPIE
Vol. 5368 February 2004 Roos, Pieter G. et al.

System Components
H. MVD Anatomy
1. Enclosed by a protective plastic cover which attaches to a collision detection

system.
2. Maximum image size ~ 40 x 30 cm2
 Only the rectangular window should be exposed to the beam (Figure 21). The
two wide areas along two edges along the active area should never be
exposed.
Figure 21: Active image area
The following table shows the relation between maximum SID and the maximum field
size (
 Table 1):
Maximum SID and Maximum Field Size
SID Max. field size (cm2)
100 40.0 x 30.0

110 36.4 x 27.3
120 33.3 x 25.0
130 30.8 x 23.1
140 28.6 x 21.4
150 26.7 x 20.0
160 25.0 x 18.8
170 23.5 x 17.6
180 22.2 x 16.7
Table 1: Maximum Field Sizes

System Components
I. Control Rack
1. Made up of the cards that control all arm processes.

2. It houses three individual arm controllers, which operate the arms.
 The blade card is located in the kVS.
3. With respect to the OBI supervisor, the arm controllers act as subordinates.
4. Located behind the digital display readout on older systems and to the left of the
digital display on newer systems (Figure 22 and Figure 23).
Figure 22: MCNR -Motion Control Node Rack (behind Digital Display)
Figure 23: MCNR on newer system

System Components
J. Supervisor Interconnect Panel (ICP):
1. The ICP is a free standing unit or in the top of the Clinac stand. Most units come
with the ICP mounted at the top of the drive stand. Upgraded systems that have
the ‘Kona’ stand will also have a stand mounted ICP. Older systems will have the
ICP mounted to the wall (Figure 24 and Figure 25).
2. The ICP is the motion master and drives the individual arm controllers housed in
the control rack.
Figure 24: X-ray generator and ICP Figure 25: X-ray generator and ICP
Floor Stand Mounted in top of Clinac drive stand
3. Things to look for inside of the ICP (Figure 26 and Figure 27):
 Steady “Heartbeat” located by reset button(s). Flashing green light.
 Supervisor reset button(s). Older systems have two small white buttons on
older units located between the blue cable labeled “Ethernet” and red cable
labeled “Serial” or one recessed button on new systems.
 Motion control node reset (MCNR) located either inside or outside the ICP
cabinet.
 Control module Power Supply Unit (PSU) beside the MCNR.

System Components
Figure 26: ICP on older systems
Figure 27: ICP on new systems

System Components
K. Backup Motion Control (BMC)
4. Pendant-like device that manually controls the motion of one arm at a time (Figure
28).
 Enables the operator to perform motions in cases when the ExactArm (or its
controller) is defective or when communication with the hand pendant cannot
be established.
Figure 28: Backup Motion Controller
5. The collision detection system is inactive.

6. Functions without physical limits.
 You can damage the arm by exceeding the software limits and extending
beyond the mechanical limits.
7. Plugs into the Interconnect Panel for Clinacs with OBI (Figure 29).

System Components
Figure 29: BMC plugs into ICP
8. Recommended sequence of motions for retraction using BMC (Figure 30).
Figure 30: Arm Anatomy
NOTE: If there is a faulty card in the control rack, the Backup

Motion Controller (BMC) will not work.

System Components
NOTE: During a power failure the arms will not be active. The
emergency pendant can be used to lower the couch and evacuate
the patient.
L. LaserGuard:
 Secondary collision monitoring system (Figure 31).

 Monitors the region between the collimator face, the patient, and the couch.
 Laser sensor provides an invisible sensing “shield” that is contoured to cover
the collimator face except for a small notch. This area is called the protection
zone.
 The protection zone is inclined by three degrees and has a notch called a
conformal notch.
 The purpose of the tilt and the notch is to maximize patient’s clearance and
system usability.
Figure 31: LaserGuard

System Components
M. Gating Camera and IR illuminator (Figure 32)
 Charge coupled device (CCD): sensitivity to light within the infrared spectrum
as well as the visible spectrum.
 Illuminator ring: infrared emitter.
 In treatment room mounted to the wall.
 In CT mounted to the couch. Maintains constant distance between marker
block and camera while the table is indexed into the CT gantry.
 In-room viewfinder: displays video image from the tracking camera.
 Verify that the marker block can be visualized, and that there are no other
reflections.
 Junction box: connected to the power supply.
 Signal distribution from the camera to the RPM workstation.
Figure 32: Camera, In-room viewfinder, and Junction box

System Components
N. Provided Phantoms
1. The following phantoms are provided for OBI Imaging QA and/or calibration
(Figures 33, 34, 35, and 36):
Figure 33: Marker Block Phantom
Figure 34: Blade Calibration Plate

System Components
Figure 35: Leeds TOR Phantom
Figure 36: Cube Phantom

System Components
2. The following phantoms are provided for CBCT calibration and or QA (Figures 37,
38, 39, 40, and 41):
Figure 37: Five-Needle Phantom
Figure 38: Head Norm Phantom

System Components
Figure 39: Body Norm Phantom
Figure 40: Catphan Phantom

System Components
Figure 41: Isocal Phantom
NOTE: Isocal is a purchasable option.

System Components
O. Hand Pendant
1. Key Features (Figure 41):
1. Infrared
Device
2. Display
3. Motion enable
bar
4. Handle
5. Paddle
6. Thumbwheels
Figure 41: Hand pendant

System Components
NOTE: The pendant can be used on multiple Clinacs. The

behavior of the pendant is based on the configuration of the Clinac,
PV, and OBI.
2. Infrared device: communication link between pendant and control system.

3. Display and notations: LCD with LED backlight. Only active when enable bars
are pushed.
 “**”: exceeded its limit of motion.
 INTK: non-collision interlock: To clear select mode (hold for two seconds until
the special service menu appears) – P2 – P1, press CLR. If “trip” becomes
active the MVD button in the interconnect panel needs reset.
 TRIP: hardware motion interlock: Press the trip reset switch, and manually
clear all interlocks.
 COL: collision: Hold the Clinac override or motion interlock override switch.
 CAL: arm needs to be indexed.
 N LVL: the arm (or arms) is not level.
 BAT: battery needs recharged. Has enough charge to finish the day. Charge
for at least 12 hours. Leaving the pendant on the station longer than 12 hours,
such as over a weekend, will not cause any damage.
 LOW BAT: the battery has no charge.
 FLT: non-collision fault. To clear press MODE, P2 for clinical utility, P2 to
select fault utility, clear key for more than one second.
 NL: no link.
 KEY: a key is jammed on the paddle. To clear check the keys to verify none
of them are jammed and press CLR.
4. Paddle features:
 OUT: “out of the way” position. Between retract and extended. Also known
as PARK.
 RETR: moves arm to the retracted position.
 AUTO GO: moves the arms to the downloaded position. If no field is MODED
UP at the 4DITC it will take the arms to the preset position configured in
Treatment Administration.

System Components
 LAST: Last “clinical” position it was in when it came to a complete stop.

 MODE: used to display the five exact arm configurations, and to enter special
service menus.
 CLR: takes user to previous display or selects all three arms when on the
‘home’ screen.
 MVD/P1, OBI/P2, kVD/P3, kVS/P4: Used to select the corresponding arm or
set of arms
 MOVE/P5: the main menu of an activated arm is shown in the display.
 P1-P5: moves arm to five predefined positions.
5. Handle features:
 VRT: raises and lowers the cassette. Towards or away from the MV beam
path. Left = down, Right = up.
 LNG: moves the cassette toward and away from the gantry. Parallel to the
path of the MV beam path. Left = away from gantry, Right = towards the
gantry.
 LAT: moves the cassette from side to side. Left = Left as you face the gantry,
Right = Right as you face the gantry. Please note this function is inactive for
the kVS.
 ANG: is not active in directional motion.
 Enable bars: need to be pressed and held continuously in order to activate
the pendant and invoke any motion.
 Range of motion and coordinates (Figure 42 and Figure 43):

System Components
Figure 42: kV Motion Axes
Figure 43: Motion Axes
 ExactArm travel ranges (Table 2).

System Components
NOTE: The distance (FAD and SID) between the kV source, kV

detector, and the isocenter can vary. These distance values are
shown on the OBI workstation.
Table 2: ExactArm travel ranges
 Factory preset positions (Table 3).
Table 3: Factory preset positions

System Components
6. To display target position:

 Press the appropriate arm key (shows current position),
 Press MOVE (activate the arm),
 Then press P1 – P5. This displays the target position for each of the presets.
 Example: To display the target positions for the MVD arm, press MVD/P1,
MOVE, P1 – P5.
NOTE: If OBI/P2 is selected, the position of the kVS and kVD will
be displayed. To display the positions of the kVS, kVD, and MVD
press OBI/P2 then CLR. This will display all three.
7. To move to a preset position:
WARNING: The moving joints of the OBI ExactArms are pinch

points that can cause severe injury or death. Keep clear of the
ExactArms and joints while they are moving.
 Press and hold the appropriate arm key, press and hold MOVE, press and
hold P1 – P5. This will move the arm to the preset position. When the arm
reaches its preset position, CURR will be displayed.
 Example: To move the kVS/kVD arms. Press OBI/P2, MOVE, P1 – P5.
NOTE: To move the kVS, kVD, and MVD arms. Press CLR,
MOVE, P1-P5.
8. To change presets:
 Move to the new position, Press and hold MODE – P1 – P1, select save
position P1, P2, P3, P4 or P5, press CLR.
9. Hand Pendant Test:
 Select Mode – P1 – P2, test the control, press CLR to exit. When in test mode
select any button or thumbwheel and it will say what button/thumbwheel you
have selected on the display. This verifies that all buttons/thumbwheels are
operational.

System Components
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Tools
PROCEDURE
Objective:
After completing this module, the student will be able to review available OBI
Tools from the OBI/Clinical School Manual.
A. Exercise Key
 Right mouse click denoted as RMC.

 Left mouse click denoted as LMC.
 Parentheses () denote additional options.
 The ">" symbol denotes drill down from menus.
OBI Tools
C. OBI Tools
Several image tools are available from the OBI application toolbar. The tools let the
operator:
 match images automatically or manually,
 improve the image display,
 change the view parameters, and
 perform maintenance and calibration functions (Table 1 and Table 2).

OBI Tools
Table 1: OBI Verification Tools

OBI Tools

OBI Tools

OBI Tools
Table 2: OBI Maintenance Tools

OBI Tools

OBI Tools
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


System Components
EXERCISE
Objectives:
 Using the OBI/IGRT Clinical School as a reference, the student will complete the
following lab exercise:
 Identify all of the ICP components and list their primary functionality.
 Identify all of the major OBI software and hardware components and list their
primary functionality.
 Outline the steps to successfully change the pendant pre-set positions.
A. Participants will complete a “fill in the blank” exercise outlining the key
features of the ICP and OBI software and hardware components.
Afterwards, the instructor will review the intended results.
1. Enables the user to switch control of the dedicated alphanumeric keyboard and
mouse between monitors and software applications if multiplicity is not
functioning: _________________________.
2. During verification, this software application transfers the plan and setup fields to
the OBI workstation, and transfers the couch shifts to the Clinac:
____________________________.
3. Displays the Plan Tree and Image Gallery on the OBI
workstation:_________________________.
4. ________________________ is the OBI workspace used by service engineers
for calibration.
5. ____________________________ is the dedicated control panel that enables the
user to control the motion and function of the kV imaging system.
6. The heartbeat and motion control node reset are located inside of this OBI
component: _______________________________.
7. This function automatically sets the field size to the active area of the kVD:
___________________________________.
B. Participants will work in teams of two using their OBI Operations Manual as
a reference to change one of the preset MVD/OBI pendant positions to a
newly saved value.

2D/2D Match (kV/kV) Verification
PROCEDURE
Objectives:
resource,
the student will be able to:
 Verify the prepared On Board Imager (OBI) plan
 Setup the patient
 Acquire kV images
 Analyze images
 Shift the Couch into treatment position
 Treat the patient
A. Exercise Key

2. Parentheses () denote additional selection options
1. Load Session on 4DITC

2. On Board Imager Graphical User Interface
3. Acquire Images
4. Imaging and Verification Tools
CAUTION: Always visually verify clearance when rotating or

moving the gantry, collimator or couch.

CAUTION: Verify the identity of the patient prior to treating or

imaging.
CAUTION: The OBI does not check if the orientation of the

treatment field matches the orientation of the reference image. It is
not possible to have different orientations between the treatment
field and the reference image when plans come from ARIA. It might
be possible to have this situation for third party information
systems. Always make sure that the patient orientation information
is consistent in the plan. The OBI will use the orientation from the
reference image.
WARNING: When using OBI, closed circuit video and an audio

intercom must be available to the user to observe and communicate
with the patient. The priority is to avoid all collision risks.
C. 4DITC
1. Check-in the patient at the Treatment Queue (or from ARIA).

2. Select the patient from the Treatment Queue and click Treat (Figure 1).
Figure 1: 4DITC Treatment Queue

3. If a plan has a large number of structures, the operator has the option to select
the structures to load for image guidance (Figure 2). Set the maximum size of
the plan in OBI Administration.
Figure 2: Select Structures for Matching
4. Select the appropriate kV set up field and click Mode Up (Figure 3).
Figure 3: 4DITC Mode Up
5. Set up the patient.

6. Extend the arms from inside the room using the OBI/MVD hand pendant.
7. Rotate the gantry and verify clearance.

8. If using a bowtie filter during the acquisition process, be sure it properly fits and
is secure prior to imaging.
CAUTION: Verify the security of accessories even if the Interface

Mount Indicator Light is green. Unsecured accessories may fall and
harm the patient.
D. On Board Imaging (OBI) Workstation
1. If not completely positioned inside the room, finish extending the arms from
outside the room by selecting Download Axes (Figure 4).
 Press Motion Enable and Auto buttons on the OBI Console to complete the
download.
Figure 4: Download Axes is selected: Green Arrows
2. To open the kV blades to the largest active area of the detector panel, click
Track (Figure 5).
 To collimate to a specific image size or blade position, de-select Track and
type the value into the appropriate target box or use the up and down arrows.
To move the blades to the target positions, click Download Axes.

Figure 5: Blade Collimation
NOTE: Blade collimation allows imaging to specified areas.

Blade collimation may also improve image quality.
3. Select the appropriate X-ray technique from the Anatomy dropdown (Figure 6).
 Verify the imaging parameters or define the imaging parameters manually.
 The ‘Anatomy’ name does not save and appears as 'None' during the next
imaging session. However, the X-ray technique used for acquisition does save
and automatically populates in subsequent sessions. This refers to the kV,
mA, and ms numerical values.
 Prior to Mode Up, the operator can adjust the acquisition technique manually
by using the up and down arrow keys next to each value or by typing in a
value (Figure 7).
Figure 6: OBI Anatomy Menu Figure 7: OBI Manual Adjustment of Technique

4. The status bar under the imaging area prompts the next step or indicates the
status of the imaging application (Figure 8).
Figure 8: Imaging status bar examples
5. Press the footswitch or hand switch to acquire the first image. An icon notifies
the user when imaging is in "Prep" Mode (Figure 9).
Figure 9: Icon for imaging about to engage
 The "prep" icon changes to the exposure icon during image

acquisition.
6. The image displays on the OBI monitor. The lower right corner of the acquired
image displays the dose associated with acquiring the image in mGy
(Figure 10).

Figure 10: OBI Workstation: AP Image with mGy Dose Displayed
7. Images from previous sessions can be viewed by dragging them into the
imaging area from the Image Gallery (Yellow border = Reference Image, Blue
Border = Historical Image, No Border = New Acquired Image) (Figure 11).
Figure 11: OBI Workstation: Dynamic Window, Image Gallery

8. Operators can de-select all structures and then select the structures individually
to superimpose onto the images. Right mouse click in the Plan Tree View to see
options (Figure 12).
Figure 12: Plan Tree Structure Selection
9. Resize the Dynamic Window (Image Gallery/Plan Tree Window) by dragging the
right edge of the window with the mouse. This provides a larger or smaller
workspace. Select the pin icon to hold the Dynamic Window in place.
10. OBI Verification Toolbar Buttons (Table 1)


Table 1: Verification Toolbar Buttons
11. To acquire the second image, click the 2D/2D Match button (Figure 13).
Figure 13: 2D/2D Match Button
12. OBI automatically uploads the second set up field on the screen (Figure 14).

Figure 14: OBI Workstation: Lateral Image
NOTE: The 4DITC displays a blue wash stating that OBI Console
has control (Figure 15).
Figure 15: 4DITC: OBI has control
13. To move the gantry to the imaging position, press and hold MEB and >> keys
on the Clinac’s dedicated keyboard. Another option is to use the hand pendant
in the treatment room.

 If needed, click Download Axes and then press and hold the Motion Enable
and Auto buttons on the OBI Control Console (Figure 16).
Figure 16: OBI Download Axes
14. Select the appropriate X-ray technique from the Anatomy menu (Figure 17).
 The X-ray technique used for acquisition will save and automatically populate
in subsequent sessions.
Figure 17: OBI Anatomy Menu

• Press the footswitch to acquire the second image. The image displays on the
OBI monitor (Figure 18). When a parameter (kV, mA, or ms) is changed, the
anatomy selection displays ‘None’ as it does not match the previously selected
template (Figure 18).
Figure 18: Acquire Workspace: Images
15. If the couch is moved between acquiring images, the following status message
appears: Match is not allowed. Couch position mismatch (Figure 19).
 Click the first image. A yellow box will highlight this area signifying it as the
active window.
 The user is prompted to rotate the gantry to position for re-imaging.
 If necessary, select a technique from the anatomy menu and then re-image.

Figure 19: Couch Position Mismatch Message
16. Click Analyze (Figure 20).
Figure 20: Analyze Button
WARNING: Image matching in OBI should be based on anatomical

structures or fiducial markers. DO NOT use digital graticules or
Isocenter markers for matching.
17. The Analyze Workspace opens. The Show Reference Image and Manual
Match tools are automatically active (Figure 21).

Figure 21: Analyze Workspace
18. Use Keyboard Shortcut Keys to aid in the match and match verification
processes (Table 2):
Keyboard Shortcut Keys (Table 2)
Shortcut Keys Description
F8 Enable/Disable Pixel Interpolation
F10 Mask Patient Name
Toggle Full Screen Mode ([Esc] key will
F11
also close full screen mode)
[Ctrl] + Z Undo
[Ctrl] + Y Redo
[Ctrl] + Roll Mouse Wheel Zoom
Press down on Mouse
Pan
Wheel
Arrow Keys Fine translational match adjustment
[Alt] + Arrow Keys Large translational match adjustment
[Ctrl] + Arrow Keys Fine Rotational match adjustment
[Ctrl] + AutoMatch Button Display AutoMatch dialog window

19. OBI 2D/2D Analyze Workspace Toolbar Buttons (Table 3)

Button Description
Show Treatment Image
Split Window
Moving Window
Manual Match
Automatic Match
Region of Interest
Complementary Color Blending
Image Filter
Table 3: OBI 2D/2D Analyze Buttons
20. At this point, there are two options for matching: Automatic Match (Step 22) and
Manual Match (Step 27). Use these steps individually or in combination.
21. To perform an Automatic Match:
 Define the Region of Interest (ROI) for the Automatic Match process
(Figure 22).
 Click and drag the red corners to resize the ROI or press and hold the CTRL
Key and LMC and drag the mouse to define the region.
 Move the entire ROI by clicking on the rectangle's edge (A four-prong arrow
appears), drag, and drop the ROI to a new location.

Figure 22: Defining the Region of Interest for Auto Matching
22. Click on the Automatic Match button .
o NOTE: OBI performs an automatic match using the Mutual

Information Algorithm. To modify the Automatic Match settings,
select the Settings option from the dropdown next to the Auto
Matching button (Figure 23).
o Authorized users may access and change the parameters by
entering "admin" for the password.
o For more information on the Mutual Information Algorithm, refer
to the On-Board Imager (OBI) Advanced Imaging Reference
Guide, Chapter 9: OBI Automatch Algorithms).
Figure 23: Auto Matching and Settings

23. The Auto Matching dialog box appears (Figure 24).
Figure 24: 2D/2D Auto Matching Dialog Box
 Select the appropriate Parameter Set.

 Select or deselect the appropriate Axes.
 Click Start.
 The Start button becomes a Stop button indicating that you can cancel (and
Start again) the match process at any time.
 An alternative to stop the match process is to press any key on the keyboard
(Figure 25) or specifically press the Ctrl key to abort and exit the match
process.
Figure 25: Stopping the Auto Matching process

24. OBI begins the Automatic Match process (Figure 26). When the process is
complete, click Close.
25. Always verify the Auto Match results using the Match Verification Tools
(Table 4).
Figure 26: Auto Matching In Progress
26. To perform a Manual Match, select the Manual Match button . Then use the
mouse or the arrow keys on the keyboard. Please refer to Table 2 for Keyboard
Shortcuts.
 In the active window, move the reference image on top of the acquired image
using bone, outlined anatomy, or markers to help with the match process.
 Adjust the image using the arrow keys on the keyboard. This allows for small
adjustments in the match alignment. Make large adjustments by holding the
Alt key and press any arrow key. Large adjustments are also made by clicking
and dragging the image with the mouse (Figure 27).

Figure 27: Adjust Match Manually with Content Image Filter Applied
 Rotate the image by holding the left mouse button and then click and drag
outside of the dotted red circle (Figure 28) or hold the Ctrl key and use the
right or left arrow keys. Rotate the image in large steps by holding the Alt+Ctrl
keys and using the right or left arrow key.
 The dotted red circle is in a fixed location (Figure 28).
NOTE: The Manual Match mouse icons couch rotation and
couch translation will be white in color when moving items

such as the ROI. The mouse icons will turn red when able to
perform matching functions.

Figure 28: Adjust Match: Dotted Red Circle Defining Rotation
CAUTION: Deselect manual match prior to using evaluation tools to

avoid inadvertent shifts.
27. Verify the match using the Match Verification Tools
 Select the Window and Level button . This allows manual adjustment of
brightness and contrast (Figure 29). The blend tool follows to the image side
that the user is window and leveling. Another option to adjust the window and
level settings is to click the left mouse button and move the mouse horizontally
and vertically in the display (Cannot be in Match Mode).
 Select Split Window . This allows for viewing 50% of the Reference
Image and 50% of the Acquired Image within four areas (Figure 29).

Figure 29: Split Window and Window/Level
 Select the Moving Window button . This allows viewing of the reference
image inside an adjustable rectangle (Figure 30).
 To adjust the size, drag the red corners of the Moving Window.
Figure 30: Moving Window

 Selecting the Dashboard button will toggle (on/off) the dashboard. This
allows for a larger viewing window (Figure 31).
Figure 31: Dashboard Off
 For a larger viewing area of a selected image use the Expand Window button
(Figure 32).
Figure 32: Expand window

 For Full Screen Mode, use the F11 key to toggle on/off the feature or use the
Esc key to close Full Screen Mode (Figure 33).
Figure 33: F11 Full Screen Mode
 To enhance the appearance of a reference image or an acquired image, select

an image filter from the dropdown in the top toolbar (Figure 34). Acquired
images are automatically "Optimized."
Figure 34: Image Filters

 Select Show Reference Image Icon . This toggles (on/off) the four
separate image windows. This allows for a larger viewing area of the blended
images (Figure 35).
Figure 35: Reference Images Off
 Select Color Blending . The blend function overlays one image over
another showing the two images in complementary colors assisting with
matching. Change to other complementary colors in OBI Administration
(Figure 36).
Figure 36: Color Blending

Other Tools
Tool Description
Blended Images The blend function is used to overlay one image over another with consideration to the
images’ scales and positional alignments. The blend control slide supports dissolving
from one single image to the other.
 To view only the newly acquired image, slide the blend control all the way to the
right and to view only the reference image, slide the blend control all the way to the
left.
 Another option is to hover/hold the mouse over the Window and Level Bar and the
blend tool will follow.
Delete Images from You must delete images individually.
Image Gallery Image deletion is only available in the Acquire workspace.
Flicker Display To activate this tool, take the following steps:

1. Move the Blend slider to the extreme left or right.
2. Press Ctrl+A to make the display switch between the one blend setting (100%
reference image) and the other (100% acquired image). When you see no motion or the
smallest amount of motion, then the two images are superimposed properly.
Zoom The Zoom tool can be used to resize the image.
 If you would like the image to fill the screen, you can click on the small resizing
window in the upper right corner of each image quadrant.
 Alternatively, use the scroll wheel of your mouse to zoom in or out of the
superimposed images.
F10 The F10 button will Mask the patient name and ID in the Match environment.
• Useful for patient privacy
• Press F10 again to switch back to the original view.
Table 4: Other Tools
WARNING: Always manually verify the images are properly aligned

prior to applying shifts. Reimaging post shift can be used to verify
positioning prior to treatment.
28. Verify the match result and accept the couch correction values, then apply the
couch shifts.
 If Save Match is selected the match is available in Offline Review (Figure 37).

 Un-checking an Include box results in that shift not sent to the Clinac. The
check boxes reset to default values every time the operator re-enters the
match environment. Therefore, if an operator de-selects a translation axis
before applying the couch shift it re-applies if the operator re-enters the match
environment. This occurs even if different images (e.g., kV/kV and then CBCT)
are used in one session.
Figure 37: Save Match
 Click Apply Shifts (Figure 38).
Figure 38: Select "Include" check boxes and Apply Shift
29. In OBI Administration, it is possible to enable or disable whether the couch

rotation is, or is not, selected by default in the match environment.
30. Verify Clearance. Use the MEB and the >> key on the Clinac dedicated keyboard
to move the couch into the new position.
31. Click Done on the OBI workstation (Figure 39).
 The shift saves back to the database after it has been Applied and Confirmed.
Figure 39: Select Done
32. Prior to treating, retract the OBI arms to reduce damage to the kV detector from
scattered radiation.

E. 4DITC
33. The 4DITC Apply Couch Shift dialog box opens with two options:
 Select Apply for Session and then click Apply (Figure 40).
 Select Apply Permanently only if it is desired to apply the couch values
permanently and then click Apply (Figure 41).
Figure 40: Apply Shifts for Session Figure 41: Apply Shifts Permanently

34. Plan, Shifted, and Actual Couch parameters:

 Shown Applied for Session (Figure 42)
 Shown Applied Permanently (Figure 43)
Figure 42: Couch Parameters Applied for Session
Figure 43: Couch Parameters Applied Permanently

35. Select the first field to treat and click Mode Up (Figure 44).
36. If the couch values are out of tolerance, the following warning message will
appear asking for confirmation of table parameters (Figure 45).
 Enter User Name and Password and then click OK.
Figure 45: Out of Tolerance Override

37. If acquiring a couch rotational shift permanently is enabled, a message appears

on the 4DITC (Figure 46).
Figure 46: 4DITC Warning
38. When applying shifts permanently, the 4DITC asks for an acknowledgment to
continue (Figure 47).
Figure 47: Warning to Continue
39. Continue treatment as usual.

with the patient. The priority here is to avoid all collision risks.

F. Non-Orthogonal Setup Fields
When using non-orthogonal setup fields, the Analyze workspace will have a
different behavior than with orthogonal setup fields. Non-orthogonal setup fields
share the Longitudinal, Lateral, and Vertical axes. Lining the images up
longitudinally will behave as before; however, the lateral alignment of the images
will be an iterative process performing several shifts to each of the setup fields to
perform the match (Figure 48).
Figure 48: Non-orthogonal setup fields

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


2D/2D Match (MV/kV) Verification
EXERCISE
The participants will work in teams of two and use their OBI Operations Manual
as a reference to perform MV/kV verification.
Objectives:
 Using the OBI/Clinical School Manual as a reference, the student will complete
the following lab exercise:
 Extend and retract the OBI arms using the MVD/OBI hand pendant and
from the OBI Control Console.
 Mode up a patient from the 4DITC.
 Acquire an MV image, enhance the quality, and adjust the technique if
necessary.
 Acquire kV image, enhance the quality, and adjust the technique if
necessary.
 Evaluate the match using a variety of verification tools.
 Remotely shift the couch to the treatment position
 Verify and record the couch shift at the 4DITC.
 Perform a Double Exposure Before (Plan->Open), 2D Match Portal Image,
enhance the image quality using image filters and window leveling, use
keyboard shortcut keys to perform the match, and apply shifts.
 Treat the patient.

Cone Beam CT Verification
PROCEDURE
Objectives:
 After completing this module the student will perform the following tasks using the
OBI/IGRT clinical school Manual as a resource:
 Perform a Cone Beam CT
 Export the Images to OBI
 Analyze images
 Shift the Exact Couch into treatment position
A. Exercise Key

3. Parentheses () denotes additional options.

3. Acquire Images
5. Review CBCT Images

moving the gantry, collimator, or couch.


imaging.
WARNING: When using OBI/CBCT, closed circuit video and an

audio intercom must be available to the user to observe and
communicate with the patient. The priority is to avoid all collision
risks.
C. 4DITC


3. Select the CBCT Setup Field and click Mode Up (Figure 2).
Figure 2: CBCT Setup Field
WARNING: NEVER ‘Acquire Actuals’ when a CBCT field is

selected. Doing so could lead to a mistreatment. If the following
warning appears, verify a CBCT field was not selected when
‘Acquire Actuals’ was pressed. If this is the case, select No, press
‘Undo Changes’, then highlight a treatment field and re-acquire
actuals (Figure 3).
Figure 3: Parameters affecting dose have been changed

5. Remove couch rails (For Exact Couches with UniPanel and Flat Panel).

6. Insert appropriate Bow Tie Filter. Be sure the bow tie filter fits securely into the
kV Source.

harm the patient. For information on Bow-Tie Filters, refer to the
System Components Procedure in this manual.
7. Extend the OBI arms using the hand pendant while inside the treatment room.
8. Verify clearance using the hand pendant while inside the treatment room.
D. OBI Workstation
1. If not completely positioned, extend the arms from outside the room by clicking
Download Axes.
 Press Motion Enable and Auto buttons on the OBI Console to position the
arms.
WARNING: Always verify clearance prior to extending the OBI

arms from the OBI console.
2. To start the acquisition on the OBI workstation, click 3D Match (Figure 4).
 The OBI application closes and the CBCT application opens automatically.
The original planning CT downloads to the CBCT software for matching.
Please wait a moment for this to take place.
Figure 4: 3D Match Button
 A warning message may appear Make sure Couch Rails are removed (if
fitted). Remove the couch rails and confirm the warning message by clicking
OK (Figure 5). This message can be disabled in CBCT Administration.

Figure 5: Remove Couch Rails Dialog Box
3. A message appears on the 4DITC to inform the operator that OBI has control on
the 4D Console.
4. The Select Reconstruction Type wizard displays on the CBCT screen.
5. The following options are available:
 Acquire new scan
 Reconstruct Existing Scan
 Quick Scan (Param. Display)
 Quick Scan
6. Select Quick Scan (Param. Display) (Figure 6). The other options will be
addressed later.
E. The Quick Scan (Param. Display)
1. The Quick Scan (Param. Display) button (Figure 6) opens up the Scan
Parameter menu for quick and easy selection of CBCT settings (Figure 7).
Figure 6: Quick Scan (Param. Display)

Reconstruction Filter:
 Standard: 50/50 smooth and
sharp
 Smooth: Best at defining soft
tissue
 Sharp: Emphasis on bone
 Ultra Sharp: Max emphasis
on bone
Ring Artifact Suppression:

You can control the strength of the
image correction by selecting one
of the following levels of ring artifact
suppression:
 None: allows you to switch
ring artifact suppression off
 Weak: might miss some rings
 Medium: is recommended
 Strong: might remove
essential information
Figure 7: Scan Parameters
2. Quick Scan (Parameter Display) provides an overview of the CBCT settings.

 If this is the patient's first day, select the appropriate CBCT Mode and other
drop down menu items to prepare for the CBCT.
 Review the settings from the last CBCT if this patient was previously scanned.
3. After setting or reviewing the parameters, select Start Scan.

F. Quick Scan
1. When selecting Quick Scan (Figure 8), the system applies the same
parameters that were selected in the previous CBCT acquisition for that patient.
Figure 8: Quick Scan
2. Only the settings in the parameter window save, dashboard changes are not
saved.
G. Acquire New Scan
1. Select Acquire new scan (Figure 6).
Figure 6: Acquire New Scan

2. The Acquire new scan option starts a wizard that systematically takes the
operator through the settings for acquisition (Figure 7).
1 - The CBCT Modes and the default CBCT

mode are defined within the CBCT application.
Select the CBCT Mode from the drop down.
Unless changed, this CBCT Mode will save as
the mode for subsequent scans.
2 - Patient Orientation should be verified and
match the plan. The patient orientation must
be set for the matching process.
3 - Adjusting the patient Diameter LR or PA
reduces the diameter of the CBCT volume that
is reconstructed, but does not change the
volume of the patient irradiated during the
acquisition.
4 - Acquisition Mode relates to the Fan type
used for the selected CBCT Mode. Full fan
modes acquire 200 degrees of data. Half-fan
modes require a 360 degree rotation.
Acquisitions can occur in clockwise or counter
clockwise directions. Full fan modes are set to
rotate the kVS underneath the patient (to
minimize dose to the eyes for head scans).
5 - The Reconstruction Volume is a default
value dependent upon installation.
6 - The Slice Distance is the slice thickness.
This does not have to match the reference CT
thickness. The smaller the thickness, the
longer reconstruction takes, coronal and
sagittal views will be smoother, and the axial
view will be noisier.
Figure 7: Patient Setup Wizard Page
3. Select the appropriate CBCT Mode from the CBCT Mode Menu and verify or
select the appropriate patient orientation (Figure 8).

Figure 8: CBCT Mode
 Depending on which CBCT Mode is selected, Diameter and Acquisition

Mode change to values defined in the CBCT application.
4. Click Next in the Patient Setup Wizard area.

5. If a topogram is required, refer to the OBI Instructions for Use Manual. The
topogram step can be turned off in CBCT Administration in which case the
system will continue to Step 6.
6. The system calculates the maximum scan range based on the CBCT Mode
selected approximately 18 cm for Full Fan scans and 16 cm for Half Fan scans
(Figure 9). Scan range definitions display (Figure 10).
Figure 9: Scan Range calculating

Scan Range Type:
OBI only allows Single Scan

CBCTs.
Scan Range:
Width - Axial length of the

scan.
Center - Defines the

Isocenter of the scan.
Changing the value will
result in a couch shift.
Z-Zero Pos. - Defines the

position of the DICOM
Origin for the scan.
Figure 10: Scan Range Definition
7. Press Start Scan (Figure 11).
Figure 11: Start Scan
8. Once Start Scan has been selected, the system automatically displays the steps
necessary to acquire a CBCT:
 If the couch is setup outside of the safe zone a message will appear displaying
a corrected couch position for CBCT acquisition, select OK. Press and hold
MEB and >> on the Clinac dedicated keyboard to move couch into the safe
zone (Figure 12).
 A message appears if the couch movement is aborted. The Couch Position
error signifies that the couch is outside of the allowed area (Figure 13).

 If the OBI arms have not already been moved to position, a green box
appears. Press MEB and Auto on the OBI console to position the arms
(Figure 14).
 Press and hold MEB and >> on the Clinac dedicated keyboard to move gantry
into the start position (Figure 15).
Figure 12: Center Couch
Figure 13: Couch out of range for Scan
Figure 14: Position Arms

Figure 15: Couch or Gantry message
9. CT Dose Index (CTDI) is not a direct measure of patient dose, but a

standardized measurement to quantify the radiation dose associated with CT
scans. The CTDIw is a weighted sum of several measurements in a phantom.
The CTDIw displays in the CBCT application at the last step before the CBCT is
acquired. Hovering the mouse over the value provides a tooltip showing the
type of phantom used to measure the displayed values (Figure 16).
Figure 16: kV Exposure panel during CBCT
10. The At Start Position… Dialog Box appears.

 Read instructions and then click OK (Figure 17).

Figure 17: Start Scan Position
11. First press and hold X-ray Footswitch or the Hand Pendant to engage beam-
on. Then also press and hold the MEB and >> keys on the Clinac’s dedicated
keyboard for gantry rotation and to start the CT acquisition.
 Hold all three depressed until the acquisition has finished (audio signal will
stop).
 Once the scan is complete release the MEB and >> first and then release the
X-ray footswitch.
12. Acquisition and reconstruction progress displays on the screen (Figure 18).
 The Acquisition Progress is the data acquired and sent from the CBCT cache
to the Reconstructor computer.
 The Reconstruction Progress is the process of reconstructing the projection
data by the Reconstructor computer.
 The Serialization Progress is the process of sending the data back from the
Reconstructor computer to the OBI computer.

Figure 18: Acquisition Progress
13. If the scan is interrupted due to a purposeful action (ex. Breath-hold CBCT) or
an accident (release of dedicated keyboard or foot/hand switch) the scan can be
resumed.
 Acknowledge the warning message and click OK.
 Then select Resume Acquisition (Figure 19).
Figure 19: Warning and Resume

 The system will request the gantry be repositioned approximately 9 degrees

prior to the interruption position (Figure 20). The system will then request to
resume the acquisition (Figure 21).
Figure 20: Reposition Gantry
Figure 21: Resume Acquisition
14. If the couch was moved to a safe position for scanning, it will need to be
returned to the original set up position prior to beginning the match process
(Figure 22).

Figure 22: Restoring Couch Positions
 Press and hold MEB and >> on the Clinac dedicated keyboard to move the
couch into position (Figure 23).
 The following message will appear if the couch movement is aborted:
"Reminder! Couch positions have been changed since startup!" (Figure 24).
Figure 23: Enable Clinac Movements

Figure 24: Couch Position
15. Once the scan is complete, the reconstructed image displays on the screen
(Figure 25).
 Select Accept and Export Scan (File > Export to DICOM).
 If the patient moved during the scanning process, select Decline Scan and re-
start the process.
Figure 25: CT Image Review Page
16. After selecting the Accept and Export Scan button, the CBCT image stores on
the OBI workstation.
 The CBCT image imports to the 3D Match workspace.
 This process may take a few seconds to complete.

 Upon completion, the Acquisition workspace closes and the Analyze

workspace opens automatically.
H. 3D Match Workspace
1. At this point, there are two options for matching: Automatic Match (Step 2) and
Manual Match (Step 5). Use these options individually or in combination.
2. To perform an Automatic Match,
 Set the Region of Interest box in all three viewing panes.
 Click on the Automatic Match Icon (Figure 26).
 The system performs an automatic match using the Mutual Information
Algorithm. For more information, refer to the OBI Reference Guide, Chapter 9.
Figure 26: 3D Match Toolbar
3. The Auto Match Control dialog box opens. After selecting the appropriate
parameter set, click Start. Subsequent sessions will automatically use the
selections from the last auto match (Figure 27).
 Select the appropriate Axes to include in the match.
 Intensity Range defines the HU range the auto match algorithm will use to
determine the match (Table 1).
 Structure VOI defines the structure VOI the auto match algorithm will use to
determine the match (Table 2).

Figure 27: Auto Match Control Dialog Box
NOTE: OBI users can select combinations of Intensity Range

parameters and structure VOI parameters.
NOTE: The 3D match algorithm uses logical "AND" operations.

When multiple criteria are selected (for example, rectangular VOI +
structure VOI with margin + soft‐tissue intensity range) only those
voxels in the reference CT image that meet all selected criteria are
used in the match.

Table 1: Intensity Range

Table 2: Structure VOI

Table 2 Continued.

4. The system shifts the two superimposed images relative to each other during
the match and calculates the couch correction values (Figure 28 and Figure 29).
Figure 28: Automatic Match in progress
Figure 29: Dashboard Couch Values
WARNING: Always manually verify an automatic match using the

match verification tools.

5. To perform a Manual Match, make sure the Manual Match Icon is active.
Then use the mouse or the arrow keys on the keyboard (Figure 30).
 Adjust the image using the arrow keys on the keyboard. This allows for small
adjustments in the match alignment. Make large adjustments by clicking and
dragging the image with the mouse or hold the Alt key and press the
appropriate arrow key.
 Rotate the image by holding the left mouse button and then click and drag
outside of the dotted red circle or hold the Ctrl key and use the right or left
arrow keys. Rotate the image in large steps by holding the Alt+Ctrl keys and
using the right or left arrow key. The dotted red circle displays on the Frontal
view (Figure 30).
 To rotate the main viewing window between Transversal, Sagittal, and Coronal
views press Ctrl+R or this icon in the main viewing window (Figure 30).
 Verify the match using the match verification tools.


Figure 30: Manual Match Button, Switch viewing pane positions, and Dotted Red Circle


6. Verify the match using the Match Verification Tools.
 Select the Window and Level button . This allows manual adjustment of
brightness and contrast (Figure 31). When positioning the mouse is over the
left or right window and level bar, the blend tool in the center also follows to
that side. This feature assists with using the window and level tool quickly.
 RMC on the Window and Level bar to select Range, which adjusts to a
selected anatomical selection and can be used on the CBCT and the
reference CT (Figure 32).
Figure 31: Window and Level

Figure 32: Range
 From the Dynamic Window check or uncheck contours as needed during the
verification process (Figure 33).
 Contours can be turned off and on as a group using the Contour button
 RMC in the Plan tree for other structure selection options (Figure 33).
Figure 33: Dynamic Window
 Select Split Window . This allows for viewing of 50% Reference CT and
50% Cone Beam CT (Figure 34).

Figure 34: Matching; Split Window View
 Select the Moving Window button . This allows viewing of the acquired
Cone Beam CT within the rectangle (Figure 35).
Figure 35: Moving Window View

 Select Color Blending . The blend function is used to overlay one image
over another and shows the two images in complementary colors to assist in
matching. Colors can be changed in OBI administration (Figure 36).
Figure 36: Color Blending

 RMC on an isocenter "bullseye" for the option to move the three viewing
planes quickly to the selected isocenter (Figure 37).
Figure 37: Move Viewing Planes to isocenter
Other Tools used during the Match Verification Process
Tool Description
Page Up and Page You can scroll through the sagittal, coronal, and transversal views of CBCT or CT
Down Keys images by pressing the Page Up/Page Down keys.
Flicker Display To activate this tool, take the following steps:

1. Move the Blend slider to the extreme left or right.
2. Press Ctrl+A to make the display switch between the one blend setting (100%
reference image) and the other (100% acquired image). When you see no
motion or the smallest amount of motion, then the two images are superimposed
properly.
Zoom Use the Control Key and mouse wheel to zoom in and out of a CBCT image.
The zoom occurs where the mouse is positioned.
Table 3: Other Match Verification Tools


7. Once you have verified the match result and accepted the couch correction
values, you can apply the couch shift. If for some reason you do not want to
send a specific shift it can be deselected by un-checking the include box.
 Reset Shift will zero out any shifts and realign the images to their initial
positions.
 The Save Match button saves the match back to the database for immediate
review in Offline Review.
 Click Apply Shifts to send the Target positions to the Clinac Console
(Figure 38).
Figure 38: "Include" checkboxes and Apply Shift
 Verify clearance. Retract the OBI arms if necessary.

 Use the MEB and the >> key on the Clinac dedicated keyboard to move the
couch into the new position.

I. 4DITC
1. The 4DITC Apply Couch Shift dialog box opens with two options:
2. Plan, Shifted and Actual Couch parameters

 Show Applied Permanently (Figure 43)

Figure 42: Couch Parameters Apply for Session
Figure 43: Couch Parameters Apply Permanently

Figure 44: Mode Up
4. If the couch values are out of tolerance, the following message will appear
asking for confirmation of table parameters (Figure 45).
 Enter User name and password and then click OK.

WARNING: When using OB, closed circuit video and an audio

J. Reconstruct Existing Scan
1. Reconstruct Existing Scan can be used in situations where changes to the

reconstruction parameters would be beneficial to the matching process or when
certain system errors occur during the CBCT process. Clinically this would be
performed immediately following a CBCT acquisition. For example, following
the CBCT acquisition the therapist decides that the smooth filter would have
been a better option than the selected sharp filter.
2. Assume the operator has just acquired a CBCT and wishes to reconstruct it
prior to matching. The operator selects Accept and Export Scan.
3. Select Cancel in the 3D Match Analyze workspace (Figure 48).
Figure 48: Cancel
4. Re-enter the 3D Match application. Select 3D Match (Figure 49).
Figure 49: 3D Match

5. The CBCT application reopens.

 Select Reconstruct Existing Scan (Figure 50).
 Select the most current (just performed) scan (Figure 51).
 Click Next.
Figure 50: Reconstruct Existing Scan
Figure 51: Select scan
6. Make changes to the reconstruction parameters in the Advanced Parameter

Definition area (Figure 52) or they can remain the same.
 Click Reconstruct (Figure 53).

Figure 52: Parameters
Figure 53: Reconstruct
7. When reconstruction has finished, select Accept and Export Scan and
continue with Section E.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


EXERCISE
Objectives:
 Using the OBI/Clinical School Manual as a reference, the student will complete
the following lab exercise:
 Extend and retract the OBI arms using the MVD/OBI pendant and from the
OBI Control Console
 Mode up a patient from the 4DITC
 Demonstrate and perform all steps necessary to acquire a Cone Beam CT
 Demonstrate and perform all steps necessary to export the Cone Beam CT
scan
 Demonstrate and perform all steps necessary to reconstruct an existing CT
 Evaluate the match utilizing all of the verification tools
 Remotely shift the Exact Couch to the treatment position
 Verify and record the couch shift at the 4DITC
A. The participants will work in teams of two and will use their OBI Operations
Manual as a reference to perform a Cone Beam CT, export the images, and
review the images.
B. The participants will work in teams of two and will use their OBI Operations
Manual as a reference to Reconstruct an existing Scan, export the images,
and review the images.

Imaging Modalities
PROCEDURE
Objective:
After completing this module, the student will be able to utilize Imaging Modes using
the OBI Manual as a resource.
A. Exercise Key

3. Parenthesis () denote additional options.
4. The ">" symbol denotes drill down from menus.
1. Overview of Imaging Modalities

2. Common X-ray Generator Functions
3. Fluoroscopy Controls
4. Digital Radiography Controls
5. Tools for Image Enhancement
6. Commonly used Techniques
7. Challenges of Imaging
8. Imaging Reminders
C. Overview of Imaging Modalities
1. Radiographic Mode
 Acquire and match single MV or kV images for patient repositioning

Imaging Modalities
 Acquire and match image pairs: kV/kV, MV/kV, or MV/MV for patient
repositioning
 Acquire gated kV and MV images, where the moment of acquisition is
determined by signals from the RPM gating system
 Automatic detection of Radiopaque markers in MV and kV radiographs
 Acquire and match CBCT images for patient repositioning
2. Fluoroscopic Mode
 Acquire fluoroscopic images (at 15 frames per second) for pretreatment
verification of the RPM gating system
D. Overview of Common X-ray Generator Functions
1. kV Exposure Dashboard (Figure 1)
1 2 3 4
1 - Fluoroscopic Exposures
2 - Single Exposure
3 - ABC, which stands for automatic brightness control for fluoroscopy operation
4 - Focal Spot (0.4 mm or 0.8 mm)
Figure 1: kV Exposure Dashboard

Imaging Modalities
2. Common Controls for Fluoroscopy and Digital Radiography Modes (Table 1)
Common Controls
Icon Description Function
Use up/down arrows or swipe and type the new

kV kV menu
value to increase or decrease kV=penetration.
mA mA menu
value to increase or decrease mA=contrast.
Ms ms menu
value increase or decrease ms-exposure time.
Anode heat
Anode Displays Anode heat in percent
display
Housing heat
Housing Displays Housing heat in percent
display
Bow Tie Filter Filter the X-ray Beam
Table 1: Controls for Fluoroscopy and Digital Radiography Modes
3. A Bow Tie Filter is a mechanical device that mounts to the kV collimator in order
to filter the X-ray beam. The OBI bow tie filter is made of aluminum. It improves
the quality of the image. The use of a bow tie filter for acquiring images can offer
the following advantages:
 reduces skin dose,
 reduces X-ray scatter, which results in improved image quality,
 reduces charge trapping in the detector, and
 allows higher X-ray techniques without saturating the detector.

Imaging Modalities
E. Overview of Specific Fluoroscopy Controls
1. Controls for Fluoroscopy Mode (Table 2)

Fluoroscopy Mode
Function
Selects Fluoroscopy mode
selector button
Press to select Automatic
Brightness Control (ABC). ABC
ABC selector
ABC will adjust kV, mA and ms
button
automatically to provide the best
image acquisition and display.
Indicates how long fluoro has been
on (total time). A buzzer will sound
5 Minute after 4.6 minutes. Press the Reset
Time Display
Timer button to zero the fluoro time.
Timer disappears in High Technique
mode.
The Anatomy selector will set
Anatomy
Anatomy predefined X-ray techniques for
selector
stored anatomy.
The Size selector will set a
Size Size selector predefined X-ray technique for a
stored size.
Table 2: Controls for Fluoroscopy Mode
2. Turn on Fluoroscopy Mode by selecting the Eye Icon . When switching

between Imaging Modes, the Image Acquisition System will lock temporarily.
Refrain from imaging during this time.
3. Select X-ray settings from the Anatomy and Size drop down menus (Figure 2).
The anatomy and size chosen from the menu list will set a predefined X-ray
technique, Manually or by using Automatic Brightness Control (ABC).

Imaging Modalities
Figure 2: Fluoroscopy Anatomy and Size Selector
 When ABC is active, the tube potential (kV), current (mA), and pulse width
(ms) automatically adjust to maintain consistent brightness.
 In cases of poor image quality due to “flash”, “flaring,” or “patient anatomy,”

manual adjustment of kV, mA, and ms may be necessary. First, image using
ABC, then turn it off and make manual technique adjustments. Achieve the
penetration required by adjusting the kV and then adjust mA and time. Also,
collimate the kV blades as small as possible.
4. Operators can select which contours on the DRRs to superimpose onto

fluoroscopy images.
 Use the Plan Tree in the Dynamic Window to select contours.

 This occurs when gating is active or inactive.
 If gating is active, then the contours will change color in conjunction with the
respiratory gating signal.
 The color change associated with beam on and beam off on the DRR contours
used can be selected in OBI Administration to match previous versions of OBI
or to match the colors used in TrueBeam-blue and yellow (Figure 3).

Imaging Modalities
Figure 3: OBI Administration: Fluoro Overlay Color
5. Fluoroscopic images are acquired using Pulsed Fluoro.

With Pulsed Fluoroscopy, the acquisition system uses pulses of radiation to
acquire the image. The X-ray pulse remains on for the time (ms) set. This helps
reduce blurring of the image due to patient movement and/or movement of the
imager. The available ranges for mA, kV, and time stations are 10 to 80 mA, 40
to 125 kV, and 4 to 32ms respectively (Figures 4 - 7).
Figure 4: Dose rate indication for fluoroscopic exposure.

No alarm indicator displays when below 88.0 mGy/min.

Imaging Modalities
6. The Fluoroscopy Mode Button has an option to click “Allow High Dose
Rate.” To select a higher dose rate, check the box in front of "Allow High Dose
Rate" (Figure 5). An alternative is to RMC on the warning sign (alarm indicator)
for higher dose rate when the limit is reached (Figure 6).
Figure 5: Fluoro Allow High Dose Rate Check Box – unchecked and checked

Alarm indicator when dose rate exceeds 88.0 mGy/min

Imaging Modalities

Alarm indicator if dose rate exceeds 176.0 mGy/min.
NOTE: Regarding the dose rate alarm indicator, the color coding
does not imply an error or that the dose rates should not be
used. Rather, the dose rate alarm indicator provides a visual
element for the operator to raise awareness that a certain dose
rate band was entered and may, if not being careful, result in an
undesired dose for long exposure times.
7. Manually adjusting the kV and mA will alter the contrast and brightness of the
image.
 Increasing kV increases energy and therefore, penetration. This will increase
the total intensity of the beam.
 Increasing mA increases quantity and therefore, decreases “graininess” and
improves image quality.

Imaging Modalities
F. Overview of Specific Digital Radiographic Controls
Digital Radiographic Mode
Function selector
Selects Digital Radiography mode
button
Use up/down arrows or arrow keys to

mA mA Menu
increase or decrease mA.
Use up/down arrows or arrow keys to
ms ms Menu
increase or decrease ms.
Resolution and Pulse RMC on the icon and select half or full
Mode
selector resolution and single or dual pulse
The Anatomy Selector will set predefined
Anatomy Anatomy selector
X-ray techniques for stored anatomy
The Size selector will set predefined X-
Size Size selector
ray techniques for a stored size
Table 3: Digital Radiographic Mode
8. Turn on Digital Radiography Mode by selecting the Camera Icon . Wait

for the Image Acquisition System to switch modes.
9. The Digital Radiography Mode feature allows the operator to use a technique
typically reserved for film exposure, to expose the imager. A high intensity shot of
radiation is used to form a single image.
10. Digital Radiographs can be acquired either by manually entering the generator
settings or by selecting the patient anatomy and size from the Anatomy Selector.
 Selecting an X-Ray technique from the Anatomy drop-down list automatically
updates the Size drop-down list and the parameters kV, mA, ms, and mAs
(Figure 8).

Imaging Modalities
Figure 8: Anatomy and Size Selector
 Depending on the X-ray technique selected from the Anatomy drop-down list,
the text boxes kV, mA, ms, and mAs are populated automatically with the
parameters assigned to the selected X-ray technique. Use the up and down
arrow buttons to increase or decrease the values.
 The kV, mA, and ms parameters are disabled when the ABC button is
selected.
 The mAs parameter is a read-only value visible when the Single Exposure
button is selected.
 Most Anatomy templates for kV settings can be added or edited in OBI
Administration (Figure 9).

Imaging Modalities
Figure 9: OBI Administration kV Templates
11. There are two modes of use: Dual Gain (DG) and Single Gain (SG). DG is
available in 1024 x 1536 resolution and SG is available in 2048 x 1536 resolution.
A larger dynamic range is available with the DG mode.
 RMC on the camera icon to select the appropriate mode (Figure 10).
Figure 10: Digital Radiograph Modes

Imaging Modalities
12. Maximum kV, mA and ms.

 The absolute maximum tube voltage is 150 kV.
 The absolute maximum current in the tube is 400 mA.
 At 80 kV the maximum current is 400 mA.
 Maximum ms varies based on kV and mA settings (absolute maximum ms is
6300)
 Maximum mAs value, 630, is not just the product of the mA and ms.
NOTE: Images can be acquired with either the handswitch or

footswitch.
G. Tools for Image Enhancement
13. Tools available to set before and use during imaging are closing the blades,
including a bow tie filter, and manually adjusting the technique.
14. Tools available after the image is acquired are Window/Level and Image Filters.
H. Challenges of Imaging
15. Test image examples using a phantom.

16. What can I do when imaging a lateral pelvis for markers or seeds and cannot see
the packing or marker wires?
 The couch and Imager should be set as closely as possible to the collimator to
enable maximum beam intensity to reach the imager.
 Collimate the field size by closing the blades.
 Include a bow tie filter ensuring a proper and secure fit.

Imaging Modalities
 Try using Digital Radiography Mode Single Gain High Resolution, which can
help visualize the detail.
 When using pulsed fluoroscopy, use ABC. If you are still having trouble
seeing the markers, turn off ABC and alter kV, then mA, then ms.
 Post processing tools can bring out image detail to enable you to see the
markers. Use window and level and apply an image filter to enhance the
image contrast.
17. How can I improve an image that is too dark with no contrast detail (Figures 11,
12, and 13)?
 If Fluoroscopy Mode is being used, ensure ABC is turned on. If it is, then ABC
is not giving the best image and should be turned off.
 Manually increase the kV. If changing the kV makes little improvement to the
image information, increase the mA and then the ms.
Figure 11: Low kV and mA: Insufficient Penetration and Grainy Image

Imaging Modalities
Figure 12: Higher kV low mA: Better Penetration but Image Still Grainy
Figure 13: Higher kV and Higher mA: Penetration Good
18. How can I improve an image that is bright and washed out (Figure 14)?
 Collimate/Close the blades as much as possible (Figure 15).
Figure 14: Large Blade Size

Imaging Modalities
Figure 15: Blade Size Reduced
19. How can an image be improved that shows good soft tissue detail but little bony
anatomy?
 Increase your kV to get the X-ray penetration to see the bones and then your
mA to improve image quality.
 Contrast is also affected by scatter radiation, so irradiation of thick body parts
can result in decreased contrast.
20. How can flaring be reduced with imaging the lung (Figure 16 and 17)?
 Reduce the blade field size as much as possible.
 Position the imager center within anatomy if possible.
 Turn off ABC and manually adjust kV and mA and ms.
 Add a bow tie filter that is properly fit and secured into the kVS.
Figure 16: Image Flaring with No Bow Tie Filter

Imaging Modalities
Figure 17: Flaring Reduced with Bow Tie Filter in Place
21. How can flaring be reduced when imaging a Head and Neck and already using
ABC?
 Use the bow tie filter that is properly fit and secured into the kVS.
 Use ABC to acquire the image initially. Then turn off ABC and manually adjust
the technique. It is important to use ABC initially as this will quickly present
you with an initial image to start the adjustment.
22. How do I improve a grainy image (Figure 18)?
 Increase the mA (Figures 18 and 19).
 Use the Invert Image Filter (Figure 20).
Figure 18: Grainy Image has Low mA

Imaging Modalities
Figure 19: Higher mA than Figure 18 but remains grainy
Figure 20: Increasing by 20 mA Provides Good Image
Figure 21: Grainy image with Invert Image Filter

Imaging Modalities
23. How can I correct an overexposed image (Figures 22 and 23)?

 Overexposed images occur when the mA (or mAs) or kV settings are too high.
This is common when imaging lung fields.
 Reduce the kV and or the mA to improve the image.
Figure 22: Overexposed image
Figure 23: Corrected overexposed image
24. How do I avoid oversaturation of the imager?

 Oversaturation is a form of overexposure. When an image is oversaturated, it
may be possible to see the Asics display of the imager within the image
(Figures 24 and 25). Oversaturation of the detector panel indicates that the
intensity of the x-rays is too high. Intensity relates to mAs and kV. Decreasing
either of these reduces saturation.
 Decreasing the kV reduces the oversaturation faster than reducing mA.
However, if a higher kV for penetration is required, then it will be necessary to
decrease the mA and/or ms.

Imaging Modalities
Figure 24: Oversaturated Head Image
Figure 25: Oversaturated Head and Neck Image with Invert Image Filter
 Oversaturation with fluoro will not normally occur if ABC is switched on unless
a large amount of air is present in the field due to the patient’s anatomy or
setup (Figure 26).

Imaging Modalities
Figure 26: Pulsed Fluoro Technique (125kV, 80mA, 32ms)
I. Imaging Reminders
25. Adjusting the kV and mA will alter the contrast and brightness of the image.
 Increasing kV increases energy and therefore, penetration. This will increase
the total intensity of the beam.
 Increasing mA increases quantity and therefore, decreases “graininess” and
improves image quality.
26. In case of poor image quality due to “flash”, “flaring” or “patient anatomy” manual
adjustment of kV, mA, and ms may be necessary.
 First image using ABC, then turn it off and make manual technique
adjustments.
 Achieve the penetration required by adjusting the kV and then adjust mA and
time.
 Collimate the blades as small as possible.
 Use the bow tie filter confirming proper fit and security.
27. Image Processing Tools available on OBI:
 Bow Tie Filter
 Filters (Image Processing) and the Region of Interest Tool
 Manual Adjustment of the X-ray technique
 Collimating/Closing the blades

Imaging Modalities
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Optimizing Image Quality
___________________________________________________________________
A. Optimizing Image Quality
1. There are a number of factors that influence image quality. This section focuses
on how to manipulate clinical factors to optimize patient images.
2. Default X-ray imaging techniques are provided with OBI Advanced Imaging for
several different patient anatomies. While these X-ray techniques have been
selected to produce high quality images, due to differences between patients,
there will be times when it is necessary to adjust the technique factors used.
3. When selecting the technique factors, remember the
 kV setting controls the penetrating power of the beam
 mA setting controls the quantity of X-rays produced
 ms setting determines the duration of the exposure.
4. An image will be of poor quality if it is under- or overexposed. A noisy or grainy
image results from a poor signal-to-noise ratio due to underexposure. An image
that is lacking in contrast detail may not provide the detail needed for patient
verification.
5. This section seeks to provide indications of what steps can be taken to improve
upon image quality.
B. Underexposed Images
1. An image is underexposed if an insufficient quantity of X-rays is recorded by the

detector (Figure 1). There may be several causes of this. If the mA (or mAs)
setting is too low, not enough X-rays will be reach the detector resulting in
underexposure.
2. Image exposure is also affected by the kV setting. The penetrating power of the
beam increases with increase in kV. Selecting too low a kV setting will also result
in an underexposed image.
3. An image may be underexposed in particular areas or throughout the image.
4. The mA (or mAs) setting will need to be increased as the X-ray path through the
patient increases (that is, a larger patient will require a higher mA (or mAs) setting
than a smaller patient for the same anatomy).

5. The kV setting will need to be increased with increase in electron density in the X-
ray path. A tangential breast image will require a lower kV than a lateral pelvis
image. There are other considerations to be made before determining the kV
setting required (Refer to the Image Contrast section).
Figure 1: Underexposed Image
C. Grainy Images
1. If an image is grainy, it is an indication that there was insufficient X-Ray intensity

at the imaging panel (Figure 2). This can be addressed by increasing the mAs
and/or the kV (Figure 3). When increasing mAs, you may increase the mA, the
ms or both. When deciding whether you wish to increase the kV and the mAs to
address graininess, you should also consider the contrast in the image (Refer to
the Image Contrast section). If the image has the desired contrast, you should
increase mAs rather than kV.

Figure 2: Grainy Image (Invert Filter Applied)
Figure 3: Image after mAs Increased (Invert Filter Applied)

D. Overexposed images
1. The causes of underexposure are the opposite of underexposure - too high of a

mA (or mAs) setting or kV setting (Figures 4 and 5).
Figure 4: Overexposed Image

Figure 5: Image with Appropriate Exposure
E. Saturated Images
1. If an image is saturated, it may be possible to see the Asics display of the imager
within the image. Oversaturation of the panel indicates that the intensity of the X-
Rays at the imager is too high. Intensity of the X-Ray beam relates to mAs and
kV, therefore reducing either of these will reduce the saturation. The same
considerations should be given as for overexposed images as saturation is a form
of overexposure.
2. Reducing kV will reduce saturation faster than reducing the mA. However, if a
higher kV is required for penetration, the mA should be reduced.
3. Oversaturated Image shows an oversaturated image with the image detector
panel Asics display visible in the image (Figure 6).

Figure 6: Oversaturated Image
F. Image Contrast
1. Does the image have sufficient contrast between bone and soft tissue?
 The ability to distinguish between different tissues (for example, bone and soft
tissue) is governed by the image contrast. The primary factor affecting image
contrast is the kV setting. As the kV is increased, the difference in attenuation
though different tissues is decreased, reducing the contrast. Contrast is also
affected by scatter radiation, so irradiation of thick body parts can result in a
decreased contrast.
 If the contrast detail in an image is insufficient (and the image exposure is
correctly set), the kV should be decreased (and the mAs increased to
compensate for the reduction in exposure).

G. Dual Gain Readout Imaging
1. OBI Advanced Imaging introduced the use of Dual Gain Readout with kV imaging.
This permits an increase in the Dynamic Range of the imager as well as an
increase in the grayscale of images. With Dual Gain Readout, the exposure
signal to the panel is read out using both high and low gains. The imaging system
will select which of these signals provides more information based on saturation
levels. This in turn provides images with better contrast definition between bone
and soft tissue. The default anatomic imaging techniques provided with OBI
Advanced Imaging are all Dual Gain Readout techniques. Selection of these
techniques should offer good bone - soft tissue contrast (Figure 7).
Figure 7: Dual Gain Readout Image
H. Additional Factors to improve upon clinical image quality
1. In addition to manipulation of the X-Ray imaging technique, there are other

measures you may take to improve upon clinical image quality.
 Blade Collimation

 To minimize scatter radiation, collimation of the blades to the imaging region of

interest should be performed. Selection of 'Track' will ensure that the blades
are collimated to the imaging detector, however additional collimation to the
imaging region of interest will further reduce scatter and improve image quality
(Figures 8 and 9).
Figure 8: Lateral Pelvis DGR Image with Blades Collimation 10x10
Figure 9: Anterior Pelvis DGR Image with Blades Collimation 10x10

I. Imaging Filters
 Once the images have been acquired, imaging filters may be used to further
enhance the quality of the images. There are a number of filters available
within OBI Advanced Imaging (Figures 10, 11, and 12). Acquired Image
without Image Filter Applied and Same Acquired Image with the Optimized
Image Filter Applied demonstrate how use of filters can improve image quality
without re-exposing the patient. Additional information about the variety of
filters available with OBI Advanced Imaging can be found in “OBI Advanced
Imaging Reference Guide.”
Figure 10: Acquired Image without Image Filter Applied

Figure 11: Same Acquired Image with the Optimized Image Filter Applied
Figure 12: List of Imaging Filters for OBI

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Marker Match Verification
PROCEDURE
Objectives:
 After completing this module, using the IGRT/OBI Clinical School Manual as a
 Verify the prepared On Board Image (OBI) plan
 Auto Detect Markers
 Analyze images in the Marker Match workspace
 Shift the Exact Couch into treatment position
A. Exercise Key

3. Parentheses () denote additional options.
4. The ">" symbol denotes drill down from menus.

3. Acquire Images

moving the gantry, collimator, or couch.


imaging.

field and the reference image when plans come from ARIA. It might
reference image.

C. 4DITC
1. Check-in the patient from the Treatment Queue (or from ARIA).

3. If a plan has a large number of structures, the operator has the option to select the
structures to load for image guidance (Figure 2). Set the maximum size of the plan
in OBI Administration.
4. Select the appropriate kV setup Field and then click Mode Up (Figure 3).


7. Rotate the gantry and verify clearance.
8. If using a bow tie filter during the acquisition process, be sure it properly fits and is
secure prior to imaging.

harm the patient.
D. On Board Imaging (OBI) Workstation
1. If not completely positioned inside the room, finish extending the arms from
outside the room by selecting Download Axes (Figure ).
 Press Motion Enable and Auto buttons on the OBI Console to complete the
download.
Figure 4: Download Axes is selected: Green Arrows
2. To open the kV blades to the largest active area of the detector panel, click Track
(Figure 5).
 To collimate to a specific image size or blade position, de-select Track and
type the value into the appropriate target box or use the up and down arrows.
To move the blades to the target positions, click Download Axes.

Figure 5: Blade Collimation
NOTE: Blade collimation allows imaging to specified areas.

Blade collimation may also improve image quality.
3. Select the appropriate X-ray technique from the Anatomy dropdown (Figure 6).
 The 'Anatomy' name does not save and appears as 'None' during the next
imaging session. However, the X-ray technique used for acquisition does
save and automatically populates in subsequent sessions. This refers to the
kV, mA, and ms numerical values.
 Prior to Mode Up, the operator can adjust the acquisition technique manually
by using the up and down arrow keys next to each value or by typing in a
value (Figure 7).

Figure 6: Anatomy Menu Figure 7: Manual Adjustment of Technique
4. Press the footswitch or hand switch to acquire the first image.

 The operator can enhance the acquired and reference images, delete and
retake this image, or alter the size of the imaging area for a different view.
5. Click the Marker Match button (Figure 8).
Figure 8: Marker Match Button
6. The reference CT loads and the 2D reference images display on the OBI
workstation (Figure 9). The lower right corner of the acquired image displays the
dose associated with acquiring the image in mGy.

Figure 9: Reference CT is Loading
NOTE: The 4DITC displays a blue wash stating that OBI Console
has control (Figure 10).

Figure 10: 4DITC: OBI has control
7. The appropriate field should be active. The yellow frame highlights the active
field. The active field is the field that the system will prepare to image. To
highlight with a yellow frame, move the cursor over the desired field area and
LMC in the image space (Figure 11).
Figure 11: Yellow box represents active field

8. Press and hold MEB and >> keys on the Clinac dedicated keyboard to move the
gantry to the imaging position or use the hand pendant in the treatment room.
 If needed, click Download Axes and then press and hold the Motion Enable
and Auto buttons on the OBI control console (Figure 12).
Figure 12: Download Axes
9. Select the appropriate X-ray technique from the Anatomy menu (Figure 13).
Figure 13: Anatomy Menu

10. Press the footswitch or hand switch to acquire the second image. The image
displays on the OBI monitor (Figure 14).
Figure 14: Lateral Image
11. Click Detect (Figure 15).
Figure 15: Detect Button
NOTE: With the ARIA information system, the reference locations

of the markers save and detecting the markers in the reference CT
image only needs to be done on the first day of treatment. With the
ARIA information system, if using the newest version of Eclipse,
markers may be defined in Eclipse and will automatically be
detected in the reference CT image thus making the ‘Detect’ step
unnecessary.

12. The Reference CT image displays in the Detect workspace.

 To detect the markers, first define the volume of interest by adjusting the red
box in all three planes.
 Click Start (Figure 16). Hint: Moving the VOI within the body is usually
sufficient.
 Verify the marker placement by browsing through the CT slices using the
PageUp/PageDown arrow keys.
Figure 16: Markers Detected
13. Once the marker placement is verified, close the Auto Marker Detection dialog
box (Figure 17).
 Click Close.

Figure 17: Auto Marker Detection
NOTE: With the ARIA information system, markers may be defined

in Eclipse and will automatically detect in the reference CT image.
If the markers were defined in Eclipse, it is recommended to not
delete or remove the markers.
14. If necessary remove all markers, add, delete or move a marker, auto detect
markers, and use volume of interest tools (Figure 18).
 Select Delete all Markers to remove all of the

markers.
 Select Remove all Markers to remove all manually and automatically

detected markers.
 Select Add, Delete or Move a Marker to identify the markers in the CT

slices. Click on them one at a time. As soon as you click on the marker, the
software will automatically detect the marker in the remaining slices. Use the
same tool to delete or move a marker.
 Use the Volume of Interest tool to draw a rectangle around all the
markers in the reference image.
 Select Automatic Detection to have the software detect the markers in

the CT slices.

Figure 18: Detect Workspace Toolbar
15. Once the markers have been detected, select Analyze (Figure 19).
Figure 19: Analyze button
16. OBI loads the acquired images and the markers from the reference 3D image
project onto the acquired images (Figure 20).
Figure 20: Analyze Workspace Markers projected

17. To perform a Manual Match, make sure the Marker Detection Icon is active.
It should be activated when you enter the Analyze workspace.
 Manually move the markers by clicking on one of them to move them as a
group to a new position. The markers will turn blue when selected (Figure 21).
Figure 21: Manually Match move markers as a group
 To move an individual marker, press and hold the Ctrl key, click on the marker
and drag it to a new position. Only that marker turns blue.
 Repeat Step 17 for the second 2D image (Figure 22).

Figure 22: Marker alignment
18. Perform a visual inspection of the detected markers in both 2D images

(Figure 23).

Figure 23: Completed Marker Match
 If necessary, select Reproject Markers to reset the marker selections

from the 3D reference image onto the acquired image.

prior to applying shifts. Reimaging post shift is used to verify
19. Once you have verified the match result, accepted the couch correction values,
and checked the appropriate "Include" boxes, you can apply the couch shift.
 Click Apply Shifts (Figure 24).

Figure 24: Include Check Boxes and Apply Shift
NOTE: The “Residual Match RMS Error” is the measure of how

well the corrected target position matches with the reference
marker coordinates. More specifically, it is the remaining error after
suggested setup variation is applied. The statistical RMS is the
square root of the sum of the squares of a set of individual marker
errors divided by the total number of markers. It is a measure of
how well the reference marker positions computed at planning fit
the actual observed marker positions in on-line images.
20. Use the MEB and the >> key on the Clinac dedicated keyboard to move the
couch into the new position.

E. 4DITC
1. The 4DITC Apply Couch Shift dialog box opens. There are two options:
2. Plan, Shifted, and Actual Couch parameters:

 Shown Applied Permanently (Figure 29)

Figure 28: Couch Parameters Applied for Session
Figure 29: Couch Parameters Applied Permanently

Figure 30: Highlight Treatment Field and Mode Up
4. If the couch values are out of tolerance, the following warning message will
appear asking for confirmation of table parameters (Figure 31).
 Enter User Name and Password and then click OK.



Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


EXERCISE
The participants will work in teams of two and will use their OBI Operations
Manual as a reference to perform Marker Match verification.
Objectives:
 Using the OBI/IGRT Clinical School Manual as a reference, the student will
complete the following lab exercise:
 Extend and retract the OBI arms using the MVD/OBI pendant and from the
OBI Control Console
 Acquire kV images, evaluate the quality, and adjust the technique if
necessary
 Confirm the 3D CT Volume download
 Identify the markers
 Evaluate the match utilizing all of the verification tools

D o s e in C B C T – OB I A d v a n c e d Im a g in g
®
On-Board Imager (OBI) kV imaging system
December 10, 2009
A. Introduction
1. Patient dose can be reduced by a variety of methods when acquiring cone-beam

CT (CBCT) images; including:
• Reducing the volume of the patient being irradiated by adjusting the collimator
blades.
• Using the X-ray technique that best matches the clinical task.
• Selecting the direction of the kV beam to avoid sensitive structures.
• Calibrating the Pelvis Spot Light mode to use the full fan bow-tie filter.
2. The doses used for CBCT image acquisition (CTDIw – CT Dose Index weighted)
are given by the product of the normalized CTDIw, value ( CTDIw, norm) and the
exposure (given in mAs). These values are listed in Table 1. Table 1 also shows
that there are a large number of CBCT modes that operators can chose from
when using OBI Advanced Imaging. The Appendix describes how the values in
these modes can be changed to further adjust the dose.
• For an explanation of CT dose terminology, see the section titled “How to
Measure CTDI” below or examine the presentation at the link:
http://www.impactscan.org/slides/tarragona/patientdose/sld001.htm.
B. User Adjustment of Doses
1. Collimation
• In OBI, the size of the kV X-ray beam is controlled by adjustable blades. By
default, the blades are opened so that the radiation beam irradiates the entire
imager. However, operators can adjust the “Scan Width” value when
acquiring CBCT images to reduce the cranial-caudal extent of the CBCT scan.
Reducing the cranial caudal extent of the scan not only reduces the irradiated
volume of the patient (thereby reducing the integral dose) but also improves
CBCT image quality by reducing the X-ray scatter contributing to the
© Varian Medical Systems December 09 Page 1 of 10

Dose in CBCT – OBI Advanced Imaging
reconstructed images. This is especially helpful in scans of the pelvis where

X-ray scatter generates a significant fraction of the measured signal.
NOTE: Any changes in the Scan Width are saved and will be
automatically loaded the next time a scan of that patient is
acquired. Therefore, one only needs to adjust the Scan Width once
for each patient, regardless of the number of times that the patient
is scanned.
not typically calibrated

Standard-Dose Head
Filter). Note – mode

High-Quality Head
(Half Fan Bow-Tie
Low-Dose Thorax
(Full Fan Bow-Tie
Low-Dose Head
Pelvis-Spot light
Pelvis-Spot light
Pelvis
Filter)
X-Ray Voltage [kVp] 100 100 100 125 125 125 110
X-Ray Current [mA]

20 10 80 80 80 80 20
per Projection
X-Ray Millisecond 20 20 25 13 25 25 20
[ms] per projection
Gantry Rotation 200 200 200 360 200 200 360
Range [degrees]
Number of 360 360 360 655 360 360 655
Projections
Exposure (mAs) 145 72 720 680 720 720 262
CTDIw, norm 2.7 2.7 2.7 2.6 2.0 3.4 1.8

(mGy / 100 mAs)
CTDIw (mGy) 3.9 2.0 19.4 17.7 14.4 24.5 4.7
Fan Type Full fan Full fan Full fan Half fan Full fan Half fan Half fan
Default Pixel Matrix 384 x 384 384 x 384 384 x 384 384 x 384 384 x 384 384 x 384 384 x 384
Slice Thickness [mm] 2.5 2.5 2.5 2.5 2.5 2.5 2.5
Reconstruction Sharp Standard Sharp Standard Standard Standard Standard

Filter
Ring Suppression Medium Medium Medium Medium Medium Medium Medium
Algorithm
Table 1: Pre-defined CBCT modes installed with OBI Advanced Imaging (CTDIw and
CTDIw,norm values are ± 10%)

2. Selecting a Suitable X-ray Technique

• Another effective way of reducing patient dose is to select the X-ray technique
suited to the clinical task. In some clinical situations, such as repositioning the
head and neck, soft-tissue contrast is often not needed, because the
repositioning task typically uses the bony anatomy of the skull. Several
investigators have shown that very low CBCT doses are sufficient to position
patients when using bony anatomy of the skull.[1, 2] However, when one
needs soft-tissue contrast higher CBCT doses are required.[1]
• There are six different CBCT modes that are available after OBI Advanced
Imaging installation, with doses ranging between ~ 2.0 mGy to ~24.5 mGy
CTDIw per scan. These allow operators to select the appropriate X-ray
technique for the clinical task.
• In addition to selecting one of the installed and calibrated CBCT modes, there
are a variety of ways of adjusting the X-ray technique used for CBCT
acquisition. Existing CBCT modes can be copied and changed. Changing the
mAs (either adjusting mA or ms values) does not require a recalibration of a
copied mode, so CBCT modes with higher (for larger patients) or lower (for
smaller patients) patient exposures can be easily generated. In addition, just
before the CBCT acquisition starts, the kVp, mA, and ms parameters used for
a scan can be changed interactively by the operator – also with no need for
calibration. The ability to adjust the kVp is new in OBI Advanced Imaging. If
the patient requires special acquisition techniques, then there is now more
flexibility in OBI Advanced Imaging to customize the X-ray technique for each
individual patient. Details on how to change the X-ray techniques are
described in the Appendix.
3. Avoiding Sensitive Structures
• OBI Advanced Imaging can now use 200 degree CBCT acquisitions – so the
gantry does not need to rotate completely around the patient. Thus, one can
avoid irradiating some regions of the patient. By default, the 200 degree
CBCT modes are setup so that the X-ray source rotates underneath the
patient. For a supine patient being treated in the head, this means that the kV
X-ray source traverses the back of the head. Therefore, only the exit beam,
which has much lower dose than the entrance beam, reaches the lens of the
eye. In this way, dose to superficial anatomic structures can be minimized.
4. Pelvis Spot Light Mode
• In addition to collimating in the cranial caudal direction, OBI Advanced Imaging
has a mode that takes advantage of collimation in the scan diameter direction
to reduce patient dose. When using the Pelvis Spot Light mode, the central
24-25.5 cm diameter of the patient can be reconstructed while reducing
irradiation of the patient’s surface. This Pelvis Spot Light mode also uses a
200 degree scan, thereby reducing the acquisition and reconstruction time.
Examining Table 1, one can see that the dose to the patient can be made less

for the Pelvis Spot Light mode compared to the Pelvis mode if the full fan bow-
tie filter is used. Currently the half fan bow-tie filter is used for the calibration
during installation. However, users can recalibrate the Pelvis Spot Light mode
themselves (or create a separate mode) while employing the full fan bow-tie
filter. Once the Pelvis Spot Light mode has been recalibrated, users can
employ the full fan bow-tie filter when acquiring clinical scans.
C. How to Measure CTDI
1. The CT dose index (CTDI) is a standardized measurement to quantify the

radiation dose associated with CT scans. Although the CTDI is not a direct
measure of patient dose, it defines dose measurements under standard
conditions that allow doses to be compared between different CT scanners (e.g.,
different OBI units) and between different scan techniques. While there are a
variety of ways of measuring CTDI, we have adapted our measurement approach
to the tools that are available for measuring dose in conventional CT scanners.
We have used standard head and body Lucite CTDI phantoms – 16 cm and 32
cm in diameter respectively – along with the standard CT ionization chamber (100
mm active length) to measure central and skin doses in the phantoms. These
have then been averaged to yield the CTDIw quantities reported in this document.
2. In conventional CT dosimetry the basic measurement quantity is called CTDI100,
which is defined as:
1 50mm
CTDI100 =
J D(z) · dz
L -50mm (1)
• Where, L is the extent of the CT scan in the direction of the gantry rotation axis
(e.g., the size of the primary beam – which in a single slice CT scanner would
correspond to the slice thickness); the integration limits of +/- 50 mm represent
the 100 mm length of the ion chamber; and D(z) is the air kerma measured in
dose units (e.g., Gy, cGy, mGy).
• CTDI100 is measured at five locations in a standard CTDI phantom to generate
the CTDIw value. The five locations consist of a hole in the center of the
phantom and four equally spaced holes around the periphery of the phantom.
In Equation (2), D1 is the value measured in the center of the phantom, D2 –
D5 are measured in the periphery of the phantom. The weighted sum is given
by:
1 2 1 5
CTDIw = D +
1 I
2D I i
3 3 l4 i=2 J (2)

• Showing that the average dose measured in the periphery of the phantom is
given more importance in the dose estimate. CTDIw, norm is then calculated by
dividing the CTDIw by the mAs/100 used in the scan protocol.
3. Normally, CTDI100 is measured using a narrow X-ray beam that is significantly
shorter than the 100 mm length of the ionization chamber. The assumption is that
the ion chamber is able to measure the signals due to the primary beam plus the
entire scatter arising from the primary beam using its 100 mm length. Somewhat
fortuitously, a narrow X-ray beam and a lengthy dosimeter is the geometric
inverse of a point dose measurement in a broadly irradiated phantom. The point
dosimeter measures the primary beam at that point plus the entire scatter reaching
it from a broadly irradiated phantom. This latter situation represents the typical
CBCT irradiation conditions. Therefore, the standard CTDI measurement protocol
can substitute for measurements where point dosimeters are used in a broadly
irradiated CTDI phantom. [And since CBCT involves one rotation about the
patient, helical corrections to the CTDI measurements are not needed.] Therefore,
merely by narrowing the blade opening, we can measure CTDIw using
conventional CT dosimetry equipment.
• Our experimental approach is to set a 12 mm field length for the blade
opening. There is a 4 mm margin automatically applied to the top and the
bottom of the blade opening, which yields a nominal opening of 20 mm.
However, because of uncertainties in blade settings for such small settings the
length, L, of the collimated volume must be measured (see Figure 1).
• A single CBCT projection acquired during the CTDI measurement is used to
measure the full-width-at-half maximum (FWHM) of the blade opening. We
find the most reliable estimate of the FWHM is made in the region of the
projection outside of the phantom where scatter has a much smaller effect on
the measured signals. Once the length of the collimated volume, it can be
used to correct the readings from the standard CT ion chamber which are
typically given in Gy*cm units.

Figure 1: A single X-ray projection generated during a CTDI measurement showing the
collimated kV X-ray beam irradiating a 32 cm phantom. The air outside of the phantom is
visible on the left of the figure. The plot on the right of the figure shows the signal intensity in
the region selected by the green box. The FWHM of the signal intensity plot can be used to
determine, L, the length of the blade opening.
• The proposed technique has the advantage of being able to use widely
available equipment used for CTDI measurements of conventional CT
scanners. Reproducibility of the technique is mainly affected by the variability
of the air kerma measurement and by the variability of the slit width
measurement. The former is a property of the air kerma measurement device
and is typically less than 10%. The latter is typically smaller than ±5%.

D. Limitations of CTDI in CBCT
• The adoption of CTDI for CBCT doses does have at least one limitation.
Equation (2) shows that CTDIw uses the average dose in the periphery of the
CTDI phantom. However, for the scans that use a 200 degree rotation, the
dose in the periphery of the phantom is quite non-uniform, especially for the
Pelvis Spot Light mode. Therefore, the average value can be misleading,
because it hides the variation in the surface dose inherent in the 200 degree
scans.
NOTE: For more information on how dose can be estimated during

IGRT procedures, see the AAPM Task Group 75 report.[3]
E. Conclusion
• There are a number of ways of minimizing dose to patients – or regions of

patients – when using CBCT and OBI Advanced Imaging.
F. References
1. Kan, M.W.K., et al., Radiation Dose from Cone Beam Computed Tomography
for Image-Guided Radiation Therapy. Int J Radiat Oncol Biol Phys, 2008.
70(1): p. 272-9.
2. Sykes, J.R., et al., A feasibility study for image guided radiotherapy using low
dose, high speed, cone beam X-ray volumetric imaging. Radiother Oncol,
2005. 77(1): p. 45-52.
3. Murphy, M.J., et al., The management of imaging dose during image-guided
radiotherapy: report of the AAPM Task Group 75. Med Phys, 2007. 34(10): p.
4041-63.

G. Appendix
1. User Adjustment of CBCT Doses

• While Varian installs CBCT acquisition modes with default dose settings, the
exposures/doses used by the operator can be adjusted to suit their clinical
needs. The user can:
o Alter/duplicate existing CBCT mode files to change the X-ray
techniques from those installed by default; or,
o Adjust the X-ray techniques at the time of CBCT acquisition for each
individual patient.
2. Both of these are trivial to do and allow the user great flexibility in the
exposure/dose used for a CBCT scan.
H. Changing the Settings in the CBCT Mode File
1. To edit the mode file, start the CBCT application. This is easiest to do in CBCT
“stand alone” operation with the OBI application stopped.
• Stop the OBI application. Wait ~ 15 seconds.
• Choose Windows Start menu > Programs > CBCT >CBCT Application to start
the CBCT application – or – double click on the CBCT Icon in the folder on the
desktop.
• Select the Workspace menu > Calibration and Maintenance.
• Enter SysAdmin as the username and password.
• Select the Mode Setup (see Figure 1).
• Select the mode to edit and then click Edit.
• Adjust the X-ray Current [mA] and/or the X-ray Millisecond to the desired
values. Do not change the X-ray voltage [kV]. This will force a recalibration of
the mode.
2. An alternative is to create a copy of an existing mode file, rename the mode, and
then make the desired changes to the X-ray Current [mA] and/or X-ray
Millisecond values. This will create an additional mode to select. Make sure to
identify the mode as a Clinical Mode.

Figure 2: CBCT Mode Calibration Screen
I. Changing the Settings for an Individual CBCT Scan
1. The operator can change the voltage [kV], current [mA], or the pulse width [ms]
just before an individual patient is scanned. The ability to adjust the Voltage is
new in OBI Advanced Imaging.
• Follow the normal CBCT acquisition process until the “At start position” dialog
box appears (see Figure 2).
• Adjust the voltage [kV], current [mA], or the pulse width [ms] settings in the
dashboard.
• Select enter on the keyboard so the system recognizes that new values have
been entered. Make sure the target and actual readings for the voltage [kV],
current [mA], and the pulse width [ms] settings agree.
• Select OK and start the CBCT scan normally.

2. Caveats
• If the CBCT acquisition is interrupted, the edited values will have to be re-
entered.
• The edited values will not be saved with the scan. The voltage [kV], current
[mA], and pulse width [ms] values defined in the mode file will be saved with
the scan.
NOTICE: This document is FOR EDUCATIONAL PURPOSES ONLY. It is not

intended to replace or modify the relevant Varian Operator’s Manual. For complete
information refer to your Varian Operator’s Manual.

RAD 10020B © 2009 Varian Medical Systems, Inc. 12/09
RPM Overview
PROCEDURE
Objective:
After completing this module, using the OBI/IGRT Clinical School Manual as a
resource, the student will be able to state the basic features and functionality of
each of the RPM components.
A. Exercise key:

2. Parentheses () denote additional selection options.
1. Clinical rationale:
 Interfraction
 Intrafraction
 ICRU 50 and 62
2. Imaging and planning:
 Prospective
 Prospective treatment process
 Retrospective
 Retrospective treatment process
 Simulation treatment process
3. Tracking methods:
 Amplitude
 Phase

RPM Overview
 Duty cycle
 Treatment time multiplier
 Treatment process
4. RPM components:
 Marker block
 Tracking camera
 In-room viewfinder
 Junction box
 RPM switchbox
 RPM workstation
 Toolbar
 Image window
 Chart window
C. Clinical rationale
1. Organ motion is often categorized as:

 Interfraction: Motion occurs between fractions and primarily relates to
changes in patient localization.
 Intrafraction: Motion occurs during fractions and primarily relates to
respiration.
2. Volume definitions are typically defined by the guidelines outlined in ICRU report
50 and 62.
3. ICRU report 50 defines:
 GTV: gross tumor volume
 CTV: clinical target volume
 PTV: planning target volume
 ITV: internal target volume

RPM Overview
4. ICRU report 62 defines (Figure 1)

 IM (Internal margin) as variations in size, shape, and position of structure due
to breathing, organ motion, and organ filling (i.e. bladder, rectum, etc.).
 SM (Setup margin) as uncertainty with patient, beam position, and setup
errors.
 The CTV-to-ITV margin (IM) accounts for Intrafraction motion.
 The ITV-to-PTV margin (SM) accounts for Interfraction motion.
PTV
CTV
ITV
GTV
Figure 1: Volume definition
D. Imaging and planning for respiratory motion:
1. There are two ways to take into account respiratory motion:

 Prospective
 Retrospective (4DCT)
 Usually depends on equipment options.

RPM Overview
2. Prospective: Images are acquired during one phase of the respiration cycle
(Figure 2).
Respiration Waveform from RPM Respiratory Gating System
Inhalation
Exhalation
Scan Scan Scan
CT Scan
Axial scan Axial scan trigger, Axial scan
trigger, 2nd couch position trigger,
1st couch position 3rd couch position
Figure 2: Prospective
 Prospective treatment process (Figure 3).
Track and Coach patient

Position
Setup patient record patient for respiration
marker block
respiration protocol
Set threshold
Review Save CT
per Acquire
patient image
prospectively prospectively
respiration reference
gated CT gated CT data
data session
protocol
Figure 3: Prospective treatment process

RPM Overview
3. Retrospective: Images are acquired during the entire respiration phase.

Software sorts the images into the appropriate respiration phases (binning). The
plan is typically done on one particular phase of images (Figure 4).
Respiration Waveform from RPM Respiratory

Gating System
Inhalation
Exhalation
“Image
acquired” signal
to RPM system
X-ray on
1st 2nd 3rd couch
couch couch position
position positio
n
(Ford and Vedam, 2003)
Figure 4: Retrospective
 Retrospective treatment process (Figure 5).

Position
marker block
Acquire Review Save CT

retrospective patient image
gated 4D CT respiration reference
data data session
Figure 5: Retrospective treatment process

RPM Overview
4. Simulation treatment process (Figure 6).

Position
marker block
Evaluate
Save
Review planned
Acquire fluoroscopic
patient gating
fluoroscopic imaging
respiration thresholds
data reference
data using gated
session
playback
Figure 6: Simulation treatment process
E. Tracking Methods
1. Established during reference session

2. Cannot be changed at a later time
3. Amplitude (Displacement) (Figure 7)
 Performed at inhalation or exhalation
 Thresholds define the gating range. Beginning of gate (upper threshold) and
end of the gate (lower threshold).
Figure 7: Amplitude

RPM Overview
4. Phase (Figure 8)
 Performed between two points of the breathing cycle
Figure 8: Phase
5. Duty cycle
 Ratio of the entire treatment delivery time to the fraction of the time for which
the beam is on
6. Treatment time multiplier
 Value by which the time calculated by the Clinac should be multiplied to avoid
time out
 This minimum value should be slightly increased.

RPM Overview
7. Treatment process (Figure 9)

Position
marker block
Deliver gate
treatment Save
using planned treatment
gating session
thresholds
Figure 9: Treatment Process
F. RPM Components
1. Marker block (Figure 10)

 Two reflective markers (2-Dot most common) or 6 reflective markers (6-Dot)
 Diameter of each marker is 5 mm
 Attached to a lightweight block made of synthetic material
 Distance from marker to marker equals 3.0 + 0.1 cm

RPM Overview
 System tracks both markers to maintain calibration of the vertical component

of the motion.
Figure 10: Marker block
 The marker block location should be reasonably flat (Figure 11).

 If the block tilts more than 25 degrees, the camera may not be able to track
the block motion.
 Transparent to radiation
 Initial placement during the capture of the reference session
 For lung patients, the marker block is typically placed between the xyphoid
and the umbilicus.

RPM Overview
Figure 11: Marker block proper placement and taping
2. Tracking camera with IR illuminators (Figure 12)

 Charge coupled device (CCD): sensitivity to light within the infrared spectrum
as well as the visible spectrum
 Illuminator ring: infrared emitter
 In the treatment room it is mounted to the wall.
 In CT, the camera is attached to the couch. Maintains constant distance
between marker block and camera while the table is indexed into the CT
gantry.
3. In-room viewfinder
 Displays video image from the tracking camera
 Verify that the markers on the marker block can be visualized in the viewfinder
and that there are no other reflections.
4. Junction box
 Connected to the power supply
 Signal distribution from the camera to the RPM workstation.

RPM Overview
1 3
2
1 Junction Box 2 In-room viewfinder 3 Tracking Camera
Figure 12: Junction Box, In-room Viewfinder, and Tracking Camera
5. RPM switch box (Figure 13).

 Enables the operator to disable gating or hold the beam manually.
 Two controls: gating disabled or enabled.
 Beam hold button: manually press to place the beam on hold.
 Key can be removed in gating disabled position.
Figure 13: RPM switchbox (new / previous)

RPM Overview
6. RPM workstation (Figure 14)

 PC based workstation
 Common patient database located on the network
 Not connected to the verification system
 Video tracking software
 Breathing trace display
Menu
Toolbar
Status bar
Image window Chart window
Figure 14: RPM graphics window

RPM Overview
7. Menu toolbar (Table 1):
Definition for Toolbar Icons

Tool Name Description Tool Name Description
nd Displays live video

2 video
Displays live video from tracking or
Camera channel
from tracking camera live video from
or fluoro
fluoroscope.
Starts video tracking Records motion

Track Record
for a reference session and video data
Starts a gated
Stops recording,
playback recording
Stop playback, or gated Playback
of motion and
treatment
video data
Saves the most Stop Disables gating in

Save
recently recorded data. Gating treatment mode
Enable gating radiation

Displayed on RPM
Enable treatment or automatic
Verify systems attached
Gating triggering of CT
to clinacs with OBI
scanner
Displays the Image
Area in the upper left-
hand corner showing Treat/Track/Verify – when selected, all 3 buttons
Treat live video from the will cause the system to begin tracking the marker
tracking camera or block.
playback from a
recorded session
Table 1: RPM toolbar
8. Image window
 Displays the simulation playback or the marker block
9. Chart window
 Displays motion signal recorded by the tracking camera
 Signal displayed as respiration waveform, representing the patient’s
respiratory pattern.
 Indicates the extent of marker block motion in centimeter scale
 One rotation or indicator represents one complete breathing cycle.

RPM Overview
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Gated kV/kV Verification and Pre-Treatment
Fluoroscopy Verification
PROCEDURE
Objectives:
 After completing this module using the OBI/IGRT Clinical School Manual as a
resource, the student will be able to perform the following tasks:
 Verify the prepared OBI plan
 Enable the gating console
 Open the appropriate reference session
 Track the patient’s current respiration
 Enable gating
 Acquire and analyze kV images
 Shift the couch into treatment position
A. Exercise key

B. Procedure content
1. 4DITC
2. RPM
3. OBI

Gated kV/kV Verification and Pre-Treatment Fluoroscopy Verification


imaging.

field and the reference image when plans come from ARIA. It may
reference image.

C. 4DITC:


3. If a plan has a large number of structures, the operator has the option to select
the structures to load for image guidance (Figure 2). Set the maximum size of the
plan in OBI administration.

4. Select the kV set up field and click Mode Up (Figure 3).
5. Set up the patient with the marker block as it was for the reference session.
D. RPM workstation:
CAUTION: The RPM system uses chest wall or abdominal motion

as a surrogate for the respiration-induced motion of the tumor and
other organs and structures within the body. The adequacy of this
surrogate indicator for application to the treatment of any specific
patient condition or setup must be based upon clinical evaluation
using CT or fluoroscopic imaging and other studies as deemed
appropriate. These judgments are the sole responsibility of qualified
medical personnel using the equipment.

1. Open the RPM software from the RPM workstation (Figure 4).
Figure 4: RPM desktop Icon
2. The Patient List dialog box displays (Figure 5).

 Select the appropriate patient and click Select.
Figure 5: RPM Patient List
WARNING: Make sure the correct patient is selected from RPM

patients list. The RPM database is independent of all Verify and
Record systems.

3. The treatment fields and session dialog box displays (Figure 6).
 Select the appropriate reference session and click Select.
Figure 6: Treatment Field and Session
4. Turn the key at the RPM console to Gated Enabled.
 Review the reference session.
WARNING: The Gating Key should remain in the Enabled position

throughout the session. Turning the key to Disable during the
session could lead to mistreatment.

5. Click Stop (Figure 7).
Figure 7: Stop Gating
6. Click Verify or Treat to begin tracking the marker block (Figure 8).
Figure 8: Verify
 Use On-Board Imaging to Verify the planned gating before treatment.

 Select Treat to start a treatment session for a planning session.
7. Confirm the RPM respiratory gating system dialog message and click OK
(Figure 9).
Figure 9: RPM respiratory gating system

8. Watch the Periodicity Meter and wait for the system to establish Periodicity.
9. Click Record to view the gating trace in the chart window of the RPM system
(Figure 10).
Figure 10: Record
10. Select Enable Gating (Figure 11).
Figure 11: Enable Gating
E. OBI Workstation:
1. Extend the OBI arms from inside the room using the hand pendant or from
outside the room by clicking Download Axes. Press the Motion Enable and
Auto buttons at the same time to move the imaging arms (Figure 12).


harm the patient.
2. Set (collimate) blade positions.

3. Move the gantry to the plan position at the Clinac Console.
 Press the MEB and the >> keys, or use the hand pendant in the treatment
room.
4. Select the X-ray technique on the anatomy drop-down list (Figure 13).

5. Verify or define the kV imaging technique manually.

6. Press the footswitch or hand switch to acquire the first image. The first image
displays at the OBI workstation (Figure 14).
Figure 14: Gated image
NOTE: The X-ray generator will wait until the RPM gating
application has detected that the patient breathing has reached the
gating threshold. The X-ray system will not irradiate immediately.
Keep pressing the footswitch or hand switch until the RPM gating
system detects that the patient is at the correct phase of the
breathing cycle.
7. To acquire the second image, click the 2D/2D Match button. OBI automatically
uploads the second set up field on the screen. If the set up field is not loaded,
select the set up field from the dynamic window, drag and drop it to the
appropriate OBI screen (Figure 15).

8. The 4DITC displays a blue wash stating that the OBI console has control
(Figure 16).
Figure 16: Imaging Application has control
9. To move the gantry to the next imaging position press the MEB and the >> keys
on the Clinac's dedicated keyboard. Another option is to use the hand pendant in
the treatment room.
10. If needed, click Download Axes then press and hold the Motion Enable and
Auto buttons on the OBI Control Console (Figure 17).

11. Select the appropriate X-ray technique from the Anatomy drop-down menu
(Figure 18).
12. Verify or define the kV imaging technique manually.

13. Press the footswitch or hand switch to acquire the second image. The second
image displays at the OBI workstation (Figure 19).

Figure 19: Acquire Workspace: Gated Images
NOTE: The X-ray generator will wait until the RPM gating
application has detected that the patient breathing trace has
reached the gating threshold. The X-ray system will not irradiate
immediately. Keep pressing the footswitch or hand switch until the
RPM gating system detects that the patient is at the correct phase
of the breathing cycle.
14. Click Analyze (Figure 20).
Figure 20: Analyze


15. Select Automatic or Manual Match.

16. If selecting Automatic Match, proceed to step 21. Otherwise, proceed to the next
step for Manual Match.
17. Click on the Manual Match button .

18. Perform the match by moving the first reference image on top of the acquired
image using the mouse or arrow keys on the keyboard.
19. Move the second reference image on top of the acquired image using the mouse
or arrow keys on the keyboard.
20. Verify the match using the Match Verification tools (Figure 21).
Figure 21: Match Verification with Content Filter, Window/Level, and Split Window

NOTE: The Manual Match mouse icons couch rotation and
couch translation will be white in color when moving items

such as the ROI. The mouse icons will turn red when able to
perform matching functions.
21. If selecting Automatic Match, click on the Auto Matching button . The
Auto Matching 2D/2D dialog box displays (Figure 22).
Figure 22: 2D/2D Auto Matching Dialog Box

 Select or deselect the appropriate Axes.
 Click Start.
 The start button toggles to become a Stop button indicating that you can
cancel (and Start again) the match process at any time.
 An alternative to stop the match process is to press any key on the keyboard
or specifically press the Ctrl key to abort and exit the match process.
 Click Close when the match is complete.

22. Always verify the Auto Match Results using the Match Verification Tools.


23. In the Dashboard, check the “Include” boxes for the desired shift (Figure 23).
Figure 23: Include shift
24. Click Apply Shift (Figure 24).
Figure 24: Apply Shift
WARNING: Always re-track (reacquire the breathing trace) after

performing a couch shift. Movement of the couch will cause the
breathing trace to move in relation to the thresholds.

Warning: If the treatment couch is moved for any reason while

RPM is recording the breathing trace, select Stop and then re-track
the marker block. Failure to do so could lead to a mistreatment.
25. After applying the couch shift on the imaging dashboard, at the RPM console re-
track the breathing trace on the RPM system (Steps A4-10).
26. To perform fluoroscopy verification, click Acquire on the OBI workstation (Figure
25).
Figure 25: Acquire
27. When OBI switches to the Acquire workspace it 'Modes Up' on the most recent
setup field acquired and does not require any changes to the setup (Figure 26).
Activate the appropriate field to fluoroscope by clicking on the image area to
highlight it with a yellow frame.
Figure 26: Acquire
28. Maximize the view of the selected setup field for better evaluation (Figure 27).

Figure 27: Maximize View
29. Operators may select which contours on the reference image to superimpose
onto fluoroscopy images. This occurs when gating is active and inactive. If
gating is active, then the contours will change color in conjunction with the
respiratory gating signal.
 The color change of the contour is associated with beam on and beam off on
the reference image. This setting is in OBI Administration to match previous
versions of OBI or to match the colors used in TrueBeam (Figure 28).
Figure 28: Using TrueBeam color scheme for Fluoroscopy

 The OBI color scheme and TrueBeam color schemes for non-gated plans are
Green for all contours except Blue for the field aperture contour (Figure 29).
Figure 29: Contour Overlays in Fluoroscopy

 OBI color scheme for a gated plan is Green for Beam On and Red for Beam
Off (Figure 30). TrueBeam's color scheme for a gated plan is Yellow for Beam
on and Green contours for Beam Off and Blue field aperture contour for Beam
Off (Figure 31).
Figure 30: OBI Color Scheme: Green-Beam On and Red – Beam Off
Figure 31: Color Scheme Differences with Fluoroscopy and Gating
30. Select the Fluoroscopy button and ABC. The dose per minute value displays
during and after Fluoroscopic Imaging (Figure 32).

Figure 32: Fluoroscopy and ABC buttons with Dose
31. Press and hold the footswitch or hand switch to acquire the fluoroscopic image.
The live image displays in the corresponding window as long as the footswitch or
hand switch is pressed, or until the time limit has elapsed.
 The Fluoroscopy Mode has an option to select "Higher Dose Rate" for a higher
dose rate when the time limit is reached. The operator may RMC on the
warning sign (alarm indicator) for a higher dose rate (Figure 33).
Figure 33: High Dose Rate Fluoroscopy
 If the dose rate is higher than 88.0 mGy/min an exclamation point and yellow
background displays on the dashboard. If the dose rate is higher than 176.0
mGy/min and exclamation point and red background displays.
 Regarding the dose rate alarm indicator, the color-coding does not imply an
error or that the dose rates should not be used, rather the dose rate alarm
indicator provides a visual element for the operator to raise the awareness that
a certain dose rate band was entered and may, if not careful, result in an
undesired long exposure.

32. Analyze the motion and verify the gating threshold data against the fluoroscopic
image.
 When the footswitch or hand switch is released, the last image held displays
on the OBI workspace. Make adjustments as necessary and as defined by
your clinic's gating protocols.
33. Verify the second field if necessary.
34. When finished, click Cancel.
35. At the 4DITC, the Apply Couch Parameters dialog box displays (Figure 34).
 Select Apply for Session or Apply Permanently.
 If selecting Apply Permanently, type the appropriate username and password.
 Click Apply.
Figure 34: Apply couch parameters

36. Select the field to treat and click Mode up.

37. A message asking for confirmation of table parameters may appear if the shifted
position is outside of tolerance limits. Type the appropriate username and
password (Figure 35).
Figure 35: 4D Console: Override out of tolerance couch parameters
38. Continue with Gated treatment as usual.
WARNING: When OBI is used, closed circuit video and an audio


Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Gated kV/kV and Fluoro Verification
EXERCISE
The participants will work in teams of two. Using the OBI/IGRT Clinical School
Manual as a reference, perform a gated kV/kV verification followed by pre-
treatment fluoroscopic verification.
Objectives:
 Using the OBI Operations Manual as a reference, the student will complete the
following lab exercise:
 Extend and retract the OBI arms using the MVD/OBI hand pendant and from
the OBI Control Console
 Open the appropriate gating patient and reference session
 Track and enable gating
 Enhance the quality of the images by adjusting the technique and other image
enhancement tools
 Evaluate the match using all of the verification tools

Morning Preparation, Warm Up, Shutdown and
Interlocks
PROCEDURE
Objectives:
 After completing this module, using the On Board Imaging (OBI)/IGRT Clinical
School Manual as a resource, the student will be able to perform the following
tasks:
 Start-up sequence for the On Board Imager (OBI) and Clinac
 X-Ray Tube Warm-Up
 Shutdown sequence for the On Board Imager (OBI) and Clinac
 Troubleshoot On Board Imager (OBI) interlocks
NOTE: This procedure does not apply to TrueBeam machines.
A. Exercise Key

2. Parentheses () denote additional selection options
1. Power up OBI and Clinac with PaxScan Unit On

2. Power up OBI and Clinac following complete shutdown
3. X-ray tube warm-up
4. Shutdown sequence for OBI and Clinac
5. Troubleshoot Interlocks
6. Operator Tips

Morning Preparation, Warm Up, Shutdown and Interlocks
WARNING: Care by the user is the most important safety

mechanism to prevent accidents. For your own safety and the
safety of patients as well as to prevent damage to equipment, be
sure to read and follow the guidelines outlined in chapter “Safety
and Emergency” in the On-Board Imager Reference Guide. Always
use the On-Board Imager with care and adhere to the safety and
emergency procedures described in the On-Board Imager
Reference Guide.
C. Power Up Procedure for On Board Imaging (OBI) and Clinac
NOTE: Morning startup procedure assumes that the PaxScan Unit

has been on for 2 hours and the Clinac is in Standby. If Clinac
power is off, refer to section 4 of CTB GE-752-D: Startup from
Emergency Shutdown or Power Failure.
1. Turn on Clinac monitor and verify Clinac is in Standby.

 The major mode screen should display a KFIL interlock (Figure 1).
Figure 1: Clinac Monitor
2. If appropriate, run the F2 Diagnostic Test. The Clinac will perform a self-check to
detect problems prior to the start of treatment.
3. Turn Clinac Electronic Cabinet key switch from Standby to On. This will start the
Clinac time delay.

4. If all interlocks are clear, enter room and rotate the gantry to the 12 o’clock
position.
NOTE: DO NOT rotate the gantry from the overnight-parked

position if a FLOW or PUMP interlock is present. Follow your
hospital protocol and seek assistance for this problem.
5. Check appropriate gauge and temperature readings.
NOTE: If the Gantry will not rotate and the red collision LED is not
illuminated on the collimator interface mount, there may be an On
Board Imaging fault preventing rotation. If this is the case, it will be
necessary to launch the OBI application and clear the fault.
6. Verify couch position and move any objects to allow for Exact® Arm positioning.
7. Turn on In-Room Monitor (if turned off overnight).
8. Turn on RPM Gating Camera system in treatment room.
NOTE: If LaserGuard is installed, it is recommended to turn on the

RPM Gating camera only when needed. In some cases, the
infrared camera system can interfere with the LaserGuard system
and cause false collision trips.
9. Turn on OBI and 4DITC workstations (if shutdown overnight). If left on overnight,
it is recommended to restart the OBI workstation each morning.

NOTE: For Multiplicity Users – If Multiplicity software is installed on

the OBI workstation, log on to the OBI workstation first. This will
ensure that the Multiplicity software has connected properly,
allowing common mouse and keyboard access to the 4DITC and
optional RPM workstations. The KVM switch must be set to the OBI
workstation selection in order to control the other workstations
without having to make manual selections on the KVM switch.
10. Turn on the RPM Gating workstation if gating patients are scheduled for the day.
11. Turn on the LVI and CBCT Reconstructor computers (see following Note). If they
were on overnight, it is recommended to restart them at least once per week.
These computers will automatically boot without any operator interface required.
NOTE: Clinac accelerators that have a Dell T7500 or blue IGMA

OBI workstation will not have a separate CBCT Reconstructor
workstation. Instead, the Reconstructor software is incorporated
into the OBI workstation.
12. Turn on the X-Ray Generator.

 From the OBI Console, press the On button (Figure 2).
 The Generator On and OBI Ready LED’s should illuminate after 10 seconds.
 If not, the OBI main power breaker may be tripped and require a restart.
Figure 2: On Board Imaging Console

13. Log-in to the OBI (first for mouse multiplicity), 4DITC, and RPM Gating
workstations.
14. MLC HyperTerminal should automatically launch on the 4DITC monitor.
15. Turn on MLC Controller to initialize the MLCs automatically.
 Gantry must be in the 12 o’clock position.
16. Verify that the MLC initialization begins by the scrolling text in the HyperTerminal
window and then minimize the HyperTerminal window (Figure 3).
Figure 3: MLC HyperTerminal
17. Launch Treatment Application and Login.

 Once open, click the Standby button and proceed with Morning Checkout
(Figure 4).
 If an MLC Comm message appears, click the Exit Standby button. The MLC
may need to be re-initialized (Figure 4).

Figure 4: 4DITC
18. Launch RPM Gating application and Login only if gating patients are scheduled
for the day.
19. Verify PaxScan® Power Supply and Control Processor units are on. Visible LED’s
on the front panel indicate this (Figure 5).
 It is recommended that the PaxScan remain on at all times to provide stable
image quality (Figure 6).
Figure 5: PaxScan Unit

Figure 6: PaxScan Power On/Off Switch
20. Launch OBI application.
NOTE: If the OBI application does not automatically launch, wait

until the Varian Network icon is visible in the lower right hand corner
(Figure 7). Until this icon is visible, Windows is still loading in the
background and the OBI application may not start properly.
Figure 7: Varian Network Icon
21. Acknowledge any present OBI interlocks and faults.
NOTE: The Interlock and Faults window is opened by clicking on

the red, orange, yellow, or green dot in the lower right hand corner
of the display (Figure 8). Some faults and/or interlocks will not clear
until arms are positioned and the door is closed (Figure 9). In some
cases, it may be necessary to reset the OBI Supervisor to clear
interlocks and allow gantry rotation. The supervisor can be re-set by
cycling the two power switches on the bottom of the ICP chassis.

Figure 8: Status Indicator
Figure 9: Interlock and Fault Window
22. Position the OBI kV arms to the default position for imaging so the kV Source is at
100cm and the kV Detector is at -50cm.
23. Close the treatment room door and perform X-Ray Tube Warm-Up via prompts on
the OBI monitor. For information on performing X-ray Tube Warm-Up, see
Section D of this procedure.
24. Fully retract the kV Arms for Clinac Morning Checkout.
NOTE: It is recommended that the kV imager panel be fully retracted to

minimize exposure to megavoltage beam.

25. Verify MLC initialization is complete and place the Treatment application in
Standby for Morning Checkout.
NOTE: If Standby button is grayed out and a VI_COM interlock is

present, close the treatment application and reboot the LVI
computer. The LVI computer is located at the console area and
controls the in-room monitor display. Wait until the in-room monitor
screen displays the Clinac axes positions and then re-launch the
Treatment application.
26. Perform Clinac Morning Checkout. If an MLC interlock occurs when changing
energies, momentarily exit Standby and reselect Standby in the Treatment
application to clear the interlock
27. A Morning Checkout log can be printed and saved for maintenance historical
data.
D. Tube Warm-Up Procedure
CAUTION: There are fewer restrictions to enabling the kV X-ray

beam while the Tube Warm Up dialog box is displayed. The kV
beam can be enabled regardless of the gantry angle; regardless of
whether the MV beam is on or off; and regardless of whether a
patient is loaded on the 4DITC or not. Therefore, operators need to
be aware that irradiation by OBI is less restrictive during the display
of the Tube Warm Up dialog box.
CAUTION: If the X-ray generator remains idle for 4 hours or more,

repeat the tube warm-up procedure. Failure to follow the warm-up
recommendations may reduce the life span of the X-ray tube.

1. When the OBI application is launched a warm-up prompt and progress bar will
appear. The tube warm-up technique will automatically be selected (Figure 10).
Figure 10: Tube Warm-Up Prompt
2. Position the kV arms for imaging. Nothing should be between the source and
detector and no bowtie filter should be mounted.
NOTE: In addition to warming up the tube, tube warm-up also

conditions the panel, which results in better image quality for CBCT
acquisitions.
3. Press and hold footswitch for 20 seconds (may be longer) then release.
NOTE: Physics can change the warm-up time in OBI

Administration depending on site specifics. Tube Warm Up is
recommended whenever the tube has not been used for 4 hours.

E. Power Up Procedure from Emergency Shutdown or Power Failure
1. Turn on OBI Workstation.
NOTE: The OBI Supervisor receives power from the Clinac. Any
time the Clinac power is restored the Supervisor will automatically
reboot and initialize. Prior to powering up the Clinac be sure the
OBI workstation is on. If the OBI workstation is not on, the
Supervisor initialization will fail since it must load its application
software from the OBI workstation.
2. Reset the Clinac main circuit breaker and press the Start Button in the Modulator.
3. Turn on Clinac Monitor.
4. At the successful completion of the Clinac Self-test, follow the steps listed in the
Power up procedure for OBI and Clinac.
NOTE: A Self-test will only commence if the Clinac Electronic

cabinet key switch is in the Standby position. If the Clinac
workstation does not boot up properly, a Firmware error may be
displayed on the monitor. It will be necessary to manually reset the
STD bus inside the Electronics cabinet and reboot the Clinac
workstation. If this is the case, follow hospital protocol and seek
assistance.
5. As part of the Supervisor Power On Self-Test (POST), the Clinac collision line is
activated twice.
 After the 90-second Power On Self-Test (POST), press the Clinac touch guard
reset button to clear the collision interlock.
6. If the X-ray tube is not used for 4 hours, warm up the X-Ray tube per the
technique described in the X-ray Tube Warm-Up procedure (see Section D).
7. If the PaxScan unit was off for more than 15 minutes, image quality will be
affected until it warms up - more so for CBCT than Radiograph acquisitions.
 This should not cause any treatment delays, but do not perform any image
calibrations until the panel has warmed up for at least 2 hours.

F. End of Treatment Day Shutdown Procedure
1. Retract the MV imager arm (if extended).

2. Move the kV arms to the Out (Parked) or Retract position.
NOTE: The OBI and Clinac pendants cannot be operated

simultaneously.
3. Clinacs with OBI: Rotate the gantry to the 4 o’clock position (120°) and the
collimator to the 90° position.
Clinacs without OBI: Position the gantry and collimator to 90º.
NOTE: The parking angles above are recommended to prevent

stress to MLC leaf drive components and to minimize potential
damage to the Ion Chamber, collimator, and MLC assemblies in the
unlikely event of a water hose rupture overnight.
4. Turn off In-Room monitor (if desired).

5. Turn off RPM Gating Camera system in treatment room.
6. Charge OBI/PV Pendant ONLY if “BAT” is displayed on the Pendant.
7. Turn Clinac Electronic cabinet key switch to Standby.
8. If the MLC is running software version 7 or higher, go to the HyperTerminal
window and type “wh” followed by the <Enter> key. This saves all log files and
stops the MLC software.
9. Turn off MLC Controller.
10. Close Treatment application and Log off 4DITC workstation. Computer may be
shut down or left on overnight.
11. Close RPM Gating application and Log off RPM Gating workstation. Computer
may be shut down or left on overnight.
12. Close OBI application and Log off OBI workstation. Computer may be shut down
or left on overnight.

NOTE: If using OBI with Multiplicity software, shut down the OBI
workstation last. If the OBI workstation is left on overnight, it is
recommended to restart the workstation in the morning.
13. Turn off the X-Ray Generator by pressing the Off button on the OBI Console.
The Linac Verification Interface (LVI) and CBCT Reconstructor workstations can
remain on overnight. However, there is no harm in turning them off overnight.
NOTE: Clinac accelerators that have a Dell T7500 or blue IGMA

OBI workstation will not have a separate CBCT Reconstructor
workstation. Instead, the CBCT software is incorporated into the
OBI workstation.
14. Turn off all monitors in Control area.

15. Ensure PaxScan Power Supply and Control Processor units remain on overnight.
It is recommended these units remain on to provide stable image quality.
G. On Board Imaging Interlocks and Faults
1. Due to the complexity of the OBI system and the extensive internal monitoring of
various sub-systems, interlocks may randomly occur that will require
acknowledgement by the operator. These interlocks are viewed in the Interlocks
and Faults window on the OBI workstation monitor.
 The Interlock and Fault window is opened by clicking on the red, orange,
yellow, or green dot on the bottom right task bar (Figure 11).
Figure 11: Yellow Status Indicator
2. Most interlocks are easily cleared by clicking the Acknowledge All button in the
bottom of the Interlocks and Faults window. Since many faults will also cause
multiple interlocks, it is recommended to always use the Acknowledge All button
and disregard the Acknowledge button (Figure 12).

Figure 12: Interlock and Faults Window
3. Some interlocks and faults may require user interaction to clear.

 Example: A door fault, which also causes an X-Rays Inhibited interlock, can
be cleared by closing the treatment door.
 Example: An arm position interlock, such as kVD arm not level or MVD arm
not at zero position, is cleared by partially retracting the arms from the OBI
Console or the OBI/MVD pendant. Then reposition the arms to their target
position.
NOTE: When positioning the arms from the OBI Console or the
OBI/MVD pendant, keep the Motion Enable Bars (MEB’s)
depressed for approximately 3 seconds after the arms appear to
stop moving. This will ensure all arm axes reach their final position.
4. In some circumstances, OBI interlocks and faults may not clear or acknowledge.
This may require a reset of the sub-system. Types of resets are listed below.
Reset instructions are provided in the OBI Reset Instruction Table (Table 1).
 Motion Control Nodes Reset used for motion related faults such as Arm or
Blade problems.
 Supervisor Reset used for Supervisor related faults.
 X-Ray Generator Reset used for X-Ray or Generator faults.
 OBI Application Reset used for application related interlocks.

H. OBI Reset Instructions
On Board Imaging (OBI) Reset Instructions
Reset Type Reset Switch Location Reset Function When used
1. Node Service 1. Open Node Service.exe application

Supervisor Reset Used to reset a non-clearing
Application. on the OBI workstation. Click
Supervisor related interlock or
Reboot. Or open internet explorer
2. Interconnect Panel (ICP) and enter the following IP address fault.
cabinet. 172.20.20.65. Click Start Page. Used when no arm, blade, kV, mA
Click Reboot. or ms values are displayed in OBI
2. Open the ICP cabinet and press the Dashboard.
two white reset buttons on the side of
the Supervisor module.
This will re-initialize the Supervisor. The
process will take about 90 seconds. A
reset of the Clinac collimator touch guard
will be required. Look for green flashing
“heartbeat” LED next to the Supervisor
module.
Motion Control Interconnect Panel (ICP) Open the ICP cabinet and press the on/off Used to reset a non-clearing
Node Rack cabinet. toggle switch labeled Control Nodes 24V motion related fault or interlock.
(MCNR) Reset Power. These faults and interlocks refer to
This will reset the Motion Control Node the kVD, kVS or MVD arms or the
microprocessors. The node reset process Blade node. This can also be
will take about 5 seconds following a used to restore arm motions when
momentary collision alarm. A reset of the the arms will not respond to any
Clinac collimator touch guard will be motion commands.
required.
Interconnect Panel Interconnect Panel (ICP) Open the ICP cabinet and press the on/off Used when unsure about what
(ICP) Reset cabinet. toggle switch labeled Control Module type of fault or interlock to clear.
PSU Mains Input. This will reset the ICP, This single step will accomplish
Supervisor and MCNR. The reset process both of the resets listed above
will take about 90 seconds. A reset of the
Clinac touch guard will be required.
PaxScan Control Area “Failure to initialize the acquisition There is no communication to
system”. Power up PaxScan before PaxScan because PaxScan was
launching OBI. not powered up while starting OBI.
X-ray Generator OBI Console X-ray Generator. On the OBI X-ray Generator press the Off Used to reset an X-Ray Generator
Reset button. Wait three seconds before turning related fault or interlock. Also,
the X-ray Generator back On. The X-ray used if the kV, mA or ms boxes
Generator should reset within 10 seconds. are blank on the OBI application.
OBI System Hard Shutdown Procedure Use only when all other attempts
Reset 1. Turn off X-Ray Generator at resetting an interlock or fault
2. Close the OBI application have failed.
3. Shutdown OBI workstation
4. Turn off the Control Nodes 24V Power and the Control Module PSU
Mains Input in the ICP cabinet. An audible collision alarm will be heard.
Startup Procedure
1. Turn on X-Ray Generator
5. Turn on OBI workstation and wait for Login screen.
6. Turn on the Control Node Power and the Control Module PSU Mains Input
in the ICP cabinet. Allow Supervisor to initialize. Verify that the LED is
flashing green “heartbeat”.
7. Reset Clinac touch guard
8. Launch OBI application
9. Click on the red, orange or yellow dot in the lower right corner and click
Acknowledge All when the Interlock and Fault window appears.
Table 1: OBI Reset Instructions

I. Operator Tips
1. OBI arm motions are not possible when the Clinac Motion Enable bars are active.
CAUTION: Never attempt to drive an arm to a preset position after

partially moving the arm with the Backup Motion Controller. This
could cause damage to the fiberglass (collision flap on the MVD
arm). Always position the arm to the Out or Retract position before
moving to a preset extended position.
2. If the PaxScan unit is off or if the Fiber Optic cable has been shortly disconnected,
restart the PaxScan Power Supply unit.
 It will take approximately two minutes for the PaxScan unit to initialize.
 Initialization is complete when the Run light illuminates (Figure 13).
 There is no warm-up requirement in order to acquire images.
Figure 13: PaxScan (Left) and PaxScan Power On/Off Switch (Right)
NOTE: The PaxScan panel should be warmed up for at least 2

hours prior to performing image calibration.
3. When there are any problems acquiring an image, check for the green LED on the
Image Detection Unit (IDU) next to the orange Fiber Optic cable connection
(Figure 14).

Figure 14: IDU "green light (Left) and Location (Right)
4. The OBI workstation must be turned on prior to resetting or starting the

Supervisor for a successful initialization. It is not necessary to launch or login to
the OBI application.
5. There is no power up sequence requirements between the OBI and the 4DITC
workstations. These computers can be turned on at any time relative to each
other.
6. In some rare instances, the OBI workstation may lock up. To remedy this
condition, close the OBI application and open Task Manager. Locate and end the
ACQBIN~.exe (acquisition bridge) and/or WSWorkstationMain.exe task (Figure
15). Then restart the OBI application.
Figure 15: Task Manager

7. If the Generator power LED will not illuminate on the OBI Console, the main
power breaker located in the OBI breaker panel must be reset.
8. If beam is initiated and the generator does not fire, watch the fourth LED (X-ray
On) on the OBI Console, do not rely on the audible signal.
9. After using the Backup Motion Controller, it will be necessary to depress the small
TRIP push button (Figure 16) in the ICP and Acknowledge All interlocks on the
OBI workstation to restore normal motion operations.
Figure 16: ICP Trip Push buttons

J. Quick Tips Troubleshooting
1. Scenarios:
 Arms will not move:
1. Acknowledge Interlocks and Faults by clicking on the warning indicator
dot. The dot is referred to as the “Status Indicator” - results are instant.
2. Reset the Supervisor using Internet Explorer on the OBI workstation
(Results in ~90 seconds).
3. Reset the MCNR by turning the Motion Control Nodes power button off,
then on. Located in on the ICP (Result in ~10 seconds).
4. Reset both the Supervisor and MCNR by switching off then on both
power switches located on the ICP (Results in ~90 seconds).
5. Reboot the OBI workstation and repeat step 4.
 Images are not being displayed:
1. Switch to Pulsed Fluoro then back to Radiograph mode (Results are
instant).
2. Turn the X-Ray Generator off then on (Results in several seconds).
3. Restart the OBI application, not the workstation. Wait 10 seconds after
closing the OBI application before attempting to restart it.
4. Reboot the OBI workstation.
 Blades will not move:

1. Disable then enable Track (Results are instant).
2. Reset the MCNR by turning the Motion Control Nodes power button off
then on. Located in the ICP (Results in ~10 seconds).

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Morning Preparation, Warm Up, Shutdown, and
Interlocks
EXERCISE
Objective:
 Using the OBI/Clinical School Manual as a reference, the student will
complete the following True or False lab exercise:
A. True or False
Do not rotate the gantry if a FLOW or PUMP interlock is present.
All workstations may be left on overnight.
It is recommended to turn off the PaxScan every evening.
It is recommended to warm-up the X-ray tube whenever it has not

been beamed on in the last 20 minutes.
If there was a power outage overnight, prior to powering up the

Clinac, make sure the OBI workstation is on. Explain your answer.
The OBI/PV and Clinac pendants can be operated simultaneously.
Charge the OBI/PV Pendant every evening.
The Supervisor initialization process is considered successful when

the Supervisor Connecting fault can be acknowledged on the OBI
workstation and the green “Heartbeat” LED is flashing in the ICP.

ExactArm Indexing
PROCEDURE
Objective:
 After completing this module, the student will be able to perform the ExactArm
Indexing using the OBI Physicist Operations Manual as a resource.
A. Exercise Key

2. Brackets () denote additional selection options.
 ExactArm Indexing
WARNING: If any of the mechanical axes is not calibrated, no

clinical movements are allowed. If the mechanical calibration is
incorrect, there is a risk of irradiating the wrong area with the kV or
MV beam. The authorized person who carries out the calibration is
responsible for the correct calibration.
C. ExactArm Indexing
1. The indexing process identifies the absolute angular reference position of the
shoulder, elbow, wrist, and hand lateral positions.

ExactArm Indexing
NOTE: If an arm loses calibration, CAL displays on the infrared

pendant, and no values will be displayed for the vert, lat, and long
position on the hand pendant in Physics Mode. The indexing
procedure must be performed before any clinical movements are
allowed.
2. Depending on the arm to be verified, rotate the gantry to one of the following
positions:
 kV Detector: IEC 90.
 kV Source: IEC 270.
 MV Detector: IEC 0.
3. Select the arm to be verified by pressing one of the following keys on the hand
pendant:
 MVD / P1 for the MV Detector.
 kVD / P3 for the kV Detector.
 kVS / P4 for the kV Source.
4. FOR CLINICAL PRACTICE ONLY, bring the selected arm to a Pre-Defined
Clinical position (Ex. P2). This is not required as part of the actual indexing
Procedure.
5. Press the MODE key.
 A submenu appears in the hand pendant display.
6. Press the P3 key (physics).
7. Press the P1 key four times.
 An asterisk appears.
 A submenu appears on the hand pendant display.
8. Press the P2 key (mech. axis vel.).
9. Bring the kV Source or the kV Detector or the MV Detector to the indexing
position (Figure 3).
 The accuracy needs to be within +1.
 Use the thumbwheels on the hand pendant to move the selected arm to the
appropriate indexing position.
10. Arm indexing position:
 Shoulder – upper arm: 180 for the kV Source / kV Detector / MV Detector.
 Upper arm – elbow – forearm: 90 for the kV Source / kV Detector / MV
Detector.

ExactArm Indexing
 For the kV Source: forearm – wrist – hand: 180 (Figure 1).

 For the kV / MV Detector: forearm – wrist – hand: 270 (Figure 2 & Figure 3).
NOTE: A spirit level can be used to verify the arm indexing position.
Figure 1: kV Source position

ExactArm Indexing
Figure 2: kV Detector position

ExactArm Indexing
Figure 3: MV Detector position

ExactArm Indexing
11. When indexing the kV / MV Detector complete the following additional step for
lateral verification.
 Manually move the detector holder (hand) between the two markings on the
toothed rack (Figure 4).
Figure 4: Hand lateral position for detector and marking on the toothed rack
12. After the arm is in the indexing position, press CLR to go back to the previous
menu.
13. Press the P1 key (mech. axis cal.).
14. Move the VRT thumbwheel.
 The axis moves until the zero impulse index is found.
 When the indexing is successful, the message,“mech cal succeeded” displays.
 If the indexing message does not appear, verify step 9.
15. Repeat step 14 above using the LNG, LAT, and ANG (ANG used only on
detector arms) thumbwheels for the remaining axes.

ExactArm Indexing
NOTE: Without user interactions, the hand pendant menus

automatically time-out after a few seconds.
NOTE: If the axis cannot be indexed after repeated attempts,

indexing message “Calibration failed” appears, contact Varian
service.
WARNING: If the arm has lost isocenter contact your Varian

Service Representative.

ExactArm Indexing
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


ExactArm Indexing
EXERCISE
The participants will work in teams of two and will use their OBI Physicist
Operations Manual as a reference to perform an IDU indexing.
Objective:
 Using the OBI Physicist Operations Manual as a reference, the student will be
able to perform IDU (MV or kV) or kV Source indexing.

OBI Morning QA and Blades Calibration
PROCEDURE
Objective:
Using the OBI Operations Manual as a resource, the student will be able to perform
Daily QA checks.
A. Exercise key

B. Procedure content
 Maintenance workspace
 Daily maintenance checks
 Blades Calibration
 Blades Calibration Backup
NOTE: Always refer to the most recent On-Board Imager (OBI)

Maintenance Manual (for the installed OBI versions: 1.3, 1.4, 1.5,
or 1.6) when performing OBI calibrations.

NOTE: The OBI must be checked for operational safety, geometric

accuracy, and image quality behavior to maintain optimal
performance. The frequency of checks must be based on the
professional judgment of the person in charge and the
requirements of the existing QA program. Tests and
recommendations for their frequency are available in the scientific
literature, for example:
 Yoo, et al. “A Quality Assurance Program for the On‐Board Imager®.”
Med. Phys. 33:11. pp. 4431‐4447 (2006).
 Bissonnette, et al. Quality assurance of image‐guidance technologies
.Sem. Radiat. Oncol. 17: pp. 278‐286 (2007).
 Bissonnette, et al. A quality assurance program for image quality of
cone‐beam CT guidance in radiation therapy. Med. Phys. 35:5 pp.
1807‐1815 (2008).
Within these references, there are forms that you can use to record
the results of checks over time. Varian recommends that you keep
records of the performed checks.
C. Daily QA
NOTE: Determining Daily QA procedures is the responsibility of

your clinic. The following checks are recommendations. Review
the On-Board Imager Advanced Imaging Reference Guide and the
On-Board Imager (OBI) Maintenance Manual for further information
on QA.
1. Position the gantry at IEC 0.

2. Using the hand pendant, position the vertical position for the kVS to 100 cm
vertical and kVD to -50 cm.
3. While moving each of the arms, press their collision detectors and verify arm
movement stops.
4. Reset the collision detector by pressing the touch guard button.

5. Use the crosshair and light field of the Clinac to determine isocenter.
6. Use a ruler to measure the distance between the kV source interface plate and
the isocenter.
7. The distance should be 85.2 cm with a tolerance of + 2.0 mm.
8. Position the IsoCube phantom at isocenter (Figure 1).
Figure 1: IsoCube
NOTE: Morning QA can be performed with various phantoms. The

IsoCube provided by Varian allows for verification from multiple
gantry angles as well as kV and MV energies.

D. Maintenance Workspace
NOTE: QA images can be obtained in the Maintenance workspace. It

would be more practical to create a QA patient in your R/V system or
use QA Mode from the Treatment Queue to save QA images back to
the database.
1. To enter the Maintenance workspace, click on the Maintenance button on

the top right toolbar.
 Enter the appropriate User ID and Password and then click OK (Figure 2).
Figure 2: OBI Maintenance Mode login
NOTE: Access to the Maintenance workspace is password

restricted. Only qualified users who are familiar with the OBI should
be allowed to access. In order to access Maintenance, operators
will need to have the appropriate rights assigned in User Rights
Administration. The necessary rights in Platform Portal for ARIA
Users are: Administer Treatment Imager and Service System
(For previous ARIA versions, the rights were called: Administer
Treatment Imager and Administer Treatment Imager
Calibration).
2. In the OBI application, set the technique to Pulsed Fluoro with ABC and Track
selected.
3. Press the footswitch to acquire a fluoroscopic image.

4. Zoom in on the center of the image (Figure 3).
NOTE: To use the Zoom shortcut, click on the selected image and
scroll your mouse wheel to zoom in and out.
 Select the Graticule , and the Measure icons from the toolbar.
 Measure the distance on the monitor from the center of the IsoCube BB to the
graticule.
 The center of the BB should be less than or equal to 1.5 mm of the digital
graticule.
Figure 3: Center pixel verification

5. De-select Track, and manually set the blades to 10 cm x 10 cm to verify

calibration of the blades.
6. Press the footswitch to acquire a fluoro image (Figure 4).
 Measure the field size on the monitor. The digital graticule can be used to
make a quick assessment.
 The distance should be within + 2.5 mm.
 If tolerance is not met, calibration may need to be performed.
Figure 4: 10 x 10 field size
NOTE: The magnification factor can be verified by measuring the

IsoCube width (5cm).

E. Blades Calibration
NOTE: Blades Calibration is required only if a blade has lost

calibration. If a blade has lost calibration, the system will not
function in Verification Mode. Blades calibration may be desired if
morning QA reveals a poorly calibrated blade.
1. Place the blade check tool on the couch with the printed side of the board
facing up (Figure 5).
2. Align the crosshair and light field of the Clinac to the center mark on the blade
check tool. The crosshair and light field now points directly to the center mark.
3. The SSD to the blade check tool equals 100 cm.
4. After aligning the blade check tool, rotate the gantry to IEC 90.
5. Extend the kVS to 100 cm SSD and the kVD to – 50 cm (Figure 6).
Figure 5: Blades Calibration Plate
Notch
Stops

Figure 6: Blades calibration setup
6. Select Blades Calibration icon on the toolbar.

7. The Blades Calibration dialog box displays (Figure 7).
Figure 7: Blades Calibration

8. Select a Blade to Calibrate in the Blades Calibration dialog box.

 Predefined values for two calibration points are displayed.
 The predefined values can only be edited at this step.
9. The Blades Calibration default values are as follows:
Blades Values Blades Values
X1 first -120.0 Y1 first -90.0
X1 second 20.0 Y2 second 30.0
X2 first 120.0 Y2 first 90.0
X2 second -20.0 Y2 second -30.0
NOTE: The scale is independent of your Clinac scale. The scale is

always defined in IEC1217.
10. Select the ‘Blades Calibration’ technique from the anatomy drop down list.
 Pulsed Fluoro (40 kV, 16 mA, 8 ms)
11. While acquiring the image, click Start Calibration.
 The blade moves close to the first Cal. Point.
12. Using the image, compare the first Blade Cal. Point in relation to the dimension
marks on the check tool (Figure 8).
 Align the blade positions with the marks on the calibration tool by moving the
blade with the arrows, and acquire another image. Ignore the number next to
the Arrows.
 When the blade position matches the value set, proceed to step 13.

Figure 8: First check point
13. Click Next Cal. Step.

 The blade will move near the second blade calibration position (Figure 9).
NOTE: If the image disappears when traveling over center, either

lower the kV to improve the image or line up one edge of a movable
window as a calibration reference point on the monitor screen when
the image is visible.
14. Repeat Step 12 until the blade position matches the second Cal. Point.
15. Click Store Calibration and stop fluoro.

Figure 9: Second Calibration point
NOTE: In some cases, the blade may not retract after clicking the
Store Calibration button and a blade synchronization error
message may occur. As a remedy, click the Track button to enable
tracking and allow the blade to fully retract. When the blade has
retracted, turn the Track mode off and continue with the next blade.
16. Repeat this process if it is necessary to calibrate remaining blades.
17. To exit out of maintenance mode, select on the toolbar.

18. For information on weekly, semi-annual, and annual OBI maintenance refer to
the OBI Maintenance Manual, Chapter 4.
19. For information on OBI quality assurance, refer to section 15 of this manual.
WARNING: Incorrect calibration may result in mechanical failure of

the blades and/or irradiation of wrong areas.

F. Blade Calibration Backup / Restore
1. After calibrating the X and Y blades, successfully checking and verifying the
calibration result, you should save a backup of the calibration result.
2. To save a backup of the current blade calibration to the OBI workstation
desktop, use the Node Service Application (Error! Reference source not
found.).
 To start the application, click the NodeService.exe icon on the desktop of the
OBI workstation.
 Alternatively, search for the file NodeService.exe in this folder: C:\Program
Files\Varian\OBI\MotionControl\NodeService.
Figure 10: Node Services Application – Backup of Blade Calibration
3. Click the Blade tab, and then click Connect.

4. The Connect to Node dialog box opens (Error! Reference source not found.).
Figure 11: Connect to Node Dialog Box

5. Click the Ethernet Link and verify that the Supervisor IP address is
172.20.20.65, and then click Connect.
6. After successful connection, choose Transfer menu > Calibration > Receive
from Node.
7. Select a destination for the backup file, enter a name (for example,
BladeCalBackup.xml), and then click Save.
8. To Restore the Blade Calibration settings, select Transfer Menu > Calibration
> Send to Node.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Morning QA and Blade Calibration Exercise
EXERCISE
The participants will work in teams of two and will use their OBI Operations
Manual as a reference to perform blade calibration.
Objective:
 Using the OBI Operations Manual as a reference, the student will be able to
perform an Isocenter verification and blade calibration

Image Acquisition System (IAS) 3 Calibration
PROCEDURE
Objective:
 After completing this lesson, the student will be able to perform the Image
Acquisition System (IAS) 3 calibration task relevant to Physicists in the lab
exercise.
A. Exercise Key

1. Common Terms
2. IAS 3 Hardware and Software Components
3. Maintenance Workspace Icons
4. IAS 3 Calibration

Maintenance Manual (for the installed OBI version: 1.3, 1.4, 1.5,
and 1.6, etc.) when performing OBI calibrations.

C. Common Imaging Terms (Table 1)
Common Imaging Terms
Term Definition
Image Acquisition System type 3 includes the software and hardware required for OBI
IAS 3
imaging. The IAS 3 software is installed on the OBI workstation.
Two circuit boards located in the OBI workstation. The Universal Control Board (UCB)
UCB/Alacron
communicates with the PaxScan Command Processor. The Alacron Framegrabber board
Boards
processes the data to display the images on the monitor.
PaxScan
OBI imaging system. The Command Processor communicates directly with the imaging
Panel and
panel via a fiber optic cable to send and receive information. The PaxScan panel has a
Command
full resolution capability of 2048x1536.
Processor
Configuration files that reside on the OBI workstation. They contain the analog offset
Receptor
calibration information for each scanning mode. The configuration files are multi-mode
Configuration
configuration files. This enables a faster switching between the modes on the PaxScan
Files
Command Processor.
Generator
Imaging techniques used by the CPI generator system (kV, mA, and ms).
Techniques
Imaging techniques used by the IAS 3 software application. Each acquisition technique is
Acquisition automatically tied to a generator technique. Each acquisition technique (i.e. single gain
Techniques full resolution) is defined by specific parameters, such as frame averages and readout
panel scanning modes
The scanning method used to read the data from each vertical line in the imager panel.
Scanning
The scanning modes are automatically tied to the acquisition technique. I.e. Fluoro uses
Modes
the 2x2 binning mode.
Refer to the PaxScan Panel Pixel readout resolution mode. The 1x1 binning mode will
1x1 Binning
read and display every line in the panel, which will provide a resolution of 2048x1536
Mode
pixels.
2x2 Binning Refer to the PaxScan Panel Pixel readout resolution mode. The 2x2 binning mode will
Mode sum the outputs of every line pair and only display an image resolution of 1024x768 pixels.
Table 1: Common Imaging Terms

D. Image Acquisition System (IAS) 3 Component
1. The Image Acquisition System 3 (IAS3) is made up of a combination of hardware

and software elements:
 The PaxScan 4030CB image receptor (Figure 1).
Figure 1: Image Receptor
 The PaxScan Command Processor and Power Supply (Figure 2).
Figure 2: PaxScan Command Processor and Power Supply (Left – Old; Right – New)
 The UCB and Alacron FPB image handling boards (Figure 3 and Figure 4).
IAS3 interface and embedded firmware.
Figure 3: UCB

Figure 4: Alacron FPB
E. Image Acquisition System (IAS) 3 Calibration
1. The IAS 3 calibration procedure is used to correct for non-uniform response of the
image receptor and non-uniform intensity of the X-ray source.
2. Systematic changes occur due to:
 Variations in pixel amplifications caused by aging and temperature.
 Drift leading to offsets caused by temperature, gamma rays and aging.
3. It is recommended that IAS 3 calibration be done once every one - three months
or whenever the image quality has deteriorated.
4. Open the On Board Imaging (OBI) application.
 Select the Maintenance button (Figure 5).
Figure 5: OBI Application
 Enter appropriate User ID and Password and then click OK (Figure 6).

Figure 6: Maintenance Login
NOTE: Access to the Maintenance workspace is password

restricted. Only qualified users who are familiar with the OBI should
be allowed to access. In order to access Maintenance users will
need to have the appropriate rights assigned in User Rights
Administration. The necessary rights are: Administer Treatment
Imager and Administer Treatment Imager Calibration.
5. The Maintenance Workspace will open (Figure 7).

Figure 7: Maintenance Workspace

6. OBI Maintenance Workspace Icons (Table 2).


Table 2: Maintenance Workspace Icons

7. The IAS3 Service Monitor Dialog Box will open automatically (Figure 8).
 Do not close this window, as it is used for the Dark Field and Flood Field
calibration.
Figure 8: IAS3 Service Monitor
NOTE: There must be a stored set of calibration images for each

supported acquisition technique before an image can be acquired
with a particular anatomy.
8. There are two types of calibration images, Dark Field (DF) and Flood Field (FF).
9. A dark field image (DF image) is an image that is acquired without radiation. DF
calibration is carried out automatically in the background at regular intervals.
Several images are measured in quick succession and averaged for minimum
noise. The DF image contents reflect array imperfections and amplifier offsets. DF
has a different appearance for different sets of acquisition timing parameters but
is independent of the source, that is, no radiation is used during DF acquisition.

10. Flood Fields are acquired with radiation; therefore, the source and imager must
be in the extended position.
 Set the source to 100cm and the image detector to 50cm. Open the
blades to 40x40. Remove all objects from the beams path including the
couch and bow tie filter.
 Several frames are acquired in quick succession.
 The Flood Field image compensates for field Inhomogeneity, individual pixel
sensitivities, and amplifier gains.
 A Flood Field image not only looks different for different sets of acquisition
timing parameters, but also depends on the kV beam properties. Variations
occurring during the acquisition of the Flood Field image(s) will lead to an
incorrect FF correction.
11. Types of Calibrations:
 Full Calibration: Required on new installations, after an image detection unit
(IDU) replacement, or if the hard drive fails. A full calibration requires a Dark
Field and Flood Field Calibration Set for each Scanning mode.
 Service Call Calibration: This normally involves only re-calibrating a specific
Acquisition Technique that is exhibiting image problems. Although, depending
on the severity, a new Pixel Correction Map, Analog Offset or full re-calibration
may be necessary.
12. There are two acquisition modes of OBI, FF Last Image Hold and FF Single Pulse
Full Resolution. From the Anatomy menu, select the first acquisition technique to
be calibrated. The acquisition techniques begin with FF (Figure 9). Calibrating
the FF Last Image Hold technique calibrates the imager mode for fluoroscopy
acquisition.
Figure 9: Anatomy Menu

13. The selection in the IAS3 Service Monitor dialog box will automatically update to
the corresponding value.
 Wait until the mode is loaded and the frame counter starts counting (Figure
10).
Figure 10: Acquisition Technique Loaded
14. The appropriate dark field (DF) is acquired automatically by selecting a technique
from the Anatomy drop-down list. There is no need to click the Dark Field button
in the IAS3 Service Monitor dialog box for calibration. If you would like to visually
verify a Dark Field for an acquisition technique click Dark Field (Figure 11).

Figure 11 IAS3 Service Monitor; Dark Field
 Wait for the dark field image to be acquired. It will then display on the monitor
(Figure 12).
Figure 12: Dark Field Image

15. Next, acquire a Flood Field image. A Flood Field is the only calibration that must
be performed manually for each of the modes. Click Flood Field.
 A message “Wait - Processing” will appear (Figure 13).
 This will then be replaced with the message “Waiting for beam” ( Figure
14).
Figure 13: Flood Field Processing Figure 14: Flood Field Waiting for Beam
 Press and hold the footswitch until the frame counter stops counting and the
image is displayed on the monitor (Figure 15).
Figure 15: Flood Field Image (prior to Window and Level)

16. On the toolbar, click Area Profile. The Area Profile dialog box opens (Figure
16).
Figure 16: OBI Maintenance Workspace Toolbar
17. Select Show Details and verify a mean pixel value in the range of 4500 to 6500
(Figure 17).
 If the value is not within the specified range, adjust the kV or ms and repeat
the flood field calibration (1kV = ~500 mean counts). Be sure to close the
Area Profile tool before acquiring another Flood Field.
 Set Width and Height to match acquisition technique: Last Image Hold
1024x768 ; Single Gain Full Resolution 2048x1536
Figure 17: Flood Field; Mean Pixel Value

18. Verify the calibration results by taking a test Image.

 Click the Image button.
 Press and hold the footswitch for approximately 3 seconds until the image is
displayed on the monitor.
 The Image is the end result of the Dark Field and Flood Field calibrations. The
pixel correction map is also applied.
 It is recommended to acquire an Image as a visual check of a good calibration
set. It is not necessary to acquire an Image to finish the calibration set but
errors made during calibration are generally easy to see in the test image.
 After verifying a homogeneous test image click Save Calibration (Figure 18).
Figure 18: Test Image
19. Repeat steps 12-18 for all remaining acquisition techniques starting with FF.
NOTE: In OBI AI, only two modes are calibrated in the OBI
maintenance workspace, Last Image Hold and Single Gain Full
Resolution. The OBI Dual Gain mode for radiographs is
calibrated in the CBCT calibration workspace.

20. Once the Dark Field and Flood Field acquisitions are complete, the pixel
correction map can be updated, if necessary. Qualitative analysis of acquired
images should determine this.
21. Pixel Map Correction:
 An imager panel has several thousand defective pixels due to manufacturing
limits. The locations of defective pixels are stored in the pixel defect map.
 When an image is acquired, the pixel defect map is loaded and all defective
pixels are replaced with an average of the neighboring pixels.
 The Pixel Defect Map option in the Maintenance workspace of the OBI
application automatically creates and displays a pixel defect map based on the
last acquired dark and flood fields.
 Select Pixel Defect Map (Figure 19).
Figure 19: IAS3 Calibration and Configuration button with Options Menu
22. The Pixel Correction Maps dialog box opens (Figure 20).
 This displays the current map and new map pixel counts.
Figure 20: Pixel Correction Maps

 Select Update Map to add the additional defective pixels to the current map.
This process simply adds the newly-found defective pixels to the current map.
 The Clear Map function should only be used by trained service personnel. It
clears the entire map and some Manual Pixel Correction may be necessary
after Update Map has been performed.
23. The Show option displays the pixel correction map. You can choose to display
the newly-found Additional Pixels, the Current Map or the New Map (Additional
plus Current Map) (Figure 21).
 Select the appropriate map to display and then click Show.
 Select the Invert filter from the image filter list.
Figure 21: Show Options
24. If the dark field and flood field calibration set was not saved prior to selecting the
pixel defect map the following message will appear:
 Calibration pending in the service monitor (Figure 22).
 Click OK.
Figure 22: Calibration pending in the service monitor

25. If no calibration changes have been made when selecting the pixel defect map,
the following message will appear:
 No calibration since last update to pixel correction maps (Figure 23).
 Click OK.
Figure 23: No calibration since last pixel correction map
F. Reminders
1. Remember to remove the bow tie filter prior to calibrating. If the bow tie filter is in
the beam during calibration, it can cause image artifacts.
2. Do not overexpose (saturate) the imager during flood field calibration (Figure 24).
Over exposing during flood field calibration will result in a non-uniform correction
pattern. Since the real correction pattern would be non-uniform the images will
show a pattern that normally would be corrected. (Overexposure is unlikely to
happen if the Mean Pixel value is verified)
Figure 24: Saturated images

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


EXERCISE
Objective:
 Using the OBI Operations Manual as a reference, the student will perform an
IAS3 calibration set.
Operations Manual as a reference to perform IAS3 calibration.
Each group should perform at least one calibration of their choosing.

IsoCal Calibration
PROCEDURE
Objective:
 After completing this lesson the student will be able to perform IsoCal
calibration tasks relevant to physicists in the lab exercise.
A. IsoCal Description and Recommendations
1. IsoCal Description:
 In an ideal environment, MV and kV central beam axes intersect at the
treatment isocenter for all gantry angles. The treatment isocenter therefore
coincides with the rotation center of the kV and MV imaging system. For real
installations, these three locations may not exactly overlap.
 The purpose of IsoCal is to determine the location and alignment between the
treatment isocenter and MV / kV rotation center, and to generate corrections
for imager and X-ray source shifts—caused by repeatable mechanical
deflections and arm position errors—as a function of gantry angle. OBI may
apply the generated IsoCal calibration data to correct the acquired images for
an even more precise patient positioning.
 IsoCal consists of a cylindrical polyoxymethylene phantom with 16 inserted
tungsten-carbid ball bearings (BB’s), an aluminum collimator plate with a
central steel pin and the IsoCal Application for OBI (Figure 1).
 The general approach consists of finding the treatment isocenter, the phantom
position and Source-Imager-Distance (SID). Then find and relate the kV/MV
rotation centers to the treatment isocenter. Therefore, the phantom does not
need to be positioned precisely (within 5 mm) into the laser isocenter position.

IsoCal Calibration
Figure 1: IsoCal Phantom and Collimator plate
2. IsoCal Recommendations
 The frequency of IsoCal calibration must be based on the professional
judgment of the person in charge and also based on the requirements of the
institutions calibration program. Documents such as the AAPM Task Group
142 may be referenced for guidance. Varian recommends performing an
IsoCal calibration no more frequently than monthly and no less frequently than
annually.
 IsoCal calibration must be performed:
After a new Isocenter calibration has been done on any of the Exact Arms
(Chapter 7 of the OBI Advanced Imaging Maintenance Manual).
If the geometric check done for your periodic QA (Chapter 4 of the OBI
Maintenance Manual) fails to meet your ‘pass‘ criteria.
WARNING: If the IsoCal option is installed, a new IsoCal calibration

must be performed following the Isocenter calibration of any of the
Exact Arms (Chapter 7 of the OBI Advanced Imaging Maintenance
Manual).
NOTE: Indexing the Exact Arm without calibrating the arms to

Isocenter does not require a new IsoCal.

IsoCal Calibration
B. Calibration Process Overview
1. The basic calibration process involves the following steps (Figure 2):
 Preparation- Mounting phantom and collimator plate to machine and setup
workstations for image acquisition.
 Image Acquisition- Acquiring several MV and kV images at different gantry
and collimator angles from predefined IsoCal Dicom plans.
 Image import- Importing the previously acquired MV and kV images into
IsoCal Application.
 Phantom tracking- IsoCal algorithms detect the tungsten carbid inserts of the
phantom and the steel pin of the collimator plate in the images and extracts
the position information.
 IsoCal Analysis- From the previously detected BB’s IsoCal determines the
central MV beam axis and then the treatment isocenter as the best-fit
intersection point of the central MV beam axis at all gantry angles (analogous
to gantry star shots). The phantom position and nominal SID is computed and
from this the rotation axis for MV and kV is derived. IsoCal determines the
rotation center as the intersection point of rotation axis and the straight line
perpendicular to the rotation axis going through the x-ray source point. In a
next step, the rotation center and the treatment isocenter projections on the
imager (kV/MV) are evaluated to calculate a 2D shift vector describing the
positions relative to the imager center for all gantry angles. The result of the
calibration is presented in a review screen.
 Calibration data export- The result may then be discarded or accepted. For
the latter, IsoCal will save the calibration result to the file system.
 Correction- If enabled, OBI will correct the imager position of acquired images
(DICOM Tag) with the 2D shift vector, which describes the displacement of
imager center to treatment isocenter. The result is a more precise patient
positioning.
NOTE: Personnel performing calibration and maintenance tasks

must be familiar with the On-Board Imager Reference Guide. All
calibration and maintenance tasks follow strict sequences.

IsoCal Calibration
Figure 2: IsoCal Process Chart

IsoCal Calibration
C. In Room Preparations
1. Rotate gantry to Varian IEC 0° (head up position).

2. Insert the IsoCal Collimator plate into the slot of the MV collimator interface
mount. When the plate is correctly positioned the indicator diode on the gantry
switches from red to green light.
3. Place the IsoCal phantom at the front end of the treatment couch.
4. Move couch to align the scribed marks in the phantom with the room lasers.
D. OBI Preparations
1. On the OBI Workstation, close the OBI Application if running.

2. Remove old calibration data:
 Open File Explorer and browse to D:\VMSOS\AppData\IsoCal\Calibration\
 Delete all files in the two folders COLL and MV
 Remove all additional folders (not named COLL or MV) in the directory
D:\VMSOS\AppData\IsoCal\Calibration\. Do not delete the three IsoCal plans
(DICOM files).
 Calibration Folder should contain three IsoCal plans and two empty folders
named COLL and MV.
3. Start OBI Administration from Windows Start menu > All Programs > Varian >
OBI > OBI Administration. In OBI Administration > App & Misc Tab, turn off the
IsoCal correction:
 Uncheck the Apply IsoCal Correction for 2D Images box.
 Uncheck the Apply IsoCal Correction for 3D Images box.
4. Save settings: File > Save or press Ctrl+S.
5. Exit OBI Administration and restart the OBI Application.
6. Either abort or perform the tube warm-up when prompted at startup.

IsoCal Calibration
E. Acquire IsoCal Images
1. On the 4DITC Workstation, verify that Treatment Application is running and no

patient session is active. Otherwise, close patient session.
2. Select Tools > DICOM RT mode.
3. Load the plan named CalibrationPlan_Collimator.dcm from the X:\ drive on the 4D
ITC workstation.
NOTE: The X:\ drive letter on the 4DITC Workstation is assigned by

default to the shared folder D:\VMSOS\AppData\IsoCal\Calibration
on the OBI Workstation. If the X:\ is missing, assign it as a new
drive letter.
4. Perform machine override by selecting Machine Override > Select All >
Convert.
NOTE: If the SCIC cannot be overridden, close the Treatment

Application, open the 4DC Administration > Machine Configuration
> Preferences, and uncheck Second Chanel Integrity Check.
5. Mode up the first field of the plan (CalibrationPlan_Collimator.dcm).

6. Select RV Mode up on the Clinac console. Execute gantry- and collimator motion
to target position.
7. Bring the PV imager into the planned position [Vrt = -50,Lat = 0,Lng = 0]
8. Turn the key on the Clinac console keyboard and press Beam On to acquire the
MV image. After the acquisition, select the next field if not automatically done by
the Treatment Application. Proceed the same way with the remaining three fields
of the plan to acquire images.
9. In automatic mode-up mode, confirm closing of patient by pressing Yes in the
Close Patient dialog that opens when the last field is treated. Otherwise, select
Close Patient.
10. From the Save As dialog that is displayed upon close, name the dataset ‘COLL’
and save it in the X:\ COLL folder.

IsoCal Calibration
11. In the Treatment Application, load the plan named CalibrationPlan_MV.dcm.

Convert.
13. Mode up the first field of the plan (CalibrationPlan_MV.dcm).
14. Execute gantry- and collimator motion to target position on Clinac console.
15. Verify that the PV imager is at the planned position [Vrt = -50,Lat = 0,Lng = 0].
16. Turn the key on the Clinac console keyboard and press Beam On to acquired the
MV image.
17. Proceed the same way with the remaining seven fields of the plan.
18. In automatic mode-up mode, confirm closing of patient by pressing Yes in the
Close Patient dialog that opens when the last field is treated. Otherwise select
Close Patient.
19. From the Save As dialog that is displayed upon close, name the dataset ‘MV’ and
save it in the X:\ MV folder.
20. In the Treatment Application, load the plan CalibrationPlan_KV.dcm.
Convert.
22. Mode Up the first field of the plan (CalibrationPlan_kV.dcm).
23. Bring out the On Board Imager arms to the planned position: [SAD = 100, kV
Imager Vrt = -50, kV Imager Lat = 0, Imager Lng = 0].
24. Execute gantry- and collimator motion to target position on Clinac console.
25. In OBI Application, verify that the generator technique settings are as follows:
[60.0 kV/ 32.0 mA / 16.0 ms / Large Focal Spot / Dual Gain Standard Resolution]
To verify that Dual Gain is enabled, right click on the Single Exposure button (B)
and confirm that Dual Gain Standard Resolution is ticked (Figure 3).

IsoCal Calibration
Figure 3: Dashboard
26. Acquire the kV image by pressing either foot- or hand switch.

27. Acquire images for the remaining seven fields.
28. When all kV images are acquired, close the plan.
F. Loading Images
1. Start the IsoCal Application on OBI Workstation from Windows Start menu > All
Programs > Varian > IsoCal > IsoCal.
2. Load the four acquired Collimator images:
 Press one of the Browse buttons in the MV Collimator Shots pane and
select the first DICOM file from D:\VMSOS\AppData\IsoCal\Calibration\COLL.
 Load the remaining three images.
 Verify that the following Coll Rtns are displayed: 195, 270, 0 and 90 (for Varian
IEC scale). Order does not matter.
3. Load the acquired MV images:
 Press Browse in the MV Scan pane and select the folder
D:\VMSOS\AppData\IsoCal\Calibration\MV. Press OK.
 The names of the eight images appear in the list left to the button.
 Verify that Coll Rtn is 90.

IsoCal Calibration
4. Load the eight acquired kV images:

 Press Browse in the kV Scan pane and navigate to
D:\VMSOS\AppData\IsoCal\Calibration\.
 You should find three new folders name according to creation date and time
(YY/MM/DD HH_MM_SS). Select the most recent one and press OK.
 If the correct folder has been selected, then eight names appear in the list,
otherwise none (Figure 4).
NOTE: Every time a plan is loaded via RT DICOM mode in 4D ITC,

the DSS creates a folder. If the procedure has been followed
exactly, select the kV images from the most recently created folder.
If a kV plan has been re-loaded, make sure to select the folder with
the correct date and time.
Figure 4: Importing kV Images into IsoCal Application

IsoCal Calibration
G. IsoCal Calibration
1. Press Start to initiate the calibration. The four collimator shots are analyzed first
in order to detect central steel pin (Figure 5).
NOTE: When performing IsoCal the first time, press Yes on

warning ʺCould not read current calibration dataʺ.
2. Press Next to start MV scan tracking (Figure 5).

3. Press Next to start kV scan tracking (Figure 5).
4. Press Next to review the results (Figure 5).
5. At the end of the IsoCal processing routine, details of the results will be shown in
the Review Details window. Review results and close Review Details window.
Press Accept to accept, or Cancel to discard the new calibration in IsoCal
Application:
 If the colored bar on top of the result screen is green, all parameters are within
tolerance. Review the data. If comfortable with the results, proceed and accept
the result.
 If the colored bar is yellow (warnings) the calibration is within tolerance but the
difference between the values of the new calibration and the previous
calibration exceeds expected tolerances. Review the data and clarify the
cause of the discrepancy (e.g. an Exact Arm calibration was performed since
the previous IsoCal calibration). If comfortable with the results, proceed and
accept the result.
 If the colored bar is red (out of tolerance) please review the details of the out
of tolerance parameters to determine if they are a concern or not. If
comfortable with the results, proceed and accept the result. If the description
of the out of tolerance parameters suggests repeating the measurements,
repeat the IsoCal calibration before accepting the result.
6. Press Done to close IsoCal Application.
7. Press Yes to close the application completely.

IsoCal Calibration
Figure 5: Calibration

IsoCal Calibration
H. Post Calibration Procedure
1. Close the OBI Application.

2. Enable IsoCal correction in the OBI Administration > App & Misc Tab:
 Check the Apply IsoCal Correction for 2D Images box
 Check the Apply IsoCal Correction for 3D Images box.
3. Save settings: File > Save or press Ctrl+S.
4. Exit OBI Administration and restart OBI Application.
5. In the treatment room, remove the IsoCal phantom and partial transmission plate.
6. To verify the IsoCal calibration result follow the Daily QA Schedule (Chapter 4 of
the OBI Maintenance Manual).

IsoCal Calibration
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


ARIA RT Administration
PROCEDURE
Objectives:
 After completing this module, using the OBI Physicist Operations Manual as a
 Configure ARIA RT Administration for OBI based on user preferences.
 Configure OSP based on user preferences.
A. Exercise Key

2. Brackets denote additional selection options.
1. Administration task startup manager

2. Multi-user administration
3. External cached plans
4. Adding an imager
5. Tolerance tables
6. Sequence templates
7. OSP
8. Couch Locking

C. ARIA RT Administration
1. From the Quicklinks menu, select Quicklinks> Administration> RT

Figure 1: Quicklinks menu
NOTE: In previous versions of Aria this feature is referred to only as

“Administration” and is accessed by using the following procedure:
From the menu select Quick Links> Administration>
Administration (Alt + 8).
2. The administration task startup manager will open.

 If changes are going to be made to the machine configuration, the DICOM
daemon services will have to be restarted before the changes will be
implemented.
 Verify that all workstations are logged off before restarting the DICOM daemon
services.
 Select yes to continue (Figure 2).

Figure 2: Entering RT Administration
3. The first workspace is the System & Facilities (Workspace > System & Facilities
or CTRL + 1).
4. The Multi-User Administration tab shows a list of open task and editing stamps.
If a user is opening a patient or editing data, a stamp is created automatically.
NOTE: In cases of a system crash or other unplanned termination

of the application, stamps are removed once the application is
restarted. If the application is not restarted those stamps remain in
the system. Therefore, the system may display a multi-user error
after restarting, that is, “The following user is editing the Patient,
Name…” To clear multi-user errors, select the appropriate row in
the table and click Delete Stamp (Figure 3).
Figure 3: Multi-User Administration Tab

5. External Cached Plans

 An externally cached plan is one that is open in the Treatment application, with
a stamp attached, indicating its status. Open treatment plans are locked. In
case a user tries to open such a plan in the RT Chart application, a warning
message is shown, stating that the plan is currently used or is opened in the
Treatment application. The stamp is removed when the patient’s treatment is
completed and closed.
 If the treatment is terminated illegally, the stamp will not be closed. In ARIA
11, it will need to be cleared in the Reference Points workspace.
 Open the affected patient in Treatment Preparation.
 Navigate to Reference Points > Edit menu > Clear Externally Cached
Plans…. (Figure 4).
Figure 4: Externally Cached Plans
 Select the correct plan stamp to be cleared > check the visibility
checkbox under Clear>select Clear button (Figure 5).

NOTE: In previous versions of Aria CLEAR EXTERNALLY

CACHED PLANS is accessed using the Quick Links Drop Down,
Select RT Chart > Select the History tab > History dropdown >
Externally Cached Plans. Follow the bulleted point above (under
Figure 4: Externally Cached Plans) to clear the appropriate plan.
Figure 5: Clear Externally Cached Plans
WARNING: Only remove the stamp after the plan is manually

imported from the 4DITC or manual treatment has been delivered.
6. The third workspace is Radiation and Imaging Devices (Workspace > Radiation
& Imaging Devices or CTRL + 3).
 On the radiation and imaging devices workspace verify that the OBI Clinacs
have configured MV and kV imagers.
 First click on the appropriate OBI Clinac (Figure 6).

Figure 6: Radiation and Imaging Devices workspace
 Then select the Imager Tab (Figure 7).

 Verify that a MV and kV imager has been configured.
Figure 7: Imager tab
 Verify the properties of each of the imagers by double clicking on the ID line of
each imager. This will open the properties dialog box.
 On the Port Imager tab, the MV imager should be configured as the default,
and the kV Imager as a kV Imager (Figure 8).

Figure 8: MV imager properties (left), kV imager properties (right)
NOTE: The SAD, Default Gantry Rotation, and Gantry Pitch are
only required for Proton Accelerators, but there must be a value
here. Varian’s recommendation is to leave default values in
these fields.
 If no imagers have been configured, select New Port Imager (Figure 9).
Figure 9: New port imager
 The port imager properties dialog box will open (Figure 10).
 Configure a MV imager by filling in the ID, machine model, and manufacturer
name on the general tab. Select the port imager tab, then select the default
port imager option.
 Repeat the process and configure a kV imager. On the port imager tab, select
the kV imager option.

Figure 10: Port Imager Properties
7. The fourth workspace is Clinical Data (Workspace > Clinical Data or CTRL +4).
 Select the Tolerance tab (Figure 11).
 Verify that an OBI tolerance table has been configured.
 If an OBI tolerance has not been configured, select New Table.
 The copy limits from tolerance dialog box will be displayed.
 A new tolerance table can be created manually, by selecting Don’t Copy, or
Copy from an existing one by selecting Copy.
 Select the appropriate tolerance table in the dropdown (T1), and Copy.
Figure 11: Tolerance Tab

 The tolerance properties dialog box will be displayed. Type an ID and name,
and click OK (Figure 12).
Figure 12: Tolerance properties
 Select the new tolerance in the tolerance table window (left window). The
individual parameter tolerances for the new table will be displayed in the
tolerance window (right window) (Figure 13).
 To change the individual parameter tolerances, double click on any parameter
type and the tolerance limit properties dialog box displays.
 Custom define the tolerance value, and select Remote for auto setup level.
Click OK.
 Manual requires the parameter to be manually entered using the pendant.
 Automatic enables auto setups from the hand pendant.
 Remote enables the operator to remotely move the parameter from the control
console.

Figure 13: Tolerance Limit Properties
8. The fifth workspace is Templates (Workspace > Templates or CTRL + 5).

 Select the Sequence Template Tab.
 Verify that a kV and CBCT sequence template has been configured.
 If an MV, kV or CBCT sequence template has not been configured, select
New Sequence Template (Figure 14).
Figure 14: New sequence template
 The sequence template properties dialog box will be displayed. Fill in the ID,
name, and click OK (Figure 15).

Figure 15: Sequence Template Properties
 Select the new sequence template in the sequence template window and click
New Sequence Template Image. For example, select New Sequence
Template kV Image (Figure 16).
Figure 16: New sequence template image
 The sequence template kV image properties dialog box displays. Select kV

Image under acquisition technique, and click OK (Figure 17).
 Repeat the process and create a CBCT or MV sequence template.
 Existing MV Templates can be also be edited.

Figure 17: Sequence template image properties
9. Save the changes before exiting out of the application.
D. Platform Portal
1. Select Start > Programs > Varian Tools > Platform Portal (Figure 18).
Figure 18: Launch Platform Portal

2. Internet Explorer launches Platform Portal. Select Platform Services (Figure 19).
Figure 19: Platform Portal
NOTE: It is recommended that only one user at a time make

changes. If you and another user change the same information at
the same time, and you try to save over the other user’s change,
you will get a message that says that the save could not be
completed because another user has updated the data.
NOTE: The applications and services must be restarted to apply

the changes to those applications and services. It is recommended
to do this during off-hours, when no users are using the system.
3. Select System Configuration > System Preferences > General Preferences >
Couch Locking to select an option for couch locking (Error! Reference source
not found.). If you have a TrueBeam sharing this system, select Never.

Figure 20: Couch Locking
4. Enter User ID and Password (Figure 21).
Figure 21: User Login to Platform Portal
5. Make a selection for couch locking from the options in the drop down menu
(Figure 22).

Figure 22: Couch Locking Options
 To not allow couch edits, even after treatment approval, choose For
Treatment Approval.
 To allow couch edits before and during first treatment/setup session choose
After First Treatment.
 To allow couch edits after treatment approval, choose Never. Choose this
option if you have a TrueBeam sharing this system.
NOTE: Couch locking can be configured for the lateral, longitudinal

and vertical locking options for Plan Parameters and Acuity.
NOTE: Couch rotation is locked after planning approval.
NOTE: The couch parameters may still be editable in the Plan

Parameters workspace of ARIA 11 if the Advanced Feature Set is
enabled.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI, Cone Beam CT, CBCT Reconstructor, and
Treatment Administrations
PROCEDURE
Objectives:
 Define Parameters in OBI Administration
 Define Parameters in CBCT Administration
 Define Parameters in CBCT Reconstructor Administration
 Define Parameters in Treatment Administration
A. Exercise Key

1. Open 4DITC and OBI Administrations

2. Browse Administrations Tabs
NOTE: Refer to the most recent On-Board Imager (OBI)

Reference Guide (for the installed OBI version: 1.3, 1.4, 1.5, 1.6,
etc.) for the latest information regarding OBI Administrations.

OBI, Cone Beam CT, CBCT Reconstructor, and Treatment Administrations
C. On-Board Imager Administration (OBI Workstation):
1. Open OBI Administration (Figure 1).
Figure 1: OBI Administration (found in OBI folder on desktop)
2. OBI Administration requires proper login rights granted in User Rights

Figure 2: OBI Administration Login window
NOTE: Access to the administration tool is password restricted.

Only qualified users who are familiar with the OBI and/or CBCT
system are allowed to access the administration tool and change
the settings of the OBI and/or CBCT system. It is the sole
responsibility of the clinic to keep the password secret and to make
sure that the required user access rights are assigned to authorized
persons only.

3. The OBI Administration tool will open in the General Tab (Figure 3).
 To test that the DSS is working properly click the Ping DSS button.
 4DITC, DICOM Daemon, and DICOM Stream Service Configurations are
set up during installation.
 Object Import/Export:
 Use Unicode format: Unicode is a generalized method for
consistent representation and handling of text. When OBI is used
with information systems that support Unicode, the check box
should be selected.
 3rd Party non-Unicode: Select the check box if you want to connect
to a 3rd party Treatment Management System (TMS) that does not
support Unicode.
 Save Objects (only available if the TMS is set to Custom):
 Markers: If the OBI system is connected to an ARIA environment,
enable the check box. The detected markers are saved in the
Varian System database for later review in Offline Review and
appear as structures on the reference CT.
 2D/2D Spatial Registration and 3D Spatial Registration: If the
OBI system is connected to an Inspiration environment, enable the
two check boxes. The spatial registration of the 2D match, the
2D/2D and 3D match result is saved in the Varian System database
for review in Offline Review.
 Verification CT slices: If enabled, the CT slices are saved to the
database and are available for review in Offline Review.

Figure 3: OBI Administration Tool; General Tab
NOTE: As of the release of this manual, the latest version of

MOSAIQ supports all ‘Save Objects’ except for Markers. Please
consult Elekta documentation for the latest information regarding
supported objects.
4. Matching Tab (Figure 4).

 Display: Raw Shift: Choose 4 or 6 degrees of freedom during matching.
 Pitch/Roll Tolerance(deg): This allows a threshold to be set that determines
when alerts will appear in the status bar.

 Color Blending: Customize the colors used by the complementary color

blend tool. Enter values in the left column to set the color for the reference
image and enter values in the right column to set the color for the acquired
image.
 Viewing [mm]: Sets the size of the view window for MV and kV images.
Increasing the Init X and Init Y values makes the kV images appear smaller.
To maximize the used display area for images acquired with the imager
vertical position at -50 cm, set the Init X = 267mm and Init Y = 200 mm.
 Marker: Defines Marker Match Auto detect defaults. Parameters should be
changed to match the typical marker length used clinically. The system does
not allow you to enter less than 3 markers.
 Blend Factor: The range of the blend factor is 0.0 – 1.0 and is applied in the
3D analyze workspace:
 A setting of 1.0 will set the Blend Images tool to display 100% of
the acquired CBCT and the contours of the reference CT when
entering the Analyze workspace.
 A setting of 0.5 will result in a 50/50 blend of the reference CT and
CBCT.
 A setting of 0.0 will display 100% of the reference CT.

Figure 4: Matching Tab
5. CBCT/Tube/Patient Support Tab (Figure 5).

 CBCT region:
 Save CBCT to File System: If enabled the OBI application saves
the CBCT images to the file system. In addition to the CBCT
dataset, the OBI application also saves a structure that identifies the
scan and treatment isocenters as well as the spatial registration
object.
 Local CBCT File Load: Used for DEMO mode.
 Tube Warm-up:
 Duration [sec]: Duration in seconds. During the tube warm-up
procedure, the system asks you to press the footswitch or
handswitch for the specified number of seconds. A value of zero
deactivates tube warm-up. The application will not automatically
stop the beam, but a message to discontinue irradiation appears
after the set duration.
 Min. Anode Heat Unit [%]: When the OBI application is opened, if
the Anode HU number displayed in OBI is greater than this value
the Tube Warm-up box will not be displayed. A value of zero
deactivates tube warm-up.
 SAD Position [mm]: Expected source-to-axis distance in [mm] of
the X-Ray tube arm during the tube warm-up.

 IDU Vrt. Position [mm]: This is the vertical position in [mm] of the
image receptor during the tube warm-up. Any valid clinical position
for the image receptor allows the tube warm-up to proceed.
 Patient Support IEC 61217 [mm]:
 Couch Min./Max: These parameters define limits for the match and
should describe the mechanical limits of couch motion. Generally,
there is no need to adjust these values entered by Varian installers.
The values are always entered in IEC 61217 scale in this table.
 Include Couch Rotation in Shift by default: The couch rotation is
included in shifts by default for all matching workspaces. This
setting is used when entering the Analyze workspace.
Figure 5: CBCT/Tube/Pat. Supp. Tab

6. IAS/Mach Driver Tab (Figure 6).

 IAS Driver - Log file path: This is read-only. The IAs has its own log file
independent of the combined log used by other applications. The entries in
the IAS log file are mostly duplicated in the combined log.
 Machine Driver - Calibration Blade Value (IEC61217) [mm]: Calibration
points of the X-ray collimator blades. These default values generally do not
need to be changed.
Figure 6: IAS/Machine Driver Tab
7. App & Misc Tab (Figure 7).

 Application Configuration:
 Use Interpolation in all Views: When magnifying images,
interpolation of the display pixels is possible. The interpolation
slightly blurs the displayed images. This is especially noticeable
when an image pixel is displayed much larger. By default, this is
turned off to maximize visual sharpness. This feature is not used in
the maintenance workspace regardless of the setting.
 Load of local Reference CT File: Select this check box if you use
a 3rd party information system that does not support the transfer of
the reference CT and the plan isocenter to the 4D console. If
selected, the system allows the user to manually select the RT plan
and load the reference CT for Marker Match and CBCT.
 Reference CT Image Path: Path where the CT images are stored.
 Structure set seize threshold [MB]: The structure set contains all
of the stuctures contoured on the reference CT. When exported in
DICOM Media File format, files of different sizes are generated. If
the structure set for the plan is larger than the defined threshold,
OBI opens a dialog window when the 3D acquisition process is
initiated. Operators can select the structures to load into the OBI
application. This reduces memory usage and likelihood of out of
memory exceptions.
 Dynamic Window Popup Delay [s]: Sets how fast the Dynamic
Window appears or disappears after the mouse reaches the left
screen border or leaves the Dynamic Window. For no delay, type 0
into the text box. The default value is 0.5 seconds and the
maximum is 10 seconds.
 Use TrueBeam color scheme for fluoro overlays: During pre-
treatment gating verification and standard fluoro acquisition, the
structures of the reference image are displayed as an overlay on the
live image. In case of Gating, the overlays are colored red = gate
closed, green = gate open. When this box is checked, blue = gate
closed, yellow = gate open.
 Path to Maintenance Image Cache (read-only): Path where
maintenance kV image files are saved in .hnd format on the local file
system.
 Correction for isocenter calibration (IsoCal): IsoCal is a geometry
calibration tool that improves the alignment of the MV, kV, and CBCT images
with the treatment isocenter.
 Apply isocenter calibration (IsoCal) correction for 2D images:
When selected, OBI will apply the IsoCal corrections to the acquired
2D images. During calibration, these settings must be de-selected.
 Apply isocenter calibration (IsoCal) correction for 3D images:
When selected, OBI will apply the IsoCal corrections to the acquired
3D images. During calibration, these settings must be de-selected.
 Pathe to XML file with isocenter calibration (IsoCal) correction:
The location where the results of the IsoCal calibration are stored.

Figure 7: App & Misc tab
8. Logging Tab (Figure 8)

 The Logging tab lets you specify the amount of information that is saved to log
files during OBI operation.
 Level: min = 0: sends a minimum of logging information to the
Oncology System Platform (OSP) SysLog. max = 6: sends a
maximum of logging information about expected states,
communication errors, data input/stream errors, and program logic
to the Oncology System Platform SysLog. Setting the log level
higher than 3 creates significant CPU load and increases the size of
the log files dramatically. This can affect the behavior of the OBI
software.
 Test button: Select a line and press the Test button to send a log
message to the OSP SysLog.
 For information on specific categories, refer to Chapter 10 of the
OBI Advanced Imaging Reference Guide Version 1.6.

Figure 8: Logging Tab
9. kV Template Tab (OBI): The kV Template Tab lets you define new kV templates
for acquisition of kV images. New templates can be created, existing templates
can be edited or deleted, and the order of templates can be re-arranged. When
selecting anatomies in the OBI Dashboard, approximately 30 anatomies display in
the dialog box without the need for scrolling (Figure 9).
 The default anatomy is the anatomy that will be selected by the OBI
application after the tube warm up and when no kV exposure settings are
available from a previous session.
 You can change the name of the anatomies and anatomy sizes by selecting
the text and type.
 Image mode types (mA, ms, Focal Spot, and ABC) must be selected from the
pull down menus.
 The kV value can be entered by typing in the value. The entered value is
checked by the system and will automatically reset if they exceed the default
upper or lower range of the generator (40 up to 150 kV). Any changes made
in the OBI Maintenance mode are ignored in the range check.

 The parameters are saved to a local file, which is only readable using a
special file editor (D:\VMSOS\Config2\local\Products\OBI\KVTemplate.wox). If
this file is deleted, any user defined anatomy will be lost. If the Obi application
is updated, this file is not removed. This file could be backed up and copied
from one Obi application installation to another.

Figure 9: kV Template Tab
D. CBCT Administration (OBI Workstation):
1. Open CBCT Administration (Figure 10).
Figure 10: CBCT Administration (found in CBCT folder on desktop)
2. CBCT Administration requires proper login rights granted in User Rights


Figure 9: CBCT Administration Login window

sure that the required user access rights are assigned to authorize
persons only.
NOTE: Changing parameters required a restart of the application

for the changes to take effect. This is especially important to
remember for the Reconstructor, which runs as a service and
needs to be stopped and restarted after any parameter changes in
CBCT Administration.
3. The CBCT Administration tool will open in the General Tab (Figure 10).
 Ignore the Workspace Acquisition section
 In the DICOM section if the Do DICOM-File Export in OBI case check box is
enabled this will export CBCT scans and topograms to the local file system.
The CBCT scans and topograms will be saved to the local file system without
treatment isocenter and spatial registration tags.

NOTE: Do DICOM File Export in OBI case is available primarily

as a trouble shooting tool for service. It can be enabled to save
CBCT scans to the local file system if using the Cone-Beam CT
application in standalone mode.
 Information entered into the Institution Name, Department Name, Station

Name, and Device Serial Number boxes will be recorded in the attribute
collection of the DICOM images.
 The Export Path displays where the Cone-Beam CT scans will be exported.
Demo Mode
Not for Clinical
Figure 10: CBCT Administration Tool; General Tab

4. Acquisition Tab (Figure 11).

 Enable Skip Topogram Acquisition to eliminate the topogram step from the
Acquire New Scan acquisition option.
 Patient Database Path displays where the Patient.xml file is stored.
 The Memory Warning Size displays a warning message when the disk space
reaches 100MB.
 If disabled, the Display Couch Rail Removal Dialog and Prompt for Scatter
Grid messages will not be displayed before the start of a CBCT scan.
 The Default Scan Parameters for CBCT imaging can be defined:
 The default scan width [mm] is only used for new patients. If a
value of 0 is used here, it is not used for calculation of scan width
and a maximum possible scan range will be calculated at the time of
scan acquisition.
 Pelvis Spotlight: The two selections are full fan bow-tie or half fan
bow-tie. This selection has no effect on image quality, but
determines how the CBCT application estimates the CTDIw (CT
Dose Index), which displays before the scan. The dose index
values displayed when using a full fan bow-tie are less than those
displayed when using a half fan bow-tie.
Figure 11: Acquisition Tab

5. Calibration Tab (Figure 12).
Note: Upgraded sites may have different diameter phantoms than

new install sites. Verification of phantom diameters should be
performed during install. Older BHC/Norm Phantom Full Fan
phantoms (same phantom) have a 240cm diameter whereas the
new version has a 255mm diameter.

Figure 12: Calibration Tab
6. Operating Limits Tab (Figure 13) and Safe Zone diagram (Figure 14).
 The Operating Limits tab lets you specify four different scan zones for four
different Source-Image-Distances where CBCT acquisitions can occur safely.
 If the couch is outside of the scan zone region defined by the Couch Position
Restriction Limits parameters, the system centers the couch automatically
prior to CBCT acquisition and then allows the user to return to the original
couch position at the end of the scan.
WARNING: The Clinac Collimator is the limiting factor for clearance

during a CBCT acquisition with SIDs ≥1500. Always verify
‘Operating Limits’ are safe prior to use.

Figure 13: Operating Limits
Figure 14: Safe Scan Zone Diagram

7. Logging Tab (Figure 15).

 The Logging tab lets you specify how the system tracks parameter changes:
to the Oncology System Platform SysLog.
 Test button: Select a line and press the Test button to send a log message to
the OSP SysLog.
E. Reconstructor Workstation – CBCT Administration:
NOTE: On the OBI desktop, there will be a Cone-Beam CT

reconstructor icon. Clicking this icon allows for a virtual connection
to the reconstructor computer
1. Open CBCT Administration (Figure 16).
Figure 16: CBCT Administration (found in CBCT folder on desktop)
2. CBCT Administration requires proper login rights granted in User Rights


Figure 17: CBCT Administration Login window

sure that the required user access rights are assigned to authorize
persons only.
3. CBCT Administration on the Reconstructor workstation.

 Reconstructor Tab (Figure 20).
 Disk Warning Size [MB]: Minimum disk size in MB that has to be
available. If free disk space falls below the minimum value a
warning message appears.
 Disk Error Size [MB]: Minimum disk size in MB that has to be
available for reconstruction to work. If free disk space falls below
this limit, reconstruction is not possible.
 Max Cache Age [h]: Duration in hours after which the projection
cache on the local file system is cleared.
 Reconstruction Speed: To set reconstruction speed, the following
options are available:
 Highest Image Quality
 Fastest Reconstruction Speed.

Figure 20: Reconstructor Tab
NOTE: The Reconstructor service runs on a separate workstation

on older systems (pre Dell T7500). For new installs the
Reconstructor service runs on the OBI workstation.
4. Logging Tab (Figure 18).

 The Logging tab lets you specify how the system tracks parameter changes:
to the Oncology System Platform SysLog.
 Test button: Select a line and press the Test button to send a log message to
the OSP SysLog.

F. Treatment Administration
1. Select the treatment administration icon on the desktop. Type the

appropriate username and password.
 The treatment application needs to be closed.
NOTE: Unlike the ARIA applications that work directly with the
database, treatment administration is independent of that database.
With treatment administration, you are working locally with
information about your machine.
2. Select the General tab, and verify the default imager vertical position (Figure 19).
 The default image vertical text box contains a number that represents the
vertical position of imager. The value is applied to the MV imager. The
amount is expressed in centimeters, relative to the selected scale, from
isocenter.
 The installation default is -50.00.
 If auto is selected from the OBI control console the selected imager will go to
the pre-defined imager position set in field properties.
 If no default imager position has been defined in the field properties, the
selected imager will go to the default imager vertical position set in treatment
administration.
NOTE: The default CBCT imager position is -50.00.

Figure 19: Machine configuration - General tab
3. Select the Plan Edit Preferences Tab (Figure 20).

 Verify the couch locking options. If the first option is selected no parameter
editing or acquiring is allowed. If any option other than the first is selected, the
4D console checks to see if a user has the rights to edit or acquire the
parameters.
Figure 20: Plan Edit Preferences

WARNING: Plan Edit Preferences settings do not apply to CBCT

fields. If a CBCT field is selected when ‘Acquire Actuals’ is pressed
the ‘Actuals’ available will be determined by Treatment
Administration User Rights making it possible for ‘Gantry’ and
‘Couch Rotation’ to be selected. Editing of Gantry and/or Couch
Rotation values will result in a plan revision and a possible
mistreatment. Verify Treatment Administration User Rights are set
appropriately.
WARNING: NEVER ‘Acquire Actuals’ when a CBCT field is

selected. Doing so could lead to a mistreatment.
4. Select the Sequence Template Tab (Figure 21).

 A sequence template is a pre-defined set of images to be acquired during a
treatment session.
 A sequence template scheduled at the 4DITC will use the sequence templates
configured in treatment administration.
 A sequence template scheduled in the ARIA RT Chart application will use the
sequence templates configured in ARIA Radiation Oncology Administration.
 The sequence templates configured in treatment administration should match
those configured in ARIA Radiation Oncology Administration.
 The dose accumulation check box identifies whether the dose from the image
is included in the cumulative dose to the reference point.
 The MU subtraction check box identifies whether the dose from an image is
subtracted from the cumulative dose to a treatment field.
 From the type text box list, you can select either a digital image or port film.
 The # of images identifies the number of digital images or film that are
included as part of a specific sequence template.
5. To add a new sequence template, click Add (Figure 21).
 The Add New Sequence Template dialog box is displayed.
 Type the ID, select the template type, configure your dose accumulation, and
MU subtraction preferences. Click OK.

Figure 21: Sequence templates
6. To add images to the sequence template, select the add button.

 The edit digital images dialog box will be displayed. Select the Add button
(Figure 22).
 The setup column identifies whether the image will be taken before, during, or
after treatment.
 Beam off identifies whether the portal image will shut the beam off
automatically immediately after acquiring the image by tripping a CDOS
interlock.
 Quality identifies the quality of the image as quality, dose, or integrated.
 The collimator mode indicates the positioning of the collimator jaws during the
image. The options are; plan, plan + 4, plan + 8, plan + 16, or open.
 Energy identifies the energy used to acquire the image. The options are
lowest and planned.
 Dose rate identifies the dose rate used to acquire the image. The options are
default, lowest, and planned.
 The acquire at % identifies at what percentage of dose accumulation the
image is acquired. Used for during sequence templates.
 Select the appropriate parameters. To add additional images repeat the
above process, then click OK.
Figure 22: Edit digital image

7. Select the User Management icon on the toolbar.

 Treatment administration includes six generic user IDs and groups.
 One of the six groups is set as the default. Users entered in ARIA Radiation
Oncology Administration also need to be entered in Treatment Administration.
If they are not re-entered in Treatment Administration the user will
automatically be created by the IT Daemon and placed in the default group
when they log on at the 4DITC.
 A group is a collection of users who share the same rights.
 Users are assigned to groups, and groups have rights. Users themselves do
not have rights.
 Rights allow users to perform privileged functions that can significantly affect a
variety of actions.
 Treatment administration has 55 different rights.
 To add a new group select the add button on the group tab. The add group
dialog box is displayed. Type the appropriate ID, Name, select the appropriate
group privileges, and click OK (Figure 23).
Figure 23: Groups
 To add a new user, select the Add button on the User Tab. The add user
dialog box is displayed. Type the appropriate ID, password, first name, middle
name, last name, prefix, suffix, description, select the appropriate group, and
click OK (Figure 24).

Figure 24: Users

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Clinac Administration
PROCEDURE
Objective:
 After completing this module, using the OBI Physicist Operations Manual as a
resource, the student will be able to configure Physics Mode based on user
preferences.
A. Exercise Key

2. Brackets denote additional selection options
1. Remote auto motions

 Auto setup
 Auto goto
 Large remote auto motions
 Small remote auto motions
2. Beam time
3. RPM
4. Small motions

C. Clinac Physics Mode
1. Navigation tips in the Clinac software application.

 To navigate in physics mode use the dedicated keyboard.
 To select items in the menus and data boxes, press the arrow keys or press
enter.
 To return to a previously viewed menu select setup or F1 exit.
 To save select F5 save.
 If changes are made, when you attempt to exit physics mode, a warning
message appears, “To save your configuration data, do not exit. Select NO,
or press the SET UP key. Follow the procedure for saving the data.”
2. In the Select Major Mode dialog box, select PHYSICS and press Enter (Figure 1).
Figure 1: Select Major Mode

3. The enter dialog box will be displayed. Type the appropriate password and press
Enter. 8888 is the default password (Figure 2).
NOTE: If the password is not correct, an error message appears.

Type the password again to continue. After four attempts, the
physics mode entry program ends and the Select Major Mode
menu reappears.
Figure 2: Enter password
4. The select option menu appears. Select CONFIGURATION and press Enter.
(Figure 3)
Figure 3: Select option
5. The SELECT CONFIGURATION dialog box will be displayed. (Figure 4)

 Select REMOTE AUTO MOTIONS and press Enter.
Figure 4: Select configuration

WARNING: REMOTE AUTO MOTIONS determines the behavior of

the Clinac for remote motions. Great care should be taken to apply
settings that maximize patient safety.
6. The remote auto motions box is displayed (Figure 5).

 Enable auto setup and auto goto capabilities support auto field sequencing by
a record-and-verify system (RV). The default is set to no.
 Auto setup allows the RV system to automatically drive the gantry, collimator,
MLC, and treatment couch to their planned positions.
 Auto goto allows the user to manually enter target positions and then drive the
gantry, collimator, MLC, and couch to those target positions.
 Press F3 to toggle back and forth between yes and no.
Figure 5: Auto setup and auto goto
7. Large remote auto motions are significant changes to the position of the gantry or
couch, and are measured from isocenter. Large motions are most often
performed between treatments.
 Large remote motions are configured for the gantry, upper and lower
collimator jaws, and couch axes.
 Large remote motions cannot be moved beyond the individual parameters
physical range.
 Large remote motions cannot be made to the gantry and couch at the same
time.

 The default is set to no.

 First disable or enable large remote motions (Figure 6).
 Then configure allowable motion range boundaries for large remote auto
motions with the arms extended and retracted.
 Values that are grey are read-only and cannot be changed.
 If an operator attempts to move beyond an allowed motion range, the motion
is prevented, an error message appears.
Figure 6: Large motions
 See Table 1 for default and maximum large remote motions limits.
Gantry Coll Upper Lower Couch Couch Couch Couch
Rtn Rtn Jaws Jaws Vrt Lat Lng Rtn
Large Max 185.0 40.0 25.0 158.0 90.0

Motions,
Imager Default 180.0 8.0 2.0 132.0 2.0
arms
retracted
Large Max 185.0 40.0 25.0 158.0 90.0
Motions,
Imager Default 10.0 8.0 2.0 132.0 2.0
arms
extended
Table 1: Boundary and range limits for large remote motions

 Large Gantry with Limited Couch Rotation – allows the user to enable or
disable gantry motion if the couch is no more than +/- 0.2º outside its allowable
motion range. A selection of “YES” allows this motion. A selection of “NO”
prevents the gantry from moving unless the couch is within its allowable range.
8. Small remote auto motions are fine-tuning corrections to the position of any axis,
with emphasis on the couch and patient position. This is usually performed to
make patient setup corrections based on imaging data (Figure 7).
 Configure small remote motion ranges for gantry, upper and lower collimator
jaws, and couch axes.
 Small remote motions do not have a physical boundary.
 Small remote motions can be repeated up to the individual parameters
physical limit.
 Small Remote motions can be made to the gantry and the couch at the same
time.
 Small remote motions are enabled and disabled as a group.
 The default is set at 2 cm or 2°.
 The range can be set from 0 to 5.
 To disable an individual small motion, set the value to zero.
 Values that are grey are read-only and cannot be changed.
 If an operator attempts to move beyond an allowed motion range, the motion
is prevented, an error message appears.
Figure 7: Small remote motions

9. Remote Motion Interlocks
NOTE: Post a chart near the Clinac console outlining all the
configured parameters in the Remote Auto Motion screen. This will
help the therapist troubleshoot potential interlocks.
 If a remote auto motion falls outside the allowable boundary or range, the
motion is prevented and an error message appears on the console screen. To
close the message press clear.
 In some cases, a new value can be typed in the target positions box, and
moving to this position will remove the message. See Table 2 for more details
about remote motion interlocks.
Remote Motion Interlocks
Message Meaning Action
Simultaneous The Clinac software Move the gantry and couch

large gantry does not allow separately, in two steps, from
and couch not movement of the outside the treatment room.
allowed gantry and couch at Or
the same time from Enter the treatment room and move
outside the treatment to the target position manually or
room. use Auto Setup.
Large motion Appears when the Enter the treatment room and move
is disabled Clinac software to the target position either manually
Or receives a target value or using Auto Setup.
small and for an axis, but the
large motions remote motion is
are disabled disabled.
Current The current position is In the target positions box, type new
position outside the zone values that are within the allowable
outside set defined by the large range, and move to these values
range remote motion instead. Or
boundary limits for the Press clear to close the message;
axis. then enter the treatment room and
move to the target position
manually, or use Auto Setup.

Motion The couch is in the Enter the treatment room and move
prevented extended travel range, the couch manually using the hand
couch in ETR and remote motion is pendant or couch side panel
not allowed. controls.
Axis is The target for an axis Enter the treatment room and move
disabled yet is present when the the couch manually using the hand
axis is active axis is disabled. pendant or couch side panel
controls.
Key
CRTN Couch rotation CVRT Couch vertical
CLNG Couch longitudinal CLAT Couch lateral
GANT Gantry
Table 2: Interlocks
10. Specify whether the treatment room door can be open or closed during remote
gantry and couch motions (Figure 8).
 This functionality allows the user to open the treatment room door while
motion is in progress. The motion must begin before the door opens.
 Press F5 to save your changes.
Figure 8: Allow door to open during motion

11. Beam Time Display

 This feature may not available on all versions of the Clinac.
 The select beam time display dialog box is displayed (Figure 9).
Figure 9: Beam time display
 Expands the functionality of the time indicator.

 Useful with RPM system to turn the beam on and off in synchronization with
the patient’s breathing pattern.
NOTE: The Clinac system ends a treatment when the total

treatment time is reached.
 With beam time display enabled, two time values appear in the time indicator
area.
 The first one is for the amount of time the beam was on, and the second one is
total treatment time (Figure 10).
Figure 10: Time display
 Select the appropriate option and press Enter. To save any changes, press
F5.

12. Select BEAM GATING ICON from the select configuration box and press Enter
(Figure 11).
13. The beam gating icon dialog box will be displayed (Figure 11).
 The beam gating icon enables two indicators during beam-on to let the
operator know when the RPM system is withholding the beam.
Figure 11: Beam gating icon selection (left), Beam gating icon enabled (right)
 A beam hold icon appears next to the dose rate, and a black-on-yellow beam
hold message appears instead of the beam on message (Figure 12).
Figure 12: Beam hold icons
F5.
14. Select SMALL MOTIONS from the select configuration box and press Enter
(Figure 13).

Figure 13: Small motions
 The small motions dialog box will be displayed (Figure 14).

 Small remote auto motions are fine-tuning corrections to the position of any
axis, with emphasis on the couch and patient position. This is usually
performed to make patient setup corrections based on imaging data.
 Small remote motions are enabled and disabled as a group.
F5.
Figure 14: Small motions
15. To exit physics mode select F1. Select YES and press Enter to confirm.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Administration
EXERCISE
Objectives:
 Using the OBI Physicist Operations Manual as a reference, the student will be
able to:
 Identify the way to notify the other users when entering the RT Administration
Task.
 State purpose of multi-user stamp and externally cached plans and their
implications to safety.
 Add a kV and CBCT sequence template in RT Administration.
 Define where the default imager position, marker preferences, and spatial
resolution are configured.
 List the two applications where couch locking preferences need to be
configured.
 List the differences of small motions verses large motions and how they come
into play in the clinical setting.
Participants will complete a “multiple choice exercise” reviewing the

administration applications. For the multiple choice questions, circle the
correct answer. Afterwards, the instructor will review the intended results.

Administration
1. Which two administration applications enables you to add, delete, or edit

sequence templates?
A. ARIA RT Administration and Treatment Administration
B. Treatment Administration and OSP
C. Clinac Administration and ARIA RT Administration
D. OBI Administration and Treatment Administration
2. Which administration application enables you to add, delete, or edit kV and CBCT
sequence templates?
A. ARIA RT Administration
B. Treatment Administration
C. Platform Admin
D. Clinac Administration
3. Which administration applications enables you to configure your Markers and
Spatial Registration preferences?
A. Treatment Administration
B. OSP
C. Clinac Administration
D. None of the above
4. Which two administration applications enable you to configure your couch locking
preferences?
A. ARIA RT Administration and Treatment Administration
B. Treatment Administration and OSP
C. Clinac Administration and ARIA RT Administration
D. OBI Administration and Treatment Administration
5. This enables the RV system to automatically drive the gantry, collimator, MLC,
and treatment couch to their planned positions:
A. Auto setup
B. Auto goto
C. Large motion
D. Small motion

Administration
6. This enables the user to manually enter target positions and then drive the gantry,
collimator, MLC, and couch to those target positions.
A. Auto setup
B. Auto goto
C. Large motion
D. Small motion
7. This allows significant changes to the position of the gantry or couch, and are
measured from isocenter. They are most often performed between treatments,
and need to be configured with the arms extended and retracted:
A. Auto setup
B. Auto goto
C. Large motion
D. Small motion
8. This allows fine-tuning corrections, with emphasis on the couch and patient
positioning. This is usually performed to make patient setup corrections based on
imaging data.
A. Auto setup
B. Auto goto
C. Large motion
D. Small motion

Local Load
PROCEDURE
Objective:
 After completing this procedure, the student will be able to manually select the
reference CT when using OBI/CBCT in an Aria environment. This can be used in
both as either the preferred clinical process or as a troubleshooting technique.
A. Preparation
The process:
 Locally store the DICOM RT plan, DICOM RT structure sets, and the DICOM
CT images to a directory location accessible from the OBI workstation.
 The plan contains the isocenter and links to the structure sets. The structure
sets contain the links to the CT images and we need the isocenter location,
structures, and reference CT images to perform CBCT acquisition and
registration.
 When needed, select the RT plan that matches the patient and plan currently
undergoing treatment. Selection of the RT plan allows the OBI system to
determine the isocenter coordinates and the reference CT required to
complete the patient repositioning process.
B. Alerts
WARNING: For ARIA users: Do not add a CBCT Setup field using
the 4DITC. Institutions using ARIA MUST add the CBCT setup field
to the plan in Plan Parameters or Eclipse before sending the plan to
the 4DITC. When a CBCT setup field is added to a plan on the
4DITC, a plan revision is generated for institutions using ARIA.
ARIA users will need to “treatment approve” the plan before the
next treatment and may need to recalculate the patient plan as well.

FOR INTERNAL PURPOSES ONLY!
Local Load
C. Prior to using Local Load Verify the Following:
 User has appropriate rights to BROWSE to the local directory containing the
planning CT, manually load the plan including the structures and the CT slices,
then proceed with the CBCT acquisition as trained. Local load plans must
reside in the local directory defined in Treatment Administration (Figure 1).
 Plan contains fields with single isocenter. Multiple isocenters will require
multiple plans.
 The operator MUST ensure that the plan loaded on the 4DITC is the same as
the manually selected plan. If the plans do not match then the isocenters may
not match and the patient will be repositioned to the incorrect location.
 Synchronization – if the plan is changed midway through treatment, then the
revised plan (and structure sets and reference CT) must be transferred to the
OBI Workstation again.
Figure 1: Default RT Open Directory
D. Clinic Responsibilities
 The clinic is responsible for mapping the drives and managing the storage on the
partition of the hard drive where the planning CT's are stored.
 Manual loading of the treatment plan will require the user to verify that the
imported plan and the patient being treated are identical.
 There is no record of the planning CT that was used for matching the CBCT. We
suggest a screen shot of the match for documentation.

Local Load
E. OBI Administration
1. Local Load option must be enabled in OBI Administration.

 From the desktop click Start > Programs > OBI > OBI Administration.
 Enter username and password.
 Enable the Local Load Reference CT box (Figure 2).
Figure 2: OBI Administration
F. 4DITC
1. Check-in the patient at the Treatment Queue or from ARIA.

imaging.

Local Load
Figure 3: Treatment Queue
3. Select the CBCT Setup Field and click Mode Up (Figure 4).
Figure 4: CBCT Setup Field; Mode Up
4. Set up the patient. Make sure couch rails are removed.

5. Insert appropriate Bow-Tie Filter. For information on Bow-Tie Filters, refer to the
System Components Procedure.

Local Load

harm the patient.
6. The OBI arms can be extended using the hand pendant to verify clearance
while inside the treatment room.
G. OBI Workstation
1. If not already positioned, extend the arms from outside the room by clicking
Download Axes.
 Press Motion Enable and Auto buttons on the OBI Console to position the
arms.
WARNING: Always verify clearance prior to extending the OBI

arms from the OBI console.
2. On OBI workstation, click 3D/3D Match to start acquisition (Figure 5).
3. The Cone Beam CT application will open. If the following warning message
appears (can be disabled in CBCT Admin): Make sure Couch Rails are removed
if fitted. (Figure 6)

Local Load
4. The Plan Import Explorer Dialog box will appear (Figure 7).
 Click Change Directory.
Figure 7: Plan Import Explorer
5. The Storage Directory Dialog box will appear.

 Browse the directory for the appropriate patient and planning CT and then
click Open (Figure 8).

Local Load
Figure 8: Storage Directory
6. The patient's planning CT will open in the dialog box. Select one CT image and
then click Open (Figure 9).
Figure 9: Select CT Image

Local Load
7. The Plan Import Explorer Dialog box will show the patient and plan information
(Figure 10).
 Highlight the patient and then click Select Plan.
Figure 10: Plan Import Explorer
8. The Plan Comparison Dialog box will appear (Figure 11).

 Verify that the patient and plan loaded on the 4DITC workstation and on the
OBI workstation are the same and then click Continue.
WARNING: Verifying the patient and plan information on the

4DITC workstation and the OBI workstation is a manual process.

Local Load
Figure 11: Manually verify patient and plan information
9. The reference CT will begin to load (Figure 12).
Figure 12: CT Loading
10. Continue with CBCT acquisition and 3D Match (Refer to the Cone Beam CT
Verification Procedure).

Local Load
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Cone Beam CT Image Review After Treatment
Objectives:
 After completing this module the student will be able to perform the following
 Review previously acquired CBCT images
 Analyze images
NOTE: This procedure is intended for Aria 8.0 and Mosaic 1.6
users. Aria 8.1 or greater allows for review of CBCT images in
Offline Review.
A. Exercise Key

3. Parenthses () denotes additional options.
1. Prerequisites
3. Review previously acquired CBCT Images

C. Prerequisites
1. Before starting the offline review process, some prerequisites must be met:
 Verify that Save CBCT to File System is selected and note the CBCT Img
Path in OBI Administration (Figure 1).
 The patient ID and date/time stamp of the Cone Beam CT (CBCT) images
needed for review (Figure 2).
Figure 1: OBI Administration
Figure 2: Patient ID, Date, and Time

D. 4D ITC
1. Check-in the patient.

2. Select the patient from the treatment queue and click OK (Figure 3).
3. Select the CBCT Set up Field and click Mode Up (Figure 4).

Figure 4: CBCT Setup Field; Mode Up
E. OBI Workstation
1. Using OBI, you can perform an offline review of the CBCT images after the
patient has been treated.
 To accomplish this, RMC on 3D Match Button (Figure 5).
 This will load the reference CT and the CBCT images into the 3D Match
workspace of OBI.
Figure 5: 3D Match Button

NOTE: The key to starting the CBCT offline review process in OBI
is to Right Mouse Click the 3D Match button.
2. The original planning CT will load on OBI. Once the CT has loaded, the CBCT
Acquisition Parameters dialog box appears (Figure 6).
 Click Browse.
 If an error message occurs stating that patient files cannot be found, ignore
the message by clicking OK.
Figure 6: CBCT Acquisition Parameters Dialog Box
3. Using the patient ID and the date/time stamp, select the appropriate folder
(Figure 7).

Figure 7: Verification CT Folder
4. Select the first DICOM file (slice) in the folder and then click Open (Figure 8).

Figure 8: CT DICOM File
5. Once in the 3D Workspace, proceed with the match process.

6. All match verification tools are available.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Calibration of Existing Cone Beam CT Mode
PROCEDURE
Objective:
 After completing this lesson the student will be able to perform a calibration of
existing Cone Beam CT tasks relevant to Physicists in the lab exercise.
A. Exercise Key

1. Calibration and Maintenance Workspace

2. Dual Gain Calibration
3. I0 Calibration Mode
4. Norm Scan

Maintenance Manual (for the installed OBI version: 1.3, 1.4, 1.5,
1.6 etc.) when performing CBCT calibrations.

C. Cone Beam CT Calibration and Maintenance Workspace
1. Close the OBI application, and wait about 10 seconds until all processes have
stopped.
2. Select the appropriate CBCT QA patient from the treatment queue and click Treat
(Figure 1).
3. Start the CBCT application by double clicking CBCT Application Icon in the
CBCT desktop folder (Figure 2). (Windows Start Menu > Programs > CBCT >
CBCT Application)
Figure 2: CBCT Application
4. If the following warning message appears: Make sure Couch Rails are removed if
fitted.
 Remove the couch rails and confirm the warning message by clicking OK
(Figure 3)

5. Once the CBCT application has opened, click the Workspace menu.
 Select Calibration and Maintenance (Figure 4). The user must Mode Up the
CBCT field on the 4DITC prior to attempting any calibrations.
Figure 4: Workspace Menu; Calibration and Maintenance
6. The Login dialog box will appear (Figure 5).

 Enter the username and password then click OK.
Figure 5: Login Window
7. From the Select Process wizard page, click Calibration/QA (Figure 6).
Figure 6: Select Process; Calibration/QA

8. The Select Calibration Process Wizard will open (Figure 7).
Figure 7: Select Calibration Process
D. Dual Gain Calibration
1. Dual gain calibration determines the linearity of each pixel in the imager and
determines the threshold value above which pixel values from the high sensitivity
image are replaced by appropriately scaled pixels from the low sensitivity image.
2. The dual gain calibration is used for the following mode types:
 all CBCT modes
 OBI Single Exposure acquisition technique Dual Gain Standard Resolution.
NOTE: Modes that have the same SID, X-ray voltage, focus type,
physical filter, and scatter grid require only one dual gain
calibration. This applies to the three modes Standard-dose head,
Low-dose head, and High-quality head. When you are asked to
select the respective modes on the Dual Gain Readout wizard
page, you need to choose only one of these three modes.
NOTE: Individual dual gain calibrations are required for head,

thorax, and pelvis modes, since they use different kV settings and
different fan types (full fan and half fan).

NOTE: Half-fan modes, such as Low-dose thorax, require a dual

gain calibration for half- and full-fan although the mode itself is only
set up for half fan. A full-fan dual gain calibration is required in any
case for beam hardening calibration.
3. Verify that no bow-tie filter is mounted.

4. On the Select Calibration Process page, click Imaging System (Figure 8).
Figure 8: Imaging System
5. On the Select Readout Mode wizard page, click Dual Gain.

6. On the Dual Gain Readout wizard page, click Gain Correction.
7. Under Select Mode(s), select the particular mode you want to calibrate (Figure 9).
 If you have created a new CBCT mode with a new SID, for example SID = 160
cm, select only the new CBCT mode.
 If you want to calibrate the acquisition mode Single Exposure for OBI, select
only the OBI Radiographic Calib. mode.

Figure 9: Selected modes
NOTE: When multiple modes are selected, the system will perform
dual gain calibration only once for identical dual gain correction
sets.
8. Click Next.
9. Click Acquire DF.
10. On the toolbar, click OBI kV Imaging System to display the CBCT
dashboard.
11. On the CBCT dashboard, click Reset Time to set the fluoro timer to Zero (0).
12. Click Acquire DR Sequence (Figure 10). Be sure to select Mode Up on the
4DITC first.
Figure 10: Acquire DR-Sequence

NOTE: The calibration wizard walks you through all modes

selected. Follow the calibration wizard.
13. Press and hold MEB and >> keys on the Clinac dedicated keyboard to move
gantry and/or couch into position for the calibration if requested (Figure 11).
Figure 11: Enable Clinac Movement
14. If the OBI Enable Movement window opens press Motion Enable and Auto on
the OBI console (Figure 12).
Figure 12: Enable Movement
NOTE: Verify that the blades and the IDU are at their target
positions: The TARGET values of the IDU and Blade text boxes
agree with the respective ACTUAL values on the CBCT dashboard.
15. The At Start Position Dialog Box will appear, press OK (Figure 13).

16. Press and hold the hand-switch or footswitch until the Evaluation progress bar
appears. The evaluation process starts and may take some time (Figure 14).
Figure 14: Dual gain calibration/evaluation
Note: The Acquire DR (Dose Rate) sequence process

automatically steps through different ms stages (pulse width, from 4
to 30 ms).
17. At the end of the evaluation process, the pixel defect map and the number of
defective pixels is displayed (Figure 15).

Figure 15: Typical Pixel Defect Map—Dual Gain
18. Verify that no clusters of defective pixels are present.
NOTE: It may happen that the pixel correction map is not displayed
properly. In that case click Auto Window/Level on the toolbar.
NOTE: Do not select Determine Pixel Defects.
19. Verify that the number of defective pixels is less than 70 000 (typically around
6000). If the number of defective pixels is greater than 70 000, do not apply the
calibration result, but click Cancel. And then repeat dual gain calibration.
 Verify the following before repeating dual gain calibration:
 Verify that the blades do not cover part of the panel. An indicator would be
clusters of defective pixel at the edge of the image. If there are clusters,
verify the blade calibration.
 In the Generator Configuration dialog box > Fluoro Setup tab, verify that the
minimal allowed pulse width is 2 ms for pulsed fluoro.
 Verify that the tube is properly calibrated.
 If you have verified all previous items, repeat the dual gain calibration.

NOTE: If you have verified all previous items and number of defect
pixel is still higher than 70 000 after repeating the dual gain
calibration, then that may indicate that the panel saturates too early
for the high gain readings. Contact Varian service for assistance,
and provide Varian service with the log file residing in this folder:
D:\VMSOS\Config2\local\Products\ImgAcqKV\Data\DualGain\RawD
ata\CalculationResults.
20. Click Next.

21. Click Apply to Mode(s).
22. If multiple modes have been selected for dual gain calibration, the calibration
wizard walks you through all modes selected.
23. Click Finish once all modes are calibrated.
24. If you have just calibrated the OBI Radiographic Calib mode, then no
subsequent calibrations are required. Verify image quality in the Maintenance
workspace of the OBI application by acquiring a new image using the Dual Gain
Standard Resolution technique.
25. For new and existing CBCT modes, I0 calibration and normalization scans are
required after dual gain calibration. Continue with I0 Calibration
E. I0 Calibration
1. The I0 calibration determines not attenuated flux per pixel and reduces ring
artifacts in the scans. The calibration is stored as an Air Norm on the
Reconstructor PC.
2. On the Select Calibration Process page, click I0-Image (Figure 16).

Figure 16: Select Calibration Process; I0-Image
3. The Select Mode wizard will open (Figure 17).

 From the CBCT Mode menu, select the mode to be calibrated.
 Select Pelvis Spotlight and click Next.
Figure 17: Select Mode; Pelvis Spotlight
NOTE: 200 degree techniques (Full Fan) require only a full fan I0
calibration. 360 degree techniques (Half Fan) require half fan
calibrations.

4. The Image Acquisition wizard page will appear (Figure 18).

 Click Start Acquisition.
Figure 18: Image Acquisition; Start Acquisition
5. A Dark Field will be acquired (Figure 19).
Figure 19: Acquire Dark Field
6. Once the dark field has been acquired the gantry needs to be moved to the start
position. The couch may also move to a safe position for the calibration.
 Press and hold MEB and >> keys on the Clinac dedicated keyboard to move
gantry and/or couch into position for the calibration if requested. (Figure 20)

Figure 20: Enable Clinac Movement
8. The At Start Position Dialog Box will appear, press OK. (Figure 22)
9. Press the footswitch or handswitch and hold until the progress bar is complete
(Figure 23).
 Click Next.

Figure 23: Image Acquisition
NOTE: The key to successful calibration is to repeat the I0

calibration multiple times because of charge trapping in the
amorphous silicon material used to form the photodiodes of the
imager. The I0 calibration applies a reasonably large radiation dose
to the imager, resulting in charge trapping similar to what occurs
during CBCT acquisition. Repeating the I0 calibration multiple times,
that is 4 to 5 times, results in a charge trapping level similar to the
level reached during CBCT acquisition. Therefore, the secret to
achieving high quality CBCT images is to (a) calibrate the imager
and (b) acquire the CBCT scans with the imager while it has the
same amount of charge trapping. In this way, the imager is
behaving the same way during calibration and during CBCT image
acquisition.
10. When the acquisition is terminated, select the Window/Level icon from the
Cone Beam CT toolbar.
 The image should be as homogeneous as possible (Figure 24).
 If there are dark lines or pixels in the image, the pixel correction may not have
corrected these defects. Dark lines may cause ring artifacts in the
reconstructed image (Figure 25).

 If the I0 image contains bad pixels a dual-gain calibration is required to create

a new pixel defect map.
 Click Apply and then click Finish (Figure 26).
Figure 24: I0 Image (good)
Figure 25: Poor I0 image

Figure 26: Validation; Apply and Finish
11. Repeat steps 1-10 for the remaining scanning modes as needed.
F. Norm scan
1. Norm scan is a routine calibration to improve image deterioration. It’s used to

account for radiation scatter and beam hardening, which can cause cupping
artifacts in reconstructed images.
2. On the Select Calibration Process page, click Norm Phantom (Figure 27).
Figure 27: Select Calibration Process; Norm Phantom
3. From the CBCT Mode menu, select the mode to be calibrated (Figure 28).

 Select Pelvis Spotlight and click Next.
Figure 28: Select Pelvis Spotlight
4. Mount the required phantom to the end of the Exact Couch.

 Mount the Body Norm Phantom for a Full Fan Norm Calibration.
 Mount the Half Bow-Tie filter.
 If a CBCT field was moded up on the 4DITC while setting up the Norm
Phantom, clear Mode Up then re-Mode Up to set the correct couch position.
 Click Start Scan (Figure 29).
Figure 29: Start Scan

NOTE: For the Pelvis spotlight mode the Body Norm Phantom
should be used for the Norm calibration. For this mode disregard
the wizard instructions to mount the Head Norm Phantom.
6. At Start Position Dialog Box will appear, press OK (Figure 31).
7. Press the handswitch or footswitch and hold until the progress bar is complete
(Figure 32 and Figure 33).

Figure 32: Acquire Projections; Progress bar
Figure 33: Norm Scan image
8. Click Next.
9. Click Apply to Mode (Figure 34).

Figure 34: Norm Calibration; Apply to Mode
10. Click Finish.

11. Repeat steps 1-10 for the remaining scanning modes as needed.
 Change Bow-Tie filter when necessary.
G. Cone Beam CT Toolbar (see Table 1)
Cone Beam CT Toolbar
Icon Description
Create New Patient
Open Patient
Auto Window/Level
Manual Window/Level
Zoom In
Zoom Out
Pan
Measure Distance

Pixel Information
Table 1: CBCT Icons
NOTE: If you create a new CBCT mode, HU calibration may also

be required. For more information on the calibration of HU for
CBCT modes refer to the HU Calibration section of the On-Board
Imaging (OBI) Maintenance Manual Advanced Imaging and
Appendix G of this Manual.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks
© 2013

Cone Beam CT Existing Calibration
EXERCISE
Objectives:
 Using the OBI/IGRT Clinical School Manual as a reference, the student will be
able to perform::
 A Cone Beam CT I0 calibration
 A Cone Beam CT Norm calibration
Operations Manual as a reference to perform an I0 and Norm Calibration for
one of the six clinical CBCT modes.

CBCT PRIMER
VARIAN February 2014

ONCOLOGY
SYSTEMS
Cone Beam CT
• Uma rotação de 360 ou

200 produz um arquivo
3D completo

Slide 2
CBCT Modos de Aquisição
• Existem seis modos de aquisição CBCT:
• Aquisição Full Fan de 200 graus(diâmetro de ~25cm):

1. High-Quality Head
2. Standard-Dose Head
3. Low-Dose Head
4. Pelvis Spotlight
Todas as técnicas Full Fan rodam o tubo por baixo da mesa.
• Aquisição Half Fan de 360 graus (diametro de ~45cm):

1. Pelvis
2. Low-Dose Thorax
• A posição do imager é assumida como = 150 cm

• Abertura física de 83 cm é definida pelo MLC

Slide 3
Aquisição – Full Fan
Abertura física: 83 cm
~18 cm
~25 cm
diameter
Volume reconstruído

Slide 4
Aquisição – Full Fan
100 cm
~18 cm
~25 cm
diâmetro
50 cm
30 cm
Slide 5
Aquisição – Half Fan
Abertura física: 83 cm
~16 cm
45 cm
diâmetro
Volume reconstruído

Slide 6
Aquisição – Half Fan
100 cm ~16 cm
45 cm
Diâmetro
50 cm
30 cm
Slide 7
Calibrações CBCT
• Calibração geométrica
• Calibração do sistema de imagens
• Calibração I0
• Correção do endurecimento do feixe
• Norm Scan
• Calibração do HU
• Utilize o manual OBI Advanced Imaging Maintenance
como referência para mais informações sobre
calibrações.

Slide 8
Calibração Geométrica
• Requerido para cada SID definido no modo de setup

• O padrão de SID é 1500 mm
• Templates para SID de 1450, 1600 and 1700 mm
• Calibração geométrica corrige o isocentro kV e é feito
durante a instalação. Se você acha que há um
problema com o isocentro do CBCT, abra um chamado
com o Service.
• Utilize o manual Advanced Imaging Maintenance
Manual para mais informações sobre como criar mais
Modos de aquisição.

Slide 9
Calibração Geométrica
• Dois scans do fantoma

5 needle
• Direção CCW
• Direção CW
• Calibra o isocentro kV
correto.

Slide 10
Calibração do sistema de imagem
• Calibração Dual gain
• Modo especial de leitura para aumentar o intervalo
dinâmico do PaxScan
• Como efeito temos que cada projeção é lida duas
vezes:
• Uma imagem com a eletrônica ajustada para alta sensitividade
• Uma imagem com a eletrônica ajustada para baixa
sensitividade.
• Selecionando os melhores pixels de ambas as imagens, evita
que a projeção CBCT com alto range dinâmico seja possível
para imagens CBCT.
• Determina a linearidade de cada pixel do

detector de imagem.
Slide 11
Calibração do Sistema de Imagem
• Modos com a mesma correção dual gain,
necessitam somente uma correção Dual Gain
• Mapa de pixels defeituosos é gerado
automaticamente baseado na calibração dual gain.
• Pixels ruins, detectados pela calibração dual gain,
não necessariamente indicam que o painel está com
defeito.
• Calibração dual gain para imagens radiográficas
geradas no aplicativo de CBCT.

Slide 12
Calibração I0
• Reduz os artefatos de anel

• Determina o fluxo por pixel não atenuado.
• Usado para correção do endurecimento do
feixe.
Assegure-se de que o filtro bowtie não está
encaixado.

Slide 13
Calibração I0
• A imagem I0 deve parecer homogênea.

Inomogeneidade necessita de uma
calibração dual gain.

Slide 14
Correção do Endurecimento do feixe
• Corrige o aumento da
energia do feixe ao
passar pelo paciente.
• Reduz faixas entre
ossos e os cupping
artifacts nas imagens
CBCT

Slide 15
Correção do Endurecimento do Feixe
• Os seis modos padrões
usam arquivos genéricos
de endurecimento do
feixe. No entanto, não
necessitam de
atualização.
• Somente os modos recém
criados ou copiados, com
modificações nas técnicas
de raios-x, necessitam de
CEF.

Slide 16
Norm Scans
• Leva em consideração a
radiação espalhada
• Endurecimento do feixe, que
pode causar cupping artifacts
em imagens reconstruídas
• O filtro Bow-tie deve estar
acoplado.

Slide 17
Norm Scans
• Use o fantoma Head Norm para Técnicas ‘Head’
– Cabeça/Cabeça e pescoço

Slide 18
Norm Scans
• Use o fantoma Body Norm para técnicas de
outras partes do corpo

Slide 19
Calibração de HU
• Realizada para calcular
o número de HU para
os pixels das imagens
reconstruídas

Slide 20
Calibração recomendada para modos
existentes
• Os procedimenos de calibração
são as únicos procedimentos
necessários para manter a
qualidade da imagem.
• Dual gain (CBCT e
Radiografia)
• Calibração I0
• Norm Scan
• Os valores de HU podem
requerem calibração.
• Realize trimestralmente ou
sempre que a imagem tiver a
quallidade deteriorada.
• Please refer to TG-142 and or TG179 for
guidance of QA frequency.

Slide 21
Regras de Calibração

Slide 22

Slide 23

Slide 24

Slide 25
Criação de Novos Modos
Se um modo padrão foi copiado para criar um novo modo,
nenhuma calibração é necessária a menos que os ajustes de
voltagens de Raios-X tenham mudado. Não altere os ajustes de
aquisição de imagem. Por favor, utilize o manual OBI AI
Maintenance como referência.

Slide 26
Thank you for your interest and
attention.
Any questions?

A quality assurance program for the on-board imager®
a)
Sua Yoo
Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710
Gwe-Ya Kim
Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California 94305
Rabih Hammoud
Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan 48202
Eric Elder
Department of Radiation Oncology, Emory University, Atlanta, Georgia 30322
Todd Pawlicki
Huaiqun Guan
Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan 48202
Timothy Fox
Department of Radiation Oncology, Emory University, Atlanta, Georgia 30322
Gary Luxton
Fang-Fang Yin
Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710
Peter Munro
Varian Medical System, Palo Alto, California 94304
(Received 9 June 2006; revised 20 September 2006; accepted for publication 20 September 2006;
published 31 October 2006)
To develop a quality assurance (QA) program for the On-Board Imager (OBI) system and to
summarize the results of these QA tests over extended periods from multiple institutions. Both the
radiographic and cone-beam computed tomography (CBCT) mode of operation have been evalu-
ated. The QA programs from four institutions have been combined to generate a series of tests for
evaluating the performance of the On-Board Imager. The combined QA program consists of three
parts: (1) safety and functionality, (2) geometry, and (3) image quality. Safety and functionality tests
evaluate the functionality of safety features and the clinical operation of the entire system during
the tube warm-up. Geometry QA verifies the geometric accuracy and stability of the OBI/CBCT
hardware/software. Image quality QA monitors spatial resolution and contrast sensitivity of the
radiographic images. Image quality QA for CBCT includes tests for Hounsfield Unit (HU) linearity,
HU uniformity, spatial linearity, and scan slice geometry, in addition. All safety and functionality
tests passed on a daily basis. The average accuracy of the OBI isocenter was better than 1.5 mm
with a range of variation of less than 1 mm over 8 months. The average accuracy of arm positions
in the mechanical geometry QA was better than 1 mm, with a range of variation of less than 1 mm
over 8 months. Measurements of other geometry QA tests showed stable results within tolerance
throughout the test periods. Radiographic contrast sensitivity ranged between 2.2% and 3.2% and
spatial resolution ranged between 1.25 and 1.6 lp / mm. Over four months the CBCT images showed
stable spatial linearity, scan slice geometry, contrast resolution (1%; <7 mm disk) and spatial
resolution (>6 lp / cm). The HU linearity was within ±40 HU for all measurements. By combining
test methods from multiple institutions, we have developed a comprehensive, yet practical, set of
QA tests for the OBI system. Use of the tests over extended periods show that the OBI system has
reliable mechanical accuracy and stable image quality. Nevertheless, the tests have been useful in
detecting performance deficits in the OBI system that needed recalibration. It is important that all
tests are performed on a regular basis. © 2006 American Association of Physicists in Medicine.
[DOI: 10.1118/1.2362872]
Key words: quality assurance, on-board imager, cone-beam CT
4431 Med. Phys. 33 „11…, November 2006 0094-2405/2006/33„11…/4431/17/$23.00 © 2006 Am. Assoc. Phys. Med. 4431
4432 Yoo et al.: QA for OBI and CBCT 4432
I. INTRODUCTION
The On-Board Imager system (On-Board Imager , Varian
®
Medical Systems, Inc., Palo Alto, CA) is designed to correct

for motion and setup errors of patients undergoing radiation
therapy. The OBI system provides three imaging modes:
two-dimensional (2-D) radiographic acquisition, fluoroscopic
image acquisition, and three-dimensional (3-D) cone-beam
computed tomography (CBCT) acquisition. The fluoroscopic
images are used to verify the gating thresholds of the respi-
ratory gating system (RPM™, Varian Medical Systems, Inc.)
to account for intrafraction (i.e., respiratory) motion. The ra-
diographic images manage interfractional motion and setup
errors. The CBCT images provide soft tissue and bony struc-
FIG. 1. The OBI hardware mounted on a Varian 2100 EX linear accelerator.
ture information in 3D and also manage interfractional mo- When facing the accelerator with the MV beam pointing down, the kV tube
1–3
tion and setup errors. Using the 2D2D Match and 3D3D is on the left side, the kV detector is on the right side, and the electronic
Match analysis tools a user can register the acquired kV or portal imaging device is at the bottom.
CBCT images with their associated reference image (e.g.,
digitally reconstructed radiograph—DRR—or planning CT).
Couch corrections are then downloaded to the linear accel-
erator and the couch is moved remotely.
retracts the robotic imager arms, while, at the treatment con-
The use of this new technology necessitates a comprehen-
sole, a control box (OBI control console) extends and re-
sive quality assurance (QA) program to maintain and moni-
tracts the OBI and MV imager arms remotely.
tor system performance characteristics, which have been es-
A pair of radiographic images is acquired by remotely
tablished at the time of commissioning. Currently, there have
rotating the gantry to predetermined angles. The x-ray tech-
been no published recommendations and guidelines for a QA
program to verify the functionality, accuracy, stability, and niques (mAs and kVp) are selected using the OBI worksta-
image quality of the radiographic and CBCT modes of this tion, which has a computerized interface to the x-ray genera-
device. Several early adopters of the OBI technology inde- tor. There are approximately 20 preset anatomic techniques
that can be manually adjusted for each patient exposure. Af-
pendently developed their own QA programs using similar
but not identical methods. This paper combines the best of ter a pair of images (e.g., AP and lateral images) has been
these methods to generate a comprehensive QA program for acquired the patient position is analyzed using 2D2D Match,
the OBI and CBCT system. The QA program has three com- a match environment where the kV images and DRRs are
ponents: safety, geometry, and image quality—for both ra- overlaid. The user can use both automated and manual match
diographic and tomographic images. The most critical tests tools to align the kV images with the corresponding DRR
are those that evaluate the geometric accuracy of the OBI with the couch shift parameters being updated as the match
is adjusted. Once the desired match has been reached, the
system, since the OBI system is intended for repositioning of
couch shift parameters are downloaded to the linear accel-
the patient before/during treatment. All the geometric tests
erator and the couch is moved remotely repositioning the
described in this publication assume that the location of the
4 patient and correcting the setup error.
MV isocenter is known and can be identified independently.
CBCT images are generated from 650 to 700 projections
Therefore, the tools used to identity the location of the MV
isocenter (e.g., wall lasers, field light) are assumed to be (e.g., low dose radiographs) acquired over a complete gantry
calibrated. Image quality needs to be checked frequently rotation. When the detector (30 cm X 40 cm) is centered
enough to endure consistent image quality. Tests of image about the rotational axis, the reconstructed field of view is
quality do not need to be as frequent as the geometry tests, 24 cm in diameter with a cranial caudal extent of 15 cm
but a regular program to detect changes in the imaging chain when the source to imager distance (SID) is 150 cm. This
is still important. In this paper we describe the procedures of acquisition mode is called “full-fan” acquisition and is used
test items included in the QA program and present the results to image small diameter anatomic sites such as the brain and
of measurements over extended periods from the multiple head and neck. For larger anatomic sites, such as the pelvis,
institutions. chest, and abdomen, the detector is shifted by 14.8 cm later-
ally with the blades in KVS tracking the detector. In this
acquisition mode only part of the object is viewed at any one
II. METHODS AND MATERIALS projection. The entire object is reconstructed by piecing pro-
jections acquired 180° apart. This acquisition mode is called
A. The OBI system “half-fan.” The field of view in the half-fan mode is 45 cm in
The OBI system shown in Fig. 1 consists of a kV x-ray diameter with a 14 cm in the cranial caudal extent when SID
source (KVS) and a kV amorphous silicon detector (KVD) is 150 cm. An accessory, called a bowtie filter, is placed in
mounted on the linear accelerator using robotic (Exact ™ ) front of the kV beam to attenuate the edges of the kV beam.
arms. In the treatment room, an infrared pendant extends and The bowtie filter reduces skin dose, allows larger x-ray tech-
Medical Physics, Vol. 33, No. 11, November 2006

TABLE I. List of test items for QA of OBI safety and functionality. All items are checked daily (see Appendix A).
Test items Description Tolerance
Door interlock X-ray generator locked if door opened. X-ray locked

Warning lights During x ray on, all warning lights should be Warning light on
illuminated.
Warning sound During x-ray on, the OBI console should sound an Warning sound on
acoustic warning.
Collision detection and interlock Press covers and paddles of the KVD and the KVS. Alarm sound and motion interlock
Check that the Clinac motion interlock trips, stopping
all motions.
Hand pendant motion enable bars Release motion enable bars on the hand pendant while Motion disabled
retracting/extending the arms.
Tube warm-up Press footswitch in fluoroscopic mode for 20 seconds Operation
using a setup field of a test patient with the x-ray
technique of 75 kVp, 50 mA, and 32 ms.
Functionality Check data transfer from the information system to the Operation
treatment workstation (4D ITC), to the OBI
workstation, and to the mechanical systems.
niques to be employed without saturating the detector, re- gantry angle and position information of the KVD. The test
duces x-ray scatter, and reduces the effects of charge trap- plan is delivered exactly like a treatment for a normal pa-
5,6
ping in the detector. tient; the patient scheduled, the plan retrieved from the data-
When CBCT images are acquired for a patient, the corre- base, and the setup field moded up on the treatment worksta-
sponding planning CT and structure sets (anatomic contours) tion (4D Integrated Treatment Console, 4DITC), which sends
are transferred to the OBI application and superimposed with the data to the OBI workstation. An x-ray technique of
the CBCT images. The patient positioning is analyzed using 75 kVp, 50 mA, and 32 ms is selected on the x-ray generator
3D3D Match, a match environment in which manual and for a 20 s irradiation.
automated tools are used to align the CBCT images with the Loading the plan from the database to the 4D ITC checks
planning CT. As with the radiographic mode, the couch shift the integrity of the software services (deamons) used to
parameters are updated as the match is adjusted, the couch transfer data. On occasion, these services need to be re-
shift parameters are downloaded to the linear accelerator, and started. When a treatment or setup field is “moded up,” the
the couch is moved remotely to correct the patient setup. OBI workstation should show the associated reference image
(DRR) verifying communication between 4D ITC and the
B. Safety and functionality QA OBI workstations. Once the setup field is “moded-up,” the
arms and gantry can be remotely moved to their target posi-
The safety QA tests check the safety features built into the
tions, verifying communication among the OBI control con-
OBI system. The safety QA should be performed before any
4,7 sole, the OBI workstation, the control system of the arms,
patient is treated on a daily basis. For efficiency, we rec-
and the accelerator control system. Turning on the x-ray
ommend combining many of the safety tests with the
beam checks the communication between the OBI worksta-
warm-up procedure for the x-ray tube. Table I summarizes
tion and the x-ray generator. Beaming-on assures all compo-
the tests with a description of the tests and expected results.
nents in the OBI system are functioning properly.
Some safety features in the OBI system are similar to those
7 While the x-ray beam is on for the tube warm-up, the door
for the EPID. Appendix A contains a worksheet to record
interlock, warning lights, and audible warning can be
the results of the safety and functionality QA tests.
checked. After 20 s of the warm-up, the arms can be re-
tracted using the hand pendant in the room. While retracting
1. Procedure the arms, the motion enable bars of the hand pendant to be
Tube warm-up is recommended to prevent premature fail- released to verify that arms stop moving. The collision de-
8
ure of the x-ray tube. While the latest version of the OBI tection covers and paddles can also be checked, one at a
software (OBI 1.3) activates a tube warm-up procedure every time, while retracting the arms. Note that the collision detec-
time the application is started, it is more efficient to create a tion interlock of the linear accelerator needs to be reset each
test “warm-up” patient to be used each day during morning time a collision is initiated.
linear accelerator QA. This patient can also be used to test Thus, the QA for safety features as well as the integrity of
the integrity of the information transfer through the informa- the entire OBI system can be combined in a fast efficient
tion system as well as the integrity of the OBI system itself. process of retrieving the test patient from the information
A test plan should be associated with the test patient with system, “moding up” the patient on the 4D ITC, moving the
at least one kV setup field for the tube warm-up. The kV gantry and arms to the target positions, warming up the x-ray
setup field contains a reference image (e.g., DRR) as well as tube and then retracting the arms in the room. The whole

FIG. 2. (a) Cube phantom with four fiducial markers on the anterior and later surfaces, (b) printed circuit board, and (c) marker block with one fiducial marker
at the center and four markers at known locations inside the block.
process takes a couple of minutes including walking in and cule, zoomed in on the center of the image, and measured the
out of the treatment room. The tube warm-up should be per- distance between the center of the central radio-opaque
formed everyday before patient treatment. marker and the digital graticule using the “Measure Dis-
tance” tool in the OBI application (e.g., Fig. 6, later). The
C. Geometrical accuracy QA separation was recorded. The measured disagreement should
be less than 1.5 mm in any direction [Varian OBI - Customer
The geometrical accuracy QA tests evaluate the accuracy Acceptance Procedure, Revision D (Palo Alto, CA, Varian
and stability of mechanical hardware devices as well as some Medical Systems Inc., 2005)], and the test should be per-
of the software functions. The geometry tests should be performed daily or weekly. Appendix B contains a worksheet to
formed at the most commonly used arm setting(s). Most clin- record the results of this test.
ics use the default settings of SID = 150 cm; SAD = 100 cm. A note about terminology. The KVS can move vertically
(toward and away from isocenter) and longitudinally (in the
1. OBI isocenter accuracy same direction as the accelerated electrons). Hence, the po-
The OBI isocenter accuracy QA test evaluates whether the sition description (100 , 0) is used for the KVS. The KVD can
digital graticule generated by the OBI application coincides move vertically, longitudinally, and laterally, resulting in a
with the treatment (MV) isocenter. The OBI device does not position designation (−50 ,0 , 0). The negative number for the
have a physical graticule so an independent check of the vertical position indicates that the KVD is on the opposite
digital graticule is required. Any phantom that contains a side of isocenter from the KVS. The arm can move the KVD
small, well-defined, central radio-opaque structure can be vertically past isocenter, so it is possible for the vertical po-
sition of the KVD to become positive.
used. All phantoms (cube phantom, printed circuit board, or
marker phantom) shown in Fig. 2 can be used for this test,
although the cube phantom or marker phantom are often pre- 2. 2D2D match and couch shift accuracy
ferred. The isocenter accuracy test requires only one kV image,
A test patient was created for these geometric QA tests but taking two images at different gantry angles verifies the
with a test plan containing two kV setup fields. Each setup accuracy of the match and the remote couch shift. This test
field had a DRR associated with it so that the entire patient uses a phantom that has several markers at known positions
reposition process could be performed. The software did not relative to each other and the same test patient as in the
allow the match process to be completed without DRRs be- previous section.
ing present, however, since we did not actually use the DRRs We modified the cube phantom by adding one BB (Beek-
for the tests we found it easiest to import a bitmap file (a ley Spots® 1.5 mm pellets X spots, Beekley Corp. Bristol,
bitmap image of any object would suffice) as the DRR. This CT) to the anterior surface of the cube and another BB on the
avoided the need to acquire a CT scan of the phantoms and right surface of the cube. The BB on the anterior surface was
generate a treatment plan including DRRs. placed 1 cm right and 2 cm inferior from the center, and the
We placed the phantom on the couch—using the field BB on the right surface was placed at 1 cm anterior and
light cross-hair and wall lasers as a guide—so that the center 2 cm inferior from the center. Thus, a known shift between
of the phantom was aligned with the treatment isocenter. We the center BB in the cube phantom and the projections of the
moded up AP or lateral setup field from 4DITC, and acquired added BB’s was generated—the shift being 1 cm in the ver-
an AP or lateral kV radiograph with the KVD at (−50 , 0 ,0) tical direction, 2 cm in the longitudinal direction, and 1 cm
and the KVS at (100 , 0). Then we displayed the digital grati- in the lateral direction. This method may introduce a

0.25 mm systematic error due to the difference between SSD between the isocenter and the surface of the x-ray detector
to the surface BBs (SSD = 97.5 cm) and the SAD (SAD using a tape measure. The distance should be 48.2 ± 0.2 cm.
= 100 cm) to the central marker. The cube phantom was One institute also marked the x-y locations where the ceil-
placed so that the center marker was positioned at the iso- ing laser projected onto the collimator faceplate of the KVS
center. Anterior and right lateral kV images were acquired and the surface of the KVD. Care had to be taken to ensure
using the setup field moded up from the 4DITC using the test that the gantry angle was set accurately before marking these
plan used for the test B.1. The kV image positions were surfaces. On subsequent days, the distance between the
adjusted so that the off-centered marker(s) were aligned with marks on the KVS and KVD and the laser projections was
the center of the digital graticule. The calculated shift value measured as an additional check of the mechanical accuracy
was then recorded. of the arms. Appendix C includes the worksheet to record the
The other approach was to use the marker phantom. This results of this (optional) QA test.
phantom contains a central BB of 1.0 mm in diameter and 4
additional markers that are 1 mm in diameter by 3 mm in 4. Run-out during arm vertical travel
length. The phantom is held by an assembly with several
This test checks that a vertical motion does not have any
steps in it that allows the marker phantom to be shifted by a
longitudinal or lateral components. We moved the gantry to
very accurately 2 cm in each of the longitudinal, lateral and
90° so that the detector was pointing up, removed the cover,
vertical directions. The block was attached to the top step of
and marked where the ceiling laser hits the imager. Care was
the step assembly, attached to the couch using the exact bar
taken to ensure that the gantry was exactly at 90°. We then
and positioned so that the center of the block was at the
moved the image vertically from (−50 , 0 , 0) to (−30 ,0 , 0)
isocenter. The block was moved from the top step to the
and measured the displacement of the center of the KVD in
second step (test position). The test position is 2 cm poste-
the longitudinal and lateral directions. The tolerance is 2 mm
rior, 2 cm inferior, and 2 cm right from the reference posi-
and we suggest this test to be performed monthly. Appendix
tion. We acquired anterior and right lateral kV images and
C is the worksheet that includes this QA test as one of
then performed the 2D2D match to align the central BB with
monthly QA tests.
the digital graticule to generate the calculated couch shift.
The disagreement between the known shift and the calcu-
lated shift should be less than 2 mm in any direction. We 5. OBI isocenter accuracy with gantry rotation
also downloaded the measured couch shift to the linear ac- This test verifies stability of the OBI isocenter as a func-
celerator and moved the couch remotely. For simplicity in tion of gantry rotation. The cube phantom was placed on the
interpreting the results, we did not download the couch rota- treatment couch with the marker located at the isocenter.
tion value. This couch position was recorded. In the room, OBI images were acquired at gantry angles 0°, 90°, 180°,
we manually adjusted the couch so that the off-centered and 270°, which locate the KVS and KVD to take right
markers of the cube phantom or the center of the marker lateral, anterior, left lateral and posterior images, respec-
phantom were at the isocenter based on lasers and field light tively. The displacement of the central marker from the digi-
cross-hair. The difference between the manually adjusted tal graticule was recorded for all gantry angles. The displace-
couch position and the remotely shifted couch position was ment should be less than 2 mm. We suggest performing this
also recorded. It should be within 2 mm in any direction. We test monthly. Appendix C, the monthly OBI QA worksheet,
suggest that this test to be performed daily or weekly con- includes this QA.
currently with the OBI isocenter QA. Appendix B shows the
worksheet that includes this QA test. D. Image quality QA
The goal of the image quality QA was to establish base-
line for image quality parameters and to monitor these pa-
3. Magnification accuracy rameters over time. Corrective action (recalibration/repair)
Changes in SAD and SID will affect image magnification. was initiated if the parameters went outside their tolerance.
However, it is very difficult to measure changes in SAD and Since this QA program used only phantoms supplied with the
SID radiographically, because even a relatively large change OBI system, no additional equipment needed to be acquired.
in SID or SAD will result in only a small change in image This QA program has adopted tests from conventional QA
8 9,10
magnification. A physical measurement is the most accurate. programs for radiographic units and for CT scanners. Ap-
During the OBI commissioning, we established a baseline of pendix C includes the worksheet for OBI image quality QA,
physical measurements. The gantry was rotated to 270°; the and Appendix D includes the worksheet for CBCT image
kVS was extended to (100 , 0) so that the x-ray source was quality QA.
pointing toward the ceiling; and the distance between the
isocenter (as indicated by the wall lasers) and the collimator 1. Radiographic image quality
faceplate was measured using a measuring tape. The distance a. Contrast resolution and spatial resolution. We used
should be 85.0 ± 0.2 cm. We then retracted the KVS; rotated the Leeds phantom—TOR 18FG (Leeds test objects Ltd,
the gantry to 90°; extended the KVD to (−50 , 0, 0), remove
11
North Yorkshire, UK) to monitor both contrast and spatial
the collision cover of the KVD, and measure the distance resolution over time. The phantom has 18 disks of 8 mm

diameter each with contrasts ranging between 16.7% and ware connections to disconnect, and then starting the CBCT
0.9%, and 21 bar patterns ranging between 0.50 and acquisition application on its own. From the one scan all
5.00 lp / mm. image quality evaluations were made.
We placed the phantom on the cover of the KVD with the a. Hounsfield Units (HU) linearity. The CTP 404 insert
KVD positioned at (−50 ,0 ,0). The blades were set to a contains seven materials of different densities. The materials
14 cm X 14 cm opening and a 1 mm copper plate was placed and the expected HU values are listed in the manual that
over the KVS to simulate a modestly thick patient. We used accompanies the phantom. We selected a region of interest
x-ray techniques of 70 kVp, 32 mA, and 6 ms for the fluo- using the “Area profile” tool to measure the mean HU value
roscopic mode and 75 kVp, 25 mA, and 6 ms for the single for each material in the CBCT application. The ROI size was
high quality radiographic mode when evaluating contrast adjusted to cover approximately 0.7 cm X 0.7 cm, which
resolution. When evaluating spatial resolution, the tech- covered about 14 X 14 pixels for the full-fan mode and 8
niques were changed to 50 kVp, 80 mA, and 32 ms for the X 8 pixels for the half-fan mode. The measured HU value for
fluoroscopic mode and 50 kVp, 80 mA, and 120 ms for the each material should be within ±40 HU of the value indi-
single high quality radiographic mode. The images were then cated in the Catphan manual.
inspected visually to determine the lowest contrast disk and b. Low contrast resolution. In the CTP 515 insert there
the smallest discernable group of bars visible in the images. are three groups of nine supraslice disks with diameters rang-
Eleven (3.2%) or twelve (2.7%) contrast disks or more ing from 2–15 mm and subject contrasts of 1%, 0.5%, and
should be discernable and the 11th group of bars, equivalent 0.3%. We visually inspected the image and determined the
to 1.6 line pairs per mm (lp/mm), should be visible [LeedsT- lowest contrast and lowest diameter supra-slice disk that was
est Objects Limited, Leeds Test Objects TOR 18FG Manual visible. Our recommendation is that the 1%, 7 mm disk
(North Yorkshire, UK)]. (fourth largest disk) should be visible [Varian CBCT—
The number of discernable disks and bars is very subjec- Customer Acceptance Procedure (1.1.01) (Palo Alto, CA,
tive. It is important that the same individual performs these Varian Medical System Inc., 2005)]. This test is subjective
tests to establish the baseline values. In a large organization a and depends on the individual performing the test. Thus, it is
couple of people should cross-check the baseline values to more important to verify constancy of the measured contrast
account for interuser variability. Although certain tolerances resolution for each scanning mode rather being concerned
(2.7 − 3.2%; 1.6 lp / mm) and x-ray techniques are recom- with the absolute contrast and size threshold established by
mended, the baseline (a combination of x-ray technique, con- the test.
trast, and spatial resolution) should be established during c. Spatial resolution (high contrast resolution). The CTP
commissioning or calibration. It is more important to verify 528 insert contains a spatial resolution rule with bar patterns
constancy of image quality over time than any absolute between 1 to 21 line pairs/cm. The least discernable bar pat-
value. tern in CBCT images should be selected and compared to the
baseline obtained at the time of commissioning. Our recom-
mendation is that 6 lp / cm, which is group 6, should be vis-
2. CBCT image quality ible [Varian CBCT—Customer Acceptance Procedure
Although CBCT images do not have the same contrast (1.1.01) (Palo Alto, CA, Varian Medical System Inc., 2005)].
resolution or spatial resolution as diagnostic CT One should be able to see all five bars in the pattern to count
2,12–16
images, we have adopted some tests from QA programs that pattern as discernable.
8–10
of diagnostic CT scanners. We suggest that these image d. HU uniformity. The CTP 486 insert is a uniform disk
quality checks be performed semiannually or more often of 20 cm diameter that has been used to assess HU unifor-
(e.g. monthly, bi-monthly) until confidence in system perfor- mity. Since the CTP 486 insert is large in the axial dimension
mance has been established. CBCT images acquired in both we had to select a slice location that would be identifiable
full-fan and half-fan modes should be tested alternatively. from measurement to measurement. We used the white mark-
Appendix E shows the worksheet for the image quality QA ers on the exterior of the Catphan phantom for this purpose
tests. and always selected the image slice containing the marker
All CBCT image quality tests used the Catphan 504 phan- for our measurement of HU uniformity. The area profile tool
tom, which is provided with the OBI system. The Catphan was used to measure the HU values in 1.0 cm X 1.0 cm ROI.
504 phantom contains inserts that measure different aspects We selected five ROIs—one in the center and four symmetri-
of the CBCT image quality. The Catphan 504 phantom was cally in the upper, lower, right, and left peripheral areas in
hung over the end of the couch with the aid of its wooden the phantom. The HU values for all regions should be within
case and leveled. The phantom was centered so that its ±40 HU of each other [Varian CBCT—Customer Acceptance
physical center was at the treatment isocenter and one CBCT Procedure (1.1.01) (Palo Alto, CA, Varian Medical System
scan of the phantom—using a technique of 125 kVp, 80 mA, Inc., 2005)].
25 ms, 150 cm SID with a full-fan bowtie—was acquired. e. In-slice spatial linearity. The geometric accuracy of
The reconstruction matrix was 512 X 512 and the slice thick- the CBCT scans is determined by the magnification accuracy
ness was 2.5 mm. The acquisition used the CBCT acquisi- (see Sec. II C 3, Magnification Accuracy), since this defines
tion application in a stand-alone mode. This entailed closing the divergence of the x-ray beam. If the actual divergence of
the OBI application, waiting for �10 s for all of the hard- the x-ray beam matches that assumed in the reconstruction,

then the CBCT images will be geometrically consistent.

Nevertheless, the in-slice spatial linearity can be checked
using the CTP 404 insert. There are four rods of 3 mm di-
ameter at the corners of a 5 cm square in the CTP 404 mod-
ule. Measure and average the distance between pairs of rods
in the axial view using the distance measuring tool in the
CBCT application. The recommended tolerance is less than
1% of difference, which is ±0.5 mm [Varian CBCT—
Customer Acceptance Procedure (1.1.01) (Palo Alto, CA,
Varian Medical System Inc., 2005)].
f. Slice thickness. Since all CBCT acquisitions are axial
scans with no couch movement, the slice thickness is not FIG. 3. Results of OBI isocenter accuracy QA over eight months measured
subject to the same errors as conventional CT scans where on a daily basis for the first four months and a weekly basis for the follow-
ing four months, with a total of 60 measurements. The QA test was per-
the couch is moving. Nevertheless, the slice thickness can be formed using a cube phantom. The standard deviations in the measurements
8
measured using the diagonal wires in the CTP 404 insert. were ±0.3 and ±0.4 mm for the longitudinal and lateral directions, respec-
The measured slice thickness is the measured full width at tively, demonstrating the mechanical stability of the system over the one-
half-maximum (FWHM) length of the wires multiplied by year measurement period. The empty diamond, 0, indicates the incident
tangent of the wire angle (23 ° ). Zoom in on a wire and place
that the phantom was mispositioned more than 1 mm. The X mark indicates
the incident that the wall laser was miscalibrated by 2 mm. The solid circle
one end of the measuring tool at the one end of the wire. marker, •, indicates the incident that the KVD position was off by 2 mm and
Page up or down to see the wire in the next adjacent slice recalibration was performed as a result.
and place the other end of the measuring tool at the same end
of the wire. Multiply the measured distance by 0.42 to get
the slice thickness. The recommended tolerance is less than tal graticule and the center of the phantom was greater than
5% of difference from the set slice width [Varian CBCT— expected. On several of these occasions, the phantom was
Customer Acceptance Procedure (1.1.01) (Palo Alto, CA, mispositioned by more than 1 mm causing 1.5 to 2 mm of
Varian Medical System Inc., 2005)]. Since 2.5 mm slice the measured displacement. These incidents are marked with
thickness is commonly used for clinical applications, the the empty diamond, 0, in Fig. 3. Once the wall laser was
measured slice thickness should be 2.5 ± 0.1 mm. miscalibrated by 2 mm, causing a 2.4 mm in the measured
displacement, which is marked with an X in Fig. 3. After an
III. RESULTS upgrade of the OBI system, the KVD position was recali-
brated. By accident, it was miscentered by 2 mm during the
A. Safety and functionality QA calibration. This miscalibration incident was found during
Each safety feature has been tested daily. There have been this QA test with 1.6 mm of the measured displacement in
some instances when the safety tests have not passed, requir- one direction. The solid circle marker, •, indicates this inci-
ing immediate correction. For instance, once the lightbulb of dent. One noticeable thing in Fig. 3 is that there is a small
the radiation warning light was burnt out and needed to be systematic difference between the digital graticule and the
replaced. Apart from these rare events, the safety features treatment isocenter. Nevertheless, the OBI isocenter QA
such as the collision interlocks, door interlock, warning shows better than 1.5 mm accuracy with a range of variation
sounds and warning lights have been consistently functional. of less than 1 mm over the eight months of measurements.
There were occasions when the functionality tests had to
be discontinued because of problems with transfer of the
2. 2D2D match and couch shift accuracy
reference data. These were resolved by restarting 4DTC/OBI
workstations or the database server. By including the daily Figure 4 displays the results of 2D2D Match and couch
safety and functionality QA in the tube warm-up, the integ- shift accuracy over an 8-month period on a daily basis for the
rity of the all systems was verified and the smooth flow of first 4 months and on a weekly basis for the following 4
reference information was assured before clinical treatments months, with a total of 60 measurements. Anterior and lateral
commenced. images of the cube phantom were taken, and 2D2D Match
was performed to place the off-centered markers at the iso-
center. The disagreement between the couch shift obtained
B. Geometry QA
from 2D2D Match and the expected shift was analyzed. The
1. OBI isocenter accuracy average disagreements were 1.1 ± 0.5 mm, 0.8 ± 0.5 mm, and
Figure 3 shows the OBI isocenter displacement in longi- −0.2 ± 0.5 mm in the vertical, longitudinal, and lateral direc-
tudinal and lateral directions for an eight-month period on a tions. Positive in the vertical, longitudinal, and lateral direc-
daily basis for the first 4 months and a weekly basis for the tions means that the 2D2D Match shift disagrees with the
following 4 months with the total of 60 measurements. The expected shift in the anterior, inferior, and right directions.
average measured longitudinal displacement was The accuracy of 2D2D Match is approximately 1 mm and
0.6 ± 0.4 mm and lateral displacement was −0.8 ± 0.3 mm. On the variation over time was less than 1 mm in all directions.
several occasions the measured difference between the digi- Note that the measurements show a systematic error in the

FIG. 6. The kV images of the center BB in the cube phantom with the gantry
at 270°, 0°, 90°, and 180°. The images were obtained during the QA
performance.
have any significance at the time of QA performance, it is

important to record the directional displacement over an ex-
FIG. 4. Results of 2D2D match accuracy measurements over an eight-month tended period to track any mechanical deficits. The results of
period on a daily basis for the first four months and on a weekly basis for the this test show that the mechanical arms of the KVS and KVD
following four months, with a total of 60 measurements. Positive in the
vertical, longitudinal, and lateral directions means that the 2D2D match shift are quite accurate and stable. The measured displacement of
disagrees with the expected shift in the anterior, inferior, and right the KVD has been greater than 2 mm in only a couple of
directions. measurements. When this was encountered, the arms were
recalibrated to correct the displacement and thereafter the
accuracy was stable and within tolerance.
posterior, superior, and right directions. After the couch shift
was applied remotely, the actual shifted couch position was 4. Run-out during arm vertical travel
verified inside of the room, based on the lasers and field light
crosshair. The disagreement between the actual shift couch The QA was performed on a monthly basis over eight
position and the verified couch position was less than 1 mm. months right after the magnification accuracy measurements.
The results show accurate and stable performance for 2D2D The average displacement was 0.4 ± 0.4 mm in the longitudi-
Match and couch shift. nal direction and 0.6 ± 0.4 mm in the lateral direction.
5. OBI isocenter accuracy with gantry rotation

3. Magnification accuracy
Figure 6 shows a set of example kV images at different
Figure 5 displays the results of magnification accuracy gantry orientation. Figure 7 shows the vector displacements
QA. The QA was performed on a monthly basis over an
as a function of gantry rotation over a 4-month period mea-
8-month period with the total of 8 measurements. The mea-
sured on a weekly basis with the total of 11 measurements.
sured displacements of the center of the KVS and KVD from
the isocenter determined by the ceiling lasers and the cross- The maximum vector displacement about 1.5 mm occurred
hair were all within 1 mm, except the vertical displacement at gantry 180°. The OBI isocenter at gantry 0° and 90° have
been very stable (�0.5 mm variation for gantry 0° and
of the center of the KVS that was 1.5 ± 0.5 mm (0.5 mm of
�1 mm variation for gantry 90°) and accurate (<0.5 mm for
standard deviation). The variation of the measured displace-
gantry 0° and <1.2 mm for gantry 90°). The QA results
ment was less than 1 mm from measurement to measure-
show that the OBI isocenter is accurate and stable as a func-
ment. Positive (+) in the vertical direction means that the tion of gantry rotation.
measured vertical distance for the KVD or KVS was longer
than the expected distance. Positive displacement in the lon-
gitudinal and lateral directions means that the center of the
KVD or KVS was displaced to the inferior and right direc-
tion to the isocenter. Although + or − displacement does not
FIG. 5. Results of magnification accuracy measurements over eight months

on a monthly basis with a total of eight measurements. Positive in the
vertical direction means the measured distance was longer than the expected FIG. 7. Results of OBI isocenter accuracy QA over gantry rotation over a
distance. Positive displacement in the longitudinal and lateral directions four-month period performed on a weekly basis with the total of 11 mea-
means that the center of the KVD or KVS was displaced to the inferior and surements. The vector displacement was measured between the digital grati-
right direction from the isocenter. cule and the center marker in the kV image.

TABLE II. The HU linearity QA using full-fan and half-fan CBCT scans. The
average HU values over the four-month measurements with the standard
deviation (SD).
Full fan Half fan
ExpectedHU AverageHU ± SD AverageHU ± SD
Air −1000 −1023 ± 1.8 −1023 ± 1.9

PMP −200 −189 ± 8.2 −193 ± 10.4
LDPE −100 −94 ± 3.6 −99 ± 11.0
Polystyrene −35 −39 ± 5.2 −44 ± 13.8
Acrylic 120 128 ± 5.8 128 ± 13.9
Delrin 340 349 ± 13.4 343 ± 18.0
Teflon 990 970 ± 7.3 964 ± 20.4
ducible in the images acquired using a full-fan mode than

those acquired using the half-fan mode. The reason for this
FIG. 8. OBI image quality QA. Contrast resolution using fluoroscopic mode
difference is unclear. Yet, these are all within the manufac-
(1-a) and radiographic mode (1-b). Spatial resolution using fluoroscopic turers recommended tolerance of ±40 HU. The HU values
mode (2-a) and radiographic mode (2-b). Fluoroscopic images and radio- measured over a four-month period have been within toler-
graphic images were taken in different institutions. ance for all materials.
b. Contrast resolution. Figure 9(a) shows a CBCT image
of the CTP 515 insert, which measures low contrast resolu-
C. Image quality QA tion. Some disks in the 1.0% supraslice group are clearly
1. OBI image quality discernable while the 0.5% supraslice group may be visible
The contrast resolution was stable over the duration of the and the 0.3% supraslice group is completely invisible. The
measuring period. Twelve to thirteen disks (2.7%–2.2% con- contrast resolution averaged 5.0 ± 0.8 disks in the full-fan
trast) were discernable using the fluoroscopic mode and 13 to mode and 4.2 ± 0.4 disks in the half-fan mode. The images
15 disks (2.2%–2.5% contrast) were discernable using the acquired using a full-fan mode have better contrast resolu-
radiographic exposure over a year period on a monthly basis. tion than those acquired using a half-fan mode—probably
Although some disks were faint sometimes, the same number because the volume irradiated in the full fan mode receives a
of disks in the images appeared consistently. Figures 8 (1–a) higher dose than the volume irradiated by a half-fan mode.
and 8 (1–b) show sample images acquired in a fluoroscopic All of the measurements resulted in a higher contrast resolu-
mode and a radiographic mode, respectively. tion than the specification that four disks should be visible.
The spatial resolution—as measured using the bar pat- The measurements were reproducible over a four-month pe-
terns in the Leeds TOR 18 FG phantom was also stable over riod of measurement.
the duration of the measuring period. The 9th bar pattern was c. Spatial resolution. Figure 9(b) shows a CBCT image
of the CTP 528 insert of Catphan phantom, which contains
always clearly discernable using the fluoroscopic mode, and
the spatial resolution rule. The average results for the spatial
the 11th bar pattern was consistently discernable using the
resolution were 8.3 ± 1.3 lp / cm for the full-fan mode and
radiographic mode. The spatial resolution of the 9th bar pat-
6.2 ± 0.4 lp / cm for the half-fan mode. The images acquired
tern is 1.25 lp / mm, and the resolution for the 11th bar pat-
using full-fan mode had better spatial resolution than those
tern is 1.6 lp / mm. Figures 8 (2–a) and 8 (2–b) show sample
acquired using half-fan mode—probably because the pixel
images acquired in fluoroscopic mode and radiographic
size in the full-fan mode was smaller than that in the half-fan
mode, respectively.
mode. All measurements were better than the recommended
Visual inspection of images is a subjective task and so the
specification of 6 lp / cm. The measured spatial resolutions
visibility threshold of the disks and bars differed from mea-
surement to measurement. However, over the test period, no
trend was observed, indicating stable imager performance.
2. CBCT image quality

a. Hounsfield units (HU) linearity. Table II shows the
average HU values along with the standard deviation of the
results for the HU linearity test measured over a four-month
period. The largest differences occurred in air and teflon—
with air being measured as having a HU value of −1023 and
Teflon being measured as having a HU value of 964 HU. The FIG. 9. Sample images for (a) contrast resolution QA and (b) spatial reso-
HU values are closer to the expected values and more repro- lution QA.

TABLE III. The HU uniformity QA using full-fan and half-fan CBCT scans. linearity test. The four rods are shown and the two lines
The average HU values over the four-month measurements with the stan-
generated using the “Measure Distance” tool indicate exactly
dard deviation (SD).
50.0 mm separation between the two upper rods and the two
Slic Full fan Half fan right rods. All measurements over a four-month period
ROI position AverageHU ± SD AverageHU ± SD
ranged from 49.7 to 50.1 mm for both full-fan and half-fan
modes. The recommended tolerance, ±1% equivalent to
Center 12 ± 8.3 14 ± 48.1 ±0.5 mm, was always satisfied for this test, demonstrating
Top −2 ± 4.5 −15 ± 20.9
that there was no significant distortion in the images or mis-
Right −1 ± 3.8 −19 ± 20.0
Left −3 ± 5.1 −20 ± 18.4
alignment of the KVD or KVS.
Bottom −7 ± 5.1 −20 ± 12.7 f. Slice thickness. Figure 10(b) shows an enlarged region
of the top wire in the CTP 404 insert, which can be used to
measure the slice thickness. The measurements for the slice
thickness varied between 2.3 to 2.8 mm with the slice thick-
were reproducible over the four-month measurement period.
When the phantom was positioned such that the CTP 528 ness (2.5 mm) selected during reconstruction. During the pe-
insert was 6 cm from the isocenter plane (the geometry used riod of QA, the measured slice thickness did not always sat-
by one institution), the spatial resolution was measured to be isfy the tolerance of less than 5% variation from the slice
6 lp / cm for the half-fan mode. Thus, there was some vari- thickness set during reconstruction. We found that the mea-
ability in the measured spatial resolution from institution to sured slice thickness was very sensitive to the experimental
institution, possibly due to phantom positioning. However, at expertise of the operator. Identifying the length of the line
all institutions the spatial resolution was stable over the mea- was subject to operator interpretation and we also noticed
surement period when the test was performed under constant that the measurement was dependent on how well aligned the
conditions with the phantom at the same position for the phantom was relative to the rotation axis of the CBCT
measurements. system.
d. HU uniformity. Mean HU values in five regions of in-
terest (1.0 cm X 1.0 cm) were measured in the CTP 486-2
insert of Catphan to determine HU uniformity. Over a four-
month period, all HU values for full-fan acquisitions were
within the specification of + / −40 HU. For the half-fan ac- IV. DISCUSSION
quisition, one measurement resulted in a HU value outside
the specified range. The average HU values measured over We have developed a QA program to monitor the me-
the four-month period are summarized in Table III. The large chanical and image quality performance of the OBI system.
standard deviation, 48.1, for the center ROI in the half-fan The tests use tools and phantoms provided with the OBI
mode indicates that there was one outlier measurement of system so this program should be practical for anyone with
79 HU—while it varied between −38 and 40 HU for the an OBI system. The appendices have some tables that should
other measurements. The images acquired using a full-fan
prove useful for those trying to establish their own QA pro-
mode had more homogeneous HU values than those acquired
gram.
using the half-fan mode. The results show that the HU values
could fluctuate, sometimes over a wide range. The HU lin- Since OBI is a device to improve geometric accuracy of
earity measurements were able to monitor these fluctuations. patient treatments, the most critical tests are those of its me-
e. In-slice spatial linearity Figure 10(a) displays an im- chanical stability/accuracy. These have been performed fre-
age of the CTP 404 insert, which can be used for the spatial quently by all institutes, with the frequency varying between
daily and weekly measurements. The measurements show
that the mechanical stability of the OBI system is quite high,
with the standard deviation of 0.3 to 0.4 mm over the one
year period monitored by the radiographic checks of the geo-
metric positioning of the arms. All institutes noticed a sys-
tematic difference between the treatment isocenter and the
isocenter indicated by the digital graticule of 0.6–0.8 mm.
Therefore, the precision of the OBI system appears to be
very high, while there are some improvements possible in
the accuracy. On several occasions with the geometric mea-
surements were outside of tolerance, mainly due to errors in
FIG. 10. Sample images for (a) spatial linearity QA and (b) slice thickness positioning the phantom or room laser misadjustments. How-
QA. The thickness QA required measurements of the separation between ever, there were also a couple of occasions when the tests did
two slices. (b) shows the top wire in the upper slice with the right end of the
measure tool at the right end of the wire and in the lower slice with the left detect a need for geometric recalibration. These latter obser-
end of the measure tool at the right end of the wire. vations show the need for regular QA checks.

This paper did not include a separate geometric measure- still being established. Our expectation is that users will fol-
ment for the CBCT images. The geometry of the kV radio- low our experiences where frequent QA tests became less
graphs and for CBCT images depends upon the position of frequent as we became more comfortable with the stability of
the OBI arms. Therefore, measurement of the arm positions the equipment.
using radiographs or optical checks was considered sufficient In selecting the tests that would be described, we had to
to monitor the geometric performance for all imaging modes. trade off comprehensiveness with practicality. We were wor-
Our tests of CBCT image quality only used the Catphan ried that a very comprehensive program might prove be too
phantom. However, the CBCT images of a large patient can time consuming and therefore not be performed. As a result,
result in more artifacts due to phenomenon such as x-ray there are some tests that users might want to include that are
scatter and charge trapping than would occur with the Cat- not described here. As an example, the Leeds phantom is
phan phantom. Therefore, it is advisable to acquire CBCT placed on the top of the KVD for the radiographic image
images of an anthropomorphic phantom on a routine basis to quality tests. The phantom positioning is very reproducible,
detect changes in image quality that might not be detected by which makes the test easy to perform. However, the test will
the Catphan measurements. The best way to perform this not detect any changes in spatial resolution due to changes in
kind of test is to acquire a reference CBCT image of a phan- the size of the x-ray source, since there is no magnification
tom after installation, and to compare subsequent CBCT im- (geometric penumbra) possible with our geometry. Some
ages of the same phantom with the original dataset. In addi- readers might like to position the Leeds phantoms at the
tion, it should be emphasized that the HU values measured isocenter to ensure that changes in the size of the x-ray
for the inserts in CTP 404 may not result in the same HU source are detected. Another example is the lack of a test that
values if measured under different conditions, such as in the repositions a phantom using the CBCT mode. Indeed, one of
presence of inhomogeneous tissues; in the presence of pa- the institutes established such a test using the marker phan-
tient motion that generates streak artifacts; or in the presence tom and high-resolution reference CT scans of that phantom.
of more or less x-ray scatter. The HU measurements show Therefore, the tests described here are not intended on being
that the CBCT imaging system is relatively stable over time, comprehensive and readers might want to adapt our test for
but do not demonstrate the consistency of the HU values as their own needs/concerns.
measurement conditions change. More study is needed to
understand how different measurement conditions influence
the HU values.
There has been debate between the participating institutes
on the required frequency for the tests, especially the geo- V. CONCLUSION
metric tests. The OBI isocenter accuracy checks are per-
formed daily or weekly, depending upon the institution. Use of the tests over an extended period shows that the
Therefore, the recommended frequency for the simple, fast, OBI system has good mechanical reliability and stable image
yet important geometry tests should fall within this range. quality. Nevertheless, the tests were useful in detecting per-
There has also been a debate upon the frequency for the formance deficits in the OBI system that needed recalibra-
image quality checks, especially that for the CBCT imaging. tion. Implementation of the QA tests, methods, frequency,
One suggestion has been to follow the guidelines established and recommended tolerances could vary depending on indi-
for simulators, where radiographic properties are typically vidual institutions. After accumulating enough experience
17
checked every 6 months. However, because the OBI imag- and confidence on stability and accuracy, some institutes
ing technologies are still new, many institutions believe that have reduced the frequency of their QA checks. However, it
the frequency of these checks should be greater. Therefore, is important that all tests are performed on a regular basis
the frequency of image quality tests should probably be no within a suggested period to establish a guideline and confi-
less frequently than semiannually, but the exact frequency is dence.

APPENDIX A: OBI SAFETY AND FUNCTIONALITY QA „DAILY…

APPENDIX B: OBI ISOCENTER AND COUCH SHIFT QA „DAILY/WEEKLY…

APPENDIX C: OBI MONTHLY QA „MONTHLY…

APPENDIX D: CBCT IMAGE QUALITY QA WORKSHEET „MONTHLY/SEMIANNUAL…


a) 9
Corresponding author: Sua Yoo, Ph.D., Department of Radiation Oncol- S. Mutic, J. R. Palta, E. K. Butker, I. J. Das, M. S. Huq, L. D. Loo, B. J.
ogy, Duke University Medical Center, Box 3295, Durham, North Caro- Salter, C. H. McCollough, and J. Van Dyk, “Quality assurance for
lina 27710. Electronic mail: sua.yoo@duke.edu; phone: (919) 660–2179; computed-tomography simulators and the computed-tomography-
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8
cal Physics Publishing, Madison, WI, 2002). Publishing, Madison, WI, 1999), Chap. 4.

OBI Imaging Isocenter QA Plan Import into ARIA
PROCEDURE
Objective:
 This procedure is intended to provide instructions on how to import a simple QA
plan provided on the OBI 1.6 Physicist Operations Rev. 1.0 CD.
A. Exercise Key

2. Brackets () denote additional selection options.
 QA Plan Import.
NOTE: The plan provided on the OBI 1.6 Physicist Operations Rev.
1.0 CD is intended to provide the an example of a QA plan which
can be used for verifying Isocenter, SAD, and Blade Calibration as
described in the On-Board Imager(OBI) Maintenance Manual
(B505010R01A May 2013).
NOTE: The OBI must be checked for operational safety, geometric

accuracy and image quality behavior to maintain optimal
performance. The frequency of checks must be based on the
professional judgment of the person in charge and the
requirements of the existing QA program. Please refer to Chapter 3
of the On-Board Imager (OBI) Maintenance Manual (B505010R01A
May 2013) and Tab 13 of this manual for more information
regarding QA.

2. Login to ARIA by double clicking the User Home Icon on the desktop and entering
your User ID and Password (Figure 1).
Figure 1: User Home Icon
3. From User Home, select Quicklinks > DICOM > Import Export (Error!
Reference source not found.).
Figure 2: Quicklinks
4. Within DICOM Import Export, select Manage in the Filter Selection area. (Figure
33)
Figure 3: Manage Import/Export Filters

5. In the Manage Filters window, highlight the configured DICOM Media File Import
filter and click Configure (Figure 44).
Figure 4: Import / Export configuration window
6. Within the Configure DICOM Media File Import Filter window, select Options…
(Figure 55).
Figure 5: DICOM Media File Import Filter Configuration

7. Make sure Use ID Mapping is selected (Figure 6). Click OK to continue.
Figure 6: Use ID Mapping
8. In the Manage Filters window click Manage Machine IDs (Figure 7Figure 7).
Figure 7: Manage Machine IDs
9. Click Add Machine Mapping and Add on Mapping and then type "OBI QA" in
the External ID/Add on ID field and your machine’s ID in the Internal ID. Your
machine’s ID is the machine that will be used to perform the OBI QA procedure.
Click OK to continue (Figure 8 8).

Figure 8: Manage Machine IDs
10. Close the Manage Filters window.
11. In the Filter Selection area of DICOM Import Export, select to continue
(Figure 9).
Figure 9: File > Import > Wizard

12. DICOM Import Export scans the directory configured in the Import filter for data
(Figure 100).
Figure 10: Scanning Directory
13. Click the button to select a different import directory.
14. Navigate to the folder (or optical drive in this example) where the OBI QA plan
files are located and click OK (Figure 111).
Figure 11: Navigate to file folder

15. Select the Scan Subdirectories option (Figure 122).
Figure 12: Import wizard file selection.
16. In the Navigation pane, select the OBI QA patient (Figure 133).
Figure 13: Import wizard – Select patient.
17. Select the button to proceed with import.
18. A Patient Selection message appears stating, “Please select an existing

patient or create a new one.” Select New Patient (Figure 144).
Figure 14: Create a New Patient

19. The Patient Explorer window appears with the OBI QA patient’s information
displayed. Confirm this information by selecting OK (Figure 155).
Figure 15: Patient Explorer
20. The OBI QA Patient displays in the Patient Selection area. Select the button
to proceed with import (Figure 20).
Figure 16: Patient Selection

21. The Import Export Log appears with any Errors or Warnings that occurred
during the import process. Select Yes to continue (Figure 17).
Figure 17: Import Export Log
22. In the Connection area, a message states, “By pressing the ‘Next” button the
data will be stored to the database.” Select the to complete import of the OBI
QA patient files (Figure 18).
Figure 18: Connection

23. A Summary message states that Import is finished (Figure 19).
Figure 19: Import Finished
24. Prepare the plan for Imaging in ARIA or 3rd party R/V system.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Filters Appendix A
A. OBI Filters
1. Filters are applied to images on the OBI monitor (Figure 1).

 Image filters can be applied to reference images (DRRs) or acquired images.
 The purpose of image filters is to enhance the quality of the image.
 When an image is acquired, the Optimized image filter is automatically
applied.
2. In addition to image filters, the Automatic Window and Level (AWL) and Manual
Window and Level tools are available.
Figure 1: Imaging Filters

NOTE: Filter settings are not saved with the image.
Image Display Filters
Dynamic Filter: Combines a contrast filter with a sharpness (edge enhancement)

filter. The slide handle on the left adjusts the level of sharpening, and the slider
handle on the bottom adjusts the level of contrast enhancement. The dynamic filter
will meet most of your filtering needs.
Optimized: Locally adjusts brightness and contrast and optimizes window / level.
Content: Makes all regions of the image more uniform in brightness and enhances
the edges of anatomic structures. The Content filter also automatically sets the range
of pixel intensities so that window and level adjustments are not needed. The
resulting image appearance is similar to that when using Contrast-Limited Adaptive
Histogram Equalization (CLAHE) image display filters.
Brightness: Equalizes pixel brightness. Dark areas are brightened and bright areas
are darkened. Creates a Gaussian curve with normal distribution.
Invert: Inverts the image to create a positive image.
Median: Used for noise correction. Eight pixels around a pixel value are selected and
the 5th pixel value in the series of 9 pixels is taken, as the median value, to replace
the pixel.
Smooth: Noise reduction using a Gaussian filter on 9 pixels, to calculate the average
value. The image is smoothened and blurred.
Equalize: The gray tones in the image are evenly distributed using a histogram
equalization, which produces a flat curve.
Contrast low/high (PV): Adjusts the contrast of an image.
Sharpen low/high (PV): Sharpens the edges (contours) of an image.
Field Edge Detection: Detects the field edge on an acquired image.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


HU Calibration Appendix B
___________________________________________________________________
HU Calibration
1. HU Calibration is performed to calculate an HU number for pixels in reconstructed

images. The HU calibration carries out half-fan and full-fan scans.
2. Before the HU Calibration can be done, you must first obtain the norm
calibrations, the geometry calibration results, and the pixel defect files.
3. Any calibration process results in heating the X-ray tube. Heating is measured in
heat units. Do not mistake heat units for Hounsfield units.
4. HU Calibration Preparation:
 Position the Catphan phantom on the couch using the supplied case as the
holder (Figure 1).
Figure 1: Catphan Phantom Model 504

 Adjust the Catphan phantom so that it is level.

 Align the Catphan phantom to isocenter using the lasers. The Catphan
phantom should be positioned longitudinally so that the laser is bisecting the
HU units section (plug inserts). Refer to the Catphan manual supplied with
your phantom for more information.
 Mount the bow-tie filter for bow-tie modes.
5. Perform HU Calibration:
 Access the Calibration and Maintenance workspace of the CBCT
application.
 On the Select Process wizard page, click Calibration/QA.
 On the Select Calibration Process wizard page, click HU Value.
 In the CBCT Mode drop-down list, select the mode to be calibrated.
 Under Half- Full-Fan, select the mode type to be calibrated. For example,
Full-Fan or Half-Fan (the option buttons are grayed out for single fan modes).
 Click Next.
 Click Start Scan. The system automatically acquired a dark field. Wait until
the dark field (DF) is acquired.
 Follow on-screen instructions to Mode Up the CBCT set up field on the 4DITC
and Clinac.
 When you are done, the At Start Position message box appears. Click OK.
NOTE: Heat Units generated in the tube during HU calibration

can be saved by lowering the mA value from 80 to 40 mA. A
reduction in hear is mainly required for the High-quality Head
Mode on non-oil cooled tubes. Lowering the technique has no
effect on HU calibration. The dose is compensated with the
norm chamber signal. Never change the kV setting.
 Press the footswitch or hand switch along with the MEB and >> on the
Clinac's dedicated keyboard.
 Keep the footswitch or hand switch pressed until a complete scan has been
acquired and the X-ray is turned off automatically.
 The CBCT scan is acquired.
 At the end of the reconstruction process, click Next.

 On the toolbar, click the Window/Level button. The window/level slider

with the image histogram appears to the right-hand side of the image.
 Adjust the window level so that the eight (8) large inserts can be seen on the
Catphan phantom. The inserts represent the materials and CT numbers listed
in Table 1.
Table 1: Quantities for HU Calibration Depending on Material
 To expand the Window/Level range, RMC on the histogram, then select Zoom
> Zoom Out (Figure 2).
Figure 2: Expanding the Window/Level
 A suggested way to find the center of the HU inserts is to zoom in on the
image using the button. Zoom out using the button. To move from
one insert to the next, while zoomed in, use the Pan tool. On the toolbar,
click the Circular Region Selection tool.

 Accurately position the cursor in the center of the air insert (#1) of the phantom
(Figure 3).

Figure 3: HU Calibration Wizard Page – HU Calibration with Selection
 Click to apply the circle. Make sure that the circle does not protrude beyond
the insert. If the circle does protrude, select the particular row under Pixel
Value/HU Mapping on the HU Calibration wizard page. Press the Delete Key
and apply a new circle on the image.

 Under Pixel Value/HU Mapping, add the HU value for air (-1000).
 Repeat the process for the six remaining densities. Refer to Table 1 quantities
for HU calibration depending on material.
 Press Enter on the workstation keyboard. This applies the new values and
adjusts the HU offset and slope. This displays on the HU Calibration Wizard
Page in the HU Calibration Coefficients text box (Figure 3 and Figure 4).
Figure 4: HU Calibration Coefficients
 Click Apply to Mode(s).

 Click Finish.
6. Post HU Calibration steps:
 If you have just performed the HU Calibration for a NEW CBCT mode, acquire
a regular CBCT scan to verify image quality and HU accuracy.
 If this is the routine calibration of EXISTING CBCT modes, repeat the HU
Calibration for the remaining CBCT modes. Then acquire a regular CBCT
scan to verify image quality and HU accuracy.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Generator Numerical Codes Appendix C
OBI Generator Numerical Codes (Error Codes)
Generator Numerical codes

Numerical Error Codes
Code Description
E001 Generator CPU EPROM checksum

error
E002 Generator CPU EEPROM data
checksum error
E003 Generator CPU NVRAM error
E004 Generator CPU Real Time Clock
error
E005 Main Contactor error
E006 Rotor Fault
E007 Filament Fault
E008 Beam Fault
E009 Power Supply Not Ready
E010 No KV during exposure
E011 mA during exposure too high
E012 mA during exposure too low
E013 Manually Terminated Exposure
E014 AEC Back-up Timer Exposure
Terminated
E015 AEC MAS Exceeded Exposure
Terminated
E016 Tomo Back-up Timer Exposure
Terminated
E017 Uncalibrated exposure parameter
E018 Preparation Timeout error
E019 Anode Heat Limit
E020 Thermal Switch Interlock #1 error
E021 Thermal Switch Interlock #2 Error
E022 Door Interlock switch
E023 IAS Interlock error
E024 Cassette interlock error

E025 X-ray enable interlock error

E026 Spare
E027 Receptor time out error. Receptor did
not respond within time out
E028 Prep input active during initialization
phase
E029 X-ray input active during initialization
phase
E030 Fluoro input active during initialization
phase
E031 Communication error remote fluoro
E032 Communication error console
E033 Lithium battery low voltage error
E034 +12Vdc error
E035 -12Vdc error
E036 +15Vdc error
E037 -15Vdc error
E038 Calibration data corrupt error
E039 AEC data corrupt error
E040 Fluoro data corrupt error
E041 Receptor data corrupt error
E042 Tube data corrupt error
E043 High Voltage error kV detected in non
X-ray state
E044 Communication error
E045 Communication message not
supported
E046 Communication message not allowed
E047 Fluoro Timer limit error
E048 Focus mismatch error
E049 Not enabled error
E050 Generator limit data corrupt error
E051 AEC Feedback error (no feedback
signal detected)
E052 High small focus filament current
error in standby
E053 High large focus filament current error
in standby
E054 AEC Reference out of range
E055 No fields selected in AEC mode
E056 No tube programmed
E057 AEC Stop signal in wrong state
E058 Console back-up timer
E059 Housing heat limit exceeded

E060 kV too high during exposure

E061 kV too low during exposure
E062 EXP_SW signal error
E063 Factory defaults have been written to
NVRAM
E064 No exposure release
E065 Spare
E066 Sync Pulse error
E067 Power supply duty cycle limit reached
E068 Low ABC input current
E069 Calibration error maximum mA _u69
exceeded
E070 Calibration error calibration data table
exceeded
E071 Calibration error maximum filament
current exceeded
E072 Calibration error manually terminated
E073 Calibration error no mA
E074 Calibration error minimum mA_110
not calibrated
E075 Anode warning level exceeded
E076 Fluoro timer warning level exceeded
E077 Generator kW limit
E078 Generator kV limit
E079 Generator mA limit
E080 Generator ms limit
E081 Generator mAs limit
E082 Tube kW limit
E083 Tube kV limit
E084 Tube mA limit
E085 Tube mAs limit
E086 Calibration limit, selected parameter
not calibrated
E087 Generator AEC density limit
E088 Invalid communication parameter
E089 Housing heat warning
E090 CT termination input wrong state
E091 Spare
E092 Spare
E093 Generator PPS limit
E094 Generator power supply duty cycle
warning
E095 Connecting
E096 Initialization

E097 Ready
E098 Unexpected Prep phase reported
E099 Unexpected Rad exposure phase
reported
E100 Calibration error maximum mA
exceeded
E101 Calibration error calibration data table
exceeded
E102 Calibration error maximum filament
current exceeded
E103 Calibration error manually terminated
E104 Calibration error no mA
E105 Calibration error minimum mA not
calibrated
E106 Generator ready
E107 Supervisor connecting
Table 1: Error Codes

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


List of Persistent Parameters Appendix D
___________________________________________________________________
Persistent Parameters
A. A large number of acquisition and match parameters are automatically

saved. The same settings are automatically reused in subsequent imaging
sessions with the same patient.
Persistent parameters are saved in the following situations:
 The user-interface-related settings, including the dynamic window, are saved

when Close Patient is selected on 4D ITC.
 The match parameters, including settings for AutoMatch, are saved when
Close is selected in the AutoMatch dialog.
B. The following list provides an overview of parameters which automatically

saves for reuse in subsequent imaging sessions with the same patient:
 Match parameters are saved for reuse in subsequent sessions with the same
patient:
 The display parameters (Window / Level, gamma, inverted yes / no and image
filters) for reference images are saved in OSP and are reloaded when the field
is moded up.
 Blend setting of the image beam
 Color Blend Active (True / False)
 ROI for the 2D/2D match is saved in OSP for reuse in Offline Review.

 All parameters in the AutoMatch dialog box for 2D and 2D/2D match are saved
as persistent parameters.
C. Display settings are saved for reuse in subsequent sessions with the same
patient:
 Window/Level
 Image Filters
 Annotations
 Intensity range
 Display of outlines and structures
 Blend settings
 Dynamic Window:
 Width
 Selected tab (Plan Tree or Image Gallery)
 State of the pin

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Status Messages Appendix E
1. OBI Status Bar Messages


Table 1: Status Bar Messages

2. Troubleshooting OBI – Message Boxes
Table 2: Other Message Boxes

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Keyboard Shortcuts Appendix F
___________________________________________________________________
Shortcut Key Description

F8 Enable/Disable Pixel Interpolation
F10 Mask Patient Name
F11 Toggle Full Screen Mode ([Esc] will
also close full screen mode)
[Ctrl]+Z Undo
[Ctrl]+Y Redo
[Ctrl]+Rotate Mouse Wheel Zoom
Press Down on Mouse Wheel Pan
[Ctrl]+R Rotate through 3D views
Rotate Mouse Wheel Scroll through slices
Arrow Keys Fine translational match adjustment
[Ctrl]+Arrow Keys Fine rotational match adjustment
[Alt]+Arrow Keys Large translational match adjustment
[Ctrl]+AutoMatch Button Show AutoMatch dialog window
[Ctrl]+Y Redo
[Ctrl]+Rotate Mouse Wheel Zoom
Press Down on Mouse Wheel Pan
[Ctrl]+R Rotate through 3D views
Rotate Mouse Wheel Scroll through slices

Keyboard Shortcuts Appendix F
Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


Cone Beam CT Template ad Hoc Appendix G
Objectives:
 After completing this module the student will be able to perform the following
 Attach a CBCT template ad Hoc
 Perform a Cone Beam CT
 Export the Images to OBI
 Analyze images
 Utilize CBCT in Standalone Mode with an Emergency Patient
A. Exercise Key

3. Parentheses () denote additional options.

3. Acquire Images

C. Prerequisite
1. If performing a match, a reference CT needs to be associated with the plan.


imaging
D. 4DITC
1. Check-in the patient



harm the patient.
4. Select the plan that requires the Cone Beam CT scan (Figure 2).
Note: This procedure should not be used on patient plans by those with
ARIA. CBCT fields should be created and scheduled in Treatment
Preparation (or created in Eclipse).
Figure 2: 4DITC; Session Pane
5. Click Create Field (Figure 3)

Figure 3: 4DITC; Create Field
6. Treat Login dialog box will appear.

 The user must have rights to attach a Cone Beam CT field.
 Enter User Name, Password, and then click OK (Figure 4).
Figure 4: Treat Login dialog box
7. Create Field dialog box will appear (Figure 5).

 Click CBCT.
 Label Field ID and Field Name and then enter CBCT.
8. Click OK.

Figure 5: Create Field
9. CBCT Field attaches to the plan as Not Valid (Figure 6).

 Attach a Tolerance Table to the field.
 Select the Tolerance Table menu and attach the default table.
Figure 6: Attach Tolerance Table
10. Click the Acquire Actuals button. The Acquire dialog box appears (Figure 7).
 Select Machine Parameters to acquire and then click OK.

Figure 7: Acquire Dialog Box
11. To save the newly acquired information click the Apply Changes button
(Figure 8).
Figure 8: 4DITC; Apply Changes
12. Continue with Cone Beam CT (Refer to the Lesson, Cone Beam CT
Verification).

E. Cone Beam CT in Standalone Mode; Time Planner
1. Attaching a CBCT template to a plan that does not have a reference CT

associated with it (ex. Emergency Treatment).
2. Schedule the patient for treatment in Time Planner. Access Time Planner in ARIA
version 11 or higher using the Appointment Scheduling Quicklink (Figure 9).
Figure 9: Appointment Scheduling>Time Planner
F. 4DITC
1. Check-in the patient.

2. Select the patient from the Treatment Queue and click UTM (Unplanned
Treatment Mode) (Figure 10).

Figure 10: Treatment Queue; UTM Mode

harm the patient.
4. A message appears warning the user that they are entering Unplanned
Treatment Mode. Enter a user name and password acknowledging this
message (Figure 11).

Figure 11: 4D Console: UTM Message
Note: This procedure should not be used on patients with plans in

ARIA. Setup fields for CBCT imaging should be created and scheduled
in Treatment Preparation (or created in Eclipse).
5. The field details area of the 4DITC appears yellow to show the user is in UTM
Mode (Figure 12).
Figure 12: 4DITC UTM Mode

6. Select the Create Field button. The Create Field dialog box appears. Select
the Treatment field type (Figure 13).
Figure 6: Create Field
7. Select New Plan. The Add Plan dialog box appears. Enter Plan ID and
Patient Orientation. Select OK (Figure 14).
Figure 7: Add Plan
8. Enter Field ID (ex. AP Treatment).

9. Field appears not valid in the session pane of the 4DITC (Figure 15).

Figure 8: Field Not Valid
10. Select Acquire Actuals.

11. Select the Machine Parameters to be acquired and Click OK (Figure 16).
Figure 9: Acquire Actuals
12. The Apply Couch Parameters window appears. Select Apply (Figure 17).
Figure 10: Apply Couch Parameters

13. Select Energy, Dose Rate, Monitor Units, Time, and Tolerance Table
(Figure 18).
Figure 11: Enter field information
14. Select Apply Changes. The field is now valid and the Invalid Field warning no
longer shows in the session pane (Figure 18).
15. Select the Create Field button. The Create Field dialog box appears. Select
the Treatment field type. Choose CBCT as field type (Figure 20).
Figure 20: Create CBCT field

16. Enter the Field ID for the CBCT. Select OK.

17. The field appears as not valid in the session pane of the 4DITC (Figure 21).
Figure 21: CBCT Field not valid
18. Select Acquire Actuals.

19. Select the Machine Parameters to be acquired and select OK.
20. The Apply Couch Parameters dialog box appears. Ensure the CBCT is
selected and Select Apply (Figure 22).
Figure 22: Apply Couch Parameters
21. Select Default from the Tolerance Table field. CBCT field will now appear as
valid.

22. Select Apply Changes.

23. Select the CBCT field. Select Mode Up.
G. OBI Workstation
1. Close the OBI application, and wait about 10 seconds until all processes have
stopped.
2. Start the CBCT application by double clicking CBCT Application Icon on the
desktop (Figure 23) (Windows Start Menu > Programs > CBCT > CBCT
Application).
Figure 23: CBCT Application
3. If the following warning message appears Make sure Couch Rails are
removed (if fitted), remove the couch rails and confirm the warning message
by clicking OK (Figure 24). Message can be disabled in CBCT Administration.

4. Cone Beam CT Toolbar Icons
Cone Beam CT Toolbar Icon
Icon Description
Create New Patient
Open Patient
Auto Window/Level
Manual Window/Level
Zoom In
Zoom Out
Pan
Measure Distance
Pixel Information
Circular Region Selection
Show/Hide Dash Board
Table 1: Cone Beam CT Toolbar; Standalone
5. Select New Patient button (Figure 25).
Figure 13: CBCT Toolbar; New Patient

6. New Patient Dialog Box appears.

 Enter Patient ID, Last Name and First Name.
 Click OK (Figure 26).
Figure 14: New Patient Dialog
7. Select Acquire New Scan (Patient Orientation MUST be selected prior to

acquiring a new scan (Figure 27).
Figure 15: Patient Setup

8. Continue with CBCT (Please refer to Lesson: Cone Beam CT Verification)
NOTE: It is important that the OBI application is closed before

starting CBCT application as standalone. Only the OBI application
or the CBCT application can control the hardware at one time.

Abstract
Notice
FDA 21 CFR 820

Quality System
Regulations
(CGMPs)
ISO 13485
HIPAA
CE
93/42/EEC.
Trademarks


OBI Homework
EXERCISE
Objectives:
 Prepare RT Administration for OBI.
 Prepare Treatment Administration for OBI.
 Prepare Clinac Physics mode for OBI.
 Enable the appropriate settings in OBI Administration.
A. ARIA Radiation Oncology Administration and OSP:
ARIA RT Administration and OSP
Completed Task Reference

1. Create an OBI tolerance Tab 6: ARIA RT
table. Administration and
OSP Procedure
2. Create a kV imaging
template.
3. Create a CBCT imaging
template.
4. Create the kV imager.
5. Verify couch locking
preferences in OSP.
Table 1: ARIA RT Administration and OSP

OBI Homework
B. Treatment Administration:
Treatment Administration

1. Enable OBI. Tab 6: Treatment
and OBI
2. Establish or edit user (RTT)
Administration
rights.
Procedure
 Edit and acquire couch
positions.
3. Default MV imager position:
-50.
4. Verify couch locking
preferences.
Table 2: Treatment Administration
C. On-Board Imager Administration:
OBI Administration

1. Verify spatial registration Tab 6: Treatment
configuration. and OBI
Administration
2. Verify marker configuration.
Procedure
3. Test the DB Daemon.
 If the test fails, verify that the
DB Daemon is running.
 If the DB Daemon is running,
contact Varian service.
Table 3: OBI Administration

OBI Homework
D. Clinac Administration:

1. Verify auto setup Tab 6: Clinac
configuration. Administration
Procedure
2. Verify auto goto configuration.
3. Configure large motions with
arms extended and retraced.
4. Enable and configure small
motions.
5. Verify beam time display
configuration.
6. Verify beam gating icon
configuration.
Table 4: Clinac Administration
E. Test patient
1. Create a test patient in your treatment planning software.

2. Send the patient to the record and verify system.
3. Verify that the patient has the following parameters:
 Two kV setup fields
 One MV setup field
 One CBCT setup field
 Each setup field needs to have a scaled and aligned reference image
attached.
 The appropriate tolerance table is attached to the setup fields.
 The plan can only have one isocenter.
 The plan has at least one treatment field with MUs.
 The plan has calculated MU.
 The couch and imager positions are pre-defined.

OBI Homework
 The plan orientation needs to be defined.

 If necessary, marker locations have been defined.
 All fields in the plan need to have the same couch position.
 The appropriate image sequence template is attached to the setup fields.
 For 3D match, verify that the plan has an associated 3D image and isocenter.
4. Schedule the patient for treatment.
F. Departmental quality control and quality assurance program:
1. What type of patients or anatomical sites will be verified with OBI?

2. Length of treatment time?
3. Type of immobilization to be used?
4. How frequently will the patient be imaged using OBI?
5. Shift tolerances?
6. Re-image after shift?
 kV vs MV?
7. How to record daily shifts?
8. Does the Radiation Oncologist want to be present?
9. What type of QA tests will be performed, the frequency, and tolerance?
 Who will perform the QA test?

General Description of OBI Product

1. C Huntzinger, P Munro, S Johnson, M Miettinen, C Zankowski, G Ahlstrom, R
Glettig, R Filliberti, W Kaissl, M Kamber, M Amstutz, L Bouchet, D Klebanov, H
Mostafavi, R Stark, Dynamic targeting image-guided radiotherapy. Med
Dosim. 31(2):113-25 (2006).
Practical Tips on How to Q/A (and commission) OBI

1. S Yoo, GY Kim, R Hammoud, E Elder, T Pawlicki, H Guan, T Fox, G Luxton, FF
Yin, and P Munro, A Quality Assurance Program for The On-Board Imager®.
Med. Phys. In Press (2006).
Clinical Use of OBI

1. B Sorcini and A Tilikidis, Clinical application of image-guided radiotherapy, IGRT
(on the Varian OBI platform). Cancer/Radiothérapie, In Press, Available online: 1
August (2006).
2. TH Fox, ES Elder, IR Crocker, LW Davis, JC Landry, PAS Johnstone, Clinical
Implementation and Efficiency of Kilovoltage Image-Guided Radiation Therapy. J.
Am. Coll. Radiol. 3: 38-44 (2006).
3. JY Ting, TJ Scarbrough, Intensity-Modulated Radiation Therapy and Image-
Guided Radiation Therapy: Small Clinic Implementation. Hematol Oncol Clin N
Am 20: 63–86 (2006).
4. FF Yin, S Das, J Kirkpatrick, M Oldham, Z Wang, SM Zhou, Physics and imaging
for targeting of oligometastases. Semin Radiat Oncol. 16(2): 85-101 (2006).

Performance Characterization of OBI

1. T Fox, C Huntzinger, P Johnstone, T Ogunleye and E Elder, Performance
evaluation of an automated image registration algorithm using an integrated
kilovoltage imaging and guidance system. J. Applied Clin. Med. Phys. 7 (1): 1-8
(2006).
Novel Reconstruction Techniques Applied to OBI

Data
1. L. Tianfang, L. Xing, C. McGuinness, P Munro, Y Yang, B Loo, and A Koong,
Four-Dimensional Cone-Beam Computed Tomography Using an On-Board
Imager. Med. Phys. 33(10): 3825-3833 (2006).
2. DJ Godfrey, FF Yin, M Oldham, S Yoo, C Willett, Digital tomosynthesis with an
on-board kilovoltage imaging device. Int J Radiat Oncol Biol Phys. 65(1): 8-15
(2006).
3. L Yu, Y Zou, EY Sidky, CA Pelizzari, P Munro, X Pan, Region of interest
reconstruction from truncated data in circular cone-beam CT. IEEE Trans
Med Imaging 25(7): 869-81 (2006).
4. L Yu, D Xia, Y Zou, X Pan, C Pelizzari, and P Munro, Region of interest
reconstruction from truncated data in circular cone-beam CT. Proc. SPIE,
5747: 412-418 (2005).
Development and Characterization of OBI Flat

Panel Technology by Varian Staff
1. RE Colbeth, IP Mollov, PG Roos, EG Shapiro, Flat panel CT detectors for sub-
second volumetric scanning. Proc. SPIE 5745: 387-398 (2005).
2. PG Roos, RE Colbeth, I Mollov, P Munro, J Pavkovich, EJ Seppi, EG Shapiro, CA
Tognina, GF Virshup, JM Yu, G Zentai, W Kaissl, E Matsinos, J Richters, H Riem,
Multiple gain ranging readout method to extend the dynamic range of
amorphous silicon flat panel imagers. Proc. SPIE 5368: 140-149 (2004).
3. RE Colbeth, SJ Boyce, R Fong, KW Gray, RA Harris, ID Job, IP Mollov, B Nepo,
JM Pavkovich, N Taie-Nobarie, EJ Seppi, EG Shapiro, MD Wright, C Webb, JM
Yu, 40 x 30 cm flat-panel imager for angiography, R&F, and cone-beam CT
applications. Proc. SPIE 4320: 94-102 (2001).


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OBI Physicist Operations

© Varian Medical Systems iii

The most up-to-date contact information can be found at MyVarian.com

Ordering Additional Documents

To order additional documents, contact Varian Medical Systems:

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Communicating Using the World Wide Web

Support is available via e-mail, contact Varian Medical Systems:

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© Varian Medical Systems iv

CAUTION: A caution describes actions or conditions that can

WARNING: A warning describes actions or conditions that can

NOTE: A note describes actions or conditions that can help the

QUESTION: Lists a question.

© Varian Medical Systems v

OBI Clinical Rationale and Help Resources Módulo 2

 OBI Clinical Rationale and Help Resources

Treatment Preparation Módulo 3

© Varian Medical Systems

© Varian Medical Systems

2D/2D Match (MV/kV) Verification Módulo 6

 2D/2D match (MV/kV) and 2D Match (Portal Image) Verification

© Varian Medical Systems

 Cone Beam CT Verification

Imaging Modalities and Theory Módulo 9

Marker Match Módulo 11

© Varian Medical Systems

Morning Preparation Módulo 15

 Morning Preparation, Warm Up, Shutdown, and Interlocks

© Varian Medical Systems

© Varian Medical Systems

 OBI, CBCT, Reconstructor, and Treatment Administration

© Varian Medical Systems

 Cone Beam CT Attach CBCT Template at Treat

CBCT Calibration Módulo 19

 Cone Beam CT Existing Calibration Procedure

© Varian Medical Systems

 OBI Homework Exercise

OBI Publications/OBI Bibliography

© Varian Medical Systems

VARIAN February 2014

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• OBI/IGRT clinical school course provide

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To view Webinars, you do not have to be a member of myvarian.com

For urgent issues, dial 1.888.VARIAN5.

• The OBI consists of a kV X-ray source and an amorphous silicon kV panel.

• Prior to treatment, we image the patient in the treatment position.

• The reference image contains the planned isocenter position.

• Use 2D Match with kV or MV images.

The OBI offers a convenient clinical process:

• Varian documentation can be found on myvarian.com