Monaco IMRT/VMAT Treatment Planning: Training Module

Education and Training
Monaco IMRT/VMAT Treatment Planning

Training Module
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© 2020 Elekta, Inc. All rights reserved. Do not make printed or electronic copies of this module, or parts of it,
without written permission from Elekta, Inc.
The information in this module is for the sole use of Elekta, Inc. personnel, authorized users and licensees of Elekta,
Inc. products, and no other purpose.
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Referenced documents
Elekta does not supply all documents that we refer to in this document with the equipment. Elekta reserves the right
to make the decision on which of the documents it supplies.
Contact information
Software Support: http://www.elekta.com and click Community.
Contact Information: http://www.elekta.com/meta/contact.html
Training Calendar: www.elekta.com/training
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IMRT/VMAT Planning Training Module Date: 2019-09-092
© 2020 Elekta, Inc. All rights reserved. Page ii
Contents
Description Page
Introduction .................................................................................................................................. 4
1 Monaco concepts IMRT/VMAT ................................................................................................ 8
2 IMRT constraints .................................................................................................................... 21
3 IMRT tools .............................................................................................................................. 59
4 Optimization ........................................................................................................................... 71
5 Plan analysis tools .................................................................................................................. 91
6 Monaco planning suggestions .............................................................................................. 108
7 Bias dose............................................................................................................................... 116
8 Planning on MR Studysets.................................................................................................... 121
Appendix A ................................................................................................................................ 123
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Monaco concepts IMRT/VMAT
Scope and objectives
Introduction
Description Page
Introduction............................................................................................................................ 4
Training module description .................................................................................................... 5
Audience ........................................................................................................................................... 5
Scope and objectives ........................................................................................................................ 5
Prerequisites..................................................................................................................................... 6
Licensing and security rights ............................................................................................................ 6
Training and support references ...................................................................................................... 6
Monaco IMRT/VMAT general workflow ................................................................................... 7
What is new ............................................................................................................................ 7
Introduction
Monaco gives you a unique approach to optimization that uses the latest advancements in
IMRT and VMAT planning. They are:
 Biological and dose-based cost functions
 Constrained and Pareto optimization
 A photon Monte Carlo dose engine integrated into the optimization process
As an alternative to traditional dose-based approaches in IMRT optimization, Monaco
implements an intuitive biological model that considers the response of tissues to dose
and its particular volume effect.
When you describe the tissue-specific increase in dose tolerance with a reduction of
irradiated volume, this biological volume effect can define the shape of the optimum dose
distribution in normal tissues. You can define each tissue with its particular volume
effect. Monaco does not require you to determine weight factors for each structure.
Instead, Monaco utilizes a unique time and effort-saving approach where it determines
the weight factors for you internally based on your prescription.
Clinicians can determine prescriptions when they use not only these biological models,
but also standard dose-based models such as maximum dose, overdose DVH, and
underdose DVH.
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Date: 2019-09-09 IMRT/VMAT Planning Training Module
Page 4 © 2020 Elekta, Inc. All rights reserved.
Key features include:

 Comprehensive set of contouring and beam manipulation tools.
 Six delivery modes: Step and Shoot IMRT, dMLC, VMAT, mArc, Dynamic
Conformal Arcs and Conformal RT.
 Enhanced voxel definition controls - structure layering and properties.
 A spectrum of biological and dose-based cost functions.
 Two optimization modes: Constrained Optimization (normal tissue priority) and
Pareto mode (target volume priority).
 Multicriterial optimization to tighten constraints, if feasible, during optimization.
 Several useful plan analysis tools, like constraint Sensitivities, to guide
prescription decision-making.
 Bias Dose Planning.
 XVMC Monte Carlo dose engine or an advanced Pencil Beam integrated into the
optimization process.
Training module description
This training module is designed to show the user how to create IMRT and VMAT plans
in Monaco. IMRT and VMAT planning uses segment shape optimization and a Photon
Monte Carlo dose calculation engine for accurate results. A biological optimization
ensures superior treatment plans.
Please refer to the More Resources section for additional resources.
Audience
The Monaco IMRT and VMAT Training Module is specifically designed for Radiation
Oncologists, Physicist, Therapists, Dosimetrists, or other staff responsible for treatment
planning at your clinic. Use this training module as a reference as you participate in
Monaco training activities with an Elekta Application Specialist. In this module, the term
user describes the person logged into and using the Monaco treatment planning system.
This training module is designed to give you tools needed to create IMRT and VMAT
plans. After reviewing this training, you will be able to:
 Define concepts as they apply to IMRT/VMAT planning.
 Apply IMRT constraints including IMRT Prescription Parameters, Structure
Optimization Properties and Cost Functions.
 Utilize tools specific to IMRT/VAMT planning.
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 Describe Monaco’s optimization process.

 Use plan analysis tools to identify where to make changes and predict what effect
they will have.
 Generate plans using Bias dose and MR Image sets.
Prerequisites
Before reviewing this Monaco IMRT and VMAT Planning Training Module, it is
recommended you first complete the Monaco Basics Training Module and the Monaco
3D and Electron Training Module. Monaco Basics will give you information on the core
functionality of Monaco as well as information on how to navigate the software. The
Monaco 3D and Electron Planning Module will guide you through the planning process
for 3D and Electron plans, but also contains valuable information on basic planning tools
such as: how to add/edit beams, approve plans, and export treatment plans.
Licensing and security rights
Once Monaco is loaded, it must be licensed for the features you purchased. If your
system was set up by support personnel, the system may already be licensed. However, if
you need to verify features or make edits, you can do so on the Edit License dialog box.
If you think that an edit is needed, please contact customer support to verify your features
and get a new activation code, if necessary.
Training and support references
If you have additional questions about the functions that are not described in this Monaco
training module, refer to any of these additional resources:
 Monaco User Guide
 Monaco Online Help
 Monaco Training Guide
 Monaco Basics Training Module
 Monaco 3D and Electron Training Module
 Monaco Concepts and IMRT/VMAT Planning Training Aid
 Monaco eLearning labs and courses available to you through Elekta Care
Community
 Monaco reference videos available to you through Elekta Care Community
 Monaco Stereotactic Training Module
 Monaco Physics Training Module
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Monaco IMRT/VMAT general workflow
Figure 1: IMRT/VMAT General Workflow
Figure 1: IMRT/VMAT workflow
What is new
Date New Item Description Section Author
2019-09- New Document L. Bode

09
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1 Monaco concepts IMRT/VMAT
Description Page
1.1 Scope and objectives .................................................................................................... 8

1.2 Workflow ..................................................................................................................... 9
1.3 Setup beams for portal imaging .................................................................................. 10
1.4 Considerations before starting an IMRT/VMAT plan .................................................... 10
1.4.1 Standardize planning ........................................................................................................ 10
1.4.2 Machine energy ................................................................................................................ 11
1.4.3 Voxelization of patient...................................................................................................... 11
1.4.4 Hot spots ........................................................................................................................... 12
1.5 Status messages ......................................................................................................... 12
1.6 Definition of terms as they apply to IMRT arc planning ................................................ 12
1.6.1 Increment ......................................................................................................................... 12
1.6.2 Sector ................................................................................................................................ 13
1.6.3 Sweep sequencer.............................................................................................................. 15
1.6.4 Control point..................................................................................................................... 15
1.6.5 Arc segment ...................................................................................................................... 15
1.6.6 Dynamic segments with static gantry............................................................................... 16
1.7 Constrained optimization............................................................................................ 17
1.7.0 Objective ........................................................................................................................... 17
1.7.1 Constraint ......................................................................................................................... 18
1.7.2 Constrained optimization ................................................................................................. 18
1.8 Biological optimization ............................................................................................... 18
1.8.1 Equivalent uniform dose (EUD) ........................................................................................ 19
1.8.2 Serial and parallel organs ................................................................................................. 19
1.9 What is next ............................................................................................................... 20
1.1 Scope and objectives
Monaco Concepts gives a general overview on how to get started with Monaco
IMRT/VMAT planning. This section also contains valuable tips to help you understand
basic concepts specific to IMRT/VMAT. It is also important to know how Monaco uses
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Workflow
constrained and biological optimization to achieve desired plan objectives. After you
complete this lesson, you will be able to:
 Explain the general workflow for an IMRT/VMAT plan.
 Apply basic tools to get started.
 Define terms that apply to IMRT Arc planning.
 Describe Constrained Optimization.
 Define Biological Optimization.
1.2 Workflow
The instructions below show you the basic workflow to create an IMRT/VMAT plan in
Monaco. See the Monaco IMRT/VMAT General Workflow section in the Introduction of
this training module for a flowchart diagram of this process.
1. Import the studyset(s) and assign the CT to ED.
2. Open the patient in the workspace.
3. (Optional) Fuse multiple studysets.
4. Carefully contour all required targets and OARs.
Create necessary margins.
5. Define and lock scan reference point.
6. (Optional) Import applicable treatment devices.
7. Start a Monaco plan (load a plan template).
Use one of the default templates to create a new template from scratch. Edit the
template properties and save, as necessary.
8. Verify/edit beam geometry, isocenter, machine and energy.
9. Verify/edit prescription.
10. Verify/edit electron densities and structure layering order.
11. Resolve any structure mismatches and edit the IMRT Constraints, Calculation
Properties, IMRT Parameters, and Sequencing Parameters as necessary.
12. Do the fluence optimization (Stage one).
13. Use plan analysis tools to evaluate your plan.
14. Adjust the parameters and prescription (constraints) as necessary.
15. Re-optimize the fluence and repeat evaluation until you have an acceptable optimized
plan.
16. Do the segment optimization (Stage two).
17. Use the plan analysis tools to evaluate your final plan.
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Setup beams for portal imaging
18. If the plan is not acceptable, make edits to the properties and/or prescription
(constraints) as needed.
19. Verify plan meets all objectives.
20. Create setup beams and DRRs.
21. Save and name plan.
22. Request proper plan approval.
23. DICOM export all necessary data.
24. Export plan PDF.
25. Create a QA plan.
1.3 Setup beams for portal imaging
You can create setup beam plans in Planning Activity.

1. Open the Beams control.
2. Click the Setup Beams tab.
3. Add beams and edit their field size, isocenter, and setup parameters.
1.4 Considerations before starting an IMRT/VMAT plan
The sections below cover items to consider before you start an IMRT or VMAT plan.
1.4.1 Standardize planning
Make use of standard sets of anatomical site names and templates for recurring treatment
setups and prescriptions. This makes IMRT/VMAT planning easier and decrease the time
it takes to create a plan. Templates can be imported and exported from your system with
Manage Templates. This lets you share templates.
1. Click the Monaco Application button.
2. Select Manage Templates.
3. Select templates to import/export.
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Considerations before starting an IMRT/VMAT plan
Figure 2: Manage Templates
When you use templates, make sure that contour names are consistent from patient to
patient to simplify the workflow. Monaco identifies structure name mismatches, so you
can correct these before you begin optimization.
For more information on how to create/edit/delete templates, refer to the Monaco 3D

NOTE
and Electron Training Module.
1.4.2 Machine energy
Typically, you use low to medium machine energies (6-10 MV) for planning
IMRT/VMAT. You can also plan with multiple machine energies. There can be cases
when a higher energy is desired or required. Keep in mind that when you plan with Monte
Carlo and use a higher energy, it can increase the calculation time. Higher energy particle
showers take more time to calculate than low energy showers.
1.4.3 Voxelization of patient
Monaco is a voxel-based planning system. The advantage is being able to control voxels
and not structures. This eliminates the need to add help contours to control optimization.
For optimization and dose calculation, contoured structures must be “voxelized” or
converted to a 3D grid. The voxels extend out from the isocenter and are based off the
grid size. The finer the grid size, the greater the number of voxels. The voxel grid is
generated with the 3D representation of target volumes.
Since contours are not shaped like boxes, Monaco must determine what percentage of a
voxel is included as part of the structure when only a portion of the voxel falls inside the
structure. If 50% of a voxel is inside the contour, Monaco considers it to be part of the
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Status messages
structure and includes it in the optimization of that structure. If not, Monaco does not
assign the voxel to that structure.
The effects of voxel occupancy on optimization:
 Structures are more accurately modeled (represented by voxels) during
optimization than if you used a Boolean technique to determine voxel occupancy.
 Stage one and stage two DVH results are more consistent since the structures are
more accurately modeled.
There are multiple voxel-based tools in Monaco that give useful feedback. These are
discussed in detail in the Plan Analysis Tools lesson of this training module.
Layering order determines which structure “owns” voxels in areas where there is overlap.
Layering order is discussed in the IMRT Constraints lesson of this training module.
1.4.4 Hot spots
The use of Monte Carlo algorithm can cause more hot spots. Use the cost functions to
control these. Remember to not be too harsh as this is a more accurate representation of
actual patient dose.
1.5 Status messages
Status messages appear during the planning process at the bottom of the window. These
messages are informative, such as “Mismatch in structure names” when the prescription
does not reflect the structures available for the patient. Or, status messages, such as “Press
start to begin stage 1”.
1.6 Definition of terms as they apply to IMRT arc planning
It is important to understand some terms as they apply to IMRT arc planning.
1.6.1 Increment
The Increment setting on the Geometry tab in the Beam control controls the number of
generated static gantry positions or sectors for fluence maps during stage 1 calculations.
Figure 3: Increment setting on the Geometry tab
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Definition of terms as they apply to IMRT arc planning
If you use an increment that is too large, Monaco creates fewer sectors. This can produce
poor quality plans. When you use an increment that is too small, Monaco gives you more
sectors. But this increases planning time and does not significantly improve plan quality.
It is as if you have too few or too many beams in a standard IMRT plan.
One method to find a reasonable increment is the “Rule of 3”. This means you add three
(3) to the number of static beams used to treat this patient. For example, if you used nine
(9) beams to plan a standard IMRT plan, you can create 12 sectors (9+3) for VMAT. 360
deg arc/12sectors = increment of 30.
Increment ↑ Plan Quality ↓
1.6.2 Sector
Before stage one optimization, the system divides a sequence into sectors you use to
simulate the arc during stage one optimization. Each sector represents one sweep of the
sweep sequencer. You determine the number of sectors when you divide the total arc
degree by the increment. For example, a 360 degree arc with a 30 degree increment
equals 12 “static” sectors to optimize. So, on the Console, you would see 12 rays created
before optimization.
Figure 4: Console showing ray (sector) creation
Figure 5 shows a total arc of 360 degrees with a starting angle of 180 degrees and an
increment of 30. The system creates sectors in 30 degree increments. In this example, the
first sector starts at 180 deg and ends at 210 deg. Fluence maps generated during stage
one are computed at the increment gantry angles. The fluence profiles are centered about
the midline of the arc sector.
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Figure 5: Full 360 Degree Arc
Figure 6 shows a partial 300 degree arc with a starting angle of 210 degrees and a 30
increment. For partial arcs, the first and last sectors are only half the size as the rest of the
sectors. So, 12 sectors appear below to represent this. If the arc increment value you
select is not uniformly divisible into the total arc length, the system selects the closest
increment value that is uniformly divisible with the posterior arc increment split into two.
Figure 6: Partial 300 Degree Arc
The system generates fluence maps during stage one and computes them at the increment
gantry angles.
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1.6.3 Sweep sequencer
The basic paradigm of a sweeping leaf sequencer is that the leaves move from their start
position to their end position in a continuous, unidirectional manner. The length they do
this is determined by the sector. Beginning with the first sector, the leaves move to the
left side of the BEV. They then change direction and move to the right side of the BEV.
The leaf movement continues to alternate between sectors. Typically, both ends of the
sweep have a small window of leaves open on one side or the other. The minimum width
of these end segments is hard coded at 5mm. A starting value of 30 generally works well,
lowering to 20 for more complex volumes.
1.6.4 Control point
Control points describe the movement of the MLC during treatment delivery from the
start to the end of each segment. Certain Sequencing Parameters directly affect the
number of control points generated for a plan. You can see the number of control points
generated for a plan in the Console after stage two optimization is complete. For
reasonable treatment time and plan quality, look for a number of control points in the
range of 75-150.
1.6.5 Arc segment
The system creates the arc segments during stage two optimization. Arc size and number
of monitor units vary from one arc segment to the next, but the dose rate remains constant
in each arc segment.
When you select Start on the Fluence toolbar, the start angle of an arc segment is
represented by a solid line and the end angle of the arc segment is represented by a dashed
line. When you select End, the start angle is dashed, and the end angle is solid.
Figure 7: Fluence group
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Figure 8: Arc Segment
You can recognize arc segments on a BEV as having a uniform fluence. Uniform color
varies from segment to segment based on the range of MU for the plan.
Figure 9: BEV of Arc Segment
1.6.6 Dynamic segments with static gantry
Dynamic segments at static gantry angles are occasionally generated for arc plans if the
number of degrees for each control point for an arc segment is less than two. This type of
segment is represented by a single solid line on the transverse view and a non-uniform
fluence in the BEV.
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Constrained optimization
Figure 10:Dynamic segment with static gantry
Figure 11: BEV of dynamic segment with static gantry
1.7 Constrained optimization
1.7.0 Objective
The cost function primarily used to designate targets is considered an objective.

Objectives are anatomy-specific functions that establish dose and/or biological response
goals. When used with constraints, the objective is always limited so that constraints are
met. An objective is treated like a goal and may not be met during optimization if the
constraints are too restrictive. You must loosen constraints to improve objectives. When
you apply the Pareto optimization mode, you place priority on underdose constraints to
targets over constraints you apply to organs at risk. You must use at least one of the two
target objective cost functions (Target EUD or Target Penalty) in your prescription.
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Biological optimization
1.7.1 Constraint
Constraints are anatomy-specific functions that must be met. They are often referred to as
hard constraints. When used with objective functions, constraints are met regardless of
the effect on the objectives and can limit the dose to the target volume (objectives).
1.7.2 Constrained optimization
Constrained optimization is a more logical way to plan. With Monaco, the OAR doses
(organs at risk or dose limiting cost functions) are prioritized and will be achieved before
dose to targets (objective functions) are met. Only when OAR doses are achieved will
Monaco prioritize target objectives. If a target dose has not been met, it will typically be
because an OAR or dose limiting cost function is too harsh.
Once Monaco has completed the OAR constraints criteria, it is able to inform where the
conflicts are and what cost functions are affecting the dose to targets. This is a more
structured approach to planning because you know what to change to achieve the target
objective.
In constrained optimization, there is an order in which cost function objectives or
constraints must be met:
1st Order Constraints
 Goal is always met.
 Serial, Parallel, Quadratic Overdose, Maximum Dose
2nd Order Constraints
 Goal is met unless there is a 1st Order Constraint.
 Quadratic Underdose, Underdose DVH
1st Order Objectives
 Goal is met unless a 1st or 2nd Order Constraint prevents this.
 Target EUD, Target Penalty
2nd Order Objectives
 Goal is met or succeeded unless Constraints prevent and unless 1st order
objectives are not met.
 Cost functions that have Multi Criterial option selected.
1.8 Biological optimization
Biological optimization is a more intuitive way to control the dose distribution compared
to using a DVH point method. It accounts for the response of tissues to dose as well as the
volume effect of organs using Equivalent Uniform Dose (EUD). Monaco uses cost
functions to relate the effect of a given dose distribution to a single value. This can be an
EUD (for target or serial organs), an effective volume (for parallel organs) or a mean
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Biological optimization
RMS (root mean square) for quadratic overdose constraints. Cost functions are discussed
in detail later in this module.
1.8.1 Equivalent uniform dose (EUD)
EUD represents the dose that causes the same effect if applied homogeneously to the
entire organ volume. Stated another way, the EUD represents any two or more dose
distributions that yield the same radiobiological effect. On the IMRT Constraints dialog
box in Monaco there are two values to consider when you evaluate the Target EUD:
 Isoconstraint: The EUD you are ask for.
 Isoeffect: The calculated EUD, or what you are get.
EUD for targets is similar to the mathematical concept of an average. Therefore, the
Isoeffect can be different than your DVH statistics. While you cannot evaluate your plan
directly with the Isoeffect, the concept of EUD is a useful planning tool when combined
with the logical concept of constrained optimization.
1.8.2 Serial and parallel organs
To manage biological optimization in Monaco, we work on the theory that there are two
types of biological responses to radiation exhibited by normal tissue: serial and parallel.
The two dose limiting cost functions are based on these two types of organs.
1.8.2.1 Serial
For some organs, high doses are harmful even if they are limited to small volumes. These
organs are considered serial structures. Examples of serial structures are spinal cord and
bowel. It implements the critical volume model of normal tissue complications where it
sees the organ as a chain. It breaks when one link breaks. A serial OAR does not function
after any of the volume has received a maximum dose.
1.8.2.2 Parallel
Some organs tolerate very high dose values in small sub-volumes if the rest of the organ
is spared. Consider these organs parallel structures. Examples of parallel structures are
lungs, parotids, kidneys, and liver. This model implements the critical volume model of
normal tissue complications where it sees the organ as a rope: it breaks when a certain
number of strands break. A parallel OAR does not function after a percentage (%) of the
volume has received a specific dose or if they are paired organs where one of the organs
compensates for the loss of function in the damaged organ. Examples include lungs and
kidneys.
There are some structures, such as the rectum, that although technically are serial, also
have a dose volume response. This can require both serial and parallel constraints to
achieve high dose constraints and dose volume constraints.
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What is next
These constraints are discussed in detail in the IMRT Constraints lesson of this Training
Module.
1.9 What is next
In this lesson, you learned how to:

 Explain the general workflow for an IMRT/VMAT plan.
 Apply basic tools to get started.
 Define terms that apply to IMRT Arc planning.
 Describe Constrained Optimization.
 Define Biological Optimization.
In the next lesson, you will learn how to:
 Assign structures to an IMRT prescription.
 Identify structure mismatches and know how to correct them.
 Describe the importance of structure layering to determine voxel ownership.
 Define and apply IMRT Prescription Parameters and Structure Optimization
Properties.
 Describe how cost functions affect optimization.
 Apply cost functions to design a clinically representative plan.
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IMRT constraints
What is next
2 IMRT constraints
Description Page
2.1 Scope and objectives .................................................................................................. 22

2.2 IMRT Constraints control overview ............................................................................. 22
2.3 Pareto versus Constrained mode................................................................................. 23
2.4 Structure column ........................................................................................................ 23
2.5 Structure mismatch .................................................................................................... 24
2.6 Structure layering ....................................................................................................... 25
2.7 IMRT Prescription Parameters and Structure Optimization Properties.......................... 26
2.7.1 IMRT prescription parameters.......................................................................................... 26
2.7.2 Structure Optimization Properties ................................................................................... 34
2.8 Cost Functions ............................................................................................................ 35
2.8.1 Target Penalty ................................................................................................................... 36
2.8.2 Target EUD ........................................................................................................................ 37
2.8.3 Quadratic Overdose .......................................................................................................... 38
2.8.4 Parallel .............................................................................................................................. 40
2.8.5 Serial ................................................................................................................................. 44
2.8.6 Overdose DVH................................................................................................................... 47
2.8.7 Underdose DVH ................................................................................................................ 48
2.8.8 Maximum Dose ................................................................................................................. 49
2.8.9 Quadratic Underdose ....................................................................................................... 50
2.8.10 Conformality ..................................................................................................................... 52
2.8.11 Optional parameters for cost functions ........................................................................... 53
2.9 Enabled / Status ......................................................................................................... 56
2.10 Manual....................................................................................................................... 56
2.11 Weight ....................................................................................................................... 56
2.12 Reference Dose .......................................................................................................... 56
2.13 Multicriterial .............................................................................................................. 57
2.14 Isoconstraint .............................................................................................................. 57
2.15 Isoeffect ..................................................................................................................... 57
2.16 Relative Impact .......................................................................................................... 57
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IMRT constraints
2.17 What is next ............................................................................................................... 57
This lesson outlines the location and functionality of tools located in the IMRT
Constraints control. In this activity, you can define IMRT prescription parameters,
structure optimization properties, target objectives and OAR constraints. After you
Properties.
2.2 IMRT Constraints control overview
The key to IMRT Treatment planning is to enter a carefully planned prescription. It is

important to use a logical thought process and the tools provided. Use the Constraints tab
in the IMRT Constraints control to define the IMRT target objectives and OAR
constraints. From this tab, you receive indications of which structures are impeding you
from meeting the prescription goals. Use this information to make informed decisions as
to what trade-offs to make to improve your plan.
Figure 12: IMRT Constraints control | Constraints tab
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IMRT constraints
Pareto versus Constrained mode
2.3 Pareto versus Constrained mode
Pareto mode prioritizes target underdoses on tumor volumes and relax constraints on
healthy tissue. This effectively reverses how Monaco normally works.
Constrained mode set constraints on healthy tissue while it administers dose to target
volumes.
2.4 Structure column
When structures overlap, the structure sequence becomes important. The sequence
determines which structure owns the voxels in the overlap region.
Structure layering is discussed in more detail later in this lesson of the Training Module.
The system lets you plan with up to 32 structures (a sum of structures in the IMRT
constraints and additional structures with forced density).
Figure 13: IMRT Constraints control
Right-click a structure on the IMRT Constraints spreadsheet to get the menus below.
Figure 14: Right-click Structure options
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IMRT constraints
Structure mismatch
Figure 15: Right-click Structure options | Add Cost Function options
2.5 Structure mismatch
If you use templates to start planning, occasionally you can have a structure mismatch.
This means that the structure name in the template does not exist in the currently loaded
patient’s structure set.
A structure mismatch is easy to recognize. When you create a new plan, Monaco will
show the Map Structures dialog box. Here, you can map structures referenced in the
template to structures in your structure set.
Figure 16: Map Structures dialog box
If you don’t map the structures when you create a new plan, the structure name appears in
red on the IMRT Constraints control. An error “Mismatch in structure names” appears at
the bottom. It is also easy to resolve when you select another structure name from the
drop-down list or delete the structure altogether. Figure 16 shows an example where the
structure PTV and patient do not have a match in the current studyset.
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Structure layering
Figure 17: Structure Mismatch
2.6 Structure layering
The layering order on the IMRT Constraints control determines how the optimizer treats
the voxels in the volume where the structures overlap. It does not imply that one
structure’s objectives or constraints are more or less important. A structure that overlaps
another and is listed higher in the layering order ‘owns’ the voxels in an area of overlap
even if there are no cost functions assigned. You can also share voxels of overlapping
regions completely to one structure when you use the cost function properties.
Structure layering order also determines the density used in the overlap region for
structures which overlap with density overrides.
Before you calculate your plan, make sure that the sequence is appropriate. You can view
the layering order that applies to density overrides in the Layers tab on the Structures
control. To edit the structure layering, left-click a structure name to highlight. Click the
up or down arrow buttons to move that structure up or down in the layering order.
The images below illustrate examples of layering order applied to two overlapping
structures. These voxel priorities represent the default behavior but can be overridden by
individual cost functions with an additional parameter.
In this example, the PTV ‘owns’ the voxels in the

PTV overlap region. The cost function(s) assigned to the
rectum is only applied to the volume in blue.
Rectum
Figure 18: PTV higher in layering order than rectum
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In this example, the Rectum ‘owns’ the voxels in the

overlap region. The cost function(s) assigned to the
PTV is only applied to the volume in yellow.
PTV
Rectum
Figure 19: Rectum higher in layering order than PTV
In this example, you need to list the PTV2 higher in

PTV2 the layering order than PTV1. If not, its cost functions
will be overridden by the cost functions of PTV1 since
PTV1 totally encompasses PTV2.
PTV1
Figure 20: PTV2 higher in layering order than PTV1
2.7 IMRT Prescription Parameters and Structure Optimization

Properties
Monaco has powerful structure definition tools that let you define voxel priorities and
physical properties for each structure in the prescription. In other words, you can
determine which voxels a cost function is applied to in a selected structure. You can use
these properties alone or with each other. Rather than create more contouring to alter how
the cost function is applied to those structures, you can apply a specific structure
optimization property to accomplish the same goal. IMRT Prescription Properties are
assigned to the prescription. Structure Optimization Properties apply the values set in
IMRT Prescription Parameters to the individual structures.
Prescription parameters are applied across all structures where the associated
structure property is assigned in Structure Optimization Properties for each individual
NOTE structure. For example, when you set the Minimum CT Number, that value is applied to
all structures where Clear is applied. If the value is changed, it is changed for all
structures.
2.7.1 IMRT prescription parameters
To edit the prescription parameters, click the IMRT Parameters tab on the IMRT
Constraints control. These parameters are specific for each prescription.
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Figure 21: IMRT Parameters
This opens the IMRT Prescription Parameters dialog box.
Figure 22: IMRT Prescription Parameters dialog box
2.7.1.1 Minimum CT Number (Use with Clear option)
Apply this property when you want to identify and exclude all voxels in a structure whose
values fall below a user-defined Hounsfield number during the optimization. You
typically use the Clear property for targets that contain air voxels.
This property is sometimes used with the Fill property. Fill is always done before Clear,
when used together. Fill is applied to set a minimum electron density for all voxels that
belong to the structure. Then, the Clear property removes all the voxels in the structure
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below the selected Hounsfield number entered. The voxels where Clear is applied are not
taken into account during the optimization, but those voxels are accounted for during the
final dose calculation. This field is ignored if you are planning on an MR studyset.
The Fill ED property is located in Structure Planning control. For detailed information,
NOTE
refer to the Monaco Basics Traing Module.
It is practical to remove air density voxels from structures, so the optimization algorithm
does not artificially inflate the dose to the structure when it tries to deliver dose into an
area of very low density. This could lead to hot spots elsewhere. You can also set a
minimum density for the structure used in the dose calculation.
In this head and neck example, the contoured target volume includes air voxels. If the
structure is divided into voxels based on the selected grid spacing and electron density,
this slice can look like the image in (Figure 22). The purple voxels represent CT values in
the range of air (0.1). The yellow voxels represent ED values in the range of 0.4, since
they border air voxels. The blue voxels represent voxels with an ED of 1.0 or greater. Use
Fill to apply a minimum density 0.5 (-500 HU) to all the voxels with a density below 0.5.
See Figure 23 where it changes the purple and yellow voxels to green. When Clear (-200
HU) is applied to the filled voxels, you get an altered structure volume represented in
(Figure 24).
Figure 23: Figure 24: Figure 25:

Voxelized structure Application of Fill Application of Clear
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This is an artistic rendering of the application of Fill and Clear. These color maps do not
NOTE
appear on your screen.
2.7.1.2 Auto Flash Margin (cm)
Typically, when a target is superficial or lies in the build-up region just beneath the
patient surface (like a breast or neck), it is difficult to sufficiently cover the target with the
prescribed dose due to the rapid fall off of dose at the surface. In some cases, the target
volume could move outside of the treatment field due to breathing.
Select the Auto Flash Margin (cm) option to create a flash margin of voxels that extends
beyond the target volume, with the specified margin, in the direction of the skin surface.
Monaco automatically opens the jaws, when needed, to cover the virtual target when it is
near the surface of the patient so that the prescribed dose is better achieved to superficial
targets. Specific margin values range is 0.0-2.5 cm.
Figure 26: Coronal view of breast Figure 27: Coronal view of breast tangent
tangent fluence without Auto Flash fluence with 1.0 cm Auto Flash
2.7.1.3 Surface Margin (cm)
This parameter applies to the target cost functions. Each of the cost functions that surface
margin applies to penalizes for underdoses. Its application lets the cost function
essentially ignore the low dose in a structure where it intersects the buildup region. You
should use the Surface Margin (cm) field on superficial targets. When you select a surface
margin for a cost function, that cost function only applies to voxels inside the structure
(with the exception of the voxels that lie in the surface margin distance). The surface
margin distance value range is 0.00 to 1.00 cm from the patient surface.
The example in Figure 27 and Figure 28 shows the cost function occupancy where a 0.5
cm surface margin was applied and the same cost function occupancy without surface
margin. Only the voxels shaded in red are optimized.
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Figure 28: Surface Margin of Figure 29: No Surface Margin applied

0.5 cm applied to Target EUD
The effects of Surface Margin are shown below. There are two plans that show a
comparison of the dose distribution to a superficial brain target when:
NoSurfMargin: No Surface Margin was applied.
SurfMargin: Surface Margin was applied.
NoSurfMargin-SurfMargin: Shows the dose difference between the two plans.
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Figure 30: Application of Surface Margin
The DVH in Figure 29 shows that for this case:

 The target coverage does not vary much from plan to plan (see NOTE below).
 The dose to the patient (unspecified tissue) structure increases significantly for
the plan that does not use surface margin. This also shows well in the subtracted
plan.
If the target contour is drawn out to the patient’s surface and surface margin is
applied, the dose that intersects the target and the buildup region can have a
significantly lower dose when surface margin is applied. You must consider this when
NOTE you determine the acceptable percent coverage to the target.
Consider the use of the Clip Patient Surface by tool located in the Margins tool in
Contouring ribbon.
The benefits when you use Surface Margin are:

 Decreased MU/fx for fields that flash over the surface of the patient.
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 Decreased Total MU/fx for the entire plan.

 Decreased Global Maximum dose for the entire plan.
When you draw a target in the buildup region and you do not apply Surface Margin, fields
that flash over the patient surface attempt to compensate for the low dose in the buildup
while trying to bring the target dose closer to the prescription.
This can be a problem as demonstrated in Figure 30. Notice the difference in the Relative
MU value for the same voxel in the two images.
Figure 31: Comparison of BEV with and without using Surface Margin
2.7.1.4 Beamlet Width
The beamlet width is used during stage one and stage two optimization. In stage one, you
use it to define the resolution of the fluence map. In stage two, it is used for initial MLC
placement when Monaco generates segments. Segment Shape Optimization (SSO) is then
used to fine tune the segment shapes.
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In general, the smaller the beamlet width, the finer the fluence grid. This fine fluence grid
is an advantage since this lets the optimizer define sharper gradients where necessary. The
recommended beamlet width is 2-3 mm. Beamlet length is automatically determined by
the MLC leaf width.
2.7.1.5 Target Margin
You can alter the fluence profiles created for target structure(s) when you change the
Target Margin. A target margin is always applied when you create fluence profiles. The
default value is Normal. But, you can tighten or widen the margin when you select a
different option. If you apply a larger margin, Monaco assigns more of the surrounding
voxels to the target in optimization. If you apply a smaller margin, Monaco assigns fewer
surrounding voxels to the target in optimization. For ‘normal’ planning, try not to restrict
the margin too tight, this can affect the sequencing result.
2.7.1.6 Avoidance Margin
You can alter the fluence profiles created for an OAR structure(s) when you change the
Avoidance Margin. Avoidance margins are optional, used mainly with the Dynamic
Conformal Arcs delivery mode. It is only applied when you turn it on in the Structure
Optimization Properties for an OAR. The default value is Normal (8 mm). But, you can
tighten or widen the margin when you select a different option. Avoidance margins are
hard constraints for dynamic conformal arcs. The system assigns voxels to avoid during
the rotational delivery by the value of the margin assigned.
Figure 32: Avoidance Margin: Dynamic Conformal Arc
2.7.1.7 Bias contribution
You can select available prescriptions to enable the optimizer to consider the dose of the
active prescription while the optimization runs. This topic is discussed in more detail in
the Bias Dose lesson of this training module.
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2.7.2 Structure Optimization Properties
To assign IMRT Parameters to a specific structure, right-click the structure name in the
IMRT Constraints spreadsheet and select the Properties option. This opens the Structure
Optimization Properties dialog box. You can use other tools while the properties dialog
box is open.
Figure 33: Structure Optimization Properties dialog box
2.7.2.1 Clear all voxels below the Minimum CT number (used to create structure volumes)
In optimization, this check box neglects all the voxels that fall below the minimum CT
number you enter in the Calculation Properties dialog box.
2.7.2.2 Display Total Volume DVH
Apply this property when you want to designate that the total volume is shown in the
DVH during optimization (for the selected structure). This always pertains to the entire
volume of the structure, regardless of any overlap with higher priority structures. It is not
necessary to select this property for the first item in the Structure Layering list since the
volume of the DVH always pertains to the total volume. When you select this property, it
does not apply to voxel sharing, only the optimized DVH display. There is more
information on DVHs in the Plan Analysis Tools lesson of this training module.
2.7.2.3 Auto Flash
Selecting Auto Flash creates a flash margin around the target that will cause the field to
extend into air by the value entered into the Auto Flash (cm) field in the Calculation
Properties dialog box.
2.7.2.4 Do Not Store Dose
Often, you have a structure that you do not want to optimize (for example, you have
contoured the table, or an immobilization device and you want to account for the
attenuation, but do not want to store the dose to that structure in memory).
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The option Do Not Store Dose is available when a structure is added to the IMRT
Constraints tab, does not have a cost function applied, Display Total Volume DVH is
cleared in Structure Properties and the structure is not defined as type Couch or Bolus.
The optimizer uses the structure for dose attenuation purposes but does not optimize or
store dose for this structure. If the non-optimized structure overlaps an optimized
structure, layering order is important. Place the structure last in the IMRT Constraints tab
as structures that do not have an assigned cost function applied still occupy voxels
according to layering order. You can use the voxel visualization tools to verify the cost
function occupancy of each structure.
2.7.2.5 Avoidance
Select this check box if you want to apply the avoidance margin that was set in the
Calculation Properties dialog box to your organ at risk.
2.8 Cost Functions
Monaco gives you a set of biological and DVH-based cost functions to use during
optimization. You can use this value to define a penalty for violating an objective or
constraint. The system evaluates this penalty-value during optimization.
Most structures are considered constraints. For constrained optimization, constraints must
be met for the optimization to converge. When you use biological cost functions, this
takes advantage of the biological volume effect of structures. The biological volume
effect indicates that higher doses can be tolerated when the irradiated volume is reduced.
When you use a biological cost function as opposed to a physical (dose-based) cost
function, each structure is equipped with its particular volume effect, as opposed to the
optimizer treating all structures as if they had the same dose response mechanism.
In general, all IMRT optimizers seek to minimize a composite cost function comprised of
the sum of the cost functions that can be objectives or constraints. In constrained
optimization, the only contribution to the objective function is given by the objectives.
Therefore, the value of the composite cost function in Monaco is a measure of the
violation of the target prescription.
The Cost Function column in the IMRT Constraints control lists all the cost functions
applied to each structure in the prescription.
Figure 34: Cost Functions in IMRT Constraints control
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To select cost functions, right-click Structure | Add Cost Function. From this menu you
can select a cost function then assign cost function parameters for each structure. You can
apply multiple cost functions to a single structure.
There are Required Parameters and Optional Physical Parameters to enter for each cost
function. The selected cost function determines the available options.
Figure 35: Right-click Structure name | Add Cost Function
To delete a cost function, click the trashcan icon on the IMRT Constraints control.
2.8.1 Target Penalty
This physical cost function is for targets. The Target Penalty is a quadratic penalty which
starts at the threshold dose. You can configure the dose and reference volume. The dose
you enter is typically the prescription dose. The minimum volume is the percentage of
coverage you want to achieve.
This cost function requires a Prescription (Gy) and a Minimum Volume (%) be entered. It
always tries to meet 100% of the coverage during optimization regardless of the % you
ask for, but you can make it work harder if you increase the Minimum Volume %. For
example, if you want 95% coverage, you can input 97% or 98% into the parameters. It is
recommended that you do not input a Minimum Volume (%) higher than 98%. Monaco
does not show sensitivity values for the Target Penalty because there is no direct
relationship between isoeffect and objective function value. A change to the objective
function does not always change the reported isoeffect. Therefore, Monaco cannot report
sensitivity, which is a change to the isoeffect.
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Figure 36: Required Parameters for the Target Penalty constraint
Target Penalty is a minimum dose constraint, therefor you need to also apply a dose
limiting constraint in most instances. The image below shows a target penalty applied
without a dose limiting constraint. Notice, the tail of the DVH.
Figure 37: Target Penalty for a prescription of 68 Gy.
2.8.2 Target EUD
This biological cost function is an objective and defines a structure as a target volume.
Target EUD works well on simple targets with minimal OAR constraints or for
Stereotactic Radiotherapy where target maximum dose is not a requirement. It expresses
the probability that a target cell survives a given dose. The field size for each beam or
sequence is automatically designed to encompass the target volume.
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Figure 38: Required Parameters for Target EUD
This cost function requires that you to type in a Prescription (Gy), which is an EUD
(Equivalent Uniform Dose) prescription. If the dose distribution in the structure is
homogeneous, the EUD is close to the mean dose, which, in the case of a target, also
represents the desired prescribed dose. If severe cold spots exist, it is close to the
minimum dose and depends on cell sensitivity. Type the actual prescribed dose for the
structure. This value is the desirable effective dose for this structure.
This cost function also requires you to type in the Cell Sensitivity for the target structure.
When you increase the cell sensitivity, you increase the penalty to cold spots in the
selected structure. Figure 36 graphs the changes in the penalty for low doses when the cell
sensitivity is altered. In difficult cases, higher values of the cell sensitivity effectively
increases the pressure to deliver dose to cold spots. Cell sensitivity and tumor cell density
may become more important in future planning when functional imaging is available for
treatment planning. Until then, it is reasonable to use the default cell sensitivity value of
0.50 for most cases.
Target EUD
25
Increasing Penalty for Cold Spots
20
15
Cell Sen.
10 =0.1
Cell Sen.
=0.25
5
Cell Sen.
=0.5
0
65 67 69 71 73 75 77 79
Dose (cGy)
Figure 39: Changing Cell Sensitivity
2.8.3 Quadratic Overdose
This physical cost function is a constraint you can use with either targets or OARs to limit
high doses in the structure to which it is applied. It is often used with the Target
objectives to limit hot spots in the target. The rationale when you use this cost function is
that sometimes a strict maximum dose limits the optimizer from finding a better overall
solution while a small, yet controlled hot spot is permissible. In general, penalizing hot
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spots in IMRT can cause problems with associated cold spots in a target volume, so that a
certain violation of the maximum dose limitation appears acceptable.
Quadratic Overdose can also be an effective way to control conformity. You can limit
dose to the patient with the Quadratic Overdose cost function and a series of stepped
shrink margins. The shrink margins are used instead of optimization contours. This
technique also works well when you create transition doses between multiple target
volumes and to control hot spots in an overlap region
Figure 40: Required Parameters for Quadratic Overdose
This cost function requires that you to assign a parameter that is the Maximum Dose (Gy)
beyond which a penalty is incurred and an RMS (Root Mean Square) Dose Excess (Gy),
that is the amount of violation above the prescription dose you can accept. The
isoconstraint is the RMS and is a key value to allow flexibility. Figure 40 graphs the
shape of the Quadratic Overdose cost function curve.
Figure 41: Quadratic Overdose constraint
This cost function plays an essential role for targets. Without a dose-limiting cost
function, the Target EUD objective is bound to push the dose up to values higher than the
prescription. A Quadratic Overdose cost function is ideal to prevent this (For suggested
starting values, set the Maximum Dose (Gy) to a value 3-5% over the targets prescription
dose, and the RMS Dose Excess (Gy) to a moderate value to control target hot spots, e.g.,
0.5-1.5% of the target dose). The Root Mean Square of a set of values is determined when
you use this equation:
 D( x) 2
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D represents the voxel dose in excess of the Maximum Dose (Gy) and n represents the
total number of voxels. Only dose values above the Maximum Dose (Gy) are considered.
2.8.3.1 Calculating a Root Mean Square for dose excess
Consider a simple structure divided into four voxels. The Maximum Dose (Gy)
prescription is 70 Gy and the RMS Dose Excess (Gy) is 2 Gy. The dose above 70 Gy
appears in each voxel.
If the Root Mean Square of the maximum dose, plus the dose excess is greater than 72
Gy, the constraint is not met, and the optimizer must try harder to reduce the dose excess.
(2 2  4 2  2 2  2 2 )
= 2.65 Gy
4
Figure 42: Calculating a Root Mean Square for Dose Excess
2.65 Gy is greater than the RMS Dose Excess (Gy) of 2 Gy (or 72.65 Gy is greater than 72
Gy), so the optimizer has to keep working to lower the excess to 2 Gy.
For further application of Quadratic Overdose, see the Monaco Planning Suggestions
NOTE
section of this training module.
2.8.4 Parallel
This biological cost function is the preferred constraint for Parallel OARs. It is the
biological equivalent of the DVH constraint. For a parallel cost function, the isoconstraint
is a volume.
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Figure 43: Required Parameters for the Parallel cost functions
This cost function requires that you assign three parameters. The first parameter is the
Reference Dose (Gy) whose value is analogous to the dose that is only just acceptable for
the majority of the structure, and at which a clear dose response begins to show. For lung,
this would be around 20 Gy. If the organ were to be irradiated homogenously with the
reference dose, the probability of complication would be 50% (TD50), Lyman et al.
The second parameter is the isoconstraint, which is the Mean Organ Damage (%) to the
structure. The Mean Organ Damage is the biological equivalent to the fraction of the
volume of the structure that can be sacrificed. You can divide the function of any organ
into a large number of subvolumes (aka functional sub-units, tissue-repair-units) that all
work in parallel. The effect of radiation is assumed to knock out subvolumes, and thereby
reduce the function of the organ. Consequentially, the function is degraded on a
continuous scale.
Because each subvolume has a continuous dose-response (that is, each subvolume can
lose function on a continuous scale), 50% of the organ function can be lost in two extreme
ways.
 Irradiate 50% of the organ volume to a dose that obliterates function.
 Irradiate the entire organ to a dose that obliterates 50% of the function of each
subvolume.
The total damage to the organ is the mean of the functional losses of all subvolumes.
The isoconstraint is the value to change during optimization if your desired prescription
goal for the selected OAR is not met.
The third parameter is the Power Law Exponent (k). This value changes the shape of the
dose response curve and determines how responsive the structure is to the Reference
Dose (Gy) and Mean Organ Damage (%) values entered. k values are typically set once
and not changed during the optimization. When you select a particular k value, you
essentially select a complication model based on the desired outcome for the selected
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structure. k values range from 1-4 and can be a decimal increase for the Parallel cost
function.
Figure 44: Functional Units (Voxels)
A k value of 1 with the Parallel cost function, applies its greatest penalty to the region of
low dose and applies a penalty over most of the curve. To apply such a high penalty to
low doses can restrict the dose solution and can cause a loss of target coverage. See the
relative impact and weighting on the IMRT constraints control to evaluate if the target is
penalized with the use of a low k value.
A Parallel cost function with a k value of 4 applies penalty in the region of the reference
dose. The parallel cost function prevents any kinks in the DVH that can occur when it
meets a single point criteria while it inadequately constrains the rest of the organ as can
be seen with a single DVH point. Instead, it always has a smooth transition from low to
high dose. Parallel with a k value of 4 typically does not penalize the high and low dose
areas unless the reference dose is close to the target objective.
A k value of 2 or 3 penalizes a greater range of doses than a k of 4 as depicted in Figure
44.
Below are examples of different k values for a TG244 lung case. The goal is to keep 20%
lung at or below 20Gy.
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Figure 45: k value of 1
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2.8.5 Serial
This biological cost function is the preferred constraint for serial OARs. Consequentially,
it applies large penalties for hot spots even if they are small in volume. The Serial cost
function is the biological equivalent of a maximum dose penalty. The isoconstraint for a
serial cost function is a dose unit.
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Figure 49: Required Parameters for Serial cost functions
The isoconstraint is the Equivalent Uniform Dose (Gy) (EUD), where value is similar to
an acceptable maximum dose when the k value is large (ex., 12) and is equivalent to the
mean dose when the k value is equal to 1. The EUD is the dose that causes the same
damage if applied uniformly to the entire volume of the organ. The isoconstraint is the
value you must change during optimization to meet your desired prescription goal for the
selected OAR. Remember the EUD value is not a maximum dose, therefore the value set
does not always not give you the maximum you require, but more the dose effect.
This cost function requires a Power Law Exponent (k) volume-effect parameter. In
general, when you use a small k value, a large volume-effect is assumed. This means that
low dose volumes and high dose volumes are approximately equally weighted. When you
use a large k value, there is less tolerance for excessive damage to small volumes of the
assigned structure. In this case, low dose volumes receive a very small weight relative to
high dose volumes. Figure 50 graphs the changes in the weight (penalty) of a dose in the
overall EUD calculation when the k value is altered. k values are typically set one time
and not changed during optimization. When you select a particular k value, you
essentially select a complication model based on the desired outcome for the selected
structure.
It can be helpful for you to learn how Monaco re-samples the patient to create
voxelized structures for optimization. This effects how cost functions such as the Power
NOTE
Law Exponent for the Serial cost function are applied to the structures. For detailed
information, see the section labeled Voxelization of patient in this training module.
A Power Law Exponent (PLE) or k value of 1 applies evenly across the whole curve and
gives a mean dose effect.
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Figure 50: Serial cost function Power Law Exponent of 1
A Power Law Exponent (PLE) or k value of 10 applies more towards the maximum end
of the curve.
A Serial cost function with a Power Law Exponent (PLE) or k value of 20 exhibits more
of a maximum dose effect.
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As a rule of thumb, you can derive a clinically significant Power Law Exponent for serial
structures when you use this equation:
k = 0.15 x D50
The D50 value is the dose that causes a complication in 50 percent of all patients.
Unfortunately, this is not a well-established clinical quantity. In general, it is better to
overestimate k as this prevents potentially perilous hot spots.
2.8.6 Overdose DVH
This physical cost function is the equivalent of a DVH constraint for an OAR. When you
add more than one DVH constraint to a structure, the values for dose and percent (%)
volume must be consecutive so that they create a single continuous curve.
Figure 53: Required Parameters for Overdose DVH constraint
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This constraint requires two parameters: the Objective Dose (Gy) and the isoconstraint
Maximum Volume (%). When you apply this cost function, it keeps the volume that
receives more than the objective dose below the isoconstraint, which is given as a
percentage of the total volume. For example, use this constraint if you want no more than
50% of a structure to receive a dose in excess of 60 Gy.
Figure 54: How an Overdose DVH constraint controls the DVH curve – both DVH curves
are effectively equivalent for this DVH constraint as the constraint only controls one
point
2.8.7 Underdose DVH
This physical cost function is the equivalent of a DVH constraint for targets. If you add
more than one DVH constraint to a structure, the values for Objective Dose (Gy) and
Minimum Volume (%) must be consecutive so that they create a single continuous curve.
You should handle this constraint with caution. It can cause an infeasible configuration of
the optimization problem if used with dose limiting constraints.
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Figure 55: Required Parameters for Underdose DVH constraint
It requires two parameters, the Objective Dose (Gy) and the isoconstraint Minimum
Volume (%). When you apply this cost function, it keeps the volume that receives less
than the objective dose above the isoconstraint, which is given as a percentage of the total
volume. For example, use this constraint if you want at least 80% of a structure to receive
a dose of at least 50 Gy.
Figure 56: How an Underdose DVH constraint controls the DVH curve
2.8.8 Maximum Dose
This physical cost function is a constraint you can use with either targets or OARs. It is
effectively a hard barrier. This penalty kicks in immediately when voxels cross the
maximum dose threshold, so it can be troublesome. It can be preferable to use the
Quadratic Overdose constraint with a small RMS Dose Excess (Gy) (0.1 Gy) in most
cases. Maximum Dose can be used to control the global maximum when applied to the
external contour and optimize over all voxels is selected.
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Cost Functions
Figure 57: Required Parameters for Maximum Dose
The isoconstraint is the maximum tolerated dose, Maximum Dose (Gy), which is not
exceeded anywhere (any voxel) in the structure. Figure 56 graphs the shape of the
Maximum Dose cost function curve.
Figure 58: Maximum Dose constraint
2.8.9 Quadratic Underdose
This physical cost function is a constraint that implements a quadratic penalty for
underdose. Therefore, it implies that its structure is a target volume. You should handle
this constraint with caution. It can cause an infeasible configuration of the optimization
problem. Use this with Pareto mode to shift priority from OAR constraints to target
objectives.
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Figure 59: Required Parameters for Quadratic Underdose
This cost function requires a parameter that is the Minimum Dose (Gy) allowable in a
target. The isoconstraint is the (Root Mean Square) RMS Dose Deficit (Gy) the amount of
violation of the prescription you can accept. It is analogously applied as the RMS Dose
Excess. Figure 58 graphs the shape of the Quadratic Underdose cost function curve. Since
this isoconstraint works like an objective, it may not be met when you apply contradictory
constraints.
The same concept as RMS dose excess applies to RMS dose deficit. See the Quadratic
NOTE
Overdose section for an example of how a Root Mean Square is calculated.
Figure 60: Quadratic Underdose constraint
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2.8.10 Conformality
This physical cost function is a constraint that you can only use with OARs. The purpose
of the Conformality cost function is to shape the high dose volume tightly around one or
several target volumes. The farther away from the target a voxel is located, the higher the
cost function penalizes high doses. You can use this instead of the Quadratic Overdose
cost function. The rationale that you use this cost function is that it is more acceptable to
have a higher dose closer to the target than it is to have high doses distant from the target.
The Conformality cost function uses local importance weights that depend on the distance
of a voxel to the nearest target volume and the dose prescribed to this voxel to modify the
local effectiveness of the cost function.
1 V
 D(i ) 
F  f  D (i) 
N i 1  0 
Where D0(i) is an estimate of the desired dose at point i. D0(i) depends on the distance of
point i from the nearest target volume voxel, and the prescription dose to that voxel.
f is a local penalty function.
N is the normalization factor.
Using a decay function of:
1
g ( Ri ) 
4 R
i
Where Ri is the distance of point i from the edge of the target volume, gives a final cost
function of:
k
1 V  4 Ri D(i ) 
F
N
 



i 1  D p ( ji ) 
Dp(ji) is the dose in the current dose distribution. You only have to define one parameter,
k.
The Conformality cost function does not require you to define an absolute isoconstraint
for the prescription, which is difficult to determine. Instead, it estimates a feasible
measure of dose conformality for each case, and then requires you to prescribe how much
more or less conformal the dose distribution must be than this estimate. Hence, the cost
function only requires you to define a relative isoconstraint.
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Figure 61: Conformality dialog box
The Relative Isoconstraint ranges from 0.01 to 1.00. A good value to start with is 0.75,
the value can then be lowered until the desired conformity is achieved. Values less than
0.5 can start to restrict target coverage. Monaco applies a stronger penalty to voxels when
you use a lower value for the Relative Isoconstraint. The default distance Monaco applies
the Conformality cost function is 4 cm from the edge of the target. When you select the
Optimize over all voxels in volume check box, Monaco applies the cost function up to 8
cm from the edge of the target and ignores the layering order. You can also select
Multicriterial to make this a secondary objective.
The Conformality cost function works well for single target volumes and stereotactic
volumes where there are large areas of unspecified tissue. It does not work well with
complex head and neck cases with multiple overlapping dose volumes.
2.8.11 Optional parameters for cost functions
Each cost function has optional parameters. Not all optional parameters are available for
each cost function. When optional parameters are used appropriately, you’ll likely have
better plan results.
2.8.11.1 Shrink Margin (cm)
When you apply IMRT constraints to structures close to the target volume, this can cause
an underdose of the target because the dose gradient gets pushed in. Therefore, it is often
desired to limit the effect of the constraint on the target. For example, you can apply a
Quadratic Overdose to the unspecified normal tissue to ensure conformality. You can
specify this shrunken margin for any structure (OARs or other competing targets) to avoid
the application of IMRT constraints to the voxels near the compromised (objective)
target. Essentially, the application of a shrink margin moves the dose gradient out of the
target and into the OAR or competing target.
Use Shrink Margin (cm) when you have competing cost functions that are immediately
adjacent to each other or overlapping. Competing cost functions can be a Target and an
OAR (constraint), or a Target and the Dose Limiting constraint of a second target. You
can choose include a margin around the target. When your plan has multiple targets,
variable shrink margin values can be assigned.
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Cost Functions
The figure below shows a head and neck case where a 0.6 cm shrink margin was applied
to the Quadratic Overdose cost function of the unspecified tissue defined by the patient’s
external contour. The purpose of this is to enable the voxels near the targets and other
OARs to have a transition zone between competing cost functions. The cost function for
the unspecified tissue is only applied to the area shaded in red during optimization. Notice
that the applied margin only shrinks away from target structures.
Figure 62: Application of Shrink Margin/OAR structure
Figure 62 shows a head and neck case where GTV is inside CTV. It depicts the
application of a shrink margin to a Quadratic Overdose cost function of the CTV to create
a dose gradient between CTV and GTV. The Quadratic Overdose cost function for CTV
is applied to the area shaded in red only. The area between the two structures that is not
shaded in red has no penalty (not used by the constraint) applied to it, so it provides better
coverage to GTV.
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Cost Functions
Figure 63: Application of Shrink Margin/Target structure
For further application of shrink margins, see Monaco Planning Suggestions lesson in
NOTE
this training module.
2.8.11.2 Surface Margin
This optional parameter applies to the Target EUD, Target Penalty, Underdose DVH, and
Quadratic Underdose cost functions. When you select this option, Monaco applies the
Surface Margin that was assigned in the IMRT Prescription Parameter dialog box to the
selected cost function.
2.8.11.3 Multicriterial
This optional parameter applies to Parallel, Serial, Quadratic Overdose, Conformality and
Overdose DVH cost functions. When applied, the cost function becomes a secondary
objective. The optimizer tries to achieve an even lower dose (tighten the constraint) to the
selected OAR as long as it can still meet the target objective.
The most effective time to use multicriterial is when you have an isoeffect on the target
structure(s) that is higher than the isoconstraint. This typically means your target and
OAR are well separated from each other, and the target(s) coverage is not significantly
affected by a tighter constraint on the OAR.
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Enabled / Status
As you optimize, pay attention to the isoeffect value and the DVH of the target(s). If you
apply multicriterial to an OAR and compromise the target coverage more than you can
accept, turn off multicriterial and set the isoconstraint of the OAR to a value that, when
optimized, creates acceptable coverage to the target(s).
You can use the multicriterial option when you plan dose escalation protocols to increase
the dose to targets and keep OAR(s) dose at acceptable levels. You can also consider its
use when you re-treat a patient and a physician agrees to accept compromised target
coverage as long as the OAR’s dose can be kept at as low a dose as possible.
2.9 Enabled / Status
When you place a checkmark  in the Enabled check box, the Status is On and the
structure is included in the optimization. Use the Enabled check box to toggle a
structure’s Status On/Off.
2.10 Manual
Place a checkmark  to make manual changes to the structure weights instead of the
weight assigned by the optimizer.
2.11 Weight
This field shows the weighting assigned to the structure by the optimizer. This is a
valuable tool that shows areas of high and low impact to evaluate how your plan
performs. Values around 1-2 show a reasonable return in plan quality in Stage 2. Cost
Functions with high weight are likely impeding plan quality.
The weight, isoeffect, and relative impact on the Constraints spreadsheet help you
identify conflicts and achieve your plan objectives.
The weight is a relative number. For example, if all other weights are 0.01, but there is
NOTE
a weight that is 2-3, this is considered a high weight.
2.12 Reference Dose
This column displays the reference dose you entered for each cost function for which it is
required.
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Multicriterial
2.13 Multicriterial
When cleared, the optimizer tries to achieve an even lower dose (tighten the constraint) to
the selected OAR as long as it can still meet the target objective. See the Optional
parameters for cost functions section for detailed information on Multicriterial.
2.14 Isoconstraint
The Isoconstraint is the constraint parameter you ask the system to meet. It is a dose value
or an RMS or a percent volume depending on the cost function. With constrained
optimization, the isoconstraint will always be met for dose limiting cost functions.
2.15 Isoeffect
If the isoconstraint is what you ask for, the isoeffect is the calculated result. This isoeffect
is updated during optimization.
When the isoeffect for a target objective is lower than the isoconstraint, the target dose
has not been met. Therefore, one or more of the constraints, an OAR or another cost
function assigned to the target, is preventing the system from meeting the target penalty
constraint.
2.16 Relative Impact
Relative impact is used as a first evaluation of a constraints conflict towards the goal
while optimization is running. The relative Impact is displayed from blank to ++++. The
higher number of plus signs shown, the greater the impact.
The weight, isoeffect and relative impact are key to identifying conflict and achieving
your plan objectives. See the lessons on Plan Analysis and Monaco Planning
NOTE
Suggestions for more information and examples on how to utilize these tools for more
effective planning.
2.17 What is next

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What is next

Properties.
 Identify groups available on the Planning ribbon used for IMRT planning.
 Define functions available in the Calculation group including Calculation
Properties.
 Understand how to use the Fluence Group and Fluence analysis and visualization
tools.
 Apply tools from the Grid Volume group.
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3 IMRT tools
Description Page

3.2 Planning ribbon .......................................................................................................... 59
3.2.1 Planning ribbon: Calculation group .................................................................................. 59
3.2.2 Planning ribbon: Fluence group........................................................................................ 65
3.2.3 Planning ribbon: Grid Volume group ................................................................................ 68
3.3 What is next ............................................................................................................... 69
This lesson outlines the location and functionality of buttons and tools specific to
IMRT/VMAT planning. After you complete this lesson, you will be able to:
Properties.
tools.
3.2 Planning ribbon
The Planning ribbon contains several groups of tools specific to IMRT planning.
You can find a more detailed discussion of the tools launched from this toolbar in the
NOTE
Monaco 3D and Electron Planning Training Module.
3.2.1 Planning ribbon: Calculation group
The Calculation group lets you start, stop, and control dose calculations. It also lets you
set the sequencing parameters and calculation properties.
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Planning ribbon
Figure 64: Planning ribbon | Calculation group
The calculation region volume encompasses all structures listed on the IMRT
Constraints control. Monaco requires the external contour to be contiguous. If you
NOTE desire a smaller calculation region, you can delete contours from the superior and
inferior slices. The system generates DRR images for the extent of the CT slices, even if
patient contours do not exist.
Table 1: Planning ribbon – Calculation group buttons and tools
Buttons and Tools Description
This button launches the Calculation Properties dialog box.

It shows editable calculation and global parameters related to
your plan and structures in the prescription.
This button launches the Sequencing Parameters dialog box.

These editable parameters relate to fluence, segmentation,
and monitor unit properties of optimized segments.
The Start Optimization button starts the optimization for

stage one or stage two. The subscript number indicates
or
which stage starts when the button is clicked.
The Batch Optimization button lets you perform stage one

and stage two optimizations with no pause in between.
The Skip Forward button lets you manually stop an

optimization. It skips forward to the next converged state.
Note that when you skip forward, you prematurely end the
optimization. This can lead to an unacceptable result.
The Skip Back button has different functionalities and

depends on which stage you are in. When clicked one time,
it pauses the optimization. If you are in stage one, you can
click the Skip Back button two times to reset to the initial
(pre-optimized) fluence. In stage two, you can click the Skip
Back button two times to reset the optimized segments back
to optimized fluence.
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The Reset Calculation Engine button lets you remove

fluence, segments, and dose.
3.2.1.1 Calculation Properties
You can edit specific Calculation parameters from the Calculation Properties dialog box.
The calculation algorithm determines what parameters are available.
Figure 65: Calculation Properties dialog box – Monte Carlo
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Figure 66: Calculation Properties dialog box – Electron Monte Carlo
3.2.1.2 Calculation Properties – Grid spacing
This value refers to the uniform spacing of the calculation points on a three-dimensional
grid. Keep in mind that the calculation grid is defined by and encompasses all contoured
structures and cannot be resized.
If you have small structures such as in a head and neck case, you can use a Grid Spacing
(cm) of 0.2 cm. Understand that smaller grid spacing significantly increases calculation
time. Plans with larger structures can be set to a larger grid spacing (such as 0.3 cm) to
increase the calculation speed. Keep in mind, when you use too large of a grid spacing, it
can lead to a poorer resolution of the optimization problem and a less accurate monitor
unit calculation.
Grid spacing also affects the parameters that follow:
 Shrink Margin: The size is based on multiples of the grid spacing.
 DVH and Statistics Resolution: The resolution for the Optimized DVH is based
on grid spacing. The resolution of the total volume DVH is defined in the
template as 0.1 cm.
 Target Coverage: If you do not have good coverage superiorly and inferiorly,
make sure your grid spacing is at least as small or slightly smaller than your CT
slice spacing.
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 Voxelization of patient: Voxels are created based off the grid size extending out
from isocenter.
 Grid Volume toolbar: Grid types available in the Grid Volume toolbar are voxel
representations based off grid size.
NOTE Each of thses topics are covered in detail in their respective sections.
3.2.1.3 Calculation Properties – Calculate Dose Deposition to
You can calculate dose to Medium or dose to Water. The default value is Calculate Dose
Deposition to Medium. To be consistent, select the same option in QA Activity for your
QA plan that you select here.
Calculation Properties – Force entire volume to be treated as water
Select this check box to force the entire volume to be treated as water for the calculation.
For more detailed information on this topic, see the Report of the AAPM Task Group
NOTE No. 105: Issues associated with clinical implementation of Monte Carlo-based photon
and electron external beam treatment planning.
3.2.1.4 Calculation Properties – Algorithm
This is a non-editable field in this dialog box. You can select the algorithm you want to
use in the Beam tab on the Planning control. Monaco updates the information in the
Algorithm field on the Calculation Properties dialog box.
3.2.1.5 Calculation Properties – Statistical Uncertainty (%)
The system only uses this value during the final dose calculation when you select the
Monte Carlo Algorithm as the Secondary Algorithm. There are two options to choose
from, Per Control Point and Per Calculation.
3.2.1.6 Calculation Properties – Statistical Uncertainty Per Control Point
Statistical Uncertainty Per Control Point is the percent (%) statistical uncertainty for each
voxel, on a per-segment basis, that you can accept for the final dose calculation.
So, the mean, per-voxel uncertainty in a central region of the dose of a segment is equal to
the user-specified statistical uncertainty at the end of the dose calculation.
The uncertainty is not the same in all voxels. For example, the low dose voxels in the
peripheral regions of the patient has a higher uncertainty of dose than the voxels in the
region of maximum dose (target). The relative uncertainty of the total treatment plan is
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Planning ribbon
inversely proportional to the square root of the number of histories. Dose uncertainty in
the target volume for the final plan is calculated and appears in the Console after stage
two dose calculation. The uncertainty of the entire plan is always less than the uncertainty
value you typed in the Statistical Uncertainty field since that value is for each segment.
Figure 67: Console entry for dose uncertainty
The range for this field is 0.1-10.00%. The smaller the Statistical Uncertainty (SU), the
longer the dose calculation. Suggested values are as follows:
Table 2: Statistical Uncertainty Per Control Point (CP) suggested values
# of CP Planning SU QA SU
100 3% 2%
150 4% 2.50%
200 5% 3%
When you use these values, the result is supposed to be a final dose uncertainty of
approximately 1% for the plan in the central region of the target volume. Elekta suggests
that you use smaller Statistical Uncertainty values for QA, since QA devices have a
limited number of detectors to match computed dose to measured dose.
3.2.1.7 Calculation Properties – Statistical Uncertainty Per Calculation
The percent (%) Statistical Uncertainty Per Calculation that you can accept for the final
dose calculation.
The range for this field is 0.1-5.00% (per calculation). Suggested value is 1.0% for each
calculation. Lower values can be helpful when you plan cases with low density structures.
Calculation time is faster for this option versus the Per Control Point option since the
dose calculation is based on a smaller number of histories.
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When you have structures in the prescription with small volumes, (for example, lens)
Elekta does not recommend that you use a Statistical Uncertainty higher than 1.5 % per
calculation or 5 % per control point. If you use a higher value, it causes the system to
NOTE
underestimate the cost function value assigned to that structure. See the Monaco
Technical Reference: Post-Modeling Adjustment of MLC Parameters in Support Plus for
additional information.
3.2.1.8 Sequencing Parameters
Sequencing Parameters open the Sequencing Parameters dialog box. This controls the
segments for fluence delivery. Each treatment delivery mode has different options.
Sequencing Parameters is discussed in detail in the Optimization section of this module.
3.2.2 Planning ribbon: Fluence group
The Fluence group is associated with the fluence display. The tools vary slightly for
IMRT (IMRT, dMLC and Conformal RT) plans verses VMAT (VMAT and Dynamic
Conformal Arc) plans.
3.2.2.1 Fluence group for IMRT plans
The tools below are available on the Fluence group when you plan IMRT, dMLC and
Conformal RT plans.
Figure 68: Fluence group – IMRT and dMLC plans
Table 3: Planning ribbon – IMRT Fluence group buttons and tools
Click the up and down arrows to select the beam you want to
show in the Fluence view or click the drop-down arrow to
the right of the field and select a specific beam to show.
Gantry is a non-editable field that shows the angle of the

gantry of the active beam.
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Use the Segment Selector to movie through the segments in

the Fluence view. When the field is highlighted, you can use
the scroll wheel to movie through the segments quickly.
This shows the segment position. Static is available for static

beams.
The monitor units shown are the monitor units for the
segment currently shown in the Fluence view.
The MU Cursor tool works like the Volume Cursor tool.

But, it shows monitor units at a selected point on the BEV
instead of dose. Click the MU Cursor button. Then, hold
down your left mouse button over the intensity map. Monaco
shows a MU value associated with the intensity at that point.
The range of monitor unit values for all fluence profiles in

the plan appears on the hot/cold indicator in grayscale or
color.
Click the Fluence Color button between the two numbers to
toggle the intensity map in the BEV from color to grayscale.
To turn off the intensity map and monitor unit fluence, right-click in the BEV and select
NOTE
the Show MU/Fluence option to remove the checkmark.
3.2.2.2 Fluence group for VMAT and Dynamic Conformal Arc plans
The tools below are available on the Fluence group when you plan VMAT and Dynamic
Conformal Arc plans (Figure 69).
Figure 69: Fluence group – VMAT and Dynamic Conformal Arc plans
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Table 4: Planning ribbon – VMAT and Dynamic Conformal Arc Fluence group buttons and tools
Click the up and down arrows to select the sequence you

want to show in the Fluence view or click the drop-down
arrow to the right of the field and select a specific sequence
to show.
When the Gantry button is selected (orange), all the gantry

angles for the sequence appear in the drop-down list. Only
the segments for the selected gantry angle are available in
the Segment drop-down list.
When the Segment button is selected (orange), all the

segments for the entire sequence appear in the drop-down
list. Only the starting and ending gantry angles for the
selected segment are available in the Gantry drop-down list.
Most segments have two control points, so you can choose
to show the starting position or ending position for that
segment. Select Start or End.
This shows the segment position. Start/End is available for

dynamic beams.
The monitor units that appear are the total monitor units for
the segment that currently appears in the Fluence view.
The MU Cursor tool works like the Volume Cursor tool.

But, it shows monitor units at a selected point on the BEV
instead of dose. Click the MU Cursor button. Hold down
your left mouse button over the intensity map. Monaco
shows a MU value associated with the intensity at that point.
This option is greyed out for Dynamic Conformal since the
MU is constant for each segment.
(VMAT Only) The range of monitor unit values for all

fluence profiles in the plan appears on the hot/cold indicator
in grayscale or color.
Click the Fluence Color button between the two numbers to
toggle the intensity map in the BEV from color to grayscale.
To turn off the intensity map and monitor unit fluence, right-click in the BEV and select
NOTE the Show MU/Fluence option to remove the checkmark. This option is greyed out for
Dynamic Conformal since the MU is constant for each segment.
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3.2.2.3 Fluence visualization tools
To show the fluence image view, turn on a BEV View Type. If selected, you can right-
click in the BEV window to show these display options. Click the option to toggle the
display on/off.
Table 5: Fluence analysis and visualization options
Option Description
Show MLC Toggle the segment display on or off.
Show MLC Edges Toggle the segment edges on or off. Segment edges appear
in light green.
Show Leaf Outlines Toggle the display of the leaf outlines on or off. The color of
the leaf outline changes where the leaf is blocked.
Show Leaf Interiors Toggle the display of the leaf shading on or off. The color of
the shading changes where the leaf is blocked.
Clip Leaves at Jaw Toggle the display of the full extent of the leaves on or off.
Edges This option limits the MLC leaf display to the jaw extents.
Jaw extents appear in dark blue.
Show Maximum Toggle the segment display between showing the segment
Segment Extents extents of the selected segment to showing the maximum
extent of all segments.
Enable DRR/MIP Toggle the display of the DRR image on or off.
Show MU/Fluence Toggle the display of the Fluence on or off.
3.2.3 Planning ribbon: Grid Volume group
The Grid Volume group has different functionality based on which activity you are in.
The functionality below is available in the Planning workspace.
Figure 70: Grid Volume Group
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Table 6: Grid Volume Group Buttons and Tools
The Studyset and Grid Slider Bar lets you fade the display
between the primary studyset and any grid volume option
selected.
You can select the Grid Type from the drop-down menu.
This lets you set which visualization tool to use. For
example, the Cost Function Occupancy (available only in the
Planning workspace) shows cost function occupancy for
each voxel.
When you select certain Grid Types, you can also view a
Structure. The drop-down menu lets you select a structure
when you select VOI Occupancy, CF Occupancy, Variation,
or Relax Response as the Grid Type.
The Units button lets you view the lowest and highest level
of monitor units in the segment.
You can find more information on use of the Grid Volume toolbar in the Plan Analysis
NOTE
Tools lesson of this training module.
3.3 What is next

Properties.
tools.
 Summarize the Monaco optimization process.
 Define what happens in stage one and stage two of the optimization process.
 Identify the delivery modes available in Monaco.
 Assign Sequencing Parameters.
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What is next
 Understand Beam Splitting

 Troubleshoot optimization failures.
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Optimization
What is next
4 Optimization
Description Page

4.2 Optimization .............................................................................................................. 72
4.2.1 Stage one .......................................................................................................................... 73
4.2.2 Stage two .......................................................................................................................... 73
4.3 Delivery modes........................................................................................................... 74
4.3.1 Conformal RT .................................................................................................................... 75
4.3.2 Dynamic Conformal Arc (DCAT) ........................................................................................ 75
4.3.3 mArc.................................................................................................................................. 76
4.3.4 Step and Shoot.................................................................................................................. 76
4.3.5 dMLC ................................................................................................................................. 78
4.3.6 VMAT ................................................................................................................................ 79
4.4 Sequencing parameters .............................................................................................. 81
4.4.1 Segment Shape Optimization (SSO).................................................................................. 84
4.4.2 Min. Segment Area (cm2).................................................................................................. 85
4.4.3 High Precision Leaf Changes (Pilot Beamlets) .................................................................. 85
4.4.4 Speed – Plan Quality ......................................................................................................... 85
4.4.5 Max. # of Segments Per Plan ............................................................................................ 85
4.4.6 Max. Number of Arcs (Elekta and Varian machines) ........................................................ 85
4.4.7 Max. # of Control Points Per Beam................................................................................... 86
4.4.8 Max. # of Control Points Per Arc ...................................................................................... 86
4.4.9 Target Dose Rate (MU/min) ............................................................................................. 86
4.4.10 Min. Segment Width (cm) ................................................................................................ 87
4.4.11 Fluence Smoothing ........................................................................................................... 87
4.4.12 Min. MU/Segment ............................................................................................................ 87
4.4.13 Park Leaf Gap Under Jaw .................................................................................................. 87
4.4.14 Max. Sweep Efficiency ...................................................................................................... 87
4.4.15 Allow Move Only Segments (dMLC Only) ......................................................................... 88
4.4.16 Constant Dose Rate .......................................................................................................... 88
4.4.17 Min. MU Per Dynamic CP.................................................................................................. 88
4.5 Beam splitting ............................................................................................................ 88
4.6 Troubleshooting an optimization failure ...................................................................... 89
4.7 What is next ............................................................................................................... 90
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This lesson discusses the optimization of Monaco plans. In Dose Based Optimization,
beamlet intensities are weighted to achieve a desired dose distribution. In Evidence Based
Biological Optimization, beamlet intensities are weighted by biological models such that
the calculated dose distribution yields a known tissue response. Monaco uses both dose-
based and biological cost functions. After you complete this lesson, you will be able to:
4.2 Optimization
After you type the prescription information into the system via IMRT Constraints, it is
time to begin the optimization process. Because Monaco uses a combination of objectives
and constraints to calculate the objective function during optimization, all targets and
organs at risk appear on the IMRT Constraints page when you optimize.
You must have at least one objective and one constraint defined in your prescription
before you can begin optimization.
NOTE
You must apply some cost function to the patient contour structure and, in most cases,
list it as the last structure in the layering order.
Monaco’s optimization process is different for non-IMRT delivery modes verses IMRT
delivery Modes.
 Non-IMRT: Requires a one-step process. Monaco optimizes the fluence then
calculates the final dose (stage one only). The Monte Carlo algorithm is used for
dose calculation.
 IMRT: Requires a two-step process. Monaco optimizes the fluence (stage one)
then translates the fluence into segments (stage two). Pencil Beam is always used
in stage one, Monte Carlo is always used in stage two.
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Optimization
Optimization
Table 7: Delivery Modes: Non-IMRT/IMRT
Delivery Mode Delivery Method
Non-IMRT DCAT
Conformal RT
IMRT Step and Shoot

dMLC
VMAT
mArc
4.2.1 Stage one
Generally, in stage one, the ideal fluence distribution of beams is optimized to meet a
user-defined prescription for a single set of beams.
After you complete the fluence optimization, you can do any of these tasks:
 Review the optimized results
 Make edits to the prescription
 Re-optimize stage one
 Directly launch into the second stage of optimization where you optimize the
apertures (segment weights and shapes) for IMRT delivery modes.
When Monaco evaluates the effects of individual constraints on prescribed objectives, it
gives you information on the potential to improve the plan by relaxing specific
constraints. In other words, after the optimization, Monaco gives feedback for each target
volume and defines which constraint should be relaxed to improve target coverage. This
feedback appears on the Sensitivities tab of the IMRT Constraints control. Constraints
that limit the dose to targets have high values in sensitivity, as opposed to constraints that
are inactive or do not limit the dose to the target which show low values.
Serial, Parallel, and DVH constraints can also be set as multicriterial or in other words,
set as secondary objectives. These constraints are subsequently tightened during the
optimization process as long as they are not the limiting constraints to the objective.
See the Plan analysis tools section in this lesson for detailed information on the tools
NOTE
available during and after stage one optimization.
4.2.2 Stage two
In stage two, the ideal fluence distribution is translated into a set of segments where the
shapes and weights are optimized based on the same prescription. The Monaco Smart
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Sequencer is not limited by number of segments or segments for each degree. This means
areas of high modulation can be provided where required and areas requiring less
modulation to have less control points. The sequencer always tries to reduce the number
of control points.
4.2.2.1 Batch optimization
If necessary, you can batch the optimization process such that both stage one and stage
two are performed to completion without a pause in between. You can do batch
optimization when you click the Batch Optimization button instead of the Start
Optimization button.
If you skip forward or skip back during a batch optimization, you may have to skip
NOTE forward or backward twice. This depends on the phase of the batched optimization
when you selected the skip option.
4.3 Delivery modes
Table 8: Delivery modes
Delivery Gantry Gantry MLC Beam Dose Rate

Method Motion Speed Motion
Intensity
while beam
while beam
on
on
Conformal RT Static Constant Static Uniform Constant
Dynamic Dynamic Variable Dynamic Uniform Constant or

Conformal Arc Variable
mArc Dynamic Variable Static Modulated Variable
Step and Shoot Static Constant Static Modulated Constant
dMLC Static Constant Dynamic Modulated Variable
VMAT Dynamic Variable Dynamic Modulated Constant or

Variable
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4.3.1 Conformal RT
Conformal RT plans are non-IMRT plans that you make with the entered prescription.
Monaco optimizes the fluence of non-modulated open fields, then calculates the final
monitor units.
4.3.1.1 Stage one – Optimization and calculation
Stage one of the optimization process works as follows:

1. While in the Initialization Process, the system creates the dose calculation cube
around all defined structures and calculates structure volumes with cubic voxels.
2. The system projects the union of all target volumes, plus the margin defined as the
Target Margin on the IMRT Calculation Properties dialog box in a BEV.
3. The system then solves an unconstrained problem with a conjugate gradient
algorithm.
4. After the unconstrained optimization is done, if necessary, Monaco changes each cost
function’s relative weight to make the optimizer meet the isoconstraints and restarts
the unconstrained optimization problem.
5. Stage one optimization continues until all the constraints are met or the weighting hits
a pre-determined threshold, at which time the constraint is identified as infeasible.
4.3.2 Dynamic Conformal Arc (DCAT)
When you deliver this type of rotational arc therapy, the gantry rotates during treatment.
The MLC conforms to the target and avoids any avoidance structures, but the MLCs do
not modulate the intensity.
4.3.2.1 Stage one - Aperture optimization and dose calculation
Dynamic Conformal Arc calculation only has one stage.

The optimization process works like this:
2. The system calculates a number of static sectors that the optimizer uses to create rays
based on the Arc and the Increment you selected.
3. Monte Carlo dose calculation takes place.
4. The system projects the union of all target volumes and defines the margin as the
Target Margin. Then, it removes any OARs that are set as Avoidance with the
Avoidance Margin specified on the IMRT Calculation Properties dialog box in a
BEV.
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5. Arc weight optimization continues until it meets the best solution, or the weighting
hits a predetermined threshold. At that time, the constraint is identified as infeasible.
6. The Sequencing Parameters: Dyn. Conformal Arc Delivery dialog box has a Constant
Dose Rate check box. By default, Monaco uses a constant Monitor Unit for each
Degree of gantry rotation. Clear the Constant Dose Rate check box to vary the
Monitor Unit for each Degree of gantry rotation. This option is disabled (greyed out)
for all add-on MLCs (Apex, all micro-MLCs).
For DCA with constant dose rate the number of control points is directly related to the
Arc Increment. There is one control point at each increment and halfway between each
NOTE
increment, when variable dose rate is used the sequencer determines the number of
control points.
7. When you select Segment Shape Optimization for Dynamic Conformal Arc delivery,
you can change the initial segment shapes to better meet the prescription. (See the
VMAT SSO and Pilot Beamlet information in this lesson for detailed information).
8. If you make changes to the plan after stage one optimization, the optimizer determines
if you need to restart at stage one (for example if you remove/edit a structure, change
Calculation Properties, change Sequencing Parameters, or change Structure Properties
Target/Avoidance). If you make changes to the IMRT Constraints, click the Optimize
2 button to resume the calculation.
For DCA with constant dose rate the number of control points is directly related to the
Arc Increment. There is one control point at each increment and halfway between each
NOTE
increment, when variable dose rate is used the sequencer determines the number of
control points.
4.3.3 mArc
Modulated Arc Therapy is designed for the Siemens Artiste machine. For detailed
information on this topic see Online Help.
4.3.4 Step and Shoot
Step and Shoot is a static gantry delivery technique. Monaco divides the beams into
beamlets. The intensity of the beams is varied to create a fluence map that meets the
clinical goals. The fluence map is then converted into step-and-shoot segments. Then the
segments, weights, and shapes are optimized to duplicate the ideal fluence map goals.
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4.3.4.1 Stage one – Fluence optimization

1. When you start the Initialization process, the system creates the dose calculation cube
around all defined structures and calculates the structure volumes using cubic voxels.
2. The system projects the union of all target volumes, plus defines the margin as the
Target Margin on the IMRT Calculation Properties dialog box, in a BEV.
3. Beamlets for each beam are created. Beamlet Width is user-defined. The beamlet
length is the length of the individual MLC leaves.
4. Monaco uses an enhanced pencil beam algorithm to calculate the open field dose.
Then, the fluence optimization begins in which the weights (fluence) of all individual
pencil beams are varied simultaneously.
5. The system then solves an unconstrained problem using a conjugate gradient
algorithm.
6. After the unconstrained optimization finishes, if necessary, Monaco changes each cost
4.3.4.2 Stage two – Segmentation and dose calculation
Segmentation of IMRT plans often introduces an unwelcome reduction in the quality of

dose distributions. When you apply fluence smoothing constraints and include the
technical limitations of the MLC in the optimization problem, Monaco can overcome this
limitation and deliver efficient step-and-shoot beams with fewer segments and MUs. This
directly translates to faster QA and less time required for patients on the treatment couch.
Stage two of the optimization works as follows:
1. Monaco extracts and loads the fluence weight profiles into a static sequencer where
segments are extracted and refined.
2. Monaco optimizes the beamlet and segment weights and uses the constrained
optimization where the Minimum MU/Segment is evaluated, and segments are
refined.
3. When the problem is solved to the best of its ability, the optimizer converges if
Segment Shape Optimization is cleared. If it is cleared, the optimizer determines if
another round of refinement and optimization is allowed or needed. This is called
Smart Sequencing. If the optimizer decided another round could be useful, it will send
the problem back to the static sequencer mentioned in step 1 and continues through
step 4. The secondary algorithm (Monte Carlo) is used during the final iteration.
4. The Pilot Beamlets option is available if you select Segment Shape Optimization.
Monaco uses pilot beamlets to guide the segment shape changes made during
Segment Shape Optimization (SSO). Monaco creates a large number of pilot beamlets
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if you use large highly modulated treatment fields, multiple VMAT arcs and a small
arc increment. Pilot beamlets are stored in memory. When a large number of pilot
beamlets are created they can use all the RAM the system has. This slows the process
exponentially. If you disable this option, pilot beamlets are not created in the SSO
process. Pilot beamlets do not affect performance for the majority of treatment plans.
Disable them if the plan takes a long time to converge.
Use the Windows Task Manager to examine the RAM utilization of your system if you
NOTE
suspect the plan takes too long to converge.
4.3.5 dMLC
During optimization for dMLC plans, Monaco creates beamlets then uses the Sweep
Sequencer to move the leaves in one direction from start to finish while it changes the leaf
speeds. As the speeds change, the gaps between opposing levels also change, which lets
Monaco modulate the intensity to deliver the desired fluence.

around all defined structures and calculates the structure volumes with cubic voxels.
2. The system projects the union of all target volumes, plus the margin defined as the
3. The system creates beamlets for each beam. Beamlet width is user-defined and the
beamlet length is the length of the individual MLC leaves.
4. The system uses an enhanced Pencil Beam algorithm to calculate the open field dose.
Then, the fluence optimization begins in which the weight’s (fluence) of all individual
pencil beams is varied simultaneously.
5. The system then solves an unconstrained problem with a conjugate gradient
algorithm.
6. After the unconstrained optimization is done, if necessary, Monaco changes each cost
The sequencing algorithm used for dMLC is called the Sweep Sequencer and is the same
as used for the basis of VMAT sequencing. It is similar in nature to Sliding Window
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Sequencers, but different in that it has significant improvements to improve delivery

efficiency and minimize loss of dose quality.
The basic paradigm of the Sweep Sequencer is that the leaves move from their start to
their end position in a continuous, unidirectional manner. When you move the leaves
across the field from one side to the other, vary the leaf speeds and thereby the gaps
between opposing leaves, the system modulates the intensity of the delivered fluence. To
change the leaf gap, either accelerate the leading leaf (more fluence) or the trailing leaf
(less fluence). At least one leaf moves at maximum velocity at any given time to provide
for the shortest possible delivery time.
1. Starting with the optimized fluence profiles from stage one, the system converts each
profile to a series of leaf trajectories (that is, leaf position as a function of MU). All
trajectories are synchronized to arrive at the same MU count for all leaf pairs. Monaco
uses the beamlet width to sample these leaf trajectory positions.
2. Translate the leaf trajectories into piecewise linear movements between control points.
You can control the coarseness of this decomposition, or total number of control
points when you use the parameter, Max # Control Points / Beam. In general, the
system inserts a control point whenever a single leaf changes velocity.
3. The system does weight optimization on resulting segments and repeats the
optimization until it converges.
4. If you leave Segment Shape Optimization cleared, Segment Shape Optimization
combines segments and re-weights them to create better plan quality and more
efficient delivery times.
Segment Shape Optimization. Monaco creates a large number of pilot beamlets if you
use large highly modulated treatment fields, multiple VMAT arcs, and a small arc
increment. Pilot beamlets are stored in memory. When a large number of pilot
process. Pilot beamlets do not affect performance for the majority of treatment plans.
Disable them if the plan takes a long time to converge.
4.3.6 VMAT
Volumetric Modulated Arc Therapy is a rotational IMRT where the MLCs and gantry
move while the radiation beam is on. The system uses variable gantry speed and variable
dose rates to achieve variable MU for each degree. The Sweep Sequencer moves the
leaves from their start position to their end position in a continuous unidirectional
manner. The system moves the leaves across the field from one side to the other and
varies leaf speeds (and the gaps between the opposing leaves) to modulate the intensity of
the delivered fluence.
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2. The system projects the union of all target volumes and defines the margin as the
3. The system calculates a number of static sectors that the optimizer uses to create rays
based on the Arc and the Increment you selected.
4. The system creates beamlets for each sector. Beamlet width is user-defined and the
beamlet length is the length of the individual MLC leaves.
5. The system uses an enhanced Pencil Beam algorithm to calculate the open field dose.
Then, the fluence optimization begins in which the weights (fluence) of all individual
pencil beams are varied simultaneously.
6. The system then solves an unconstrained problem. It uses a conjugate gradient
algorithm.
7. After the unconstrained optimization completes, if necessary, the system changes each
cost function’s relative weight to make the optimizer meet the isoconstraints and
restarts the unconstrained optimization problem.
a pre-determined threshold, at which time, the constraint is identified as infeasible.
1. Stage two takes each fluence map and sequences so that it is spread over the original
sector that it represents. The system determines leaf trajectories based solely on the
target dose rate entered. If Segment Shape Optimization is selected, the Target Dose
Rate option is not available. In this case, the sequencer controls the target dose rate to
make sure it is optimally set for the given plan.
Segment Shape Optimization. Monaco creates a large number of pilot beamlets if you
use large highly modulated treatment fields, multiple VMAT arcs and a small arc
increment. Pilot beamlets are stored in memory. When a large number of pilot
process. Pilot beamlets do not affect performance for most treatment plans. Disable
them if the plan takes a long time to converge.
3. The system converts optimized fluences into a deliverable arc sequence with multiple
control points.
4. The system optimizes gantry positions. They are not necessarily equally spaced.
5. Monte Carlo dose calculation takes place.
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6. The system optimizes segment weights.

7. If you keep Segment Shape Optimization selected, Segment Shape Optimization
combines segments and re-weights them to create better plan quality and more
efficient delivery times.
VMAT is available for Apex MLC when used with MCS 3.0 and MOSAIQ 2.62 or higher.
Apex MLC cannot be used with a variable dose rate, so VMAT with Apex is only
NOTE
available with Constant Dose Rate. The Monaco VMAT segmenter is used, but the dose
rate is not modulated during Apex VMAT delivery.
4.4 Sequencing parameters
This section introduces the sequencing parameters and how they apply to each delivery
mode. Sequencing parameters are saved in templates but can be edited any time during
planning. If you edit the sequencing parameters after stage two, the system intelligently
decides how far back to go in the calculation, which depends on the parameter that was
changed.
Click the Sequencing Parameters button to view and edit the sequencing parameters for
each type of delivery mode (Figure 73 through Figure 78). Table 9 shows which
sequencing parameter applies to which delivery mode.
Figure 71: Sequencing Parameters for Figure 72: Sequencing Parameters for
Step and Shoot VMAT
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dMLC Conformal RT
Dynamic Conformal Arc mArc
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Table 9: Sequencing Parameters for All Delivery Modes
Step and
Sequencing Shoot Conformal
Parameter IMRT dMLC VMAT RT DCA mArc
Segment Shape X X X X X
Optimization
Min. Segment X
Area
High Precision X X X X
Leaf Positions
(Pilot beamlets)
Max Number of X
Segments Per
Plan
Max Number of X
Arcs (Elekta and X
Varian)
Max # Control X
Points/Beam
Max# Control X X
Points/Arc
Target Dose Rate X* X* X*
Min Segment X X X X
Width
Fluence X X X
Smoothing
Min MU/Segment X X
Park Leaf Gap X

Under Jaw
Max Sweep X
Efficiency
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Step and
Sequencing Shoot Conformal
Parameter IMRT dMLC VMAT RT DCA mArc
Allow Move Only X

Segments
Constant Dose X X
Rate
Min. MU Per X
Dynamic CP
* Target Dose Rate for VMAT, dMLC, and VMAT is only available when you clear
Segment Shape Optimization.
4.4.1 Segment Shape Optimization (SSO)
Segment Shape Optimization (SSO) is enabled by default. SSO improves plan quality and
deliverability. It allows fro areas of high and low modulation to better meet the IMRT
constraints. Segment Shape Optimization includes smoothing, sequencing (clustering)
and optimization of beam weights and shapes. The MLCs can only move +/-1mm for
each SSO loop and the optimizer uses up to five SSO loops (this permits a maximum of
+/- 5mm from original positions). It works the same for these delivery modes: Step and
Shoot IMRT, VMAT, dMLC, DCA, and mArc. It is turned on by default and is highly
recommended to improve plan quality and decrease delivery times.
Table 10: Segment Shape Optimization characteristics
Characteristic Increases/Decreases
Optimization Time Increases
Plan Quality Increases
Delivery Time Decreases
Segment # Decreases
MU Can Increase
Since SSO is hard-coded to do five loops, you can use the Optimization Console and add
the filter shapes changed to see where the optimizer is in the process. To make changes
during optimization, wait until 2-3 loops have occurred. This gives the optimizer a chance
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to converge before it changes its pathway. You can use the Skip Forward button to bypass
SSO loops from continuing.
There is detailed information on Skip Forward functionality in the Planning ribbon:

Calculation group section in this training module.
NOTE
There is detailed information on the Console in the Console section of this training
module (Plan Analysis Tools lesson).
4.4.2 Min. Segment Area (cm2)
This value represents the smallest segment field area (cm2) you can accept in your plan.
The area is the total area of any open apertures in the segment.
4.4.3 High Precision Leaf Changes (Pilot Beamlets)
The High Precision Leaf Changes check box is available if you select SSO. Monaco
uses pilot beamlets to guide the segment shape changes made during Segment Shape
Optimization. Monaco creates a large number of pilot beamlets if you use large highly
modulated treatment fields, multiple VMAT arcs and a small arc increment. Pilot
beamlets are stored in memory. When a large number of pilot beamlets are more memory
is required.
4.4.4 Speed – Plan Quality
Use the Speed – Plan Quality slider bar to adjust the number of shape changing loops.
The range is from 1 to 20. The default number of shape changing loops is 5. As the
number of loops increase, the plan quality increases, and the dose calculation time
increases.
4.4.5 Max. # of Segments Per Plan
Enter the maximum number of segments you want in the plan. If you do not have a value
saved in your plan template, this field defaults to 250 segments. This parameter controls
the maximum number of segments so that no new calculation yields more segments than
the value of this parameter. The number of segments allowed represent the complexity of
the plan.
4.4.6 Max. Number of Arcs (Elekta and Varian machines)
This value is the maximum number of rotations for each arc that you want to use for an
Elekta or Varian VMAT plan. If you change the value to greater than one, it creates
multiple rotations of the same beam.
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4.4.7 Max. # of Control Points Per Beam
This value represents the maximum number of control points for each beam that you can
accept for a dMLC plan. More control points are required for more complex plans.
4.4.8 Max. # of Control Points Per Arc
This value represents the maximum number of control points that you can accept for each
VMAT arc. More control points are required for more complex plans.
4.4.8.1 VMAT specific information
When you use Elekta VMAT to plan, you can determine the value for the maximum
number of control points for each arc based on how complex the plan is. When you use
SSO, Elekta recommends a range of 150-180 for highly complex plans. For simple plans,
you can use around 75-120 control points for each arc.
When you use a Varian machine to plan VMAT, you can do simple plans in a single arc
rotation. When you have a more complex plan, more rotations are necessary due to the
linac limitations.
4.4.9 Target Dose Rate (MU/min)
This value is the desired dose rate you want to use to deliver a dMLC plan. SSO, which is
defaulted to ON, controls the target dose rate for VMAT, dMLC. If the Segment Shape
Optimization is left on, the Target Dose Rate (MU/min) option is not available. In this
case, the sequencer controls the target dose rate to make sure it is optimally set for the
given plan. If Segment Shape Optimization is turned off, Monaco uses Target Dose Rate
(MU/min) for VMAT and dMLC so that it knows the maximum possible distance the
gantry can travel between control points based on the machine’s available dose rate.
Monaco is sensitive to the Target Dose Rate (MU/min) and control point input you type
in. Therefore, Elekta recommends that you keep Segment Shape Optimization selected
for VMAT, dMLC, and mArc.
4.4.9.1 Recommended Ranges for Non-SSO VMAT
 Elekta-specific information: You must use a higher target dose rate for simple
plans. For more difficult plans, you must use a lower target dose rate. The
recommended range for all plans that use Elekta machines is 120-360.
 Varian-specific information: When you use a higher target dose rate, the number
of rotations increases. It is possible that the number of rotations can increase up to
the defined maximum that you set. For simple plans, Elekta recommends that you
use a Target Dose Rate at Max (600) which typically causes a total of 2 rotations.
For complex plans, Elekta recommends a target dose rate of approximately 400,
which typically causes a total of 3 rotations.
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Elekta highly recommends that you use Segment Shape Optimization which controls the
dose rate and results in better plan quality.
4.4.10 Min. Segment Width (cm)
This is the minimum distance between opposing MLC leafs you can accept. The
recommended value is 0.5 cm.
4.4.11 Fluence Smoothing
The Fluence Smoothing parameter controls the smoothing of the fluence in stage one of
the optimization. Fluence smoothing options are Off, Low, Medium and High. If you
select Off or Low, this can cause the generation of too many segments. If you select High,
this can cause the fluence to be too smooth which can degrade the final result. Medium is
a recommended starting point.
Smooth  Plan Quality  Control Points 
4.4.12 Min. MU/Segment
This is the minimum Monitor Unit value you can accept for any segment the system
creates.
4.4.13 Park Leaf Gap Under Jaw
When planning using MLC models that allow interdigitation, the system automatically
creates more efficient segments by placing closed leaf gaps inside the fluence map. The
system optimizes dose leakage through the gaps and contributes to the total dose
delivered by the plan.
To override this feature, select the Park Leaf Gap Under Jaw option. The closed leaves are
instead parked under the jaw. This can add additional time to the delivery in particular for
beam modulator.
4.4.14 Max. Sweep Efficiency
When you use Max. Sweep Efficiency, you can improve the MU efficiency during
sequencing of dMLC beams without negatively affecting plan quality. It positions some
leaf pairs further apart at the start or end of a sweep pattern and thereby minimizes the
overall leaf travel. For example, when you use the Max. Sweep Efficiency check box on a
typical prostate plan, you can reduce the total number of MU by 100 or more, with only a
slight reduction in dose quality. The recommended setting for this check box is selected
(on).
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Beam splitting
4.4.15 Allow Move Only Segments (dMLC Only)
When you select this check box, you allow Move Only segments for Elekta or Varian
linacs. Move Only segments are segments without fluence that move the leaf carriage to
the next beam segment. Once the leaf carriage is in the starting position for the next
segment, the dose turns back on.
When you clear this check box, the dose remains on during the entire beam delivery.
Your plan quality can decrease if you clear this check box.
This option was added in 3.10. Before 3.10, Monaco always allowed Move Only
segments.
ARIA Customers: If you select this check box for dMLC planning (recommended), you
NOTE must set the machine Field X operation limit motion mode to dynamic or multiple
static segment in ARIA to approve the treatment plan in RT Chart. Failure to do so can
cause validation of fields to fail with this message “ERROR: The fields below are large
fields, but the defined machine does not support them.”
4.4.16 Constant Dose Rate
The Constant Dose Rate option is only available for those Varian machines that support
constant dose rate. It is also available for MLCi/MLCI2, and Apex MLC on Agility.
When you select the Constant Dose Rate check box, the system uses a constant dose rate
for your DCA or VMAT plan.
4.4.17 Min. MU Per Dynamic CP
The Min MU Per Dynamic CP is only available for mArc plans. This variable gives you
extra control over the plan quality. For simple single arc Prostate or single lesion plans,
you can increase this value to 3 or 4 to keep the level of plan modulation down and
improve the delivery efficiency. Siemens recommends a minimum of 2.
4.5 Beam splitting
For machines that can splitting beams, beam splits are listed in Beam Spreadsheet and
appear in all T/S/C and BEV views. Monaco simply creates segments with different jaw
settings that avoid the carriage restriction. An optional approach is to use the Fixed Jaw
setting on the Beam spreadsheet. You can define the field sizes for each beam that does
not violate the carriage restriction. Monaco retains the resulting fluence and segments
inside this jaw setting.
Generally, this is how Monaco determines when to split beams.
1. First, it determines a set of potential carriage groups.
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Troubleshooting an optimization failure
2. Next, it generates all segments that can be delivered without splitting.

3. It splits up the remaining fluence into segments. It starts from the side where the
leaves appear at the most retracted positions. These segments are split at the carriage
group edge. No feathering is applied.
4. Finally, if carriage groups are present with few segments that can be redistributed to
other carriage groups, it deletes these. The jaw positions of the carriage groups are
shrunk to fit at the end.
5. Beam splitting is triggered by the combination of MLC parameters, like maximum
protrusion from neighboring leaf, minimum leaf tuck, etc. The split beams are
exported as separated beams with different jaw settings. The beam names in the
DICOM export appear as B1S1, B1S2, etc.
If the plan contains split beams, you cannot make changes to the child beams.
NOTE Setup beams that you create in Planning on the Setup Beam tab are not included in the
dose calculation for the given plan. Monaco does not account for dose accumulation
for setup beams. The system exports any assigned monitor units for use during filming.
4.6 Troubleshooting an optimization failure
 Infeasible error in the IMRT Constraints means the cost function parameters are
not reasonable and the values must be changed.
 Offending error in the IMRT Constraints means the optimizer is impeded by
contradictory constraint values and must be changed.
 Check the Logfile. Click the Monaco Application button and select the Log Files
| Log. Review the latest entries on the General Logfile for possible clues that
show the failure.
 Check the Optimization Console. Click the Workspace ribbon and click the
Controls drop-down | Optimization Console option. Review the information on
the Console for possible causes that show a failure.
 One common problem is incorrect structure layering. Verify that there are no
structures lower in the layering order (IMRT constraints list) that are completely
encompassed by a structure higher in the layering order and Optimize over all
voxels in volume was not selected. You should receive the error ‘cost function
occupies no voxels’.
 Another common problem occurs when there is no CT-to-ED file assigned to the
patient. If you use a CT studyset, Monaco requires a CT-to-ED file for
optimization and dose calculation. If you use an MR studyset, you must manually
set electron density values for your structures.
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What is next
4.7 What is next

 Understand functionality of the Console.
 Use the Progress Meter to view optimization progress.
 Evaluate sensitivities to determine how to make plan adjustments.
 Interpret a cost functions impact by using the Weight and Relative Impact.
 Use Grid Type on the Grid Volume Toolbar to show voxel occupancy.
 Asses plans using dose displays and DVHs.
 Utilize Intensity Maps, fluence statistics and MUs to evaluate dose efficiencies.
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What is next
5 Plan analysis tools
Description Page

5.2 Showing the Console during optimization ................................................................... 92
5.2.1 Console messages after stage two ................................................................................... 93
5.3 Using the Progress Meter ............................................................................................ 94
5.3.1 Target EUD(s) .................................................................................................................... 95
5.3.2 Constraint Violation .......................................................................................................... 95
5.3.3 Modulation Degree........................................................................................................... 96
5.4 Evaluating sensitivities................................................................................................ 96
5.4.1 Point sensitivity................................................................................................................. 97
5.5 Weights ...................................................................................................................... 97
5.6 Relative Impact .......................................................................................................... 97
5.7 Grid Volume toolbar ................................................................................................... 98
5.7.1 Dose .................................................................................................................................. 98
5.7.2 Dose Raw .......................................................................................................................... 98
5.7.3 Electron Density ................................................................................................................ 99
5.7.4 VOI Occupancy .................................................................................................................. 99
5.7.5 CF (Cost Function) Occupancy .......................................................................................... 99
5.7.6 CF (Cost Function) Variation ........................................................................................... 100
5.7.7 CF (Cost Function) Relax Response ................................................................................. 101
5.7.8 CF Sensitivities ................................................................................................................ 102
5.8 Evaluating the isodoses and dose volume histograms (DVH) ...................................... 102
5.8.1 Total Volume DVH .......................................................................................................... 103
5.8.2 Optimized DVH ............................................................................................................... 103
5.8.3 Optimized Total DVH (Bias Dose plans only) .................................................................. 103
5.9 Evaluating intensity maps and monitor units ............................................................. 104
5.9.1 Review segments and monitor units for each segment ................................................. 104
5.9.2 Using the Fluence Statistics ............................................................................................ 105
5.9.3 Using fluence statistics to evaluate dose efficiencies .................................................... 105
5.10 What is next ............................................................................................................. 107
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There are many tools available to analyze your plan during and after each optimization
stage. You can only use some tools during or after a particular stage. You can use others
at any time. Options that are only available during or after a particular stage are noted in
each section. After you complete this lesson, you will be able to:
5.2 Showing the Console during optimization
During optimization, you can optionally show internal status messages from the
optimizer. You can view the patient name, patient ID, studyset, plan name, and server
name on the Console title bar.
On the Workspace ribbon, click on the drop-down arrow below Controls and select
Optimization Console. OR press Alt + C your computer keyboard.
When you save a plan, the log file is saved, each information line is time stamped and you
can recall it when you re-open the plan. You can:
 Save the current file as a plain text file
 Print the saved file
 Email the file information
There are three view options at the top of the Console log:
 Auto Update
 Auto Scroll
 Always On Top
When the Auto Update and Auto Scroll check boxes are selected, the Console log
automatically moves down when a new line is read. When you select the Always on Top
check box, the Console log stays on top of all other open windows.
At the bottom of the Console window in the Message Filter field, you can type in
keywords to filter through the messages in the Console log.
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Showing the Console during optimization
Figure 77: Optimization Console
5.2.1 Console messages after stage two
Below are some useful messages that appear at the end of stage two optimization.
Figure 78: Console messages after stage two
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Using the Progress Meter
Table 11: Console messages generated after stage two
Message Description
Number of This is the number of segments generated for a beam plan, or

Segments/CP the number of control points generated for a VMAT plan.
Number of Monitor This is the total number of monitor units generated for this
Units plan.
Estimated Total The estimated total delivery time is, as it says, an estimate
Delivery Time and does not include the time individual machines need
rotate the gantry to a new angle for beam plans or to ramp up
and beam on intermittently during a dynamic treatment. So,
this estimate can be close to the actual treatment time or can
be off by quite a bit (this depends on the complexity of the
treatment that is to be delivered). Regardless, the Estimated
Total Delivery Time is always shorter than the actual
delivery time.
Minimum # of MU for This value is calculated based on the fluence profiles after
ideal delivery sequencing and depends only on the degree of modulation of
the plan. This value is always lower than the actual number
of monitor units that the plan needs to deliver. Monaco uses
this value to calculate the estimated total delivery time. You
can control this value when you change your prescription
and allow more dose to your organ at risk or a less
homogenous target dose.
Estimated MU The estimated monitor unit efficiency shows how Monaco

efficiency compares the efficient plan’s actual monitor units to the
monitor units for the ideal delivery. Therefore, the higher the
efficiency the lower the total monitor units for the plan. To
increase the MU efficiency of the plan, lower the Minimum
Dose Rate Segment Shape property.
Efficiency  Total MU  Min Dose Rate 
5.3 Using the Progress Meter
The Progress Meter consists of three real-time graphs, designated by the colors blue, red,
and green that update with each iteration during both stages of optimization.
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Using the Progress Meter
Figure 79: Progress Meter
The red graph shows the convergence of the target objectives Target EUD(s) and the
overall target coverage of the prescribed dose. When the dotted line converges to 1.0, all
objectives applied to the targets are met during optimization.
The blue graph shows the current status of all constraints, essentially the Constraint
Violation. If this graph converges to 0.0 during constrained optimization, this means that
all applied constraints are being met.
The green graph shows the Modulation Degree. This indicates the current total relative
degree of modulation of all beams or sequences. Modulation increases for more complex
plans.
NOTE The range on the vertical axis of each graph changes during optimization.
5.3.1 Target EUD(s)
Target EUD(s) demonstrates the average over all target objectives of the current Target
EUD(s). This means 1.0 indicates that on average, 100 percent of the prescribed EUDs
are achieved for the target(s). If the Target EUD(s) completed above the 1.0 line, this
indicates that the prescription to the target(s) was met, but there can be hot spots. If the
Target EUD(s) completed below the 1.0 line, this indicates the prescription to the target(s)
was under-achieved. Target EUD(s) is calculated with the equation:
Isoeffect/Isoconstraint
If there is more than one target, then the average of all the targets isoeffects and
isoconstraints are used in the equation.
5.3.2 Constraint Violation
Constraint Violation (CV) calculates the maximum of all constraint cost functions. If a
constraint cost function equals zero, it is either inactive or the isoconstraint has been
reached (the isoeffect is smaller than or equal to the isoconstraint). Therefore, you can use
the maximum value of the CV to determine convergence. A high value indicates that
either the constraint is violated or its current impact on the result is too large and has to be
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Evaluating sensitivities
lowered not to excessively reduce the target objectives. In the latter case, the CV can
show a large value even if all constraints are satisfied. (A slack constraint is denoted as
inactive).
You can determine a proper convergence (all constraints are met) when the objective
function has been minimized and the CV equals zero.
5.3.3 Modulation Degree
The Modulation Degree indicates the current total relative degree of modulation of all
beams and sequences. Monaco calculates this relative value. It divides the total monitor
units of all beams or sequences by the sum of:
[(Segment Area x Segment MU)\Total Beam Area]
In general, more complex plans have a higher degree of modulation than simpler plans.
5.4 Evaluating sensitivities
After each stage of optimization, use the sensitivities information in the IMRT
Constraints control to make informed decisions as to what prescription trades-offs you
can make to improve your plan. Guided by the Sensitivities tool, you can easily solve the
conflicts between target goals and dose-limiting constraints.
After optimization, the Sensitivities tab is available on the IMRT Constraints control.
Figure 80: IMRT Constraints control– Sensitivities tab
Sensitivity values of constraints appear for each target. When you place your mouse
cursor over any sensitivity value, Monaco shows the relationship of the constraint to each
objective. Each constraint represents a row, each target objective a column. Along a
target’s column, you can find the entry with the highest value, which applies to the
constraint limiting that target’s coverage the most. Monaco links the changes of a
constraint to a potential gain of EUD to a target.
Another use for this tool is to assess the low sensitivity values. Very low sensitivity
values identify structures that do not conflict with the target dose goal. This indicates that
changes made to the prescription for these structures will probably have little to no effect
on the dose to the target.
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Weights
After you determine what constraint you need to loosen, edit the Isoconstraint value and
re-optimize.
Sensitivities are volume-based. Therefore, small local hot or cold spots may not be
NOTE
obvious when you use this table.
5.4.1 Point sensitivity
You can use the mouse to determine the sensitivity of each constraint at a particular point
in the target(s). Higher values on the organs at risk indicate that a change to the
isoconstraint for that structure makes the most impact at that point in the target(s).
With the Sensitivities tab in view, click your mouse on any point inside the target(s) on a
transverse, sagittal, or coronal view. Point coordinates appear on the bottom-right corner
of the IMRT Constraints control.
5.5 Weights
The Weight is shown in the IMRT Constraints control and shows the weight applied to
the cost function.
Figure 81: Weights
Values around 1-2 show a reasonable return in plan quality in Stage 2. If you have areas
of high weight, identify areas of conflict and make adjustments. For example, if you do
not have good target coverage, look at the weights to see which cost function has had an
impact on the target dose and make changes. If you have areas of low weight, these areas
can be reduced to make the plan work harder. Doing one step at a time speed ups the
calculation process and makes it easier to understand your changes.
5.6 Relative Impact
Relative Impact is located in the IMRT Constraints control and can be used as a first
evaluation of a constraints conflict towards the goal during and after optimization. The
Relative Impact is displayed from blank to ++++. The more +, the greater the impact. Use
this information to make changes to your plan. Similar to the use of Weights, see what
areas are having a high impact (impeding target coverage) or low impact (OAR
constraints can be lowered) and make necessary changes.
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Grid Volume toolbar
Figure 82: Relative Impact
5.7 Grid Volume toolbar
This section discusses the Grid Volume options available in the Planning Activity. Use
the Volume Cursor tool on the Main toolbar to show the information below in a tooltip in
any transverse, sagittal, or coronal view.
Figure 83: Planning ribbon – Grid Volume group
NOTE The options below are voxel representations based on the calculation grid resolution.
5.7.1 Dose
When you select this option, the calculated dose appears on the image set. You can use
the Volume Cursor tool to show the dose to a point. The range of dose color values
appears on the Grid Volume toolbar. You can edit the dose range and values on the
Isodose control. You can use the Slider Bar to transition the opacity of the dose shown on
the primary image set.
5.7.2 Dose Raw
When you select this option, the un-interpolated dose returned from the optimizer
appears. Voxel size represents the actual calculation grid resolution. The range of raw
dose color values appears on the Grid Volume toolbar. You can edit the dose range and
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Grid Volume toolbar
values on the Isodose control. You can use the Slider Bar to transition the opacity of the
dose that appears on the primary image set.
NOTE You can only see Raw Dose when the dose display option selected is not Isolines
5.7.3 Electron Density
The Electron Density option on the Grid Volume toolbar to ensure you have set your
densities correctly for calculation. Use the Volume curser to sample the CT image. The
top line indicated by P: for ‘pixel’ gives the Hounsfield value at that pixel and the
electron density as converted from your CT-to-ED file. The second line G: for ‘grid’
shows the electron density for each voxel used for calculation. This will show if you have
applied the density overrides correctly for calculation. The range of electron density
color values is editable on the Grid Volume toolbar. You can use the Slider Bar to
transition the opacity of the electron dose grid that appears on the primary image set.
5.7.4 VOI Occupancy
When you select this option, the percent of 3D voxel occupancy for the selected Volume
of Interest (VOI) appears. Therefore, you must also select a Structure drop-down option.
This shows you what voxels are being used during optimization for the selected structure.
The range of percent VOI occupancy color values is editable on the Grid Volume toolbar.
You can use the Slider Bar to transition the opacity of the VOI occupancy grid that
appears on the primary image set.
Figure 84: VOI Occupancy
5.7.5 CF (Cost Function) Occupancy
When you select this option, the voxels assigned to a selected cost function appear.
Therefore, you must also select a Cost Function drop-down option. This is a particularly
useful tool to visualize the voxel occupancy where the cost function is being applied. The
Cost Function Occupancy grid is available prior to stage 1 optimization.
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Grid Volume toolbar
The range of percent CF occupancy color values is editable on the Grid Volume toolbar.
You can use the Slider Bar to transition the opacity of the cost function occupancy grid
that appears on the primary image set.
Figure 85: CF Occupancy: Rectum Serial cost function with a Shrink Margin of 0.4 cm
Figure 86: CF Occupancy: Patient Quadratic Overdose cost function with 0cm Shrink
Margin with PTV and Rectum above it in the Layering order
5.7.6 CF (Cost Function) Variation
When you select this option as your secondary volume, along with a structure’s cost
function, the relative impact of that cost function on a voxel by voxel basis appears for
that structure. The cost function variation shows you which voxels are most affected
when you change the cost function parameters for a given structure.
Consider the examples below. The first is a Serial cost function variation on the rectum.
The higher penalty area appears in orange. The lower penalty area appears in blue. There
is essentially no penalty where there are no colored voxels in the structure.
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Grid Volume toolbar
Figure 87: Cost Function Variation – Serial
The second example is a Parallel cost function on a parotid. The highest penalty (appears
in red) is being applied to the voxels receiving the reference dose entered in the
prescription for that structure and cost function. The lower penalty area appears in blue.
There is essentially no penalty where there are no colored voxels in the structure.
u
m Ref Dose
e Dose
Figure 88: Cost Function Variation – Parallel
The range of variation color values is editable on the Grid Volume toolbar. You can use
the Slider Bar to transition the opacity of the cost function variation grid as it appears on
the primary image set.
5.7.7 CF (Cost Function) Relax Response
When you select this option and an associated Cost Function drop-down option, you see
the predicted, incremental change of the dose distribution if a given constraint were to be
relaxed by some small amount. Relaxing some constraints can increase dose in some
areas, but at the same time, can decrease dose in others. This tool gives a visual
representation of this effect. The range of color values is editable on the Grid Volume
toolbar. You can use the Slider Bar to transition the opacity of the cost function relax
response grid as it appears on the primary image set.
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Plan analysis tools
Evaluating the isodoses and dose volume histograms (DVH)
Figure 89: CF Relaxed Response: Patient Quadratic Overdose cost function
5.7.8 CF Sensitivities
When you select this option and an associated Cost Function drop-down option, the area
that is most sensitive to changes made to the selected cost function appear. You can use
the Volume Cursor tool to show the percent sensitivity the selected cost function has on a
voxel. The higher the percent value, the more sensitive the voxel is and therefore is
affected more if you made a change to the selected cost function’s prescription. The range
of color values is editable on the Grid Volume toolbar. You can use the Slider Bar to
transition the opacity of the cost function relax response grid as it appears on the primary
image set.
Figure 90: CF Sensitivities
5.8 Evaluating the isodoses and dose volume histograms (DVH)
You can evaluate the fluence-optimized isodoses and dose-volume histograms before you
continue with the second stage of optimization. Or, you can review them after stage two
optimization. You can evaluate the isodoses on the transverse, sagittal, and coronal
images or in a 3D view.
There are three types of dose-volume histograms you can review.
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Evaluating the isodoses and dose volume histograms (DVH)
 Total Volume DVH

 Optimized DVH
 Optimized Total DVH.
Right-click in the DVH window to select these options.
5.8.1 Total Volume DVH
This DVH shows all structures that are turned on in the structure control list.
The total volume DVH resolution is calculated with the chosen grid resolution that is then
interpolated to a resolution of 0.1cm (default) and a bin width of 1cGy. This resolution is
editable. Make sure you always base the final plan evaluation on the Total Volume DVH.
The volumes of the structures that appear are total volumes. Structures that overlap
belong to both volumes.
When the plan includes bias dose, you can toggle the Total Volume DVH to show the
DVH dose based on the composite plan or the current plan when you select/clear the base
plan Dose check box on the Beam Visibility control.
Figure 91: Beam Visibility control
5.8.2 Optimized DVH
This shows the DVH dose based on the current optimized state of the plan.
This DVH shows only the structures used in the prescription.
The resolution for the Optimized DVH is based on grid spacing. It uses the voxelized
dose grid resolution of the optimized plan to calculate the DVH for these structures.
Optimized DVH also takes into account Structure Optimization Properties such as total
volume DVH and overlapped volumes.
The volumes can be compromised based on the assigned structure properties.
5.8.3 Optimized Total DVH (Bias Dose plans only)
This shows the DVH dose based on the composite plan.
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Evaluating intensity maps and monitor units
This DVH shows only the structures used in the prescription.

It uses the dose grid resolution of the optimized plan to calculate the DVH for these
structures. The volumes can be compromised based on the assigned structure properties.
DVH statistics in the Planning activity always shows the total volume DVH, not the
NOTE
Optimized DVH structure volumes.
5.9 Evaluating intensity maps and monitor units
To evaluate the intensity map and point MUs, you must first show the Fluence view. In
Planning and QA activities, you can show the Fluence view when you right-click inside a
BEV window and select Show Fluence view. At the end of stage one or two, you can
review the intensity map for each beam/sequence.
5.9.1 Review segments and monitor units for each segment
After the constrained aperture optimization is complete, you can review the segments
created in a BEV window.
Figure 92: Example of a static segment in a BEV
Toggle through the beams or sequences and segments. Use the controls on the Fluence
group on the Planning ribbon.
For more information about the Fluence group on the Planning ribbon, see the Planning
ribbon section in the IMRT Tools lesson of this training module.
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5.9.2 Using the Fluence Statistics
The fluence statistics gives information regarding monitor units for each fraction for each
beam/sequence. On the Plan Options ribbon, click Fluence Statistics.
This opens the Fluence Statistics dialog box.
Figure 93: Fluence Statistics dialog box
The Area of the fluence appears for each beam/sequence. Take the square root of this
value to derive the blocked equivalent square of the fluence map.
The point-wise Minimum, Maximum and Mean MU for each beam/sequence appear here
along with the Standard Deviation. Use these values to determine dose delivery
efficiencies.
The mean fluence is the sum of the fluences of the segment in MU weighted by their area,
divided by the total area covered by all segments of this beam/sequence. Monaco can
interpret this as the MU of this segment if it is an un-modulated field.
A larger standard deviation typically translates to a more modulated beam/sequence with
more monitor units required to deliver the treatment, and therefore a longer beam on time.
Total MU for each beam/sequence is also shown.
The Total number of Monitor Units and Mean Monitor Units for the entire plan also
appear at the bottom of this dialog box.
5.9.3 Using fluence statistics to evaluate dose efficiencies
Make use of the fluence statistics after either stage of optimization to evaluate plan
delivery efficiencies. Consider this example: We created three plans with superficial
targets and used the same number of beams and beam arrangements. But, one plan used
Auto Flash, another used Surface Margin, and the third plan used neither. The fluence
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Plan analysis tools
maps and applicable fluence statistics for beam one of each plan appear below with
comments.
Error! Objects Fluence Statistics

cannot be created
from editing field
codes.
Figure 94: Auto Flash ON
A plan with Auto Flash (cm) produces reasonable monitor units for each fraction and a
small standard deviation. The fluence is slightly hotter in the build-up region as shown on
the left side of the fluence map. Application of this tool gives a uniform distribution in the
build-up region.
Fluence Statistics
Figure 95: Surface Margin On
A plan using Surface Margin produces reasonable monitor units for each fraction and a
small standard deviation. The fluence is fairly homogeneous.
Fluence Statistics
Figure 96: Neither Auto Flash ON or Surface Margin On
A plan that does not use these tools produces a large number of maximum monitor units
and a large standard deviation. The fluence is very hot in the build-up region as shown on
the left side of the fluence map. Without the proper application of structure optimization
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What is next
properties or global parameters, you can produce plans that create too many monitor units
for each fraction and therefore inefficient beam-on times.
5.10 What is next

 Apply general suggestions for improving plan results.
 Evaluate performance issues.
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Monaco planning suggestions
6 Monaco planning suggestions
Description Page
6.1 Scope and objectives ................................................................................................ 108

6.2 Target coverage ........................................................................................................ 108
6.3 IMRT beam arrangement .......................................................................................... 109
6.4 Number of arcs ......................................................................................................... 109
6.5 Prescription .............................................................................................................. 110
6.5.1 General suggestions........................................................................................................ 110
6.5.2 Tips when creating target volume prescriptions ............................................................ 110
6.5.3 Tips when creating organ at risk prescriptions ............................................................... 112
6.5.4 Controlling hot spots and conformity using quadratic overdose ................................... 112
6.5.5 Using biological cost functions to control dose .............................................................. 113
6.5.6 Controlling mean dose in OARs ...................................................................................... 114
6.6 Performance............................................................................................................. 114
6.6.1 Grid spacing .................................................................................................................... 114
6.6.2 Statistical Uncertainty Per Calculation vs. Per Control Point ......................................... 114
6.6.3 Pilot beamlets ................................................................................................................. 115
6.7 What is next ............................................................................................................. 115
The planning suggestions reviewed here are general suggestions for planning and
troubleshooting in Monaco. After you complete this lesson, you will be able to:
6.2 Target coverage
If you do not have good target coverage superiorly and inferiorly after optimization, make
sure your grid spacing is at least as small as, or slightly smaller than your CT slice
spacing.
You cannot influence the overall target dose homogeneity by target dose penalties alone.
If the target dose is not homogenous enough, either reduce normal tissue sparing, or add
more beams or sequences.
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6.3 IMRT beam arrangement
 For non-concave targets, any standard arrangement that used for regular 3D
planning is sufficient, since the modulation improves on the dose distribution.
Five (5) evenly spaced beams is a good place to start.
 For concave targets, you are more likely to require more beams to shape the dose
distribution around the target. Seven to nine (7 to 9) beams usually work.
 At least fifteen (15) degrees of separation between beams is a general rule of
thumb for beam independence.
 Use a BEV to find beam angles that yield the best separation between target and
critical structures.
 In general, the more beams you use, the fewer total segments Monaco generates.
6.4 Number of arcs
There are two ways to set multiple arc rotations in Monaco. One is to have two or more
beams in the Beam spreadsheet. Monaco does not permit duplicate beams. For example,
if all parameters are the same, one must be defined clockwise and the other counter-
clockwise. The advantage of this method is to allow collimator or floor rotations to vary
the increment settings for each beam. This method is an appropriate choice for cases such
as SBRT.
The second method is to allow two rotations of the same beam. This is done by setting the
Max Number of Arcs to greater than one. This automatically rotates the beam twice.
Double the rotation does not mean double the delivery time. The number of segments
does increase, but the number of MUs is relatively the same. This method can be useful in
cases such as a prostate with nodes. Monaco essentially splits the fluence through central
axis. On one rotation, Monaco optimizes one half of the volume. With the second
rotation, Monaco optimizes the other half.
Figure 97: Two arc rotations of the same beam.
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Prescription
The effect of the two plans is seen below:
Figure 98: Effect of two arc rotations of the same beam.
6.5 Prescription
6.5.1 General suggestions
 For best results, add all targets and dose limiting organs at risk to the prescription
control at once and assign cost functions.
 You must have at least one objective and one constraint to optimize.
 You must use at least one of the two target objectives (Target EUD or Target
Penalty) in the prescription.
 At least one constraint must have a structure type of External.
 For very small structures (example, optic chiasm, optic nerves), you can create a
1-2 mm expansion margin and use this structure in the prescription. While in plan
evaluation, make sure that you evaluate the actual structure instead of the
expanded structure.
6.5.2 Tips when creating target volume prescriptions
 If you do not want to apply bolus but want dose closer to the surface than what is
achievable, keep in mind normal skin sparing effects and use the Auto Flash
feature with a 5-7 mm margin to improve the coverage. You must still use the
minimum surface margin or clip the target inside the skin to avoid high MU at the
skin surface and a potentially inhomogeneous dose distribution.
 To make sure you have a uniform dose distribution in the target, apply a
Quadratic Overdose penalty on the order of 3-5% above the prescribed dose with
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Prescription
a 0.5 – 1.5% RMS. In general, the smaller the target volume, the smaller the
isoconstraint value for the Quadratic Overdose.
 When you have overlapping or close target volumes with different prescriptions,
you can apply a shrink margin to the Quadratic Overdose cost function of the
target with the lowest dose to achieve a transition dose gradient between the two
structures (highlighted in yellow below).
 Due to the higher dose gradient in the area where higher dose and lower dose
targets abut (highlighted in yellow), unacceptable cold spots in the lower dose
target can occur in areas further away from the high dose target. When you have
overlapping or close target volumes with different prescriptions, you can increase
the isoconstraint of the Target EUD to the lower dose target(s) about 2 Gy. This
makes sure that you received an acceptable dose gradient through the lower dose
target.
Figure 99: Transition area
 When you have overlapping or close target volumes with different prescriptions,
it can be useful to apply a second Quadratic Overdose penalty to the target with
the lower dose with a 0 cm Shrink Margin. Assign a prescribed dose to the lower
dose target that is equivalent to or slightly lower than the prescription of the
highest target dose and assign an Isoconstraint value of 0.1 Gy. This lets you
have an appropriate dose gradient inside the lower dose target and keeps the hot
spot inside the target with the highest dose.
 Understand that when you use EUD cost functions, it is possible that resulting
cold spots in a target can be compensated by hot spots in another area of the
target. This is the nature of EUD usage. Smaller isoconstraint values on the
Quadratic Overdose cost function for the target can help to limit the range of hot
to cold voxels. If the target is large, you can split the target into two separate
structures and use the same prescription for both.
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Prescription
 To avoid the incidence of EUD generated hot spots in the target, you can use the
Target Penalty dose objective option. Because it is a non-EUD based physical
dose objective, you can achieve lower hot spots.
6.5.3 Tips when creating organ at risk prescriptions
You can add a Serial cost function to a parallel OAR in addition to a Parallel cost function
to reduce hot spots in that structure.
6.5.4 Controlling hot spots and conformity using quadratic overdose
6.5.4.1 Hot spots
Occasionally, hot spots are created near a target volume, but not inside. To avoid any hot
spots created near a target, try the prescription tip below:
Apply a Quadratic Overdose penalty to the structure defined as the patient with a
Maximum Dose (cGy) equal to 2/3 of the highest target volume prescription. Type an
isoconstraint value of ~0.3 Gy above the maximum dose. Apply a Shrink Margin (cm) to
this cost function of 1.5 cm to control the dose just beyond the target volume.
Figure 100: Target with margins
If you still have a hot spot that is in normal tissue and not in the target, you can apply a
second Quadratic Overdose penalty to the patient structure with a Maximum Dose (cGy)
equivalent to the target prescribed dose, a small prescription isoconstraint value, and zero
(0 cm) Shrink Margin. The first cost function controls the doses 1.5 cm beyond the target.
The second cost function works to control any high dose that tries to escape the margins
of the target volume.
Quadratic Overdose can be useful to control high doses in an overlap region such as the
rectal or bladder wall where there is overlap with the PTV. Apply the quadratic overdose
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Prescription
to the OAR with a maximum dose of about 103% with a small RMS of 2-5cGy and use
Optimize over all voxels in volume so the cost function can work in that high dose
region.
6.5.4.2 Conformality
You can apply additional Quadratic Overdose penalties on the patient structure with a
series of stepped shrink margins to further conform the dose. The shrink margins are used
instead of optimization contours. Start with values close to the PTV with small RMS
values.
An example on a typical prostate patient is to assign the first Quadratic Overdose to the
same value as the target with no shrink margin. This keeps the target dose inside the
target. The second Quadratic Overdose is set to a smaller dose value and has a shrink
margin of .9 cm. Add a third Quadratic Overdose of an even smaller dose volume with a
shrink margin of 2.4 cm.
You can adjust the values is Stage 1 until weight and relative impact values tell you the
cost functions are effective.
6.5.4.3 Controlling global maximum dose
To control the global maximum dose, you can apply the Maximum Dose cost function to
the external contour with apply over all voxels selected. This applies a global ceiling to
the optimization. Values of 107-110% depending on complexity work well. As this is a
hard constraint, if this value is too tight you put a limit on possible solutions and can lose
target coverage.
6.5.5 Using biological cost functions to control dose
You can use the biological cost functions to help shape your dose distribution to avoid
normal tissue complications. For example, to prevent fibrosis of the entire rectum, use
either the Serial cost function with a middle range Power Law Exponent such as 12 or a
Parallel cost functions with a shrink margin to create a steep dose gradient and spare the
posterior rectal wall.
For structures, such as lung and parotids, you can apply a Serial cost function with a
Power Law Exponent (k) of 1 to distribute the penalty equally in the volume to control the
mean dose. In this case, apply a shrink margin if the OAR overlaps with a target volume
to avoid cold spots in the target volume.
Parallel cost functions act similarly to DVH Point Dose constraints, but also work on the
OAR volume rather than just a specified point. Use them to prevent side effects
associated with lower radiation doses. You can also use the Parallel cost function to
prevent such side effects as, for example, Parotid: Salivary Gland function and Rectum:
Diarrhea.
Monaco does not limit you to a single dose constraint for OARs. There can be multiple
dose ranges to control for each OAR. Therefore, it can be useful to apply multiple cost
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Performance
functions, Serial and/or Parallel. You can control the high and low dose regions as well as
the mean dose when you use multiple cost functions together. When you use the
appropriate Power Law Exponent values and shrink margins, they help direct the penalty
towards specified doses in the OAR volume so you can achieve optimal plan quality.
6.5.6 Controlling mean dose in OARs
If you need to reduce mean dose, you can add an additional Serial cost function to the
structure with a k value of 1. This Serial cost function effectively controls the mean dose
in the structure.
Figure 101: Serial cost function
6.6 Performance
6.6.1 Grid spacing
Use smaller grid spacing (0.3 cm or less) when the structures are smaller (example,
H&N). Use larger grid spacing (0.4 cm) when the structures are larger (example,
Prostate). Calculation time increases with smaller grid spacing.
6.6.2 Statistical Uncertainty Per Calculation vs. Per Control Point
If you use Statistical Uncertainty Per Calculation, it results in a faster calculation than the
Per Control Point option.
It is possible to decrease calculation times for VMAT plans if you use a higher Statistical
Uncertainty Per Calculation value for initial planning. For the first iteration of stage one
and stage two, select a higher Statistical Uncertainty than what is recommend for clinical
use. When the final plan is calculated, change the Statistical Uncertainty Per Calculation
to a lower, more clinically acceptable value. The segmented plan automatically begins a
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What is next
re-calculation and returns the new results. Then select Skip Forward when it becomes
available to return the “Segmentation Complete” message. The recommended values are
2-3% for each plan for initial planning followed by 1% for the final calculation.
Please note that as a consequence of using a higher statistical uncertainty, you must
review all aspects of the plan which includes dose distribution and DVH to make sure the
plan is acceptable. If you use a higher Statistical Uncertainty, dose to small structures can
be affected.
6.6.3 Pilot beamlets
The Pilot Beamlets option is available if you select Segment Shape Optimization.
Monaco uses pilot beamlets to guide the segment shape changes made during Segment
Shape Optimization (SSO). Monaco creates a large number of pilot beamlets if you use
large highly modulated treatment fields, multiple VMAT arcs and a small arc increment.
Pilot beamlets are stored in memory. When a large number of pilot beamlets are created
they can use all the RAM the system has. This slows the process exponentially. If you
disable this option, pilot beamlets are not created in the SSO process. Pilot beamlets do
not affect performance for the majority of treatment plans. Disable them if the plan takes
a long time to converge.
6.7 What is next

 Understand what Bias dose is.
 Know how to create a plan using Bias dose.
 Identify Bias dose planning tips.
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Bias dose
7 Bias dose
Description Page

7.2 General workflow for creating a bias dose plan from a base plan ............................... 116
7.3 Bias dose planning with Multiple Rx .......................................................................... 118
7.4 Bias dose planning tips ............................................................................................. 119
7.5 What is next ............................................................................................................. 120
Bias Dose lets you make composite plans by loading previous plan dose files in to a new
plan. This allows you to account for previously planned doses during optimization. After
you complete this lesson, you will:
7.2 General workflow for creating a bias dose plan from a base plan
These steps provide a high-level overview on how to create the bias dose plan from an
existing base plan.
1. Right-click a base plan and select New Bias Dose Plan.
The system adds a yellow B next to the plan in the Workspace control to designate it as
NOTE
a base plan.
2. Create a new plan with a template.

3. Enter the prescription for the bias plan only.
4. In the IMRT Prescription Parameters dialog box, place a checkmark adjacent to the
prescription(s) to contribute dose to the Bias Dose plan.
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Bias dose
General workflow for creating a bias dose plan from a base plan
Figure 102: IMRT Prescription Parameters dialog box | Bias Contribution
5. From the IMRT Constraints control, make these changes:

a. Clear the check box under Bias Dose for all cost functions on the Target(s) and
the patient. Select Bias Dose for all other OARs. This lets you achieve a
homogenous dose distribution over the secondary target with uniform dose fall
and also lets you use total prescription limits on the OARs.
b. Scale the Quadratic Overdose for the Target(s) to reflect only the Bias Dose
prescription.
c. Scale the Quadratic Overdoses on the patient structure to for the values that only
apply to the Bias Dose plan.
d. All other structures reflect values for the composite plan. Elekta recommends that
you leave these values first, then optimize and see where you need to make
adjustments.
Figure 103: Example IMRT Constraints
6. Start optimization and dose calculation.

7. Review plan and make changes as necessary to achieve desired plan objectives.
8. Toggle the Total Volume DVH to show the DVH dose based on the Composite plan
or the Current plan when you select/clear the Base plan dose on the Beam Visibility
control.
9. (Optional) Save the current plan or the composite plan when you select or clear the
Include Base Doses check box.
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Bias dose
Bias dose planning with Multiple Rx
A Composite plan displays with a yellow plus sign in the Workspace control:
Composite Plan (Bias Dose)
Composite Plan (With Dose)

When you approve a Bias Dose plan, the system only approves for the current plan.
7.3 Bias dose planning with Multiple Rx

These steps provide an overview of how to create a Bias dose plan with Multiple Rx
1. Create a single Rx plan and save as a template.
2. In the prescription tab select Add Rx and use Rx A template.
3. Enter the prescription for Rx B.
4. In the IMRT Constraints tab select the IMRT Parameters.
5. Check Rx A in Bias Contribution and OK.
6. In the IMRT Constraints tab uncheck Bias Dose for the Target and Patient cost
functions. Excluding the Maximum cost function if in use.
7. Edit the cost function values of the Target and Patient to reflect the current Rx plan
dose.
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Bias dose
Bias dose planning tips
8. Ensure the OAR constraints are clinically relevant to the combined dose of all
prescriptions.
9. Calculate the plan and adjust if necessary.
10. Evaluate the plan using the Optimized DVH, Optimized total DVH, and Total
volume DVH options.
11. Review your individual and composite plan by turning the dose on/off in the beam
visibility tab. This will also automatically update the display in the Total volume DVH
7.4 Bias dose planning tips
 Base plans must have dose to be used in Bias Dose planning.

 You can use multiple studysets for Bias Dose, but they must be fused first. Refer
to the Monaco Basics Training Guide for information on the Fusion activity.
 When planning the base plan, you want to lower your OARs as much as is
feasible to make sure that you meet your composite OAR goals. Plan the smaller
volume first as this is the easier plan to control OAR doses on. Plan with the total
prescription. When finished, to rescale your plan, change the number of fractions
appropriately. The dose automatically updates. Save the plan. When you start a
bias dose plan with this plan as the base plan, the IMRT constraints you used are
defaulted so there is less editing and cross multiplying required to enter
appropriate values for your biased OARs.
 For the Bias dose plan, with the change in target volume, the volume of the OARs
that you prescribe to can change, also the proximity of OARs to the target can
change. For some structures you need to loosen your constraints to avoid
conflicts, others you can tighten. Conflicts are indicated by a status of
‘infeasible’.
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Bias dose
What is next
7.5 What is next

 Be able to create MR plans using MR studysets (Transverse and oblique).
 Understand the differences between MR planning and CT planning.
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Planning on MR Studysets
8 Planning on MR Studysets
Description Page

8.2 MR studysets............................................................................................................ 121
8.3 Creating a plan from a MR studyset .......................................................................... 121
In Monaco, you can create plans from MR transverse or oblique studysets. After you
 Create MR plans using MR studysets (Transverse and oblique).
 Understand the differences between MR planning and CT planning.
8.2 MR studysets
You can use oblique and transverse MR Images to create treatment plans. If you use
oblique images you can contour on the oblique images and copy the contours to a
transverse studyset for planning purposes. If you use a transverse studyset you can both
contour and plan on the studyset. See the Monaco Basics Training Module for
information on the Fusion activity.
8.3 Creating a plan from a MR studyset
Creating a plan from an MR studyset follows the same workflow as creating a plan from a
CT studyset with only a few exceptions:
 When you create a New Monaco Plan, you must acknowledge the message that
“All Structures are set to Force ED for Planning”.
 You can change the Relative ED of structures from the default value of 1.00
(such as femoral heads in the pelvis)
 When planning off an oblique MR studyset:
 First fuse the MR with a transverse CT study set.
 Load MR as primary.
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Planning on MR Studysets
Creating a plan from a MR studyset
 Contour structures on the MR studyset.

 Copy structures to the CT studyset.
 Load CT as primary.
 Create desired plan using associated Monaco workflow.
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Appendix A
Description Page
Abbreviations ..................................................................................................................... 123

More resources................................................................................................................... 124
Business policies ................................................................................................................. 124
Confidentiality ............................................................................................................................. 124
Disclaimers ................................................................................................................................... 124
Abbreviations
Abbreviation Definition
BEV Beam’s Eye View
CF Cost Function
CP Control point
CV Constraint Violation
DCAT Dynamic conformal arc therapy
DRR Digitally reconstructed radiograph
dMLC Dynamic multileaf collimator
DVH Dose volume histogram
ED Electron density
EUD Equivalent uniform dose
IMRT Intensity modulated radiation therapy
mArc Modulated arc
MLC Multileaf collimator
MU Monitor unit
OAR Organ at risk
PLE Power law exponent

PTV Planning target volume
QA Quality assurance
RMS Root mean square
SSO Segment shape optimization
SU Statistical uncertainty
VMAT Volumetric modulated radiation therapy
More resources
This training module does not replace the Monaco Online Help system. The Help system
gives in-depth information on all available Monaco features.
Elekta Care Community is the dedicated online support system of Elekta to help you get
the most from your Elekta management system. It contains installation and
troubleshooting documents, training manuals, upgrade checklists, downloadable software
tools, as well as access to Learning@Elekta which offers eLearning opportunities.
The Monaco 5.11.02 Training Guide contains a variety of IMRT/VMAT training
exercises. The exercises listed are only examples. There are many ways to create
IMRT/VMAT plans in Monaco.
NOTE: Your Elekta service agreement shows your access levels.
Business policies
Confidentiality
The information in this module is for the sole use of Elekta personnel, authorized users
and Licensees of Elekta, Inc. products, and for no other purpose.
Disclaimers
 Elekta does not accept liability if you use this module after a change, not
approved by Elekta, is made to the contents or format.
 Elekta is careful to verify that the information in this module is truthful and
accurate, but it does not accept responsibility or liability for possible errors or
omissions.
 Elekta reserves the right to make changes to the product, without notice, to
improve the reliability, function, or design.
 Elekta supplies this module without warranty, implied or expressed, including,
but not limited to, the implied warranty of merchantability and fitness for a
particular purpose.
 The examples and exercises used in this training module are for illustrative
purposes only and are in no way to be construed as Elekta acting in any way to
provide medical direction or advice.
 The information included in this training guide is not intended to replace or to be
a substitute for the knowledge, expertise, skill, and judgment of a qualified
healthcare professional.
 The professional duty to the patient in providing healthcare services lies solely
with the healthcare professional providing patient care services.
 Full responsibility for the use of information provided in this training guide
resides with the healthcare professional providing patient care services.
www.elekta.com Human Care Makes the Future Possible

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Monaco 5.51.02 E009383 / 1.01

1 Monaco concepts IMRT/VMAT ................................................................................................ 8

2 IMRT constraints .................................................................................................................... 21

3 IMRT tools .............................................................................................................................. 59

5 Plan analysis tools .................................................................................................................. 91

6 Monaco planning suggestions .............................................................................................. 108

7 Bias dose............................................................................................................................... 116

8 Planning on MR Studysets.................................................................................................... 121

Appendix A ................................................................................................................................ 123

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Key features include:

Training module description

Scope and objectives

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 Describe Monaco’s optimization process.

Licensing and security rights

Training and support references

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Monaco IMRT/VMAT general workflow

Figure 1: IMRT/VMAT General Workflow

Figure 1: IMRT/VMAT workflow

Date New Item Description Section Author

2019-09- New Document L. Bode

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1 Monaco concepts IMRT/VMAT

1.1 Scope and objectives .................................................................................................... 8

1.1 Scope and objectives

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1.3 Setup beams for portal imaging

You can create setup beam plans in Planning Activity.

1.4 Considerations before starting an IMRT/VMAT plan

1.4.1 Standardize planning

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Figure 2: Manage Templates

For more information on how to create/edit/delete templates, refer to the Monaco 3D

1.4.2 Machine energy

1.4.3 Voxelization of patient

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1.4.4 Hot spots

1.5 Status messages

1.6 Definition of terms as they apply to IMRT arc planning

It is important to understand some terms as they apply to IMRT arc planning.

Figure 3: Increment setting on the Geometry tab

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Figure 4: Console showing ray (sector) creation

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Figure 5: Full 360 Degree Arc

Figure 6: Partial 300 Degree Arc

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1.6.3 Sweep sequencer

1.6.4 Control point

1.6.5 Arc segment

Figure 7: Fluence group

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Figure 8: Arc Segment

Figure 9: BEV of Arc Segment

1.6.6 Dynamic segments with static gantry