CK Precision 3.3.x Manual

Treatment Planning
Manual
Version 3.3.x
Accuray Precision® Treatment Planning System

Date of Revision: 2021-07
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Accuray Precision® Treatment Planning System
Treatment Planning Manual
1072963-ENG B Ac cur a y Pr ec isio n® T r ea tm en t P l an nin g S yste m i

Customer Support
For more information, to request documentation, or if you have a service issue, please contact Accuray
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NOTE: If your facility works with a third-party service provider, please contact them directly for
your service-related issues.
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1072963-ENG B Ac cur a y Pr ec isio n® T r ea tm en t P l an nin g S yste m i ii

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With proper care and maintenance, the expected service life of the Accuray System is 10
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The Accuray System, including each computer workstation and associated system soft-
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ating system updates. Any effect on the safe and intended operation of the Accuray System
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Hardware and Software Maintenance

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If you feel that Accuray System hardware components or associated features or functions
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Use of Third-Party Software

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Source code for an applicable open source software component is available upon written
request. Automatic image registration is based on routines in Numerical Recipes: The Art
of Scientific Computing, published by Cambridge University Press, which are used with
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Instructions for Use of the Accuray System

Safe operation of the Accuray System requires careful attention to the serious hazards
associated with the use of linear accelerators and complex radiation therapy equipment
and ways to avoid or minimize the hazards, and familiarity with emergency procedures.
Untrained or careless operation of the Accuray System can damage the system, its compo-
nents or other property; cause poor performance; or lead to serious bodily injury and
possibly death. Anyone who operates, services, maintains, or is otherwise associated with
the Accuray System must read, understand, and be thoroughly familiar with the information
in this manual, and take precautions to protect themselves, their associates, patients, and
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the equipment. At each step in the installation, specific warnings and cautions are given for
specific actions.
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research or clinical purposes. Accuray System documentation was originally drafted,
approved, and supplied in English (US).
The following statements are intended to alert the user to potential conditions that could
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(caution).
Warning Warning statements describe possible conditions that can result in serious or fatal
injury to the patient or facility personnel. Each warning gives the possible
condition and how to avoid it.
Caution Caution statements describe possible conditions that can affect system
performance or cause damage to system components. Each caution gives the
possible condition and how to avoid it.
Prescription Device Statement
CAUTION: Federal law restricts this device to sale by or on the order of a physician.
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Contents
Chapter 1 Overview
Use of the Accuray Precision® Treatment Planning System
 Indications for Use 3
 Intended Use 3
 Requisite Hardware and Software 4
 Clinical Benefits 4
 Performance Characteristics 4
 Performance Efficiency 5
 Undesirable Side Effects 5
 Residual Risks 5
 Accuray Precision System Workstation Specification 6
 Workstation Storage and Handling 6
 System Label 7
 Symbols 7
 System Compliance 9
 Use of Unapproved Equipment 9
 Accuray Cybersecurity Information 10
 Virus Protection Software, Network, and Firewall 10
 Documentation List for Accuray Precision Treatment Planning
System 11
 Accuray Precision MD Suite Application (Option) 12
Logging On
 Log On to the Accuray Precision System 13
 Change Password 14
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Home Page
 Overview 15
 Patients and Plans Icons 17
 Administration Icons 18
 System Icons 21
Overview of the Accuray Precision System
 Overview 23
 Screen Layout 25
 Task Bar 26
 Windows Controls 27
 Step Bar 27
 Global Tool Bar 27
 3D Visualization 31
 Capture Screen Image 35
 Save Plan 37
 Printing Reports 37
 Reports 39
 Reports Viewer 39
 Patient Information 41
 VOI Visibility Options 42
 Multiple Sessions 45
 Status Bar 47
 Basic Data Panel 47
 Image Viewer 48
 Display Layouts 52
 Keyboard Controls 54
 Exporting DICOM Data Overview 55
 PreciseART® and PreciseRTX® for MIM 59
Chapter 2 Treatment Planning

About Loading Images
 Criteria for Secondary Image Series 62
 Loading PET Images 62
 DICOM RT Structure Sets 65
 Loading DICOM Data 65
 Loading Alignment MVCT/kVCT (Tomo only) 65
 Longitudinal Resampling 66
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Treatment Planning Applications
 Creating a New Plan 68
 Monte Carlo Plan 77
 QA Plan 77
 Add Fraction Plan 77
 Loading an Existing Plan 78
 Loading an Inconsistent Plan 78
 Loading a MultiPlan Plan (CyberKnife Only) 80
 Loading a Conformal Plan (CyberKnife Only) 80
 Loading a 4D Plan (CyberKnife Only) 80
 Makeup Plan (CyberKnife Only) 80
 Deleting a Plan 84
 Plan Recovery 85
 Commissioning Tools (CyberKnife Only) 86
Plan Transfer (Tomo® Only)
 Machine Transfer 87
 Self Transfer 88
 Mark As Equivalent 89
 Review Transferred Plans 90
Chapter 3 Commissioning Tools (CyberKnife Only)
Section 3-1 Commissioning Requirements and Reports

Introduction
 Before You Begin 94
Commissioning Requirements
 Beam Data Requirements 95
Commissioning Reports
 Reports Viewer 97
 Commissioning Report Types 98
 Generate a Report 101
 Switch Viewing of Single View Reports 102
 Close a Report 102
 View Two Reports One Above the Other 102
 View Two Reports Side by Side 103
Section 3-2 Fixed and Iris Collimator Commissioning
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Commissioning Tools: Ray-Tracing Dose Calculation
 Overview 106
 Viewing and Printing Beam Data Tables 106
 OCR Step 108
 TPR Step 114
 OF Step 120
Commissioning Tools: Monte Carlo Dose Calculation
 Overview 126
 MC Source Step 126
 MC TPR & OCR Step 135
 MC OF Step 147
Section 3-3 Multileaf Collimator Commissioning

Overview
 About MLC Commissioning 154
 Graphics Tools for OCR, TPR, OF, and Open Beam Profile 154
Commissioning Tools for the Finite Size Pencil Beam
Calculation
 Overview 157
 Viewing and Printing the MLC Beam Data Tables 158
 MLC OCR Step 159
 MLC TPR Step 161
 MLC OF Step 164
 MLC Open Beam Profile Step 166
 MLC PB Model Step 169
 MLC Final Approval Step for Patient Plans 173
Commissioning Tools for Monte Carlo Dose Calculation
for Multileaf Collimator
 MC Source Step 176
 MC TPR Step 182
 MC OCR Step 187
 MC OF Step 193
 MLC Final Approval Step for Patient Plans 196
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Chapter 4 QA Plans
Section 4-1 QA Plans for Tomo®

About QA Plans
 Creating a QA Template Plan 202
 Creating a QA Plan 203
 Auto Registration 206
Register Step
 Tools 208
 Manual Registration 209
Machine Step
 Tools 211
Phantom Step
 Tools 213
Review Step
 Tools 215
 Dose Calculation 216
 Calculate Dose Per Beam (TomoDirect Only) 216
 Saving a QA Plan 217
Confirm Angles Step
 Tools 219
 Validate 221
MultiSlice Step
 View Multiple Planar Slices 223
Loading a QA Plan
 Load a QA Plan to Review 225
Section 4-2 QA Plans for CyberKnife

About QA Plans
 Creating a QA Template Plan 228
 Creating a QA Plan 229
 Auto Registration 232
Register Step
 Tools 234
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 Manual Registration 235
Align Step
 Tools 238
 Define the Alignment Center 238
Finetune Step
 Tools 240
 BEV Display 243
 Finite Size Pencil Beam Dose Calculation 244
 List Tools 244
 Nominal Position 247
Review Step
 Tools 249
 Rescaling the MUs for a QA Plan 251
 Saving a QA Plan 252
MultiSlice Step
Beams Step
 About the Beams Step 255
 Print the Beam Data List 256
Loading a QA Plan
 Load a QA Plan to Review 258
Chapter 5 Fuse Task

Setup Step
 Tools 260
Register Step
 Tools 262
 Loading Pre-registered Image Series 263
 Registration Using Seed Points 264
 Rigid Image Registration (Seedless) 267
 Deformable Image Registration (Optional) 268
 Copying a Registration 269
Manual Fuse Step
 Tools 271
 Perform a Manual Fusion 272
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Chapter 6 Contour Task
Manual Step
 Tools 275
 Image Viewer 276
 Appearance of Contours 277
 Select VOI 281
 Drawing Tools 284
 VOI Operations 289
 Options 294
 Import VOIs 295
 Templates 295
 Import Dataset 296
 Create VOI from Isocurve 297
 Guideline to Avoid Unexpected Skin Reactions 297
Autosegmentation Step
 Brain Autosegmentation 299
 Male Pelvis Autosegmentation 303
 Head and Neck Autosegmentation 317
Skin Step
 Tools 320
 Assigning and Modifying Skin Structures 321
Spine-Tracking Step
 Delineate a Spine Tracking Volume 322
Ball-cube Step
 Delineate the Ball-cube 324
Chapter 7 Setup Task
Section 7-1 Setup Task for Tomo®

Machine Step
 Tools 331
 Density Models 334
 Couch Replacement 340
Patient Step
 Tools 343
 Move Patient 344
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 Move Red Lasers 344
Synchrony Method
 Overview 345
 Simulation Plan 345
Fiducials Step
 Tools 349
Angles Step
 Tools 352
 Imaging Angles - Presets 354
 Imaging Angles - Display Colors 354
 Prevalidate 355
 View Options - Score Wheel 356
Section 7-2 Setup Task for CyberKnife

Machine Step
 Tools 358
 Density Models 361
 InTempo Adaptive Imaging System (Option) 366
 Synchrony Methods and Patient Positions 368
Fiducials Step
 Tools 371
 Identify Fiducials 371
Align Step
 Tools 374
 Define the Alignment Center 374
DRR Review Step
 Tools 376
 Default Mode 377
 Generating DRR Images 377
Chapter 8 Plan Task
Section 8-1 Plan Task for Tomo®

Plan Task Controls
 Isocurves Legend 382
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 Isocurves Pane 383
 Prescription Dose 385
 Dose Volume Histograms 386
 Plan Statistics 389
 Display Tab 391
Optimize Step
 Tools 393
 Saving a Script 394
 Loading a Script 396
 Match VOI Names 397
 Deleting a Script 398
 Field Width 399
 Pitch 399
 Modulation Factor 400
 Prescription 400
 Target Objectives 401
 Critical Constraints 403
 Dose Statistics Table, Dx Vx Values, Plan Information
and Dose Points 404
 Optimization Procedures (IMRT) 408
3DCRT Dose Calculation
 Tools 411
 Perform 3DCRT Dose Calculation 411
TomoDirect Plans
 Beam Angle Step 413
Forward Planning (TomoDirect Only)
 Beam Angle and Field Tables 417
 Tools 419
 Beams Eye View 420
 Dose Group 422
 Display Tab 423
 Create a Plan Using Forward Planning 423
Section 8-2 Plan Task for CyberKnife

Plan Task Controls
 Dose Calculation Box 426
 Isocurves Legend 428
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 Collimators (Fixed and Iris Collimators Only) 434
 Scripts 436
 Auto-shells 440
 Dose Volume Histograms 442
 Plan Statistics 445
and Dose Points 447
 Prescription 452
Settings Step
 Overview 455
 Tools 456
 Setting Step Procedures 458
Isocentric Step
 Tools 461
 Isocentric Planning Procedures 462
Sequential Step
 About Sequential Optimization 465
 Display 466
 Tools 466
 MLC Settings (MLC only) 478
 Relaxed Convergence 479
 Time Reduction 479
 Beam Reduction 481
 Node Reduction 482
 Segment Reduction (MLC only) 483
 Status Indicators 484
 Dose-Volume Histogram in Sequential Step 485
 Data Saved in a Sequential Optimization Plan 488
 Sequential Optimization Procedures 489
VOLO Step
 About VOLO Optimization 498
 Display 499
 Tools for Multileaf Collimator (MLC) 500
 Tools for Fixed and Iris Collimator 501
 Plan Setup - Max Nodes 502
 Interactive Dose Volume Histogram in VOLO Step 504
 VOLO Optimization for Multileaf Collimator (MLC) 508
 VOLO Optimization for Fixed and Iris Collimators 515
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 VOLO Optimization Procedures 520
Chapter 9 Evaluate Task
Section 9-1 Evaluate Task for Tomo®

Review Step
 Review Step - Tools Tab 528
 Display Tab 534
 Viewing and Printing Reports 535
Confirm Angles Step
 Tools 537
 Validate 540
MultiSlice Step
Compare and Sum Plans Step
 Tools 545
 Perform a Reference Plan Comparison 546
 Perform a Sum Plan Comparison 547
 Create a Summation Report 548
Image Tools
 Dose Probe Box 549
 Isocurves / Dose Difference Panels 549
 Dose-Volume Histogram 554
 Dose Statistics Table 557
 Dx Vx Values 558
 Plan Information 559
 Leaf Open Times 560
 Dose Points 560
Section 9-2 Evaluate Task for CyberKnife

Review Step
 Tools 563
 High Resolution Dose Calculation 564
 Finite Size Pencil Beam Dose Calculation 566
 Setting the Plan Prescription Dose 567
 Reference Point 567
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 Save a Plan 568
 Viewing and Printing Reports 573
 DxVx Criteria 574
 Display Tab 574
MultiSlice Step
 Tools 578
 Perform a Reference Plan Comparison 580
 Perform a Sum Plan Comparison 581
 Create a Summation Report 582
Finetune Step
 Tools 584
 3D Beam Display 588
 BEV Display 588
 Dose Calculation 589
 List Tools 589
Beams Step
 About the Beams Step 595
 Print the Beam Data List 596
 Sorting Order of Beams 596
Image Tools
 Dose Probe Box 597
 Isocurves / Dose Difference Panels 597
 Dose-Volume Histogram 603
 Dx Vx Value 607
 Plan Information 609
 Dose Points 609
Chapter 10 Utilities Task

3D Filter Step
 Tools 612
Flythrough
 Use Flythrough Mode 614
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 Use Dual or Multiple Data Mode 615
3D Presets
 3D Display Options 618
Color 3D Filter
 Use the Color 3D Filter 619
Ball-cube Plan Step
 Overview 621
Chapter 11 Settings Task

Preferences Step
 Display Parameters 624
 Planning Parameters 626
Maintenance Step
 Delete an Image 633
 Delete a Remote Host 634
Plan Template Step
 Tools 636
 Managing Plan Templates 637
 General Tab 640
Plan Template Parameters for Tomo®
 Plan Setup Parameters Tab 642
 Planning Parameters Tab 644
 Evaluate Parameters Tab 645
 VOI Name Matching Tab 646
Plan Template Parameters for CyberKnife
 Planning Parameters Tab 648
 Plan Setup Parameters Tab 651
 Script Parameters Tab 654
 Evaluate Parameters Tab 655
 VOI Name Matching Tab 657
 QuickPlan Tab 659
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Chapter 12 Synchrony® Spine Tracking (CyberKnife Option)
Introduction
 About the Synchrony Spine Tracking 666
 Accuracy of Synchrony Spine Tracking 666
Treatment Planning
 Spine Tracking Volume Segmentation 667
 Tracking Mode Selection 669
Imaging Center Selection
 Guidelines for Setting the ROI Height 671
Chapter 13 Synchrony® Lung Tracking™ with Respiratory

Modeling (CyberKnife Option)
Introduction
 Overview 676
 About the Synchrony Lung Tracking with Respiratory
Modeling 676
Treatment Planning
 Tumor and Spine Tracking Volume Segmentation 677
 Tracking Mode Selection 680
Alignment Center Selection
 Overview 681
 DRR Review 682
Chapter 14 Lung Optimized Treatment (CyberKnife Option)

Simulation Plans
 Before You Begin 690
 Creating a New Dual CT Simulation Plan 693
 Creating a New Single CT Simulation Plan 696
Lung Optimized Treatment
 Accuracy of Spine Supine Tracking 699
 Creating a New Lung Optimized Treatment Plan
Using 2 CTs 699
 Creating a New Lung Optimized Treatment Plan
Using 1 CT 703
 Synchrony Method Selection 706
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 Creating an ITV (1-View and Spine Supine Tracking) 706
 Creating a PTV (1-View and Spine Supine Tracking) 709
 Align Center Selection 710
 DRR Review (Lung with Respiratory and 1-View Tracking) 712
 ITV and PTV Evaluation 720
Chapter 15 PreciseART® and PreciseRTX® (Option)

PreciseART® (Tomo® Only)
 PreciseART® Replanning 724
 Accessing PreciseART® 725
 Enrolling a Plan in PreciseART® 725
PreciseRTX®
 PreciseRTX® Workflow 728
 Exporting Dose and VOIs to PreciseRTX® Session 732
Appendix A Warnings, Errors, and Messages

Tables
 Table 1 736
 Table 2 758
 Table 3 770
 Table 4 771
 Table 5 800
Appendix B Glossary
Acronyms and Definitions
 Table 812
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Chapter 1
Overview
Use of the Accuray Precision® Treatment Planning System 3
Logging On . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Home Page. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Overview of the Accuray Precision System. . . . . . . . . . . . 23
WARNING: Treatment plans must be created, approved, and performed by trained

personnel. Use of treatment planning functions by unqualified personnel could
result in patient mistreatment. Users are solely responsible for determining
appropriate data values and treatments for any given situation.
WARNING: Do not attempt to modify a treatment file manually. Improperly changed

data could result in death or injury of the patient.
WARNING: Regardless of the language translation, all numeric data that you enter
or that is displayed in the software uses the period character (.) as a decimal
separator. Be aware of this notation convention when interpreting or entering
numeric data. Incorrect interpretation or entry of numeric data could result in patient
mistreatment.
CAUTION: Do not modify the Accuray Precision® Treatment Planning System

software code or data.
1072963-ENG B C h ap te r 1 : O v er vie w 1
NOTE: The software has limits on numeric values and text that can be entered. In
the event an invalid value is entered, the system will display a range of acceptable
values.
NOTE: The Accuray Precision System includes a check to ensure that the files
used by the software application and the application itself have not been modified.
In the event that either is modified, the system will not start and display an error. If
this occurs, contact Accuray Customer Support for assistance.
NOTE: Any serious incident that has occurred in relation to the device should be
reported to the manufacturer and the competent authority of the Member State in
which the user and/or patient is established. Contact Accuray Customer Support for
more information.
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Use of the Accuray Precision® Treatment Planning System
 Indications for Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 Intended Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 Requisite Hardware and Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
 Clinical Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
 Performance Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
 Performance Efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
 Undesirable Side Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
 Residual Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
 Accuray Precision System Workstation Specification . . . . . . . . . . . . . . . 6
 Workstation Storage and Handling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
 System Label. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 Symbols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
 System Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 Use of Unapproved Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 Accuray Cybersecurity Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
 Virus Protection Software, Network, and Firewall . . . . . . . . . . . . . . . . . 10
 Documentation List for Accuray Precision Treatment Planning System 11
 Accuray Precision MD Suite Application (Option) . . . . . . . . . . . . . . . . . 12
 Indications for Use

The Accuray Precision Treatment Planning System is indicated for creation
and assessment of external photon beam irradiation treatment plans for
radiation therapy, stereotactic radiotherapy or stereotactic radiosurgery for
lesions, tumors and conditions anywhere in the body when radiation
treatment is indicated. A treatment plan provides an estimate of the dose
distribution and the parameters utilized by the radiation delivery system.
Plans must be reviewed and approved by qualified medical practitioners
prior to delivery.
 Intended Use
The Accuray Precision Treatment Planning System is indicated for creation
and assessment of external photon beam irradiation treatment plans for
radiation therapy, stereotactic radiotherapy or stereotactic radiosurgery for
lesions, tumors and conditions anywhere in the body when radiation
treatment is indicated. A treatment plan provides an estimate of the dose
distribution and the parameters utilized by the radiation delivery system.
Plans must be reviewed and approved by qualified medical practitioners
prior to delivery.
The Accuray Precision Treatment Planning System is intended to be used
by physicians, medical physicists, and dosimetrists to generate radiation
therapy, stereotactic radiotherapy or stereotactic radiosurgery treatment
plans. Plans may be created with the Accuray Precision Treatment
Planning System for delivery using Intensity Modulated Radiation Therapy
(IMRT) or 3-D Conformal Radiation Therapy (3DCRT) techniques.
The users will be able to create a plan that satisfies established clinical
objectives. For stereotactic radiosurgery, the plan will generally involve
delivering a tumoricidal dose to target tissue, while minimizing dose to other
tissues. For radiation therapy and stereotactic radiotherapy, the plan will
generally involve delivering a damaging dose to diseased tissue at a level
that allows healthy tissue in the target volume to recover, while also
minimizing dose to tissue outside the target volume.
The treatment plan with dose distributions and complete delivered dose
value along with the input data will be available through a user display or
printed report for user review and evaluation against the treatment
prescription and established physics models. The treatment plan will then
be saved by the user, approved by the qualified medical practitioner, and
subsequently delivered by the treatment delivery system.
 Requisite Hardware and Software

The Accuray Precision Treatment Planning System creates plans that are
delivered on Accuray Treatment Delivery Systems.
iDMS Data Management System is an essential component of Accuray

Precision Treatment Planning System for function.
 Clinical Benefits
The Accuray Precision Treatment Planning System is used to generate and
store treatment plans to treat tumors, other lesions and nervous system
disorders. As such it is an important part of Accuray treatment systems. The
goal of these treatment plans is to provide conformal dose distribution that
enables delivery of higher doses to the target with minimal damage to
healthy tissues.
 Performance Characteristics
The Accuray Precision Treatment Planning System creates plans with
accurate dose calculation. The details of dose calculation algorithms and
specifications related to performance characteristics are defined in the
Physics Essential Guides for each Treatment Delivery Systems.
For Radixact and TomoTherapy Treatment Delivery System with iDMS, see
the “Dose Calculation Accuracy” sections.
For CyberKnife, see Appendix 5B for Dose Calculation Results for Typical
CyberKnife Treatments and Algorithm Accuracy Summary. All dose
accuracy requirements are tested and validated.
 Performance Efficiency
The Accuray Precision Treatment Planning System loads a standard
patient CT of 512 x 512 x 512 within 60 seconds. The system can export a
primary patient CT of 512 x 512 x 512 to a local disk in 60 seconds.
 Undesirable Side Effects

The treatment system delivers ionizing radiation that can have undesirable
side effects such as nausea, burns, nerve damage, and even death. To help
prevent these side effects, all personnel who operate the treatment system
should be appropriately educated and trained.
 Residual Risks
All hazardous situations associated with the product have been evaluated,
and any information on residual risks are provided accordingly in each
feature sections. Refer to the appropriate sections of the documentation for
further details and warnings.
• Temperature (High): Thermal damage (heat stress, physical pain,
thermal burn, tissue damage)
• Socio-Psychological (Indirect Hazard): Socio-Psychological damage
(including breach of privacy)
• Mechanical: Mechanical damage (mechanical stress, physical pain,
tissue/material damage from physical impact)
• Ionizing Radiation, Functional (Under Dose: Ineffective treatment of
cancer cells, increase in resistance to Ionizing Radiation treatment of
cancer cells.Over dose and hot spots
• Ionizing Radiation, Functional (Over Dose): Damaging/killing cells,
genetic damage to living tissue
• Electrical breakdown: Weakened materials
• Immunological/Biocompatibility: Change to Immunological Response
(irritation, inflammation, physical pain, change to tissue shape or
function, tissue damage)
• Electrical: Disruption of nervous system function (physical pain, muscle
strain, cardiac arrest)
• Electrical burn (external or internal)
For more details, also refer to Residual Risk section of the CyberKnife
Physics Essentials Guide or Radiact Treatment Delivery Manual.
 Accuray Precision System Workstation Specification
NOTE: Accuray Precision System continues to support M5000/M4000 or

P5000/P4000 for Graphic Cards and GPU for existing users.
Item Description
CPU Intel Xeon E5-2620v3 (x 2)
Memory 48 GB DDR4
Graphic Card RTX4000
GPU RTX5000
Storage 240 GB SATA RAIDI SSD (x 2)
Operating Microsoft Windows 10

System
Monitor 24” NEC Multisync 1920 x 1200 Native Resolution with ISP
Panel Technology
 Workstation Storage and Handling

The Accuray Precision Workstation platform tolerates operated in the
temperature range of 10 to 35 degrees Celsius and at a relative humidity
level in the range of 30% to 60%. You must allow the workstation to adjust
to this environmental range after shipping and storage.
The Accuray Precision Workstation platform tolerates shipping and storage
in the temperature range of -40 to 60 degrees Celsius and at a relative
humidity level in the range of 5% to 90%.
 System Label
This label is fixed to the Accuray Precision System and gives the “indication
of origin”, “model or type reference”, and electrical supply requirements. It
also indicates compliance with the European Regulatory Requirements.
 Symbols
This section describes symbols that are used to identify controls and
indicators on equipment. It also describes labels that provide equipment
information.
Item Description
CE Marking
Located on the system and subsystem labels to signify that Accuray Incorporated
declares that the equipment complies with the regulatory requirements of the
European Union. Symbol source: 93/42/EEC, Annex II and 2017/745, Annex V.
Model Reference Number

Located on the system and subsystem labels to identify the model reference
number associated with the Accuray System. Symbol source: ISO 7000; 2493.
Serial Number
Located on the system and subsystem labels to identify the serial number
associated with the Accuray System. Symbol source: ISO 7000; 2498.
Date of Manufacture
Located on the system and subsystem labels to identify the date that the Accuray
System was manufactured. Symbol source: ISO 7000; 2497.
Related Power Input

Located on certain system labels to identify the acceptable range of voltage and
current supplied to the Accuray System. Symbol source: IEC 60417; 6045.
Manufacturing Facility
Located on the system and subsystem labels to identify the facility where the
Accuray System was manufactured. Symbol source: ISO 7000; 3082.
Item Description
European Authorized Representative

Located on the system and subsystem labels to identify the location and contact
information of Accuray Incorporated's European Authorized Representative.
Symbol source: EN ISO 15223-1; 5.1.2.
Caution
“Attention, proceed with caution.”
This label appears on the system to indicate that accompanying documents
include related safety information. Symbol source: IEC 60417; 0434A.
Follow Instructions For Use

“Attention, follow instructions for use.”
This symbol indicates that you should consult the accompanying documents for
information related to the labeled item. The symbol also indicates that the item is
mandatory and safety related. Symbol source: IEC 60878; ISO 7010-M002.
By Prescription Only
(United States) Caution: Federal law restricts this device to sale
by or on the order of a physician. Symbol source: 21 CFR
801.109.
Data Matrix Barcode

Located on the system label, this barcode contains encoded information about
the Accuray System.
 System Compliance
The system is compliant with the following standards.
Item Description
IEC 62083:2009 Medical electrical equipment requirements for the

YY 0637-2013 safety of radiotherapy treatment of planning
systems, including applicable deviations of USA,
EU, and Canada.
IEC 62304:2006/A1:2015 Medical device software – Software life cycle

YY/T 0664-2008 processes.
IEC Part 1: application of usability engineering to

62366-1:2015/AC:2016 medical devices.
ISO/IEC 25051:2014 Systems and software Quality Requirements and

(GB/T 25000.51-2016) Evaluation (SQuaRE) — Part 51:Requirements for
quality of Ready to Use Software Product (RUSP)
and instructions for testing.
YY 0832.1-2011 Stereotactic and planning system for radiotherapy

with X-Radiation—Part 1: Stereotactic and
planning system for radiotherapy with X-Radiation
for head lesion.
YY0832.2-2015 Stereotactic and planning system for radiotherapy

with X-Radiation—Part 2: Stereotactic and
planning system for radiotherapy with X-Radiation
for body lesion.
 Use of Unapproved Equipment

Use of equipment or accessories not approved by Accuray Incorporated for
use with the treatment system may result in damage to equipment or
personal injury. Accuray Incorporated will not be held liable for damages or
injuries resulting from the use of unapproved equipment or accessories.
Consult accompanying documents provided by the accessory
manufacturer for safety precautions, maintenance requirements,
conditions, and limits of use.
 Accuray Cybersecurity Information
As part of our Product Security program, Accuray Incorporated assesses
Accuray products for potential cybersecurity risks based on credible
threats identified through H-ISAC, our Information Sharing and Analysis
Organization (ISAO), as well as other reliable sources. Accuray
assessments attempt to identify and characterize vulnerabilities with the
potential to impact Accuray products in the installed base. For security
threats deemed to be significant, Accuray addresses those
threats/vulnerabilities with proportional measures consistent with
regulatory guidance. Security Measures can include mitigations in the form
of field actions which Accuray Service personnel would deliver. In certain
cases, mitigations can include information to customers about how the
Accuray system might be protected via locally deployed
mitigation/compensating controls, consistent with accepted MDM and
HDO shared responsibility practices.
Information related to ongoing threats/vulnerability assessment and

respective mitigations is available on Accuray Customer Security
Information Website at the following link:
https://www.accuray.com/services/customer-resources/
Accuray is committed to providing you with innovative technology that

enables you to confidently and securely deliver the best possible care to
your patients. Please contact your Accuray Service Representative for all
product, product procedure, or site-specific questions.
 Virus Protection Software, Network, and Firewall

Accuray Incorporated employs an off-the-shelf whitelist anti-virus malware
solution that is installed on the Accuray Precision System and Accuray
Precision MD Suite workstations at customer sites. Periodic updates are
not necessary because the software only allows previously authorized
applications per the whitelist to run. The iLinkSM system employs a single
Security Appliance as its main point of connection to the hospital's network,
and additional Security Appliances per connection to each system or vault.
All Security Appliances come standard as part of your Accuray System, and
are required for complete iLink functionality.
Each of the Security Appliances has its configuration tuned to the exact
needs of each deployment location and its users. These configurations
include providing product and location-specific access control rules and
network address translation to each of the devices behind the Security
Appliances. The access control rules and network address translations
restrict incoming and outgoing traffic to a few select applications and
programs approved by Accuray Incorporated.
The Accuray System Network is a Local Area Network (LAN) that uses
Client/Server (CS) architecture. Network Data Port for external system
supports only DICOM with OIS interface software.
For more information about the CyberKnife System network environment

and its security features, refer to the System Administration section of the
Physics Essentials Guide.
For more information about the Radixact and TomoTherapy with iDMS
Treatment System, refer to the Network System Requirements, Radixact or
TTDS w/iDMS.
IMPORTANT: No other anti-virus software is supported.
 Documentation List for Accuray Precision Treatment

Planning System
• Accuray Precision® Treatment Planning System, Treatment Planning
Manual (this document)
• Customer Release Supplement for Accuray Precision® Treatment
Planning System, Treatment Planning Manual
• VOLO™ Ultra and Advanced Search - Addendum for Accuray
Precision® Treatment Planning System Treatment Planning Manual
• iDMS® Data Management System, Data Management Manual
• Customer Release Supplement for iDMS® Data Management System,
Data Management Manual
• Oncology Information Systems, iDMS® OIS Connect Interface User
Manual
• MIM For Use With Accuray® PreciseART® and PreciseRTX® User
Guide
• Radixact® Treatment Delivery System Physics Essentials Guide
• Addendum for VOLO™ Ultra for TomoTherapy® and Radixact® Physics
Essentials Guide
• CyberKnife® Treatment Delivery System Physics Essentials Guide
• Accuray Incorporated Addresses Addendum
 Accuray Precision MD Suite Application (Option)
The Accuray Precision MD Suite application includes a subset of the
features of the Accuray Precision Treatment Planning System that is fully
documented in this manual. With the Accuray Precision MD Suite
application, you can perform pre-planning preparation and post-planning
review of treatment plans. You can fuse images, contour structures,
perform autosegmentation, load existing plans for review and approval,
compare and sum plans, generate reports, create templates, and create QA
plans using existing patient and template plans.
Users licensed for PreciseART® and PreciseRTX® can also enroll plans in
Adaptive monitoring.
The following features are not available in the Accuray Precision MD Suite
application:
• Plan: Optimize, Beam Angles, Calculate, Forward Planning.
• Plan Transfer.
Logging On
After the Accuray Precision System is launched, the Logon dialog box
appears. Accuray Precision System allows only one user at a time.
 Log On to the Accuray Precision System . . . . . . . . . . . . . . . . . . . . . . . . 13
 Change Password. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
NOTE: It is recommended that the Accuray Precision System be rebooted daily in

order to perform a hardware diagnostic check.
 Log On to the Accuray Precision System

1. In the User ID text box, enter the user ID.
2. Type the password in the Password text box. As information is entered,
white dots appear.
3. Click the Logon button. After a successful login, the Accuray Precision
System Home Page appears. Features are available depending on your
access privileges
NOTE: Access to perform tasks using the Accuray Precision System depends on
user permissions in the iDMS®Data Management System. Contact your System
Administrator to create or modify individual user profiles.
 Change Password
The Logon dialog box allows you to change your password.
1. Click the Change Password button from the Logon dialog box. The Change
Password dialog box appears.
2. Enter your user ID and current password in the User ID and Old Password
text boxes.
As information is entered, white dots appear in the Old Password field.To
make corrections, press the DELETE or BACKSPACE key. Then press the
TAB key.
3. Enter a new password in the New Password text box. Then press the TAB
key.
4. Re-enter the new password in the Confirm New Password text box, and
click the OK button.
5. After the password has been changed, a success message indicates that
the change has been accepted. Click the OK button.
The Logon dialog box appears requiring the user to log on using the new
password.
6. If an error occurs, read the instructions in the error message. Then click the
OK button to return to the previous dialog box and make the necessary
corrections.
Home Page
Use the Accuray Precision System Home Page to access procedures,
tools, and database applications. The Home Page appears when you log on
or exit to the Home Page. Based on privileges assigned to the user, icons
for available tools are displayed in full color. Icons for unavailable tools are
grayed out. Commissioning Tools and Beam Data Import icons are
available for CyberKnife® only. Plan Transfer and PreciseART® icons are
available for Tomo® only.
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
 Patients and Plans Icons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
 Administration Icons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
 System Icons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
 Overview
The home page consists of the following:
• Patients and Plans section.
• Administration section.
• System section.
• Access to multiple sessions.
• Exit button.
Accuray Precision System Home Page
Once you have logged into the Accuray Precision System, you can launch
any of the iDMS System applications from the plan creation and loading
procedures, as well as all of the task steps.
A mini Dashboard can be accessed by clicking the icon to the right of the
Accuray Precision System logo to allow switching between the Accuray
Precision System and the administrative applications. Icons for the
available tools, based on the privileges assigned to the logged in user, are
displayed in full color.
NOTE: The Accuray Precision System cannot be closed if any of the iDMS System
applications are running.
Mini Dashboard
 Patients and Plans Icons

Use the Patients and Plans icons to launch treatment planning applications.
The system displays icons based on the permissions granted to the user
profile. To launch an application, click the corresponding icon.
Item Description
New Plan
• Create a standard treatment plan.
• Create a QA plan.
• Create an Add Fraction Plan
CyberKnife Only
• Create a Simulation plan.
• Create a Lung Optimized plan.
Load Plan
Load an existing plan.
Item Description
Delete Plan
Delete selected plans.
Plan Transfer (Tomo only)

Transfer a plan by reconfiguring the plan to be treated on a different Tomo Treatment
Delivery System.
Review Transfers (Tomo only)

Review and compare the transferred plan with the original or another plan of the
same patient.
PreciseART® (Tomo only)

Starts the PreciseART® software to:
• Review daily treatment results and related statistics.
• Monitor treatment status.
• Review each delivered fraction.
• Compare the planned dose with the projected dose.
PreciseRTX®
Adjust plan information (image, dose, VOIs) from a previously delivered treatment
and account for the prior treatment dose in a new plan.
 Administration Icons
Use the Administration icons to launch iDMS System administration
applications. The system displays icons based on the permission granted
to the user profile. To launch an application, click the corresponding icon.
Item Description
Image Review and Import

• View a list of stored DICOM image series.
• Delete a stored DICOM image series.
• Load DICOM image series from disk.
• Import and associate a stored DICOM image series to an existing patient.
• Import and associate a stored DICOM image series to a new patient.
• Register new modality scanners for import.
• Associate the names of clinical specialists to the DICOM image series to be
imported.
Report Administration
• View a list of report forms.
• Generate and view one or more reports.
• Save or print generated reports.
• Sign reports digitally.
Patient Administration
• View a list of patient records.
• Create, update, and delete patient records.
• Review patient audit trail.
• Export patient records to Accuray.
Item Description
Plan Administration
• View a list of patients with associated treatment plans.
• View a list of treatment plans associated to a patient record.
• View a list of QA plans associated with a selected treatment plan.
• View and update Simulation Plans.
• View a list of Transferred plans associated with a selected treatment plan.
• Review patient treatment plan details.
• Update specialists.
• Review and update treatment site and pathology.
• Review and update specialists.
• Discontinue, approve, hold, and release a treatment plan.
• Export detector data for static couch QA fractions.
• Export detector data for transferred plan.
• Export RT plan to OIS system.
• Anonymize DICOM series.
• View list of treatment plan fractions.
• View list of treatment plan fraction beams.
• View Beam’s Eye View (BEV) image.
• Export detector data for treated fraction.
• Download kv images.
• Discontinue a treatment plan fraction.
• View list of treatment plan or QA plan DICOM series.
• Export or download a treatment plan or QA plan DICOM series.
• Create and discontinue a QA plan fraction.
• Add, update, or download a QA plan analysis record.
• View details of discontinued treatment plan.
• Manage documents.
• Update Enrollment in PreciseART®.
DICOM Administration
• View a list of active patients with associated DICOM series.
• View list of DICOM series.
• Export a DICOM series.
• Delete a DICOM series.
• Assign specialists to a series.
• Add a referring physician.
Item Description
Patient Record Archive and Restore

• View a list of active and archived patient records.
• Archive and restore patient records.
• Import, overwrite, download, and delete SGI patient records.
• View patient record audit trail.
 System Icons
Use the System icons to launch iDMS System administration applications.
The system displays the icons based on permissions granted to the user
profile. To launch an application, click the corresponding icon.
Item Description
Planning Settings
• Set display and planning parameters. Review, add, edit, and delete Isocurve
Templates, VOI Set Templates, Rendering, Window/Level Presets,Treatment
Time Parameters, Density Models, and Auto-save interval.
• Perform local database maintenance, remote machine maintenance, and file
maintenance.
• Review, create, edit, and delete plan templates.
User Administration
• Create, view, or update user records.
• Activate or de-activate user records.
• Reset a user password.
• Create, view, update, or delete profiles.
• Manage patient access.
System Administration
• View system events.
• Manage DICOM Hosts.
• Review and update system login and access policies, auto hide, MITA, digital
signature, and set the radiation units preference to Gy or cGy.
• Manage lock handling.
• Manage system backups and database events.
• Register Oncology Information Systems (OIS).
• Create and update an organization profile.
• Display and manage data storage locations.
• Deregister scanners.
• Document archive.
Item Description
Commissioning Tools (CyberKnife only)

Review and access all beam commissioning data and tools.
Beam Data Import (CyberKnife only)

• Import and retrieve measured beam data.
• View pending treatment plans.
• Make all pending treatment plans unavailable.
• Download audited measured beam data files.
• Download stored beam data files.
• View measured beam data import audit entries.
• Declare collimation device equivalent.
Recover Plan
Recover an unsaved active plan saved by the auto-save feature.
Overview of the Accuray Precision System
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
 Screen Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
 Task Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
 Windows Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
 Step Bar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
 Global Tool Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
 3D Visualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
 Capture Screen Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
 Save Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
 Printing Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
 Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
 Reports Viewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
 VOI Visibility Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
 Multiple Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 Status Bar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
 Basic Data Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
 Image Viewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
 Display Layouts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
 Keyboard Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
 Exporting DICOM Data Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
 PreciseART® and PreciseRTX® for MIM. . . . . . . . . . . . . . . . . . . . . . . . 59
 Overview
Throughout this manual, note the following terminology regarding image
series:
Term Synonyms
Primary image series Primary image, reference image, fixed image, A image, Dataset A
Secondary image series Secondary image, moving image, B image, Dataset B
Fused series Fusion of A and B image series
Automatic fusion Intensity-based registration
Each procedure consists of tasks, and each task has one or more steps.
The treatment planning workflow varies depending on the entry point you
choose and goals and requirements of the given plan. In planning a
treatment, the user will typically follow some or all of these steps:
1. Export required medical image series (including at least one CT series)
from an imaging system or other source of imaging data to the primary
workstation for the Accuray Precision System.
2. Load the images into the central patient database.
For more information on importing data into the Accuray Precision System,
see the Data Management Manual.
3. Start the Accuray Precision System.

4. Click an icon on the home page to start a procedure.
5. Select a patient.
6. Select a primary CT image series.
7. (Optional) Select one or more secondary image series, and fuse each
selected secondary image series with the primary image series.
8. Contour required structures.
9. Select the following:
For Tomo For CyberKnife
• Select Delivery Mode, Plan Mode, and Jaw • Select Planning Method, Number of Fractions,
Mode, and a Synchrony Method. Collimator, Treatment Anatomy, Template
• Replace the couch image. Path Set, and Synchrony Method to be used for
the treatment.
• Set Patient Position and Red Lasers.
• View DRR projections of the primary CT study
• Set Field Width, Pitch, Modulation Factor, and
and confirm the alignment center.
dose constraints for the plan, target, and critical
structures. • Set dose constraints for the plan, targets, and
critical structures.
• Generate a treatment plan.
• Generate a treatment plan.
• View and evaluate the generated treatment
plan. • View and evaluate the generated treatment
plan.
• Modify the plan if appropriate.
• Modify the plan if appropriate.
• View and evaluate the dose volume
histograms, plan statistics, and the isodose • View and evaluate the dose volume
distribution. histograms, plan statistics, and the isodose
distribution.
• Save the treatment plan for delivery.
• Save the treatment plan for delivery.
 Screen Layout
Screen layout example
Item Area Description
1 Basic Data Displays basic patient and plan information, including patient name,
medical ID, plan name, date and time stamp, and plan prescription. The
tooltip for this panel displays additional information including Patient
Key and Plan Key.
2 Mini Dashboard Click to switch between Accuray Precision system and the
administration applications.
3 Task Bar Displays a task for each major procedure.
4 Step Bar Displays a button for each step (screen). Click a button to access the
screen.
5 Product Identifies the product.
6 Window Controls Displays buttons to minimize the screen or go back to the home page.
7 Global Tool Bar Provides access to functions such as Zoom image, Pan image, and
Window/ Level. Tools that are not appropriate for the current screen are
grayed out.
Item Area Description
8 Multiple Sessions Displays icons to launch and switch between sessions.

Access
9 Status Bar During certain calculations, displays progress and status information,
and a flashing circle.
10 Control Panels Displays the controls available for the active screens.
11 Image Viewer Displays images and graphical information. The layout varies according
to the workflow.
 Task Bar
Procedures are displayed on tasks. Each task displays one or more steps.
Task Description
Fuse Multiple image series only: Fuse multiple image series so they are aligned to the same
physical space.
Contour Contour anatomical volumes of interest (VOIs).
Setup • For CyberKnife, set the planning method, treatment anatomy, template path set,
Synchrony method, identify fiducials, collimator type, alignment center, and review
Digitally Reconstructed Radiographs (DRRs).
• For Tomo, set machine parameters, couch replacement, patient position, and red lasers.
Plan • For CyberKnife, generate and modify isocentric and non-isocentric plans, set
optimization goals and constraints, optimize, calculate, and finetune the dose distribution
for a plan.
• For Tomo, set direct beams, perform forward planning, optimize, and calculate dose.
Evaluate Review and evaluate the dose distribution, DVH, set reference point, and compare and sum
the plans.
Utilities Displays tools for viewing 3D images in W/L, Color, Flythrough, or Crosscut modes.
Settings Build templates, set color preferences for the isodose curves, VOIs, and screen overlays,
build density models, and set the behavior of the zoom and pan controls. Perform local
database maintenance, remote machine maintenance, and file maintenance.
 Windows Controls
Use the screen control icons to control the Accuray Precision System
application.
Icon Tooltip Description
Go back to Home Page Return to the Accuray Precision System home page.
During planning, this action unloads the current plan and
associated files.
Minimize the application Minimize the Accuray Precision System window.
 Step Bar
Tasks are divided into steps. Each step consists of a unique set of tools and
image displays. See specific chapters of this manual for more detailed
information on each of the steps.
 Global Tool Bar

The right side of the screen displays icons on the global tool bar.
Pointer Used as the default selection tool.
Zoom image Increase or decrease zoom level of either the current

image plane or globally.
• To increase zoom level, click in any 2D window.
• To frame the zoom, drag the top left of the field of view
to the bottom right. (A box bordered by a dashed line
indicates the resulting field of view.)
• To zoom in or out, use the mouse scroll wheel.
Pan image Pan either the current image plane or globally. To

reframe the view, drag the image to the desired location.
Measure image Measures any distance on the 2D image.
Window/Level Adjust the window and level settings and apply 2D

presets.
Reset zoom and pan Click to reset the display to original zoom and pan
settings.
Capture screen image Click to capture the image of interest and save the image
in JPG format.
Save Plan Displays the Save Plan dialog box.
Export DICOM Data Displays the Export DICOM Data dialog box.
Print Displays the Precision Reports Viewer.
Patient Information Displays the Patient and Plan Information dialog box.
VOI Visibility Options Displays the VOI Visibility Options dialog box. Sets VOI
display options for the Accuray Precision System.
Measure Image
The measurements are displayed as overlays on the 2D display panel. If all
measurements are cleared, they cannot be displayed again.
Sample image measurements
Measure a Distance
1. Click to set the starting point.
2. Drag to the end and click.
Reposition a Measurement
1. Click to select a line.
2. Drag the line to a new position.
Delete a Measurement
1. Click to select a line.
2. Click Delete.
Delete All Measurements
Click Clear All.
Window/Level
To adjust window/level settings, choose either the display panel or
histogram method.
In split (A/B) and checkerboard modes (A+B), the system automatically
detects the image to adjust the window and level based on the cursor
position.
In overlay mode (A&B), the left mouse button controls adjustment of the
window and level in the A image, and press both right and left mouse
buttons to adjust the B image.
Adjust Window/Level Settings on the Image Viewer
1. Click the (Window/Level) icon .
2. Move your cursor to the image viewer to be adjusted.
3. Do one of the following:
• Click and drag up and down to adjust the window, and click and drag left
to right to adjust the level.
OR...
• Click and position the Window/Level icon over the Window/Level
box in the top right corner. Click and the dialog box appears.
For PET SUV images, the Window/Level dialog will display maximum
and minimum SUV scale values.
4. Enter values and click Apply.
2D Presets
The Accuray Precision System provides default 2D presets for bone and
soft tissue.
Adjust Window/Level Settings on the Histogram
The histogram is a representation of the distribution of the grayscale values.
You can view details of peaks along the histogram. Histogram for PET
images displays values according to the type of SUV method selected.
Window/Level histogram
1. Click a tab (Dataset A or Dataset B) to view the histogram and adjust the
Window/Level settings.
2. To adjust the view on the Window/Level histogram, drag a turquoise line on
the inset box on the upper right.
• The horizontal line adjusts the scale of the y-axis of the histogram.
• The right line adjusts the upper value of the x-axis.
• The left line adjusts the lower limit of the x-axis.
 3D Visualization
The Accuray Precision System displays image series with enhanced 3D
capabilities, including 3D image tools and layout options. The images can
be displayed in crosscut or standard 3D views, panned and zoomed,
viewed in flythrough mode, and the color and opacity can be adjusted. For
more information, see “3D Filter Step” (page 612).
To display the quick access menu, right-click in 3D image window. The
menu allows the user to set 3D options and change the layout of the
images. The layout is context sensitive, depending on which display panel
is right-clicked.
3D Image and Layout Options quick access menu for CyberKnife
Item Description
Pointer Used as the default selection tool.
Zoom image Increase or decrease zoom level of the either the current image plane or globally.
To increase zoom level, click in any 2D window.
To frame the zoom, drag the top left of the field of view to the bottom right. (A box
bordered by a dashed line indicates the resulting field of view.)
To zoom in or out, use the mouse scroll wheel.
Pan image Pan either the current image plane or globally.

To reframe the view, drag the image to the desired location.
Window/Level 3D Adjusts the 3D view window and level settings.
Window/Level Displays the list of available 2D presets.

Presets
3D Options Displays the 3D Display Options dialog box.
Item Description
Flythrough 4 Four view layout with flythrough option selected (3D flythrough, axial, sagittal,
Layout and coronal). Full Screen Mode Displays images in full screen mode by removing
the control and information panels. SUV Parameters appear only if PET images
are loaded. The SUV Parameters dialog box allows editing of the SUV
parameters of the PET images.
Crosscut 4 Layout Four view layout with crosscut option selected (3D crosscut, axial, sagittal, and
coronal).
Single View Displays only one view.

(Context)
Full Screen Mode Displays images in full screen mode by removing the control and information
panels.
SUV Parameters SUV Parameters will be shown only if PET images are loaded. The SUV
Parameters dialog box allows editing of the SUV parameters of the PET images.
3D Display Options
3D Display Options allows the user to choose presets, transparency of 3D
image, change display mode, turn beams on and off, and change the
displayed dose.
3D Display Options dialog box
Area Item Description
3D Presets List All Presets Displays list of all presets, including customized presets. Displays
check box the gallery of factory presets determined by the selected image
modality (read only). Displays currently selected 3D preset.
Selection Displays the selected 3D preset.
3D Global Whole Volume: The entire volume of 3D image is rendered.

Settings Sub Volume: Allows user to define a sub volume of an image. A
cube is used as the boundary of the 3D volume and can be
adjusted by selecting and dragging three pink crosses on the 3D
surround box or clicking and dragging the control points on the
green cube in the 2D views. Only the 3D volume content within the
cube will be rendered.
Oblique Cut: Allows user to define an oblique cut plane for the 3D
volume. Only the 3D volume content below the cutting plane will
be rendered. The default position is determined by the primary
CT's focus position or the secondary image volume's focus
position, if the secondary image set has not been registered to
primary CT. By using the mouse wheel in 3D view, the user can
change the cutting plane position. Not supported using split
screen view (A/B).
Lighting check box Changes the lighting to alter the image contrast.
Global 3D Opacity Set the transparency of the 3D image.

slider
VOI Settings VOI Point Mesh Displays VOI in point mesh instead of opaque surface.
check box
Mesh Point Size Changes the mesh point size for the display.
slider
Beam Beam Cone check Displays beams as a cylinder. When unchecked, beams are
Settings box shown as a single line.
(Cyberknife
only) None: (Option) This default setting does not display the beams.
With Dose: (Option) Displays the beams with dose.
All: (Option) Displays all of the beams.
Dose Rainbow (Option): Displays multiple level dose in different colors

Settings based on the 2D dose curve setting.
Watershed (Option): Displays dose above the upper bound in red
and below the lower bound in blue.
Shell (Option): Displays the dose as a shell within lower and upper
bounds in a user selected color. The default range is Rx ~ Rx +
4% max.
Off (Option): Dose is not displayed.
Dose Opacity Allows control of 3D dose shell opacity.

slider
Dose Color Allows you to change the 3D dose shell color.

drop-down list
Dose Level Range Allows the range of absolute dose levels to be set for the
(Gy/cGy) text box Watershed and Shell modes.
VOI When selected, the content for the 3D image within the
Subvolume corresponding VOI is displayed.
check boxes
Close button Click to close the dialog box.
 Capture Screen Image

You can capture a screen snapshot and save it in JPG format.
1. Click the Capture screen image icon .
2. On the Save As dialog box:
• Select a destination.
• Enter the file name in the File name field.
The default name is the current date with a counter number.
Save As dialog box
3. Click Save to save the screen snapshot, or click Cancel to discard the
changes and exit.
 Save Plan
The plan and its components can be saved to the iDMS System. For plans
created using Autosegmentation, the Save Plan dialog box requires you to
review and acknowledge each of the automatically generated items prior to
saving the plan as deliverable.
1. Click the (Save Plan) icon . The Save Plan dialog box appears.
Save Plan Dialog Box for Tomo
2. (Optional) Modify the plan name.

3. Click Save to save the plan.
 Printing Reports
WARNING: All treatment plan reports must be approved by trained personnel prior
to plan treatment. Use of treatment planning reports by unqualified personnel could
appropriate data values for any given situation.
Report Images
All medical images viewed in the Accuray Precision System can be
captured and added to a report by clicking the camera icon at the bottom
right of each view.
Report images are only available when the Accuray Precision System is
running. The report images are not saved with the plan, and the images are
deleted when the Accuray Precision System is properly closed.
Print a Report or Reference Data

1. From Evaluate > Review, click Print.
The Precision Reports Viewer with the available reports is launched.
• For CyberKnife deliverable plans, the Plan Overview, Path Check List,
Beam Data List, and Commissioning reports are available.
• For deliverable plans, the Plan Overview, Path Check List, Beam Data
List, and Commissioning reports are available.
• For Tomo deliverable plans, the Plan Overview report is available.
• Plan Overview report is available for both deliverable and
non-deliverable plans.
• For non-deliverable plans, Plan Overview and Beam Data List report
are available for CyberKnife, and only Plan Overview is available for
Tomo.
• For non-deliverable plans, Plan Overview and Beam Data List report
are available.
Click on a report name from the report list. The description of the selected
report will be displayed in Report Description section.
2. Choose a method to select a report:

• Double-click the report name from the report list.
• Click on the report name from the report list, and then click the View
Report icon from the action bar.
3. Choose a method to generate a report:
• To generate a report with all available information, click without
modifying the parameters.
• To generate a report with specific information, set the necessary
parameters and click .
The report will be generated according to the specified parameters and
displayed in the report viewer.
NOTE: You cannot print planning reports for new plans that have not been saved.
 Reports
Treatment planning reports provide information related to treatment
planning.
Item Name of Report Description
Patient Plan Overview Provides detailed information for a selected patient and
treatment plan. Once all data has been reviewed and verified,
the physician and physicist can sign and enter the date of
approval on the signature page.
Report includes:
• Overview (Patient details and plan summary)
• Image series
• Plan details (treatment parameters, prescription details, dose
calculation grid, fiducial information, density model, DVH and
VOI list)
• Approval details
QA Plan Overview Provides QA plan details and plan comparison information

(QA Plans only) between the selected QA plan and the patient plan.
Path Check List Provides a list of each beam in a path. The list gives the node ID,
(Cyberknife only) number of monitor units, reference dose, indicates if the beam is
blocked, and provides a line to check off each beam as it is
delivered. A signature line for each path is provided for the
operator to sign and enter the date of approval.
Beam Data List Provides a list of the beams and their associated geometric
(Cyberknife only) parameters. The data in the report is used to perform hand
calculations to verify that the reference dose for each beam is
consistent with the number of MUs for that beam.
Segment Report Provides a list of the beams and their associated geometric
(CyberKnife parameters. The data in the report is used to perform hand
calculations to verify the reference dose for each beam is
MLC plan only) consistent with the number of MUs for that beam.
Commissioning For more information on Commissioning reports, see

“Commissioning Reports” (page 97)
 Reports Viewer
The reports viewer contains tools enabling the user to generate, view,
download, and print reports when a saved plan is loaded. The viewer
consists of the following:
• Forms tab which allows the user to access, select and learn about the
reports that can be viewed.
• After a report has been generated, the report viewer allows the user to
view the report.
Report Viewer
The following controls are available on the Forms tab.
View Selected Report Form Displays the selected report.
Single Window View Allows user to switch from the dual window view to a single
window view.
Dual Window Horizontal View Allows user to view two reports in the horizontal two-report
view.
Dual Window Vertical View Allows user to view two reports in the vertical two-report view.
View One or More Reports in Separate Tabs
1. Generate two or more reports.
2. Click the tab of the report to view.
Close a Report
1. Generate a report.
2. Click from the report tab.
View Two Reports One Above the Other

2. Click from the Forms action bar to view reports in the dual window
horizontal report view.
The empty secondary view appears and the report tabs for all open reports
will contain the directional arrow.
3. Click the report tab of the report you want to move to the secondary view
and click .
The report appears in the secondary view and the directional arrow
changes to . A split bar can be used to widen or narrow the report panes.
View Two Reports Side by Side

2. Click from the Forms action bar to view reports in the dual window
vertical report view:
contains the directional arrow .
3. Click the report tab of the report to be moved to the secondary view and
click .
The report appears in the secondary view and the directional arrow
changes to . A split bar can be used to widen or narrow the report panes.
 Patient Information
The Patient and Plan Information dialog box displays detailed information
about the primary and secondary image series.
The Coordinate Information section displays the coordinates of the primary
and secondary images in the DICOM coordinate system. The display
defines the origin, size, and voxel spacing of the primary or secondary
image. The voxel spacing of an image is the distance between two voxels
in each direction, while the size of the image is the number of slices/voxels
in each direction. The CT resolution, as defined by Spacing of the primary
study, limits the minimum expansion allowed for VOIs.
Patient and Plan Information Dialog Box for CyberKnife
 VOI Visibility Options

Use the VOI Visibility Options dialog box to set and manage the display of
VOIs. Use the Search text box to find the desired VOI. You can display all
or individual VOIs, display VOIs as overlays, and adjust the opacity of
selected VOIs.
The VOI Visibility Options icon is available on any task or step that displays
2D or 3D images, or on a DVH.
When you open VOI Visibility Options in Contour task, both contoured and
empty VOIs are listed in the display priority order. When you open this
dialog box in other tasks, only contoured VOI are listed and the priority
numbers may not be in consecutive order if there are any missing empty
VOIs with priority values.
Use the Move buttons (Move Up, Move Down, Move to Top, and Move to
Bottom) to adjust the display order in this dialog box. These buttons are not
available when the Search text box contains text, or when the table is sorted
on any column other than the Display Priority.
WARNING: When viewing treatment plans whose isodose lines closely match VOI
contours, view VOIs as overlays to ensure that isodose lines and VOIs are properly
identified. This can be accomplished by selecting the Display VOI as overlay check
box in the VOI Visibility Options dialog box.
NOTE: Priority set in the VOI Visivility Options is not related to the overlap priority
values for VOIs in Tomo planning.
VOI Visibility Options dialog box
Modify VOI Visibility Settings

1. Click the (VOI Visibility Options) icon. The VOI Visibility Options dialog
box appears.
All VOIs that contain at least one defined contour on one slice and all
auto-shells (CyberKnife only) are listed.
2. (Optional) Select or clear the check box at the top of the check box column
to select or clear all VOIs.
3. (Optional) To select individual VOIs:
a) Clear the top check box. All check boxes are cleared.
b) Select individual check boxes for VOIs and/or auto-shells.
4. (Optional) Select the Display VOI as overlay check box to display the
selected VOIs as overlays on the images.
5. (Optional) Select a color on the adjacent Color drop-down list to modify the
display color of a VOI or auto-shell.
6. (Optional) Drag the adjacent slider to the desired location to modify the
opacity setting.
Opacity is expressed as a percentage (0 to 100). The opacity setting is
applied to all selected VOIs.
7. Click OK.
 Multiple Sessions
Accuray Precision System allows up to four sessions simultaneously on a
single workstation.
Use the icons on the right side of the Accuray Precision System screen to
begin a new session or switch between sessions.
Use the mouse to view the ToolTip of the session’s current state.
Multiple Sessions
Access Item Description
Click to go back to the Home Page,

and select a procedure to start a new
session.
Indicates active first session.
Indicates an active session.
Indicates empty sessions.
Starting a New Session

After starting the first session, you can launch another session. Click the top
icon to start a new session, which takes you to the Home Page where you
can select a new procedure. Plan Transfer can only run on one session at
a time.
Switching from One Session to Another

From an active session, do one of the following:
• Select a different active session button.
• Press ALT + TAB keys simultaneously and select a different active
session.
Ending a Session
1. Click the Close button in the upper-right corner from the active session.
The Accuray Precision System Home Page appears.
Exiting the Accuray Precision System

1. Click Exit. The Accuray Precision System closes.
 Status Bar
The status bar is displayed at the bottom of the screen. When certain
calculations are in progress, the status bar displays a round, blinking light,
and status messages regarding the current calculation.
Status bar
 Basic Data Panel

The basic patient and plan data is displayed on the upper left of the screen.
Mask this data prior to creating screen shots or at any other time when
confidentiality is a concern. By default, the basic data is displayed.
Tooltip for this data panel provides additional information about the patient
and the plan. User can use the displayed Patient Key and Plan Key to
communicate with Accuray if there’s any issue. For more details on the
Patient Key and Plan Key, see Data Management Manual.
Item Description
Masks basic patient and plan data.
Basic Data Panel with Patient Key and Plan Key.
Mask or View Basic Data
1. Click the basic data area. The Accuray Incorporated logo appears.
2. Click the Accuray Incorporated logo. The basic data appears.
3. (Optional) Hold down the CTRL key and click the basic data area to view
the Accuray Incorporated logo with Patient Key and Plan Key.
 Image Viewer
This section describes the basic layout tools available.
Item Description
Plane indicators Each image viewer displays an icon or label that indicates the plane of the
series. The icons are: a human head, a human body, and the name of the view.
Click the indicator to cycle through the choices.
Direction indicators Directional labels indicating the patient orientation imported with the image
series, for example, L (left), R (right), P (posterior), A (anterior), S (superior), and
I (inferior).
Image view indicator The available views include the primary series (A/fixed), the secondary series
(B/moving). The image mode include a split view (A/B), a checkerboard view
(A+B), and an overlay view (A&B). Click the indicator to cycle through the
choices.
Slice number The slider bar at the bottom right of each image viewer allows the slice number
to be selected. The current slice number is displayed within the slider bar. To
sequence through the series, click the left or right arrow or drag the slider arrow
to the right or left.
Focus The light blue lines display the focus of the three planar views currently shown.
To change the focus, drag the light blue lines to a new location or double-click at
another point.
Opacity Slider The slider bar at the bottom left of secondary images allows the opacity to be
modified.
SUV/RAW/NAC Label indicating the state of the pixel value when a PET image is displayed.
• SUV: SUV has been computed for the image series.
• RAW: SUV has not been computed and the image series is attenuation
corrected.
• NAC: The image series is non-attenuation corrected.
Item Description
Colorrmap Selector The colormap selector at the bottom left of secondary images allows changes to
the color set. When selected, the available colormaps are displayed with the
current colormap in green. When moused over, the name of the selected
colormap is in yellow.
Point Dose Tool The point dose tool appears in both the checkerboard and overlay modes. When
an image is clicked, a cross with voxel values and scales of the primary and
secondary images is displayed. If a PET image with computed SUV values is
displayed, the dose probe tool displays its voxel values and scale.
On-screen image An image scale with one major marker in mm appears on every 2D image that
scale automatically adjusts when the image is zoomed in or out. The scale does not
appear if there are less than 400 pixels in the image.
Image Series Labels

This section describes the basic layout tools available on the panels.
To change the secondary image series that appears, click B while
simultaneously pressing the mouse button. A menu appears with the
available secondary image series. Highlight to select the desired image
series, and release the mouse button. For descriptions on the available
labels, refer to the following table.
Label Description
A Primary (fixed) image series: The primary image series is always a CT image series.
B Secondary (or moving) image series: The secondary image series can be from any
supported modality.
A/B Split screen view: Split view of the primary and secondary image series in axial,
sagittal, or coronal views.
A&B Overlay view: Split view of the primary and secondary image series with different
opacity levels for each series.
A+B Checkerboard view: Primary and secondary image series in a pattern of alternating
squares.
A/B1 Multiple secondary image series: The registered volume that combines the primary
image series and the first secondary image series.
image series and the second secondary image series.
image series and the third secondary image series.
Split Screen View (A/B)
The following screenshot shows a typical 2D image viewer with two loaded
series. Axial, sagittal, and coronal views appear in the image viewer. The
bottom left of each image viewer indicates the plane of the study. In this
example, an axial slice appears.
In the split screen view, the oblique yellow slider bar separates the two
views. The point of rotation is the intersection of the two green focus lines.
Split screen axial 2D view
Modify the View

1. Drag the yellow line around its axis of rotation to display different areas of
the image.
2. Drag the green line to change the percentage of the display devoted to each
modality.
Checkerboard View (A+B)

The checkerboard view displays patient anatomy in a pattern of alternating
squares that depict the primary and secondary series.
Use the slider at the top of the image viewer to set the side length of each
square in screen pixels. The larger the number, the larger the size of each
square in the display. The square range is from 4 to 256 pixels.
Use the slider at the bottom of the image viewer to scroll through the slices
or to step through one slice at a time.
Checkerboard 2D axial view of fused CT and PET images
Overlay View (A&B)

The overlay view displays the primary and secondary image series at
different opacity levels. Set the color of the secondary image series in the
overlay view with the colormap selector in the lower left corner.
The dose probe tool displays the following:
• Values of the primary and secondary image
• Voxels
• CT coordinates of the probe point
• Dose
Overlay axial 2D view of fused CT and MR images
 Display Layouts
Each step provides multiple layout options. The options appear as buttons
on the Display tab.
To switch to another layout, click the appropriate button. Switching to
another layout affects the current view only.
Display options vary depending on which task and steps you are on.
Layout Panel examples
The following layout symbols are available:
Item Description
Axial
Coronal
Sagittal
3-dimensional
Dose volume histogram
Dose Statistics
Histogram of image volumes associated with the plan including Window/Level controls.
Item Description
Displays Optimization Parameters
Expands the Target Objectives and Critical Constraints tables.
 Keyboard Controls
The Accuray Precision System provides the following keyboard shortcuts.
Shortcut Key Description
Previous slice [left arrow], [up arrow]
Next slice [right arrow], [down arrow]
Previous page [Page up] Step five slices up.
Next page [Page down] Step five slices down.
First slice [Home]
Last slice [End]
Enter/Exit Full F11

screen
Shortcuts available only in the VOI step of the Contour task.
Copy contour C Same as Copy button in the control window.
Paste contour V Same as Paste button in the control window.
Delete contour X Same as Delete button in the control window.
Esc Pointer
Z Zoom Image
P Pan Image
W Window/Level 2D
 Exporting DICOM Data Overview
When the Export DICOM Data icon on the global tool bar is available, you
can export DICOM data for the current plan to a remote machine that is
running a DICOM server.
The DICOM data available for export depends on the DICOM data available
on the current step. For example, you can export fused images and mixed
images on the 3D Filter step of the Utilities task.
The new couch image can be exported after the couch image is inserted on
the Setup > Machine step for Tomo.
Export DICOM Data Dialog Box for Tomo
Export DICOM Data Dialog Box for CyberKnife
Export DICOM Data
To export data to Retreatment session, refer to “Exporting Dose and VOIs
to PreciseRTX® Session” (page 732).
1. Click on the global tool bar. The Export DICOM Data dialog box
appears.
2. On the Export panel, select one or more check boxes for data to export.
3. Enter a description for each selected image type.
4. To export RT Dose DICOM data with DVH, select the RT Dose check box
and the DVH check box. The Volume of Interest check box will be selected
automatically.
To export RT Dose DICOM data with Dose Grid and DVH, select the RT
Dose check box and the Dose Grid check box. The DVH and Volume of
Interest check boxes will be selected automatically.
5. To export Planar Dose DICOM data, select the Planar Dose check box and
one or all of the Axial, Coronal, and Sagittal check boxes.
6. On the Destination panel, select the destination using either the Select
Remote Machine or Select Local File Path options.
The Export button becomes available.
7. Click the Export button.

If exporting to a remote machine, an Information message appears to
confirm the destination. Click Yes to accept the destination.
If the remote machine will not accept the DICOM data, an error message
appears.
NOTE: The Export DICOM Data dialog box does not generate or export RTPLAN
files, and the RTDOSE files that are exported do not reference an RTPLAN. In
order to generate an RTPLAN file and an RTDOSE file that references it, the plan
must be saved as deliverable and approved for treatment. At that point, an
RTPLAN file is generated. For approved plans, both the RTPLAN and RTDOSE
files can be exported using DICOM Administration in the iDMS System.
NOTE: If you have run a Deformable Image Registration in Fuse step, you can
export the Deformable Vector Field (DVF) used for image registration in DICOM
format. The check box for Deformable Vector Field becomes available in Export
DICOM data dialog box.
Image Data
The following image data can be exported:
• New Couch Image (Tomo only).
• Original Fixed Image (primary image series).
• Original Moving Image (secondary image series).
• Fused Moving Image.
• Mixed Image.
Export the primary series or the secondary series. The Accuray Precision
System does not alter the data.
Export a mixed image that is a fusion of the primary series and the
secondary series. The contents of this image are created on the 3D Filter
step described in “3D Filter Step” (page 612). Only a grayscale image can
be saved and exported. If 3D Filter was used, the image is converted to a
grayscale image, saved on the local disk, and exported to the DICOM
image series.
The mixed image series has the same modality as the secondary series.
The fused moving image series has the same modality as the secondary
series in the primary CT space.
NOTE: If multiple secondary series are loaded, the Accuray Precision System
exports image data for the displayed secondary series. To display another
secondary series, select another series on the drop-down list on the upper corner of
the right side 2D view.
Volume of Interest Data

Contoured VOIs are exported as a DICOM RT Structure Set instance. The
data is in a series that is associated with the primary CT series (primary
series).
The data for each VOI includes the name, display color, type (solid or
cavity), “drawn” tag, density override (if applied), and all the points that
contain the boundary of the contour.
The Accuray Precision System allows the user to contour in the axial,
sagittal and coronal planes. These contours can be exported VOIs.
For a Fiducial plan, you can also export the fiducial markers with the RT
Structure Set.
RT Dose Data
Dose distribution data is exported as a DICOM RT Dose instance. The data
is in a series that is associated with the primary CT study (primary image).
These types of DICOM RT dose data can be exported:
• Dose grid
• DVH
Each VOI includes a DVH. The DVH is calculated within the fine dose grid
and is exported with the DICOM RT Dose instance as an array of 256 bins
on a histogram. The bins’ range is evenly spaced from minimum to
maximum dose.
Planar Dose Data

For CyberKnife, 2D axial, sagittal, and coronal planar dose data can be
exported in the DICOM RT Dose format after dose calculation (low, medium
or high) has been completed in Ray-Tracing, FSPB, or a Monte Carlo dose
calculation is performed in Evaluate > Review or Evaluate > Finetune.
For Tomo, 2D axial, sagittal, and coronal planar dose data can be exported
in the DICOM RT Dose format if a fractionated final dose distribution with
an in-plane grid resolution of at least 2 mm per cell has been calculated for
a treatment plan.
The primary CT study (primary image) must be in the HFS position.
The crosshairs define the slice of dose you are exporting. The dose must
be visible on the slice you want. If the crosshair point defining the cutting
planes is partially inside of the dose calculation box (e.g. inside of the dose
volume in coronal plane), the Coronal check box of the planar dose option
is available.
NOTE: For TomoDirect QA Plan, you can Calculate Dose Per Beam, and
export the RT Dose per Beam using Export DICOM Data.
NOTE: RTDOSE files representing exported planar dose data cannot be exported
with reference to an RTPLAN file.
 PreciseART® and PreciseRTX® for MIM

A user with appropriate license and privileges is able to access the MIM
software from the Accuray Precision home page.
PreciseART® is available for Tomo only. Click the PreciseART® icon to
open the MIM software for reviewing daily treatment results and related
statistics. You can search for a patient and monitor treatment status, review
each delivered fraction, and compare the planned dose against delivered or
projected dose.
PreciseRTX® is available for both Tomo and CyberKnife. Click the
PreciseRTX® icon to select a DICOM series from Accuray Incorporated or
third-party systems stored in the iDMS System. You can select a new
image, the images used for prior plans, or both to be used for the
Retreatment workflow.
Refer to “PreciseART® and PreciseRTX® (Option)” (page 723) for more
details.
Chapter 2
Treatment Planning
About Loading Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Treatment Planning Applications . . . . . . . . . . . . . . . . . . . . 67
Plan Transfer (Tomo® Only) . . . . . . . . . . . . . . . . . . . . . . . 87
1072963-ENG B C ha pt er 2 : T r ea tm en t P l an nin g 61
About Loading Images
Each plan on the Accuray Precision System is based on a primary CT
image series. Load the primary series and then load a secondary image
series, if appropriate.
 Criteria for Secondary Image Series . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
 Loading PET Images. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
 DICOM RT Structure Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
 Loading DICOM Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
 Loading Alignment MVCT/kVCT (Tomo only) . . . . . . . . . . . . . . . . . . . . 65
 Longitudinal Resampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
WARNING: Verify that the Accuray Precision System displays patient orientation
labels as intended by the manufacturer of the scanner. An image series scanned by
a new scanner or with a new patient orientation might not be displayed as expected
on the Accuray Precision System. Use of incorrectly labeled images could result in
patient mistreatment.
WARNING: Prior to import, you must review the images to verify that the patient did
not move during image acquisition.
 Criteria for Secondary Image Series

You must have a CT series as the primary. Then you can add up to 15
secondary image series that are any combination of CT, MR, PET, XA
(3DRA) in New Plan wizard or using the Import Dataset feature in Contour
> Manual step.
You can also include RTSS during plan creation and import other RTSS
data later in the process.
Variability in image slice thickness for any image series must be less than
10 percent.
When loading two or more image series, the Accuray Precision System
displays the Fuse task.
 Loading PET Images

The SUV Parameters dialog box allows the method to be used to compute
the SUV for PET images to be modified when PET images are loaded, as
well as the ability to modify existing or add missing parameters. The
Accuray Precision System supports the following SUV methods:
• Body Weight (g/ml)
• Body Surface Area (cm²/ml)
• Lean Body Mass (g/ml)
Item Description
SUV Method drop-down menu • Body Weight (g/ml)

• Body Surface Area (cm²/ml)
• Lean Body Mass (g/ml)
Patient Weight (kilograms) field Weight of patient in kilograms.
Patient Height (centimeters) field Length of patient in centimeters.
Patient Sex options • Female

• Male
Item Description
Series Description Read-only field that displays the description of the

series from the DICOM header.
Series Date and Time Read-only field that displays the reference date and
time for all PET image attributes that are temporally
related.
Acquisition Date and Time Read-only field that displays the date and time that
the image was acquired.
Scan Date and Time options Select which date and time is used for SUV
calculation.
• Series Date and Time
• Acquisition Date and Time
Radionuclide Half Life (seconds) Set the half life of the radionuclide that was
field administered to the patient. This value is used in the
calculation of SUV.
Radionuclide Total Dose Set the radiopharmaceutical dose administered to

(becquerels) field the patient at the start time of the series acquisition.
Radiopharmaceutical Start Date Set the actual date and time of radiopharmaceutical
and Time drop-down list/box administration to the patient for imaging purposes.
OK button The selected SUV method and parameters will be

used to display the PET image.
Cancel button The selected SUV method and parameters settings

are cancelled
Selecting the SUV Method

If PET images are loaded and SUV parameters used to calculate the SUV
are missing from the DICOM data, the SUV Parameters dialog box appears
automatically.
Method Instructions
Default SUV method for Select the Default SUV Method from the drop-down list in
Accuray Precision Settings > Preferences > Display Parameters.
Treatment Planning System All PET images for this workstation are shown using the
selected SUV calculation method.
Method Instructions
SUV method for a series 1. Do one of the following:

• Right-click in any image view and select the
SUV Parameters from the 3D options and
layout quick access menu.
• Click the SUV label in the lower left corner of a
secondary image.
The SUV Parameters dialog box appears.
2. Modify the parameters as necessary and click OK.

A caution message appears that requires
confirmation from you to overwrite the SUV
parameters.
The PET image appears using the selected SUV
calculation method.
 DICOM RT Structure Sets

You can load DICOM RT Structure Sets from other planning and contouring
stations, save DICOM RT Structure Sets, and export anatomical contours
as DICOM RT Structure Sets. The DICOM RT Structure Sets must have the
same study UID as the primary CT image series in which they are
associated.
NOTE: If a DICOM RT Structure Set is included, it must be a part of the same study
as the primary image series.
 Loading DICOM Data

DICOM data can be exported from another treatment planning system to
the iDMS System. Use the iDMS System to import DICOM data to the
Accuray Precision System.
For information on loading DICOM data, see the Data Management
Manual.
 Loading Alignment MVCT/kVCT (Tomo only)

When creating a new plan, you can add the alignment CT images that were
acquired during the treatment.
Select the check box for include Registration Images on Select Exams
screen. This check box is also available on New Treatment Data screen for
PreciseRTX®.
 Longitudinal Resampling
IMPORTANT: After planning images are imported into the system, always verify
that contours are accurate and adjust if necessary before planning the treatment.
When the treatment delivery system receives data that contains

non-uniform slices (slices that are not evenly spaced in the original planning
image), it resamples images to the finest resolution.
For example, if an image includes 5 mm slices and 1 mm slices, all slices
are resampled to 1 mm.
• If the image contains fewer than 3 slices for a given thickness, then they
are not considered for resampling.
• If a thicker slice for the image contains a contour, then that contour is
copied onto the new slices that are created during resampling.
Treatment Planning Applications
This section presents Accuray Precision System features specific to
treatment planning that can be launched from the Home Page. The icons
on the Home Page are available based on the permission granted to the
user profile. To launch an application, click the icon.
 Creating a New Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
 Monte Carlo Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
 QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
 Add Fraction Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
 Loading an Existing Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
 Loading an Inconsistent Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
 Loading a MultiPlan Plan (CyberKnife Only) . . . . . . . . . . . . . . . . . . . . . 80
 Loading a Conformal Plan (CyberKnife Only) . . . . . . . . . . . . . . . . . . . . 80
 Loading a 4D Plan (CyberKnife Only) . . . . . . . . . . . . . . . . . . . . . . . . . . 80
 Makeup Plan (CyberKnife Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
 Deleting a Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
 Plan Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
 Commissioning Tools (CyberKnife Only) . . . . . . . . . . . . . . . . . . . . . . . . 86
Accuray Precision Home Page for CyberKnife
 Creating a New Plan
WARNING: Verify that the Accuray Precision System displays patient orientation
labels as intended by the manufacturer of the scanner. Use of incorrectly labeled
images could result in patient mistreatment.
WARNING: Verify that all slices are listed and meet the image acquisition
guidelines for each DICOM image series selected. Refer to the pretreatment
scanning guidelines in the Treatment Delivery Manual for specific image acquisition
guidelines.
Creating a Standard Treatment Plan

1. Click the New Plan icon on the Home Page. The New Plan screen appears.
New Plan Screen for Tomo
New Plan Screen for CyberKnife
2. Type in the patient name, Medical ID, or HIS ID in the Search field, or scroll
down the patient list to select a patient. Under the Select Type area, the
Standard icon is selected automatically.
3. Click Next >>. The Select Exams screen appears.
• If CT exams are included, the Modality list displays CT.
• Exams associated with the selected modality are displayed in the Exam
ID list.
4. Select an exam in the Exam ID list and click Select Exam, or double-click
the exam you want to select to move it to the Selected Exam list.
If necessary, select a second exam in the Exam ID list and click Select
Exam, or double-click on the exam to move it to the Selected Exams list.
To remove an exam from the Selected Exam list, select the exam and click
Remove.
After removing an exam from the Selected Exam list, click CT in the
Modality list to refresh the Exam ID list.
5. (Optional) If you want to change the primary CT that is selected by the

system as default, designate a primary CT by selecting a check box on the
Pri. column.
6. (Optional) Select a RTSSET.
When the minimum number of series are selected, the Finish and Next >>
buttons become available.
7. Choose one of the following methods to finish:

• To complete creating a standard treatment plan without a template,
click Finish. The system loads the selected studies.
• (CyberKnife only) See “QuickPlan Tab” (page 659) to create a plan
using QuickPlan.
• To complete creating a standard treatment plan with a template, follow
the instructions described in the next section.
CAUTION: A warning appears if the designated primary CT was acquired on

Radixact System (version 3.0 or higher) with a scanning protocol not suitable for
dose calculation. For example, fast scans compromise image uniformity enough
that the resulting dose calculations would be unreliable. If you acknowledge the
warning and continue, you may not be able to use the image for dose calculation in
PreciseART®. You can cancel the operation and select a different CT set as
primary.
Complete Creating a Standard Treatment Plan With a
Template
1. Click Next >>. The Select Optional Plan Template screen appears.
2. Select a treatment machine and an anatomic region by clicking the

appropriate region of the body on the screen. The corresponding templates
for the selected anatomic region are populated.
3. Select a template.
The Template Contents area displays the template content for you to
review. You can select and copy text that can be pasted into a Notepad text
file to create a printable version of the template for reference.
4. Click Next >>. The Use Plan Template screen appears.

For Tomo,
• Plan Template button is available if the selected template has an
associated density model.
• Primary Scan button is available if the primary CT has associated
density model.
Use Plan Template Screen
5. Select a density model which you want to use for the plan.
6. Review the VOI names that are automatically matched by the system and
adjust if necessary.
7. Click Use Template. The system loads the selected studies using the
selected template.
DCE MR
The Accuray Precision System offers an integration with Dynamic Contrast
Enhanced (DCE) MR data, created by iCAD® Inc. iCAD provides image
analysis software that uses a pharmacokinetic model to illustrate regions of
increased cellular permeability. The integration enables the display of the
iCAD results within Accuray Precision System. A typical DCE MR set
exported from iCAD includes the following:
• A high resolution MRI image.
• A DCE Ktrans image (1/minute): Permeability surface area product per
unit volume of tissue, also referred to as PERM data or permeability
map data.
• A DCE Ve image: Volume of extra vascular space per unit volume of
tissue, also referred to as EVF (Extra cellular Volume Fraction) map
data.
NOTE: The DCE Ktrans and Ve image series must be exported from iCAD® and
imported via the iDMS System Image Review and Import, whereas the high
resolution MRI may be exported directly from the MR scanner to the iDMS System
for import using Image Review and Import.
Ktrans and Ve images are pre-registered with the reference MRI image so
that they are exported within the same coordinate system as the MRI
image.
NOTE: The DCE overlays are DCE-Primary, which is a RGB overlay based on a 2D
lookup table, and DCE-Perm, which is a linear purple-color lookup table.
Creating a Standard Treatment Plan using DCE MRI

1. Click the New Plan icon in the Patients and Plans section of the Accuray
Precision System home page. The New Plan screen appears.
2. Select a patient name from the patient list. Under the Select Type area, the
Standard icon is selected automatically.
3. Click Next >>. The Select Exams screen appears.
• The Modality list displays the image data types that are available.
• Exams associated with the selected modality are displayed in the Exam
ID list.
4. Select CT from the Modality list.
5. Select a CT exam in the Exam ID list and click Select Exam, or double-click
the exam you want to select to move it to the Selected Exams list.
Remove.
6. Select MR from the Modality list.
7. Select the high resolution MR exam in the Exam ID list and click Select
Exam, or double-click the exam you want to select to move it to the Selected
Exams list. See “Criteria for Secondary Image Series” (page 62) for
information on the number of secondary images that can be loaded per
imaging modality.
NOTE: DCE MR exam data can be identified with T1, T2, PERM, and EVF as
keywords in the series description.
A message appears to confirm that you want the associated DCE map data
to load.
8. Click Yes.
If the legacy DCE anatomy data was exported from a version of VersaVue
prior to 3.0.3, a warning message appears specific to the currently
supported anatomic region and requires you to select whether to load DCE
map data.
9. Click Finish. The system loads the selected studies.

After the plan has been loaded, the high resolution MRI must be fused with
the primary CT. This enables viewing of the DCE map data overlaid on the
CT image based on the registration between the high resolution MR and the
primary CT.
NOTE: DCE map data that is viewed as overlaid on the high resolution MR in the
Fuse task prior to registration is identical to the data viewed in the iCAD software.
However, once the registration has been performed, the MR and its associated
DCE map data will be resliced to match the primary CT. Therefore, the DCE map
data at a particular location in the MR matches the original appearance in the iCAD
software, except that the entire slice may appear different as a result of the fusion.
Using DCE MR
Three DCE overlay display modes are specific to DCE MR.The current
DCE overlay mode appears below the image viewer indicator. An opacity
slider is available, and the DCE voxel data can be viewed using the dose
probe tool.
NOTE: Only one colormap overlay can be displayed at any time.
The following three DCE overlay display modes will be available:

• DCE Primary: Both the DCE Ktrans voxel value and Ve voxel data are
displayed in dose probe.
• DCE Perm: Only Ktrans voxel value is displayed in dose probe.
• DCE Off: DCE map data is not displayed.
DCE Primary Overlay
DCE Perm overlay
 Monte Carlo Plan
Prerequisites for Monte Carlo planning:
• Monte Carlo is available on the Accuray Precision System.
• Monte Carlo commissioning is complete.
• The plan contains a mass density model.
When you load a Monte Carlo plan, all settings for the plan are loaded.
NOTE: If you load a Monte Carlo plan on the Accuray Precision System that is not
commissioned for Monte Carlo, the plan is loaded in read-only mode. You can
review the plan but cannot make changes.
 QA Plan
The QA plan allows the verification of a treatment plan dose delivery by
creating a plan that overlays a patient treatment plan onto a phantom CT
image series which can then be delivered to the phantom. Refer to “QA
Plans” (page 199) for more details.
 Add Fraction Plan

Add Fraction Plans are like normal plans except that they are created by
adding one or more fractions to an existing plan.
Eligible plans are used to create an Add Fraction Plan. The criteria for the
eligible plans are:
• A patient plan that is under treatment, approved, or completed.
• A plan created using Accuray Precision 2.0 or later.
Simulation, QA, partial fraction Makeup plans, and discontinued plans are
ineligible. If a plan already has an existing Add Fraction Plan, a new one
cannot be created.
The original plan and the associated Add Fraction Plan should not be
treated on the same day.
WARNING: To prevent patient mistreatment, all the delivered fractions from the
original plan, Add Fraction Plan, and any other plans such as Makeup Plan with
Add Fraction Plan should be accounted for when additional planning is required.
Add Fraction Plan should be discotinued if the original plan is discontinued.

The Plan Type appears as [Add Fraction Plan] if a plan is an Add Fraction
Plan in Plan Administration, Load Plan, and reports. You can view the
Original Plan Name in Plan Administration, Plan Information, and reports.
NOTE: Add Fraction Plan becomes inconsistent when the original plan becomes
inconsistent due to the treatment machine data change.
 Loading an Existing Plan
WARNING: Do not attempt to modify a treatment file manually. Improperly changed

data could result in death or injury of the patient.
NOTE: For information on loading DICOM data that was exported from another
machine to the Accuray Precision System, refer to the Data Management Manual.
1. Click the Load Plan icon from the Home Page. The Load Plan screen
appears.
2. Select a patient name from the patient list. The plans associated with the
selected patient appear.
3. Select a plan to load and click Load Plan. The system loads the plan.
 Loading an Inconsistent Plan

A plan becomes inconsistent if there has been any pertinent treatment
machine data change after the plan was last saved. A plan is also flagged
as inconsistent when it fails the data validation check while loading the plan.
For Tomo
Inconsistent plan will have an asterisk (*) next to the plan name on the Load
Plan screen.
1. Click the Load Plan from the Home Page. The Load Plan screen appears.
2. Select a patient. The plans associated with the selected patient appear.
3. Select the plan, and click Load Plan. A message comes up with two options.
Plan can be loaded as it is, or update the plan with the current machine
configuration.
4. Click Update or Load As Is to load the plan.
• Click Update. The dose is automatically deleted. You must replan if you
update an inconsistent plan.
• Click Load As Is. The plan is loaded as is and remains inconsistent. You
can still make changes and re-save the plan if the plan has not been
treated.
You also have the option to click Cancel, and then go to Plan Transfer from
the Home Page to process the plan using the Self Transfer.
NOTE: If treatment has already begun for the plan, then the plan cannot be
re-saved with the same name. Self Transfer is required to update the plan in that
case.
NOTE: Self Transfer is only available for plans that have been approved for
treatment or are currently under treatment.
For CyberKnife
Inconsistent plan fails the data validation check at the time of loading. The
error message to describe the inconsistency appears.
1. Click the Load Plan from the Home Page. The Load Plan screen appears.
2. Select a patient. The plans associated with the selected patient appear.
3. Select the plan, and click Load Plan. A message comes up with two options.
Plan can be loaded as read-only, or update the plan by reloading the data
files from the server.
4. Click [Yes]: Reload data files from the server or [No]: Load plan in read-only
mode.
All beams and dose are deleted and you are required to replan if you select
[Yes].
NOTE: Discontinued plan is prompted with Makeup plan dialog box (Dose Viewing
Options),
 Loading a MultiPlan Plan (CyberKnife Only)
NOTE: Plans that are created prior to MultiPlan 5.0 can be only loaded as
read-only. A plan created after MultiPlan 5.0 can be loaded as editable and
re-saved as a current plan. However there may be some other restrictions applied
depending on your CyberKnife configuration changes.
1. Click the Load Plan icon from the Patients and Plans area of the Accuray
Precision System home screen. The Load Plan screen appears.
2. Select a patient name from the patient list. The plans associated with the
selected patient appear.
3. Select a MultiPlan plan name identified by a status of Complete.
4. Click Load Plan. An information dialog box appears to notify you that the
plan will be loaded in read-only mode. Read-only mode will not allow you to
overwrite the plan.
5. Click OK. The plan is loaded. Available tasks and steps may be limited
depending on the plan. A qualified plan can be re-saved and be used for the
treatment.
 Loading a Conformal Plan (CyberKnife Only)

Plans created with the Conformal Planning feature using older versions of
Accuray Precision or MultiPlan can be loaded as read-only or by clearing
the conformal data if no fraction has been delivered.
Partially or fully delivered plans are loaded as read-only.
 Loading a 4D Plan (CyberKnife Only)

Plans created with the 4D Planning feature using older versions of Accuray
Precision or MultiPlan can be loaded only for evaluation purpose.
 Makeup Plan (CyberKnife Only)

Discontinued plans created with any collimator type are partially treated
treatment plans that will not be completed. The Accuray Precision System
offers the following options when loading a Discontinued plan:
NOTE: Makeup Plans cannot be created for the plans that were created using the
retired Conformal planning feature.
Discontinued Plan Options Typical Use
Load Original Used with Reference Plan and Sum Plan to compare
the original plan with either the sum of the delivered
dose, Makeup Plan for full fractions, or Makeup(s)
Plans for all partial fractions.
View Delivered Dose Use to create a delivered dose plan that can be
saved and associated with the original plan.
Create Makeup Plan for the remaining full Use to create a Makeup Plan for all full fractions to be
fractions. used for treatment delivery.
Create Makeup Plan for the remaining Use to create Makeup Plan(s) for a partial fraction(s)
dose for the partial fraction. Select a to be used for redelivery.
partial fraction from the list above.
These options allow the analysis of the delivered dose and generation of an
automatic set of plans to deliver the remaining planning dose. This is
beneficial when delivery system-created makeup fractions are not sufficient
to complete treatment. For example, when a CyberKnife System servicing
issue interrupts treatment that requires CyberKnife data changes, it
invalidates current plans under treatment.
NOTE: Makeup Plans cannot be created if beam data has not been commissioned.
Analyze and Recover From an Interrupted Treatment

The general workflow for analyzing and recovering from an interrupted
treatment is as follows:
1. View and save delivered dose.
2. Choose one of the following options:
• Create and save a Makeup Plan for remaining full fractions.
• Create and save individual Makeup Plans for partially treated fractions.
3. Load the original treatment plan and compare it to the sum of the delivered
dose and all of the plans created in the previous steps.
When performing the comparison, the result may not be equivalent to the
original plan.This can occur when any of the following change:
• Beam data changes, including extrapolation setting changes.

• CyberKnife System configuration data changes resulting in beams that
are no longer valid.
WARNING: Carefully review the sum of the delivered dose and the Makeup Plans
compared to the original plan prior to treatment delivery of any Makeup Plans. If
clinical differences are unacceptable, Makeup Plans can be modified to ensure the
sum is clinically equivalent to the original plan.
Load a Plan with a Discontinued Status

1. Click the Load Plan icon from the Patients and Plans section of the Accuray
Precision System home page. The Select Patient and Plan screen appears.
2. Click a patient name from the list on the Select Patient and Plan screen. The
plans associated with the selected patient appear.
3. Select a name identified by a status of Discontinued. The Dose Viewing
Options dialog box appears.
NOTE: Makeup Plans are not supported for treatment plans created using
MultiPlan System versions prior to 5.0. Accuray Precision System supports reading
embedded Delivered Dose plans that were previously saved in MultiPlan, but will
only create new Delivered Dose plans as separate plans.
4. Select one of the following methods:

• Load Original Plan
• View Delivered Dose
• Create Makeup Plan for the remaining full fractions.
• Create Makeup Plan for the remaining dose for the partial fraction.
Select a partial fraction from the list above.
Method Instructions
Load Original Plan Click OK. The plan is loaded.
View Delivered Dose For partial fractions where the treatment delivery system generated makeup
fractions have not been delivered, the dose for the partially delivered
fractions will be included in the delivered dose. If the treatment delivery
system generated makeup fractions that have been delivered, that dose will
also be factored into the delivered dose.
The Evaluate Tasks allows the following steps:
• Review
• Compare and Sum Plans
• Finetune
• Beams
1. Click OK. The delivered dose plan is loaded. The dose is recalculated
using the same algorithm, resolution, and uncertainty (for Monte Carlo)
that was used with the original plan.
NOTE: When the plan is loaded, Delivered Dose appears on the 2D view
below the dose calculation algorithm and the Plan Information tab displays
specific plan details.
2. (Option) Click Save Plan to save the plan as a Delivered Dose plan. The
Delivered Dose plan becomes read-only once it’s saved.
Create Makeup Plan for IMPORTANT: This option is available only when a discontinued treatment
the remaining full plan with a full fraction is present. You cannot change the fractionation of the
fractions plan.
1. Click OK. A Makeup Plan is created that displays the total remaining dose
for the remaining full fractions that have not been delivered.
NOTE: When the plan is loaded, Makeup Plan appears on the 2D view
2. Click Save Plan to save the plan as deliverable. The plan is saved with
the original plan type and Makeup extension.
Method Instructions
Create Makeup Plan for 1. Select the partial fraction to be used.

the remaining dose for
the partial fraction. 2. Click OK. A Makeup Plan is created that displays the total remaining dose
Select a partial fraction for the selected remaining partial fraction that has not been delivered.
from the list above
NOTE: When the plan is loaded, Makeup Plan appears on the 2D view
3. After the plan has been created, the plan can be evaluated through the
Compare and Sum Plans step.
4. Click Save Plan to save the plan as deliverable. The plan is saved with
the original plan type and Makeup extension.
 Deleting a Plan
A plan cannot be deleted if:
• Treatment of the plan has begun.
• Another user is using the same plan.
• The plan is loading.
• Plan status is Discontinued or Complete.
• (Tomo only) Image has been acquired (MVCT or kVCT).
1. Click the Delete Plan icon from the Home Page.
2. Select a patient name from the list on the Delete Plan screen. The plans
associated with the selected patient appear.
3. Select one or more plans to delete and click Delete Plan. A caution appears
to warn you that all plan data will be deleted.
NOTE: If the plan you are deleting has associated QA plans, the QA plans are
deleted.
NOTE: If you are deleting a transferred plan, all transferred versions of the plan will
also be deleted. However, deleting a transferred version of the plan (if never
treated) will only delete that transferred version.
4. Click Delete Plan. The Accuray Precision System deletes the plan and
refreshes the plan list.
 Plan Recovery
A plan can be recovered if the Accuray Precision System application shuts
down unexpectedly and if the auto-saved version of the plan exists. The
amount of work lost is based on the auto-save interval setting and, at a
minimum, dose will have to be re-calculated for the recovered plan. The
Recover Plan icon is activated after a non-standard plan closure until you
load a plan, create a new plan, or close the Accuray Precision System.
Auto-Save
By default, the Accuray Precision System automatically records the state of
the active plan regularly. You can change the interval or disable this feature
using Settings > Preferences > Planning Parameters. This tab can also be
accessed using the Planning Parameters icon from the home screen.
Recovery Plan
If a recovery plan is available when the Accuray Precision System is
started, a dialog box appears to notify you that a recovery plan is available
and allows the option to load it.
Do one of the following:

• Select the Recover Plan check box in the dialog box, and click OK. The
system loads the plan.
• Select the Delete check box, and click OK to delete the plan from the
list.
The Recover Plan button on the Home Page only appears when a
recoverable plan exists.
Home Page with Recover Plan button
 Commissioning Tools (CyberKnife Only)

Commissioning for dose calculation is based on measured and stored
beam data. If measured beam data has changed since data was approved,
the Accuray Precision System displays the home page with only the
Commissioning Tools icon enabled. In addition, if an option must be
commissioned prior to use, the user will be prompted to use the
Commissioning Tools.
To access the commissioning tools, click the Commissioning Tools icon
from the System section. The Fixed/Iris and MLC (Optional) tasks appear.
For more information, see “Commissioning Tools (CyberKnife Only)” (page
91).
Plan Transfer (Tomo® Only)
Plan Transfer is a licensable feature that allows the treatment plans to be
re-configured to be delivered on other treatment machines. There are three
available modes for plan transfer: Machine Transfer, Self Transfer, and
Mark As Equivalent.
 Machine Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
 Self Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
 Mark As Equivalent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
 Review Transferred Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
IMPORTANT: There may be limitations transferring plans between different

Accuray Incorporated product models. Plan transfer may or may not be permitted
based on model, software version, and system capabilities. Contact Accuray
Customer Support to understand the transfer options for your systems.
 Machine Transfer
Machine Transfer is the default option for plan transfer if your treatment
facility has multiple treatment machines. Machine transfer allows you to
transfer one or more treatment plans to available treatment machines for
the purpose of delivering the plans.
In order for a treatment plan to qualify for transfer, the plan status must be
one of the following:
• Approved.
• Under-treatment.
NOTE: TomoDirect, TomoHelical, and TomoEDGE plans cannot be transferred to

another treatment system if that system is not appropriately licensed.
Transfer a Plan to Another Machine

1. Click the Plan Transfer icon from the Patients and Plans area of the
Accuray Precision System home screen. The Transfer Plan screen
appears.
2. If necessary, select Machine Transfer under Select Plan Transfer Mode.
3. Use the Show eligible plans on treatment machine drop-down list to select
the machine that you want to transfer plans from.
4. In the patient list, select the check box next to the patient plans that you
want to transfer.
5. Use the Transfer selected plans to treatment machine drop-down list to
select the machine that you are transferring plans to.
If you select ALL, the system creates transferred versions of the selected
plans for every available machine in the system.
6. Click Transfer Selected Plans to begin the transfer.

Transferring plans may take a few minutes. The status bar at the bottom
displays the transfer progress. The Information dialog box appears with the
Plan Transfer Summary when transfer is complete.
NOTE: A transferred plan has the same plan name as the original plan. Transferred
plans have the status of Awaiting Approval. Transferred plans require review and
approval to use for treatment.
7. Click Next >> to go to the Review Transferred Plan screen.
 Self Transfer
Treatment plans become inconsistent when machine data or the beam
model change. The Self Transfer feature allows inconsistent plans to be
transferred to the new revision of the same machine. When a plan becomes
inconsistent, an asterisk (*) appears next to the plan name.
NOTE: Self transfer revises the patient plan based on the new machine revision.
NOTE: A QA plan can be created with an inconsistent patient plan if the template
plan is up-to-date. When the status of a self-transferred patient plan becomes
Discontinued, the status of the associated QA plan also becomes Discontinued.
Plans Imported with iDMS Plan Import Utility

Qualified plans archived from Tomo Systems can be imported into the
iDMS System using the iDMS Plan Import Utility. Imported plans can be
updated to the current machine data and beam model using the Self
Transfer feature to continue patient treatments. Imported plans contain
dose volumes as stored in the original patient archive. The imported dose
volumes can be compared with the result after Self Transfer using Compare
and Sum Plans, or the Compare Plan with Original button in Review
Transferred Plans screen. See the Data Management Manual for more
details on the iDMS Plan Import Utility.
Perform a Self Transfer

1. Click the Plan Transfer icon from the Patients and Plans area. The Transfer
Plan screen appears.
2. Select Self Transfer under Select Plan Transfer Mode.
3. Use the Show inconsistent plans for treatment machine drop-down list to
select the machine that you want to transfer plans from.
want to transfer.
5. Click Transfer Selected Plans to begin the transfer. The Information dialog
box appears with the Plan Transfer Summary when transfer is complete.
 Mark As Equivalent
Treatment plans become inconsistent when commissioning models or
delivery machine configuration change. Use the Mark As Equivalent feature
to mark inconsistent plans as acceptable in its current state and continue to
use the plan for treatment.
• Only inconsistent plans with statuses of Approved and Under-treatment
are candidates for Mark As Equivalent.
• Mark As Equivalent does not create a new revision of the plan.
NOTE: When an inconsistent plan is marked as equivalent, the associated
QA plan automatically updates to marked as equivalent.
1. Click the Plan Transfer icon from the Patients and Plans area. The Transfer
Plan screen appears.
2. Select Mark As Equivalent under Select Plan Transfer Mode.
3. Use the Show inconsistent plans for treatment machine drop-down list to
select the machine that you want to transfer plans from.
want to transfer.
5. Click Mark Selected Plans to begin the transfer. The Information dialog box
appears with the Plan Transfer Summary when transfer is complete.
 Review Transferred Plans

Transferred plans are read-only and require review and approval before
you can use a transferred plan for treatment. On the Review Transferred
Plans screen, you can:
• Load a plan to review.
• Compare a transferred plan with the original plan.
• Approve selected plans for treatment.
To review transferred plans:
1. If necessary, click the Review Transfers on the Home Page. The Review
Transferred Plan screen appears.
2. In the patient list, select the check box next to the patient plan that you want
to review.
• Click Load Plan button to load the plan you want to review.
• Click Compare Plan with Original to load the original plan with the
transferred plan.
4. Review the details of the transferred plan.
5. (Optional) Click Approve Selected Plans to approve the selected plan for
treatment.
Chapter 3
Commissioning Tools (CyberKnife Only)

Commissioning tasks are performed by a medical physicist. Use the
commissioning tools described in this chapter to commission beam data for
the Accuray Precision System. Before using the commissioning tools, you
must perform the procedures described in the Physics Essentials Guide for
beam data acquisition and import.
Section 3-1
Commissioning Requirements and Reports . . . . . . . . . . . 93
Section 3-2
Fixed and Iris Collimator Commissioning . . . . . . . . . . . . 105
Section 3-3
Multileaf Collimator Commissioning . . . . . . . . . . . . . . . . 153
1072963-ENG B C h ap te r 3 : C o mm i s s i on i ng To o ls (C y b er Kn i fe O n ly ) 91
Section 3-1
Commissioning Requirements and Reports
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Commissioning Requirements . . . . . . . . . . . . . . . . . . . . . . 95
Commissioning Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
1072963-ENG B S ec t i on 3- 1 : C om mi s s i o ni n g R eq u ir e me nt s an d R e po r ts 93
Introduction
 Before You Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
 Before You Begin
WARNING: Errors in beam data may not be easily detected and can result in
patient injury or death. A qualified person must enter and confirm the
accuracy of all beam data prior to treatment planning and delivery.
The commissioning tasks will depend on whether a fixed, Iris, or multileaf

collimator (MLC) is being commissioned.
NOTE: If your Accuray Precision System includes the Accuray Precision

Quick Review option, the Commissioning Tools icon is active only in the
primary session.
Commissioning Requirements
 Beam Data Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
 Beam Data Requirements

Prior to Accuray Precision commissioning of the Ray-Tracing dose
calculation, Monte Carlo Dose Calculation, or FSPB dose calculation
algorithms, you must acquire beam data as described in the Physics
Essentials Guide.
Ray-Tracing
The following beam data must be acquired, properly formatted, and
imported to the iDMS System prior to commissioning the Ray-Tracing dose
calculation algorithm:
• Tissue phantom ratio (TPR), off center ratio (OCR), and output factor
(OF) beam data for fixed collimators.
• TPR, OCR, and OF beam data for the optional Iris Collimator.
NOTE: The Ray-Tracing algorithm must be commissioned for fixed cones

before the Iris Collimator.
Monte Carlo for Fixed or Iris

The following additional beam data must be acquired, properly formatted,
and imported prior to commissioning the Monte Carlo Dose Calculation
option:
• Open field profile and central percent depth dose (PDD) of 60 mm field
size beam data for fixed collimators.
• Open field profile and central PDD of 60 mm field size beam data for the
optional Iris Collimator.
NOTE: (Optional) Measured in-air output factor beam data is required only if
you intend to use the In-air Output Factor method to generate the Monte
Carlo source distribution model for Fixed and Iris.
NOTE: The open field profile for the Iris Collimator uses the same beam data
as the fixed collimators.
NOTE: The Monte Carlo algorithm must be commissioned for fixed cones
before the Iris Collimator.
FSPB and Monte Carlo MLC

The following additional beam data file must be acquired, properly
formatted, and imported prior to commissioning the FSPB option
• Tissue phantom ratio (TPR), off center ratio (OCR), and output factor
(OF) beam data for the optional MLC.
• Open beam profiles for the MLC (0 degrees - x-profile, 90 degrees -
y-profile, 45 and 135 degrees) .
• MLC OCR Field Size file.
NOTE: No additional beam data is required for MLC Monte Carlo dose
calculation. Refer to Physics Essentials Guide for more details.
NOTE: The Ray-Tracing algorithm must be commissioned for fixed cones

before the FSPB algorithm can be commissioned for MLC.
The Beam Data Import (BDI) application of the iDMS System is used to
import the measured beam data to the data server. Typically, this task is
performed by the site physicist. For information on the Beam Data Import
application of the iDMS System, see the Data Management Manual. For
information on beam data acquisition, see the Physics Essentials Guide.
Accuray Precision beam data commissioning procedures are accessed
using the Fixed/Iris and the MLC tabs, located above the display window.
During commissioning, review the measured beam data, compare it with
beam data calculated by the Accuray Precision System, and approve the
calculated beam data and/or algorithm factors. During treatment planning,
dose calculation is performed based on the values that were approved
during commissioning.
Commissioning Reports
 Reports Viewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
 Commissioning Report Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
 Generate a Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
 Switch Viewing of Single View Reports . . . . . . . . . . . . . . . . . . . . . . . . 102
 Close a Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
 View Two Reports One Above the Other . . . . . . . . . . . . . . . . . . . . . . . 102
 View Two Reports Side by Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
 Reports Viewer
The Reports Viewer contains tools to generate, view, download, and print
commissioning reports. After the user clicks the Print button, the Reports
Viewer screen appears. The viewer has the following:
• Forms tab which allows the user to view the list of available reports and
each report description, and select a report to be generated.
• After a report has been selected in the Forms tab, the Reports Viewer
allows the user set parameters and generate reports.
The following icons are available on the Forms tab:
Icon Tool Tip Description
View Selected Report Displays the selected report.

Form
Single Window View Allows user to switch from the dual window
view to a single window view.
Dual Window Allows user to view two reports in the horizontal

Horizontal View two-report view.
Dual Window Vertical Allows user to view two reports in the vertical
View two-report view.
 Commissioning Report Types

Commissioning reports provide information related to beam data.
Fixed/Iris
Name of
Type Report Description
OCR Provides the measured and calculated OCR beam

data for all collimators at various depths.
TPR Provides the measured and calculated TPR beam

data for all collimator sizes and various depths.
OF Provides the measured and calculated output factor

data for different collimator sizes and source-axis
distances (SAD).
Name of
Type Report Description
Monte In-Air Output Provides the in-air output factor beam data.
Carlo Only Factor
Dose Profile Provides the open field dose profile beam data.
Central PDD Provides the central percent depth dose beam data.
Correction Provides the current Collimator Correction Factors

Factors (CCF) and Energy Correction Factors (ECF).
Phantom Provides the information about the virtual water

phantom used for the Monte Carlo commissioning
calculations.
Source Provides the calculated source distribution used in

Distribution the Monte Carlo calculation.
Fluence Provides the calculated fluence distribution used in

Distribution the Monte Carlo calculation.
Energy Spectrum Provides the calculated energy distribution used in

the Monte Carlo calculation.
MLC
Type Name of Report Description
OCR-X Provides the measured and calculated OCR

beam data at various depths for each field
size along the IEC X axis.
OCR-Y Provides the measured and calculated OCR

beam data at various depths for each field
size along the IEC Y axis.
TPR Provides the measured and calculated TPR

beam data for all collimator sizes.
OF Provides the measured and calculated

output factor data for different collimator
sizes and source-axis distances (SAD).
Open Beam Profile Provides the FSPB open beam profile data.
FSPB Model Table Provides the FSPB model data.
FSPB Model Compare X Provides the comparison between the

measured OCR X vs. the calculated version
based on the FSPB model.
FSPB Model Compare Y Provided the comparison between the

measured OCR Y vs. the calculated version
based on the FSPB model.
Type Name of Report Description
Monte Phantom Provides the information about the virtual

Carlo Only water phantom used for the Monte Carlo
commissioning calculations.
Source Distribution Provides the calculated source distribution

used in the Monte Carlo calculation.
Fluence Distribution Provides the calculated fluence distribution

Energy Spectrum Provides the calculated energy distribution

Monte Carlo MLC Provides the comparison between the

Compare X measured OCR X vs. the calculated version
based on the Monte Carlo model.
Monte Carlo MLC Provides the comparison between the

Compare Y measured OCR Y vs. the calculated version
based on the Monte Carlo model.
2D Fluence Distribution Provide the 2D Fluence Distribution used in

the Monte Carlo Model to describe the
relative probability from the CAX.
Monte Carlo MLC Provides the MLC parameter table used by

Parameters Monte Carlo Model.
 Generate a Report
1. Select Commissioning Tools icon on the Home page.
2. Select a Treatment Machine on the Select CyberKnife Treatment Machine
screen, and click the Finish button.
3. For Fixed or Iris report, go to the Fixed/Iris task. For MLC report, go to the
MLC task.
Different reports are available at each step depending on the workflow.
4. Click the Print icon to launch the Report Viewer.

5. Choose a method to select a report:
• Double-click the report name from the report list.
• Click on the report name from the report list, then click the View
Selected Report Form icon from the action bar.
The Parameters section appears.
6. Select Measured or Calculated or Interpolated (MLC) from the Data Type.
7. Select the Collimator Size to be displayed in the report.
8. Choose a method to generate the report:
• To generate a report with all available information, click View Report
icon without modifying the parameters.
parameters and click View Report icon.
The report is generated according to the specified parameters and appears
in the report viewer.
The reports can be printed on the paper or export to different file formats
such as PDF and CSV. Refer to Data Management Manual for more details.
 Switch Viewing of Single View Reports

2. Click the report tab of the report to view.
 Close a Report
Click from the report tab.
 View Two Reports One Above the Other

2. Click Dual Window Horizontal View from the action bar.
contain the directional arrow.
click .
The report appears in the secondary view and the directional arrow will be
changed to . A split bar can be used to widen or narrow the report panes.
 View Two Reports Side by Side
2. Click Dual Window Vertical View from the action bar.
will contain the directional arrow.
click .
The report appears in the secondary view and the directional arrow will be
changed to . A split bar can be used to widen or narrow the report panes.
Section 3-2
Fixed and Iris Collimator Commissioning
This section describes commissioning Ray-Tracing and Monte Carlo dose

calculation algorithm for both Fixed and the Iris Collimator. For more
information, see the Physics Essentials Guide.
Commissioning Tools: Ray-Tracing Dose Calculation . . 106

Commissioning Tools: Monte Carlo Dose Calculation . . 126
1072963-ENG B Se ctio n 3 - 2: F i xed an d I r is C o llim at or C om missio nin g 105

Commissioning Tools: Ray-Tracing Dose Calculation
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
 Viewing and Printing Beam Data Tables . . . . . . . . . . . . . . . . . . . . . . . 106
 OCR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
 TPR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
 OF Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
 Overview
The procedures for commissioning the Ray-Tracing dose calculation
algorithm for fixed collimators and the Iris collimator in the Accuray
Precision System are the same. Import the sets of measured beam data for
fixed and Iris collimators to the data server and approve in the Accuray
Precision System. If your system includes the Iris Collimator, both sets of
beam data must be approved before you can use the Iris Collimator for
planning.
Upon login, the OCR, TPR, and OF steps are all available. The
recommended sequence of steps are the following:
1. Perform the OCR, TPR, and OF steps for fixed collimators.
2. Then perform the OCR, TPR, and OF steps for the Iris Collimator.
You can return to a previous step to review beam data at any time.
NOTE: The same value for the extrapolation depth must be used in both the
OCR and TPR steps. If you change a value in one step, you must return to
the other step and re-approve the beam data. Beam data for the Iris
Collimator does not require the same extrapolation depth as for fixed
collimators.
 Viewing and Printing Beam Data Tables

The commissioning steps for the Ray-Tracing dose calculation algorithm
provide graphical and tabulated views of the following data sets:
• Measured: Measured beam data that is formatted and then loaded into
the Accuray Precision System from the iDMS System.
• Calculated: Calculated beam data that is generated by interpolation and
extrapolation of the measured beam data for Ray-Tracing OCR, TPR,
and OF values. Linear interpolation is used. The extrapolation methods
used by Accuray Precision System are listed in the following table.
Extrapolation methods for calculated beam data
Beam Data Table (parameter) Method
OCR (Radius) Least Squares
TPR (Depth) Exponential
NOTE:Taylor Series is no longer available for new commissioning. It is only

available for previous beam models that are already accepted using Taylor
Series. Any recommissioning, even for those models, are forced to use the
other method.
For more information on interpolation and extrapolation methods, see

the Physics Essentials Guide.
• Reference: The reference data is an average of measured beam data
from multiple CyberKnife Systems. This composite data is not intended
as a standard sample. It is presented for comparison only.
Select and View a Data set

1. Select a data set (Measured, Calculated, or Reference) from the drop-down
list on the OCR, TPR, or OF step.
If you select the Reference data, measured data also appears. If no
reference data is loaded, this option does not appear in the drop-down list.
Reference data curves appear in gray.
The selected beam data appears in a graph in the main image viewer. A
label above the graph indicates whether the measured and calculated
beam data represents Non-Sample data or Sample data. Sample data is
the data configured with the CyberKnife System. Sample data has not,
however, been measured on the shipped system.
NOTE: If Sample data is used in commissioning procedures, patient plans

cannot be saved as deliverable.

Example of tabulated beam data
• On the OCR step, tabulated OCR beam data for the selected collimator
is displayed.
• On the TPR step, all tabulated TPR beam data is displayed.
• On the OF step, all tabulated OF beam data is displayed.
2. Use the scroll bar on the right side of the tabulated beam data to scroll
through the data.
Printing the Beam Data Table

1. Click Print icon to launch the Report Viewer.
2. Select a beam data to print.
3. Select Collimator Type, Dose Calculation Method, Data Type and
Collimator Size, then click View Report to generate the report.
4. Review the report.
5. Click the Print icon on the navigation tool bar to print out the report. See
Data Management Manual for more details on exporting the reports to
different file formats and printing.
 OCR Step
Use the OCR step to review the measured OCR beam data at different
depths and compare it to reference data (if loaded). You can also compare
the calculated OCR beam data to reference data. When you first go to the
OCR step, OCR beam data is calculated automatically using default values
for the extrapolation depth and method. You can change these values. If the
results are acceptable, you can then approve the beam data.
NOTE: The extrapolation depth must be the same for the OCR and TPR
steps for a given collimator type (Fixed Collimator or Iris Collimator).
OCR Screen
The OCR step shows the graphs of measured or calculated OCR values as
a function of radius for different depths.
OCR step - Fixed collimators, Not Approved
Small image viewers on the right side of the screen shows graphs of OCR
beam data for each of the 12 collimator field sizes, for either the Fixed
Collimator or the Iris Collimator as selected in the Collimator Type option.
Double-click any small image viewer to view the beam data on the large
image viewer.
The beam data shown in the graph appears in a table below the large image
viewer. You can view measured, calculated, or reference data. The large
image viewer includes a legend.

The upper portion of the legend shows the display color for each depth
(mm) in the graph. Select the check boxes to view the depths.
The lower portion of the legend appears only if reference data is loaded. It
shows the depths for reference data. Select the check boxes to view the
depths for reference data.
Control Area on OCR step
Collimator Type Fixed Select to review the measured and

Available if Iris Collimator calculated OCR beam data for fixed
Collimator is licensed option collimators.
and Iris beam data has
been imported to the Iris Collimator Select to review the measured calculated
iDMS System. option OCR beam data for Iris Collimator.
Measured Data Approve Click to open the Approve OCR Table

button dialog box to approve the OCR beam data
for all 12 collimator sizes simultaneously.
Approved Info Click to open the OCR Approved

button Information dialog box to review approval
information.
Extrapolation Data Depth (mm) Displays the current extrapolation depth for
text box calculated OCR beam data. To change the
depth, enter a new value in the text box. The
entered value does not take effect until you
redraw the curve and approve the OCR
beam data. Allowed depth values are from
450 to 800 mm.
Method Displays the currently selected

drop-down list extrapolation method for calculated OCR
beam data. To change the extrapolation
method, select another method from the
drop-down list.
Taylor Series is no longer supported as an
extrapolation method for OCR and TPR
tables. Taylor Series option is for review
only if you previously approved data using
this method.
Redraw Becomes available after you change the

button Depth (mm). When you click the Redraw
button, it deletes the existing calculated
OCR beam data, then calculates and
displays a new beam data based on the
current settings.
Full radius If selected, displays the OCR radius (x-axis

range check value) to 60 mm for all field sizes. If the
box check box is clear, displays the OCR radius
from 10 mm to 60 mm depending on the
field size.
Reviewing and Approving OCR Beam Data

1. Click the Commissioning Tools icon on the Home Page. The Select
CyberKnife Treatment Machine screen appears.
2. Select a treatment machine and click Finish. OCR step appears and the
calculated OCR beam data is shown as following:
• Calculated OCR data for various depths for the smallest collimator size
appear in the large image viewer.
• Calculated OCR data for each collimator size appear on the small
image viewers.
• Calculated OCR beam data from the small image viewers appear in the
OCR Calculated Data table.

3. If Iris Collimator is licensed and Iris beam data has been imported to the
iDMS System, select a collimator type from the Collimator Type option.
(Fixed Collimator or Iris Collimator).
If the calculated beam data is not approved, the Fixed Not Approved (or Iris
Not Approved) label appears in red at the top of the large image viewer.
4. Select Measured on the OCR Dataset drop-down list. Review the

measured beam data to ensure that the appropriate data was imported to
the data server and the data was successfully loaded into the Accuray
Precision System.
5. After reviewing and verifying the measured beam data, select Calculated
on the OCR Dataset drop-down list.
NOTE: When reviewing the Least Square calculated OCR data, the OCR
value at a radius of 0.0, may not be 1.0. It is expected to be within ± 0.02% of
1.0.
6. (Optional) To modify the beam data display, do any of the following steps:
• To view data for another collimator size on the large image viewer,
double-click the corresponding small image viewer on the right.
• To hide or display curves for different depths, clear or select the
appropriate check boxes on the OCR legend.
• To hide or display reference data as an overlay on the measured or
calculated beam data, clear or select the appropriate check boxes on
the OCR legend.
7. (Optional) To change the extrapolation depth used to calculate the OCR
beam data, enter a new value in the Depth (mm) text box in the
Extrapolation Data area, and click Redraw.
8. (Optional) To change the extrapolation method used to calculate the OCR
beam data, select an entry from the Method drop-down list, and click
Redraw.
When you click the Redraw button, the existing OCR curves are deleted
and new curves are calculated using the new extrapolation depth and
method.
9. Review the calculated OCR curves and tabulated beam data.

10. If the calculated OCR beam data is acceptable, click the Approve button.
Approve OCR Table dialog box appears.
11. Click OK to approve.
The calculated OCR beam data for all 12 collimator sizes is approved and
the Fixed Approved (or Iris Approved) label appears in green at the top of
the large image viewer.
Review the OCR Approved Information

1. Click the Approved Info button to review the approval information. The OCR
Approved Information dialog box appears.
The Table Name drop-down list shows the name of approved OCR beam
data tables.

2. Click OK to close the dialog box.
 TPR Step
Use the TPR step to view the measured TPR beam data for all collimator
sizes and compare it to reference data (if loaded). You can also compare
the calculated TPR beam data to reference data.
When you switch to TPR step, TPR beam data is calculated automatically
using the same extrapolation depth used on the OCR step. You can change
the maximum extrapolation depth. However, if you change the
extrapolation depth for TPR beam data after approving the OCR beam
data, you must return to the OCR step and reapprove the OCR beam data
using the new extrapolation depth.
If the results are acceptable, approve the beam data.
NOTE: Beam data for the Iris Collimator does not require the same
extrapolation depth as for fixed collimators.
You can examine TPR beam data for fixed collimators or the Iris Collimator
in this step.
TPR Screen
The TPR step shows a graph of the measured or calculated TPR values as
a function of depth for all collimator sizes.
The associated beam data from the graph appears in the table below the
graph. You can view measured, calculated, or reference data.
TPR step - Fixed collimator, Not Approved

The legend shows the display color for each collimator size (mm) in the
graph. The check boxes control which collimator sizes appear.
shows the collimator sizes for reference data. The check boxes control
which collimator sizes appear for reference data.
Control Area on TPR step
Collimator Type Fixed Select to review measured and calculated

Available if Iris Collimator TPR beam data for fixed collimators.
Collimator is licensed option
and Iris beam data
has been imported to Iris Collimator Select to review measured calculated TPR
the iDMS System. option beam data for the Iris Collimator.
Measured Data Approve Click to display the Approve TPR Table dialog
button box, and approve the TPR beam data.
Approved Info Click to display the TPR Approved

button Information dialog box and review the
approval information.
Extrapolation Data Depth text Displays the current extrapolation depth for
box calculated TPR beam data. To change the
depth, enter a new value in the text box. The
entered value does not take effect unless you
redraw the curves and approve the TPR
beam data. Allowed depth values are from
450 to 800 mm.
Method Displays the currently selected extrapolation

drop-down list method for calculated TPR beam data. To
change the extrapolation method, select
another method from the drop-down list.The
new method does not take effect unless you
redraw the curves and approve the TPR
beam data. Taylor Series is no longer
supported.as OCR and TPR tables
extrapolation method. Taylor Series option is
for review only if user previously approved
data using this method. TPR beam data can
only be approved using the Exponential
extrapolation method.
Redraw Becomes available after you change Depth or

button Method. When you click Redraw, it deletes
the existing calculated TPR beam data, then
calculates and displays new beam data based
on the current settings.
Reviewing and Approving TPR Beam Data

1. Click theTPR step. The calculated TPR beam data appears by default.
iDMS System, select a collimator type from the Collimator Type option
If the calculated beam data is not approved, the Fixed Not Approved (or Iris
Not Approved) label appears in red at the top of the image viewer.
3. Select Measured from the TPR Dataset drop-down list. Review the
measured beam data to ensure that the appropriate data was imported to
the data server and that the data was successfully loaded into the Accuray
Precision System.
from the TPR Dataset drop-down list.
5. (Optional) To modify the display of beam data, do any of the following steps:

• To hide or display curves for different depths, clear or select the
appropriate check boxes on the TPR legend.
• To hide or display Reference data as an overlay on the Measured or
Calculated beam data, clear or select the appropriate check boxes on
the TPR legend.
6. (Optional) To change the extrapolation depth used to calculated TPR beam
data, enter a new value in the Depth (mm) text box, and then click Redraw.
7. (Optional) To change the extrapolation method used to calculate TPR beam
data, select an entry from the Method drop-down list and then click Redraw.
When you click Redraw, the existing TPR curves are deleted and new
curves are calculated using the new extrapolation depth and method.
Changes to the extrapolation depth and method only become effective after
you redraw and approve the TPR beam data based on the new settings.
8. Review the TPR curbs and tabulated beam data.

9. If the calculated TPR beam data is acceptable, click the Approve button.
The Approve TPR Table dialog box appears.
10. Click OK to approve. The calculated TPR beam data is approved and the
Fixed Approved (or Iris Approved) label is shown in green at the top of the
image viewer.
NOTE: When you change the extrapolation depth or method, you must
return to the OCR step and reapprove the OCR beam data using the
new extrapolation depth.
TPR step - Fixed collimators, Approved
Review the TPR Approved Information

1. To review the approval, click the Approved Info button. The TPR Approved
Information dialog box appears.
2. Click OK to close the dialog box.

 OF Step
Use the OF step to view the measured output factor beam data for different
collimator sizes and source-axis distances (SAD) and compare it to
reference data (if loaded). You can also compare the calculated output
factor beam data to reference data. When you switch to the OF step, output
factor beam data is calculated automatically. If the results are acceptable,
you can then approve the beam data.
You can examine output factor beam data for fixed collimators or the Iris
Collimator.
OF Screen
The OF step shows a graph of the measured or calculated output factor
values.
OF step - Collimator layout, Fixed Not Approved
The beam data depicted in the graph appears in a table below the image
viewer. A scroll bar on the right allows you to scroll through the beam data.
You can view measured, calculated, or reference data.
Control Area on OF step
Collimator Type Fixed Select to review the measured and

Available if Iris Collimator calculated OF beam data for fixed
Collimator is licensed option collimators.
and Iris beam data has
been imported to the Iris Select to review the measured and
iDMS System. Collimator calculated OF beam data for the Iris
option Collimator.
Measured Data Approve Click to display Approve OF Table dialog

button box to approve the OF beam data.
Approved Click to display OF Approved Information

Info button dialog box to review the approval
information.
Layouts COLLIM Click to display the Collimator View layout.

button
SAD button Click to display the SAD View layout.
Layouts
Two layouts are available to view the output factor values as a function of
collimator size for different SAD values or as a function of SAD values for
different collimator sizes. Select a layout by clicking a layout button at the
bottom of the control area. You can select either COLLIM (Collimator View)
or SAD (SAD View).
Collimator View Layout (COLLIM)

In the Collimator View layout (COLLIM), the output factor is shown as a
function of collimator size for each SAD value. The calculated output factor
beam data can be displayed for SAD values from 500 mm to 1100 mm. Data
is extrapolated and interpolated from the measured output factor data in a
linear fashion.
The image viewer in the Collimator View includes a legend.

The top portion of the legend shows the display color for each SAD value
(mm) in the graph. The check boxes control which SAD values are
displayed.
The bottom portion of the legend is displayed only if reference data is
loaded. It shows the SAD values for reference data. The check boxes
control which SAD values are displayed for reference data.
SAD View Layout (SAD)
In the SAD View layout (SAD) the output factor is shown as a function of
SAD value for each collimator size. The output factor beam data can be
displayed for all 12 collimator sizes. Data is linearly extrapolated and
interpolated from the entered output factor data.
NOTE: Entered data is labeled as measured data on the screen, even

though the measured data has had an inverse square correction applied
prior to being entered.
OF step - SAD layout, Fixed Not Approved
The image viewer in the SAD View layout includes a legend.
The top portion of the legend shows the display color for each collimator
size (mm) in the graph. The check boxes control which collimator sizes
appear.

The bottom portion of the legend appears only if reference data is loaded.
It shows the collimator sizes for reference data. The check boxes control
which collimator sizes are displayed for reference data.
Reviewing and Approving OF Beam Data

1. Click the OF step. By default, calculated output factor beam data appears
in the Collimator View layout (COLLIM).
If the calculated beam data has not yet been approved, the Fixed Not
Approved (or Iris Not Approved) label appears in red at the top of the image
viewer.
3. Select Measured on the OF Dataset drop-down list. Review the measured

beam data to ensure that the appropriate data was imported to the data
server and the data was successfully loaded into the Accuray Precision
System.
on the OF Dataset drop-down list.
5. (Optional) To modify the display of beam data, do any of the following steps:
• To view curves for different depths, select the appropriate check boxes
from the OF legend in the Collimator View (COLLIM) or SAD layout.
• To view reference data as an overlay on the measured or calculated
beam data, select the appropriate check boxes from the OF legend.
6. Review the calculated OF beam data.
7. If the calculated output factor beam data is acceptable, click Approve. The
Approve OF Table dialog box appears.
8. Click OK to approve the data. The measured and calculated output factor
beam data in both layouts is approved and the Fixed Approved (or Iris
Approved) label appears in green at the top of the image viewer, and the
MC Source step becomes available.
OF step - Collimator View layout, Fixed Approved
Review the OF Beam Data Approved Information

To review the approval, click the Approved Info button. The OF Approved
Information dialog box appears.

Commissioning Tools: Monte Carlo Dose Calculation
This section describes the Accuray Precision System user interface for
commissioning Monte Carlo Dose Calculation for both fixed collimators and
the Iris Collimator. For more information on the Monte Carlo Dose
Calculation algorithm, see the Physics Essentials Guide.
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
 MC Source Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
 MC TPR & OCR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
 MC OF Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
 Overview
Commissioning steps for the Monte Carlo Dose Calculation becomes
available sequentially, beginning with the MC Source step. Before you can
use the commissioning tools for Monte Carlo Dose Calculation, you must
complete the commissioning steps for the Ray-Tracing dose calculation
algorithm for fixed collimators described earlier in this chapter.
The procedures for commissioning the Monte Carlo Dose Calculation for
fixed collimators and the Iris Collimator are the same. You can import the
sets of measured beam data for fixed collimators and the Iris Collimator to
the data server in any order. However, if your system includes the Iris
Collimator, approval of the Monte Carlo beam data for fixed collimators
must be completed before you can complete approval of Iris Collimator
beam data.
The recommended sequence of steps are the following:
1. Perform the MC Source, MC TPR & OCR, and MC OF steps for fixed
collimators.
2. Perform the MC Source, MC TPR & OCR, and MC OF steps for the Iris
Collimator.
 MC Source Step
Use MC Source step to review and verify the measured Monte Carlo beam
data imported to the data server. Then you generate a calculated source
model for the LINAC radiation source. You can generate a source model for
fixed collimators or the Iris Collimator. However. the Iris Collimator option in
the Collimator Type is unavailable on the MC Source step until the OCR,TPR,
and OF steps are completed for the Iris Collimator.
The source model consists of three probability distributions; the source
distribution, the fluence distribution, and the energy spectrum. They must
be all reviewed before you can approve the model. If the results are
acceptable, you can then approve the model. For more information on how
the source model is used in Monte Carlo Dose Calculation, see the Physics
Essentials Guide.
Two methods are available for generating the source distribution:
• Gaussian method: The source distribution is modeled as a Gaussian
curve. For the calculation, you specify a value (in mm) for the photon
source full width half maximum (FWHM). Larger values produce a wider
distribution (with broader penumbra for the Monte Carlo calculated
OCR curve). Smaller values produce a narrower distribution (with
steeper penumbra for the Monte Carlo calculated OCR curve).
• In-air Output Factor method: The source distribution is calculated using
measured in-air output factor beam data. The measured beam data is
required only if you intend to use the in-air output factor method to
generate the source distribution
NOTE: The source distribution method used for the Iris Collimator can be
different from the method used for fixed collimators.
MC Source Screen
The MC Source step includes three layouts that display the calculated
source distribution, fluence distribution, and energy spectrum for the LINAC
source model. When you switch to this step, the Source Distribution layout
is displayed and the In-air OF (Output Factor) method is selected by default.
If no in-air output factor beam data was imported, this method is
unavailable.

MC Source step - Source Distribution layout, In-air Output Factor method, Fixed Not Approved
In the Source Distribution layout, the upper image viewer shows a graph of
the measured in-air output factor as a function of collimator size. The table
to the right displays the measured beam data values. This image viewer is
empty if the Gaussian method is selected.
The lower image viewer shows a graph of the calculated source distribution
as a function of off-axis radius. The table to the right displays the calculated
data values. This image viewer is empty if the source distribution has not
yet been calculated.
For more information on the source distribution, see the Physics Essentials
Guide.
MC Source step - Source Distribution layout, Gaussian method, Fixed Not Approved
Control Area on MC Source step
Collimator Type Fixed Select to review measured beam data and

Available if Iris Collimator calculated beam profiles for the Monte Carlo
Collimator is option Dose Calculation for fixed collimators.
licensed and Iris
beam data has Iris Select to review measured beam data and
been imported to Collimator calculated beam profiles for the Monte Carlo
the iDMS System option Dose Calculation for Iris Collimator.
MC Source Model Calculate Click to select a method to generate the Monte

button Carlo source distribution, then calculates and
displays the probability distributions in all three
layouts simultaneously.
Approve Click to display the approve tables dialog box,

button which allows you to approve the measured Monte
Carlo beam data and the calculated probability
distributions in all three layouts simultaneously.

Layouts
Select a layout by clicking a layout icon at the bottom of the control area.
The following three layouts are available.
Tool
Icon Tip Description
Source Measured In-air OF: Measured in-air output factor values

Distributi as a function of collimator size. If the Gaussian modeling
on icon method is selected, this beam data is not displayed.
Source Distribution: Source probability distribution as a
function of off-axis radius, calculated using the selected
modeling method.
Fluence Measured Dose Profile: Measured open field dose

Distributi profile as a function of radial position.
on icon Fluence Distribution: Fluence probability distribution as a
function of off-axis radius.
Energy Measured Central PDD: Measured central PDD as a

Spectru function of depth for the 60 mm collimator.
m icon Energy Spectrum: Energy spectrum probability
distribution as a function of energy (MeV).
In the Fluence Distribution layout, the upper image viewer shows a graph of
the measured open field dose profile. The lower image viewer shows a
graph of the calculated fluence probability distribution. The lower image
viewer is empty if the source model has not yet been calculated. The tables
to the right display the measured beam data and calculated values. Scroll
bars on the right allow you to scroll through the data.
For more information on the fluence distribution, see the Physics Essentials
Guide.
Figure 26 MC Source step - Fluence Distribution layout, Gaussian method, Fixed Not Approved

In the Energy Spectrum layout, the upper image viewer shows a graph of
the measured central PDD curve. The lower image viewer shows a graph
of the calculated energy spectrum probability distribution. The lower image
viewer is empty if the source model has not yet been calculated. The tables
to the right display the measured beam data and calculated values.
For more information on the energy spectrum, see the Physics Essentials
Guide.
MC Source step - Energy Spectrum layout, Gaussian method, Fixed Not Approved
Reviewing and Approving the Source Model

1. Click the MC Source step. By default, the Source Distribution layout and the
In-Air OF method are selected.
2. If Iris Collimator is available and Iris beam data for the Ray-Tracing dose
calculation algorithm has been approved, select a collimator type from the
Collimator Type option (Fixed Collimator or Iris Collimator).
If the measured beam data and the source model have not yet been
approved, the Fixed Not Approved (or Iris Not Approved) label appears in
red at the top of the image viewer.
3. To view another layout, click a layout icon on the Layouts area.

Review the measured beam data in all three layouts to ensure that the
appropriate data was imported to the data server and that the data was
successfully loaded into the Accuray Precision System.
4. Click the Calculate button. The Select Monte Carlo Source Model dialog
box appears.
5. Select a method for generating the source distribution:

• To select the In-air Output Factor method, click the In-air Output Factor
option.
• To select the Gaussian method, click the Gaussian option. Then enter
a value (in mm) in the Photon source full width half maximum text box.
The FWHM (Full Width Half Maximum) can have a value between 1.0 and
4.0 mm. Smaller values for the Gaussian FWHM yield narrower penumbra
of the OCR. Values between 2.0 and 2.5 tend to give the best overall fit with
the measured data.
6. Click the OK button.

The source model is calculated. To review the calculated source
distribution, fluence distribution, and energy spectrum probability
distributions, click the appropriate layout icon on the Layouts area.
NOTE: You must review the calculated source model in all three layouts.
After all three probability distributions have been reviewed, the Approve
button becomes available. You can review the layouts in any order.
7. If you are using the Gaussian modeling method, you can modify the value
of the photon source FWHM used in the calculation.
• Click the Calculate button, and enter a new value in the Photon source
full width half maximum text box.
• Click the OK button. The source model is recalculated and displayed.
8. If the calculated source model is acceptable, click the Approve button. The
Approve Source Model dialog box appears.

9. To accept the calculation, click the OK button
After the source model is approved, the Fixed Approved (or Iris Approved)
label is shown at the top of the image viewer in all three layouts. Then MC
TPR & OCR step becomes available.
NOTE: If you change the source distribution method for a collimator type
(Fixed Collimator or Iris Collimator) after approving the source model, or if
you change the value of the photon source FWHM of the Gaussian method,
you must reapprove the source model. Otherwise, Monte Carlo Dose
Calculation will not be available for treatment planning.
Also, any Monte Carlo commissioning work completed in the MC TPR &
OCR and MC OF steps subsequent to the original approval of the source
model will be lost. That is, you will lose the Monte Carlo calculated TPR,
OCR, and OF curves for that collimator type.
MC Source step - Source Distribution layout, Gaussian method, Fixed Approved
 MC TPR & OCR Step
Use MC TPR & OCR step to calculate TPR and OCR curves using the
Monte Carlo Dose Calculation algorithm. Then, you compare these curves
with the measured TPR and OCR beam data previously approved to
commission the Ray-Tracing dose calculation algorithm. If the results are
acceptable, accept the correction factors (ECF,CCF) used to generate
these calculations. You can examine Monte Carlo calculated TPR and OCR
curves for fixed collimators or the Iris Collimator.
NOTE: The MC TPR & OCR step is not available until the results of the MC
Source step are accepted.
You can calculate, review, and accept Monte Carlo calculated TPR and
OCR curves for one or more collimator sizes at a time. You can calculate
OCR curves for up to five depths per collimator. You must calculate TPR
and OCR curves for all collimator sizes and accept all calculation results
before you can proceed to the MC OF step.
You must specify a statistical uncertainty value for the calculations. You can
also modify correction factors for each collimator size to adjust the
calculated curves.
If you are using the Gaussian source distribution method, modifying the
value of the photon source FWHM in the MC Source step changes the slope
of the OCR penumbra. If you change the photon source FWHM, you must
reapprove the source model before returning to the MC TPR & OCR step
and all previously calculated TPR and OCR curves are deleted.
When you accept the TPR and OCR calculation results, you are indicating
that the current source model and correction factors, when used to perform
Monte Carlo simulation of your water phantom beam data measurements,
adequately reproduce the measured beam data. The results of the Monte
Carlo TPR and OCR calculations are for review only and are not used for
any further dose calculations performed as part of treatment planning.
Uncertainty Value
You are required to specify an uncertainty value for the Monte Carlo TPR
and OCR calculations. The same uncertainty value must be used for all
collimator sizes. Therefore, if you change the uncertainty value after
calculating curves for a collimator size, you must recalculate the curves
using the new value before you can complete the acceptance.
After a calculation is performed, the reported average uncertainty is
displayed at the top of the screen above each graph.
• The reported uncertainty for Monte Carlo TPR calculations is the
average of all collimators uncertainties calculated from the average of
the top 20 voxels with the highest dose for all water phantom
geometries used to calculate the Monte Carlo simulated TPR curves.

• The reported uncertainty for Monte Carlo OCR calculations for any
given collimator is the average of the top 20 voxels with the highest
dose for all water phantom geometries used to calculate the Monte
Carlo simulated OCR curves.
The Accuray Precision System scales the number of histories with the
depth of the Monte Carlo TPR and Monte Carlo OCR calculations so that
the requested uncertainty is maintained at each calculation depth.
Therefore, the reported uncertainty tends to be smaller than the requested
uncertainty.
For example, in order to achieve 1% uncertainty for an OCR calculation at
a depth of 300 mm, the region of maximum dose (d ~15 mm) will have a
lower uncertainty level because the area of maximum dose in the water
phantom is closer to the X-ray source and therefore will have more photon
interactions per voxel than will the voxel at a depth of 300 mm at which the
OCR data is obtained. The same is true for Monte Carlo TPR calculations.
At a requested uncertainty of 1% and depths of 15, 100, and 300 mm, a full
12-collimator set of Monte Carlo OCR and Monte Carlo TPR calculations
each takes about 2 hours. Calculations for smaller collimators and
calculations at shallower depths require less time. You can perform
calculations for all 12 collimators in a single operation or perform
calculations for a few collimators at a time.
For more information on the uncertainty value, see the Physics Essentials
Guide.
Correction Factors
If calculated curves for a particular collimator size are not sufficiently
aligned with the measured curves, you can modify the correction factors
and recalculate the curves:
• Collimator Correction Factors (CCF): There is one CCF for each
collimator size. In the calculation, the stated collimator size is multiplied
by the CCF value to adjust the full width half maximum of the OCR
curves for that collimator size. A CCF value > 1 will increase the FWHM
of the OCR profile. A CCF value < 1 will decrease the FWHM of the
OCR profile.
To determine the CCF value to use, take the ratio of the FWHM of the
measured OCR curve to the FWHM of the calculated curve. When adjusting
the CCF, it is useful to examine OCR curves for multiple depths to
determine the optimal CCF value for the overall range of data.
• Energy Correction Factors (ECF): There is one ECF for each collimator
size. In the calculation, the energy of each sampled photon is increased
from the nominal value provided by the energy distribution model by a
factor of ECF. For example, to increase the mean energy by 5%, set
ECF new = ECFold * 1.05.
Larger ECF values push the TPR curve up. Smaller ECF values lower the
curve.
For more information on correction factors, see the Physics Essentials
Guide.
MC TPR & OCR Screen

On the MC TPR & OCR step, TPR and OCR curves are displayed in
separate layouts. Both measured and calculated curves are displayed on
the same graph for comparison. Measured curves are shown as solid lines.
Calculated data points are shown as dots.
The measured and calculated beam data depicted in the graph is shown in
the tables below image viewer:
• Measured beam data is labeled Measured TPR Data in the TPR layout
and Measured OCR Data in the OCR layout.
• Calculated beam profile curves are labeled MC TPR Data in the TPR
layout and MC OCR Data in the OCR layout.
MC TPR & OCR step - TPR layout, Fixed Not Accepted

Control Area on MC TPR & OCR step
Collimator Type Fixed Select to review the measured beam data

Available if Iris Collimator and the corresponding Monte Carlo
Collimator is licensed option calculated beam profiles for the Monte
and Iris beam data Carlo Dose Calculation for fixed collimators.
has been imported to
the iDMS System Iris Collimator Select to review the measured beam data
option and the corresponding Monte Carlo
calculated beam profiles for the Monte
Carlo Dose Calculation for Iris Collimator.
Settings Correction Click to display the Set Correction Factors

Factors button dialog box, and modify Collimator
Correction Factors (CCF) and Energy
Correction Factors (ECF) for one or more
collimators.
OCR Depths Click to display the Set Calculation OCR

button Depths dialog box, and specify up to five
depths for OCR calculations. Depths for
measured OCR beam data are displayed for
reference.
Computation Uncertainty % Displays the current requested uncertainty

text box value for the Monte Carlo TPR and OCR
calculation.
Fit Correction Click to display the Automated ECF/CCF Fit

Factors button dialog box. Autofit determines the CCF and
ECF values by adjusting the CCFs and ECF
iteratively so that the FWHM of the
calculated OCR fits the FWHM of the
measured OCR and the calculated TPR fits
the measured TPR, respectively. You can
specify the Maximum Iterations for
automated ECF/CCF fit to run, and
Uncertainty (%), You can also select the
Initial CF Values to System Default or User
Defined CFs. See the Physics Essentials
Guide for more details.
Calculate Click to display the Collimator Selection

button dialog box, and select one or more
collimator sizes for the Monte Carlo TPR
and OCR calculation before starting the
calculation. You can set the uncertainty
value for the Monte Carlo calculation.
Allowed uncertainty values are from 0.1% to
4%.
Accept button This button becomes available after a

calculation is performed for one or more
collimators. Click to accepts the current
Monte Carlo calculated TPR and OCR
curves and their corresponding correction
factors.
Phantom Click to display the Phantom Information for

button MC Commissioning dialog box, and select a
data type to view the phantom geometry for
Monte Carlo TPR, OCR and OF calculation.
Layouts
There are two layouts to view the measured and Monte Carlo calculated
TPR and OCR beam profiles. Select a layout by clicking a layout button at
the bottom of the control area. You can select either TPR (TPR layout) or
OCR (OCR layout).

In the TPR layout, TPR values are shown as a function of depth for each
collimator size. The image viewer in the TPR layout includes a legend.
MC TPR & OCR legend
The legend shows the display color for each collimator size (mm) in the
graph. Check boxes in the Meas TPR column control which collimator sizes
are displayed for measured TPR curves. Check boxes in the MC TPR
column control which collimator sizes are displayed for Monte Carlo
calculated TPR curves.
In the OCR layout, OCR values are shown as a function of radius (mm) for
each depth and collimator size. The Collimator Size drop-down list above
the image viewer allows you to select the collimator size.
MC TPR & OCR step - OCR layout, Fixed Not Accepted
The image viewer in the OCR layout includes a legend.
MC TPR & OCR legend
The upper portion of the legend shows the display color for each measured
depth (mm) in the graph. The check boxes control which depths are
displayed for the measured OCR curves.
The lower portion of the legend shows the display color for each depth used
for the Monte Carlo OCR calculation. The check boxes control which depths
are displayed for the calculated OCR curves.

Reviewing and Accepting MC TPR and OCR Beam Profiles
1. Click the MC TPR & OCR step. By default, the TPR layout appears.
If the Monte Carlo TPR and OCR calculation has not yet been performed
and accepted, the Fixed Not Accepted (or Iris Not Accepted) label appears
in red at the top of the image viewer.
3. On the TPR legend, use the check boxes to select collimator sizes for the
measured and Monte Carlo calculated TPR beam data to be displayed for
review.
4. To view the OCR layout, click the OCR icon on the Layouts.
The measured OCR curves for the smallest collimator size are shown in the
image viewer. To display measured OCR curves for another collimator size,
select an entry from the Collimator Size drop-down list.
5. To view or modify the Collimator Correction Factors (CCF) and Energy

Correction Factors (ECF), click the Correction Factors button. The Set
Correction Factor dialog box appears.
You can accept the default correction factor values for the first calculation.
To modify correction factor values, do the following:
• Double-click a text box in the CCF or ECF column and enter a new
value.
• Click the Apply button to save the changes.
The range of correction factor values is from 0.5 to 1.5. Typically, the best
fits with measured data have values between 0.9 and 1.15.
6. To set depths for the Monte Carlo OCR calculation, click the OCR Depths
button. The Set Calculation Depths dialog box appears.
• Double-click a text box in the MC Depth (mm) list.

• Enter a new value for the Monte Carlo calculation depth (mm). The
value will be applied to all collimator sizes.
• You can perform the Monte Carlo OCR calculation for up to five depths
by selecting the check box for each depth value.
NOTE: Only the measured depths are available for calculation.
7. To set the automated ECF/CCF fit, click the Fit Correction Factors button.
Automated ECF/CCF Fit dialog box appears.

Set the desired number of Maximum Iterations, Uncertainty (%), and Initial
CF Values. Make sure that the ECFand CCF check boxes are selected, and
click the OK button.
8. Click the Calculate button. The MC TPR and OCR Calculation dialog box
appears.
You can select one or more collimator sizes for each Monte Carlo TPR and
OCR calculation that you perform:
• To select a collimator size, select the corresponding check box. To omit

a collimator size from the calculation, clear the corresponding check
box. The collimator size is grayed out if a calculation has been made for
the current calculation configuration (i.e. uncertainty, depths, etc.).
• To begin the calculation for the selected collimator sizes, click the OK
button, or double click to recalculate.
• To cancel and retain previously calculated results, click the Cancel
button.
When the calculation begins, screen controls are disabled and a Cancel
button in the status bar on the lower left of the screen becomes available.
The status bar displays updated status information throughout the
calculation process.
NOTE: Calculations are performed sequentially per collimator. If the Cancel

button is clicked or the Accuray Precision System is shut down during the
calculation, data for all collimator sizes for the current calculation is lost, but
previously calculated and accepted data is retained.
9. Use the default uncertainty value for the calculation, or modify the
uncertainty value by double-clicking the Uncertainty text box and entering a
new value.
NOTE: The same uncertainty value must be used for all collimator sizes. If
you change the uncertainty value after performing and/or accepting the
calculation for a collimator, you must redo the calculation using the new
uncertainty value.
10. When the calculation is completed for the selected collimators, compare the
Monte Carlo calculated TPR and OCR values with the measured beam data
plotted in both layouts. Measured curves are shown as solid lines.
Calculated data points are shown as dots.
11. If the calculated TPR and OCR curves are satisfactory, click the Accept
button. The Accept MC TPR and OCR dialog box appears.
12. Click the OK button to accept the results.You can accept partial results for
fewer than 12 collimators.
• If the calculation has not yet been performed for all collimator sizes, the
Fixed Partially Accepted (or Iris Partially Accepted) label appears in
green at the top of the image viewer. You can then continue to perform,
review, and accept calculations for other collimator sizes.
• If the calculation has been performed and accepted for all 12 collimator
sizes, the Fixed All Accepted (or Iris All Accepted) label appears at the
top of the image viewer. Then MC OF step becomes available.

MC TPR & OCR step - TPR layout, Fixed All Accepted
13. Click the Phantom button to open the Phantom Information for MC
Commissioning dialog box.
14. Select a data type from the drop-down list to view the phantom geometry for
Monte Carlo TPR, OCR and OF calculation.
NOTE: During the commissioning process of Monte Carlo, the CAX of the
beam is aligned in the middle of the phantom along the Z axis.
15. Click the Close button.
 MC OF Step
Use MC OF step to calculate the output factor (OF) value for each collimator
size using the Monte Carlo Dose Calculation algorithm. Then, compare the
Monte Carlo calculated results to the measured output factor beam data
previously approved to commission the Ray-Tracing dose calculation
algorithm.
You specify an uncertainty value for the Monte Carlo output factor
calculation.
NOTE: On the MC OF step, the same uncertainty value must be used for
fixed collimators and the Iris Collimator.
The calculation also generates an absolute dose normalization constant,

Fnormal, to convert the deposited energy to the absolute dose. The
Fnormal value calculated for fixed collimators is also used for the Iris
Collimator. You must therefore complete the MC OF step for fixed
collimators before you can complete the MC OF step for the Iris Collimator.
NOTE: On the MC OF step, the Iris Collimator option in the Collimator Type
area is unavailable until the MC OF step is completed for fixed collimators.
If the calculated results on the MC OF step are acceptable, approve the

results. Upon approval, the output data from the Monte Carlo output factor
calculation is used for all future Monte Carlo dose calculations performed
as part of treatment planning.
MC OF Screen
On the MC OF step, the measured and Monte Carlo calculated output factor
values are displayed as a function of collimator size at 800 mm SAD. Both
measured and calculated curves are displayed on the same graph for
comparison. The measured beam data appears as a solid line. Calculated
data points appear as dots.
The measured beam data and calculated values depicted in the graph are
shown in tables below the image viewer:
• The measured beam data is labeled as Measured OF Data.
• The calculated values are labeled as MC OF Data.

MC OF step - Fixed Not Approved
Control Area on MC OF step
Collimator Type Fixed Select to review measured beam data and the
Available if Iris Collimator corresponding Monte Carlo calculated beam
Collimator is option profiles for the Monte Carlo Dose Calculation for
licensed and Iris fixed collimators.
beam data has
been imported to Iris Collimator Select to review measured beam data and the
the iDMS System option corresponding Monte Carlo calculated beam
profiles for the Monte Carlo Dose Calculation for
the Iris Collimator.
OF & Absolute Uncertainty % Displays the requested uncertainty value for the
Dose text box Monte Carlo output factor calculation. This value
applies to both the fixed collimators and the Iris
Collimator.
Calculate Click to displays the MC OF Calculation dialog

button box to modify the current uncertainty value for
fixed collimators only. The same uncertainty
factor will be used for the Iris Collimator. Allowed
uncertainty values for the Monte Carlo output
factor calculation are from 0.1% to 0.5%.
Fnormal text Displays the current calculated value of the

box absolute dose normalization factor, Fnormal. This
value applies to both fixed collimators and the Iris
Collimator.
Approve Becomes available after the calculation is

button performed. Click to accepts the current Monte
Carlo calculated output factor beam data.
Phantom Click to display the Phantom Information for MC

button Commissioning dialog box, and select a data
type to view the phantom geometry for Monte
Carlo TPR, OCR and OF calculation.
Reviewing and Approving MC OF Values and Fnormal

1. Click the MC OF step. The measured output factor values at 800 mm SAD
appears in the image viewer, and the measured output factor beam data
values are tabulated below it.
If the Monte Carlo output factor calculation has not yet been performed and
approved, the Fixed Not Approved (or Iris Not Approved) label appears in
red at the top of the image viewer.
3. Click the Calculate button in the control area. The MC OF Calculation dialog
box appears.

4. For fixed collimators, if appropriate, modify the uncertainty value for the
Monte Carlo output factor calculation by double-clicking the Uncertainty %
text box and entering a new value.
To ensure adequate baseline results and complete the process of
commissioning the Monte Carlo Dose Calculation algorithm, use 0.2% as
the uncertainty value for MC OF.
If you change the uncertainty value for fixed collimators after approving Monte
Carlo output factor beam data for the Iris Collimator, you must do the following.
• Recalculate and reapprove Monte Carlo output factor values for fixed
collimators using the new uncertainty value.
• Then recalculate and reapprove Monte Carlo output factor values for the Iris
Collimator. The uncertainty value used for fixed collimators will be used for the
calculation.
5. Click the Calculate button to apply the current uncertainty value and begin
the calculation.
Or, click the Cancel button to cancel and retain previously calculated
results.
When the calculation begins, the screen controls are disabled and a
calculation status panel is displayed below the MC OF Data table with a
Cancel button on the left. A status bar displays the updated status
information throughout the calculation process in the middle, and a
progress bar on the right.
NOTE: If you click the Cancel button or shut down the Accuray Precision
System during the calculation, the calculation will be terminated and
calculation data is deleted. To reload previously calculated and approved
Monte Carlo output factor values, return to the home page and click the
Commissioning Tools icon. Then switch directly to the MC OF step and
continue.
6. If the Monte Carlo calculated output factor data is satisfactory, click the
Approve button to accept the results. The Approve Monte Carlo OF dialog
box appears.
7. Click OK to approve the MC OF.

The calculated output factor values and Fnormal are approved and the
Fixed Approved (or Iris Approved) label appears in green at the top of the
image viewer.
MC OF step - Fixed Approved
8. Click the Phantom button to open the Phantom Information for MC

Commissioning dialog box. Select a data type to view the phantom geometry.


This is the final step in commissioning the Monte Carlo Dose Calculation
algorithm.
After the Monte Carlo output factor beam data is approved, the Monte Carlo
Dose Calculation is available as a dose calculation option during treatment
planning.
Section 3-3
Multileaf Collimator Commissioning
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Commissioning Tools for Monte Carlo Dose Calculation for
Multileaf Collimator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
1072963-ENG B S e c t io n 3 - 3 : M u l t i l e a f C o l li m a t o r C o m m i s s i o n i n g 153
Overview
 About MLC Commissioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

 Graphics Tools for OCR, TPR, OF, and Open Beam Profile . . . . . . . . 154
 About MLC Commissioning

As with the fixed and Iris Collimator commissioning, the Accuray Precision
System provides both graphical and tabulated displays for MLC
commissioning for the following data types:
• Measured: Beam data measured and properly formatted and then
loaded into the Accuray Precision System from Beam Data Import
(BDI).
• Interpolated: Calculated beam data, generated by the interpolation and
extrapolation of the measured beam data for FSPB TPR and OF values.
FSPB OCR extrapolation is based on a Least Squares method. For
OCR values, fitting functions are used to generate the OCR calculated
data. TPR extrapolation is based on an exponential method.
• Modeled: The modeled FSPB OCR profiles and the model parameters.
To complete the MLC commissioning, set up the data sets using the
procedures found in the Physics Essentials Guide. Then, do the following:
• Perform the OCR, TPR, OF, Open Beam Profile, and PB Model steps.
• Create and test the phantom plan.
• Approve the commissioning results.
 Graphics Tools for OCR, TPR, OF, and Open Beam

Profile
The OCR, TPR, OF, Open Beam Profile, and PB Model steps have a
common set of graphics tools. Using these tools, you can pan and zoom the
curves, and highlight either or both the line and points.
To display the quick access menu, right-click in the image viewer. The
menu provides different options to view the curve.
Graphics tools quick access menu
Graphics Tools Quick Access Menu
Item Description
Draw Lines Draws the curve by using a solid line.
Draw Points Draws the curve by using points.
Draw Lines and Draws the curve using both a solid line and points.
Points
Point Select Click to select a point on the curve. The row highlighted in the
table corresponds to the point under the cursor. A crosshair
appears along with the point, which has a circle around it. You
can move the point vertically using the cursor and updated
information about each point appears in a box next to the point.
Zoom Increase or decrease zoom level of the either the current image
plane or globally.
• To frame the zoom, drag the top left of the field of view to the
bottom right. (A box bordered by a dashed line indicates the
resulting field of view.)
• To zoom in or out, scroll forward or backward.
Item Description
Pan Pan either the current image plane or globally.

To re-frame the view, drag the image to the desired location.
Reset Zoom and Click to reset the display to original zoom and pan settings.
Pan
Calculation
This section describes the commissioning Finite Size Pencil Beam (FSPB)
dose calculation for the multileaf collimator. For more information on the
FSPB dose calculation algorithm, see the Physics Essentials Guide.
NOTE: If your Accuray Precision System does not include the FSPB dose
calculation option, the tab for the MLC task is not available.
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
 Viewing and Printing the MLC Beam Data Tables . . . . . . . . . . . . . . . . 158
 MLC OCR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
 MLC TPR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
 MLC OF Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
 MLC Open Beam Profile Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
 MLC PB Model Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
 MLC Final Approval Step for Patient Plans . . . . . . . . . . . . . . . . . . . . . 173
 Overview
Commissioning steps for the FSPB dose calculation are available by
clicking the MLC task. The recommended sequence of steps is the
following.
The first two steps are independent of each other and can be performed in
any order. Step 3 must be completed after Steps 1 and 2, but prior to
performing step 4.
1. Perform the OCR, TPR, and OF steps.
2. Perform the Open Beam Profile steps.
3. Perform the PB Model steps.
4. Once the first three steps are approved, create a phantom plan. Then
deliver the plan to evaluate for dose accuracy.
5. Based on the results of the phantom plan, approve the model to use for
patient plans on the Final Approval step. In this step, you are approving the
results of a phantom plan and on that basis, allowing the use of the
algorithm for patient treatment planning.
 Viewing and Printing the MLC Beam Data Tables
Accuray Precision System’s commissioning steps for the FSPB calculation
provide graphical and tabulated displays of the following data sets:
• Measured: Beam data measured and properly formatted, and then
loaded into the Accuray Precision System from the iDMS System.
• Interpolated: Beam data calculated with interpolation and extrapolation.
For more information about interpolation methods, see the Physics
Essentials Guide.
Select and View a Data Set

Select a data type (Measured or Interpolated) from the drop-down list in the
Data area.
The selected beam data appears in a graph in the main image viewer. A
label above the graph indicates whether the measured and interpolated
beam data represents non-sample data (Non-Sample) or sample data
(Sample). Sample data is the data configured for initial CyberKnife setup.
This is not meant for patient treatment. Sample data was not measured on
the shipped system.
NOTE: If sample data is used in commissioning procedures, you cannot

save a deliverable plan for patient CT, but can save a deliverable plan for
phantom CT.
Tabulated beam data from the selected data type appears below the image
viewer.
Example of tabulated beam data
Printing the Beam Data Table

1. Click the Print icon to launch the Report Viewer.
2. In the Forms tab, double-click a beam data name you want to print.
3. In the Parameter area, enter the Data Type and Collimator Size, and then
click View Report to generate the report.
4. Review the report.
5. Click the Print icon on the navigation tool bar to print out the report. See
Data Management Manual for more details on exporting the reports to
different file formats and printing.
 MLC OCR Step

Use OCR step to view the measured OCR beam data at different depths
and compare it to the reference data (if loaded and then selected). You can
also compare the calculated OCR beam data to the reference data. When
you first go to the OCR step, OCR beam data is calculated automatically
using default values for the extrapolation depth and method. The
extrapolation depth is 600 mm and the method is Least Squares.
MLC OCR Screen

The OCR step displays graphs of the measured or interpolated OCR values
as a function of radius for different depths.
OCR step - MLC, Measured, Approved
The control area on the left of the screen are user-input options for OCR.
The graphs in the center of the screen pictorially depict the data from the
charts, enhanced by the user-input options. The charts at the bottom of the
page show either interpolated or measured data.
The top portion of the legend shows the display color for each depth (mm)
in the graph. Use the check boxes to select the depth to display.
The lower portion of the legend appear only if reference data is loaded. It
shows the depths for reference data. Use the check boxes to select the
depth to display.
Control Area for the OCR step
Data Type Displays the currently selected data type. To change

drop-down the data type, select another method from the
list drop-down list (Measured, Interpolated, or Reference
(if reference data is available).
Size (mm) Displays the currently selected MLC field size for
drop-down review.
list
Measured Data Approve Click to display the Approve OCR Table dialog box
button and approve the complete set of OCR beam data.
Legends Measured, Interpolated, and Reference (Reference

only appears when it is loaded).
You can select the display color for each Depth (mm)
in the graph and tables. Use the check boxes to select
the depths to display.
Reviewing and Approving MLC OCR Beam Data

1. Click the Commissioning Tools icon on the Home Page.
2. Click the MLC tab. The OCR step appears.
By default, measured OCR beam data is shown:
• Measured OCR curves for different depths for the smallest leaf size for
review (for the X and Y planes of the MLC) are displayed in the image
viewer.
• Below each graph is the measured OCR beam data corresponding to
the data that appears in the image viewer.
3. Select Measured on the Type drop-down list and select one of the sizes
from the Size (mm) drop-down list. Review the measured beam data to
ensure that the appropriate data was imported to the data server and the
data was successfully loaded into the Accuray Precision System.
4. To hide or display curves for different depths, clear or select the appropriate
check boxes on the OCR legend.
5. You can use the drawing tools quick access menu in the MLC OCR step.
6. After reviewing and verifying the measured beam data, select Interpolated
on the Type drop-down list and the size of the MLC opening from the Size
(mm) drop-down list. Review the interpolated OCR beam data.
7. If the measured and interpolated data are correct, click the Approve button
to approve the beam data.
 MLC TPR Step

Use TPR step to view the measured TPR beam data for all field sizes and
compare it to reference data (if loaded). When you switch to the TPR step,
TPR beam data is extrapolated automatically to 600 mm by using an
exponential method. If the results are acceptable, you can then approve the
beam data.
MLC TPR Screen

The TPR step displays a graph of the measured or interpolated TPR values
as a function of depth for the MLC field sizes.
TPR step - MLC, Measured, Versus Field, Approved
TPR step - MLC, Measured, Versus Depth, Approved
The top portion of the legend shows the display color for each field size (or
depth) in the graph. Use the check boxes to select the field sizes to display.
shows the field size (or depth) for reference data. Use the check boxes to
select the field sizes (or depths) to display.
Control Area for the MLC TPR step
Data Type Displays current data type (Measured or Interpolated). If

drop-down reference data generated by Accuray is available,
list Reference also appears as an option. For more
information, contact Accuray Customer Support. The
table values change depending on the option selected.
For Interpolated data, both interpolation and
extrapolation methods are used.
Measured Approve Click to accept all of the TPR beam data.

Data button
Legends Measured, Interpolated, and Reference (Reference only

appears when it is loaded).
You can select the display color for each field size or
depth in the graph and table. Use the check boxes to
enable or disable the fields to be displayed.
Layouts Versus Displays the X axis on the graph as the depth and the Y
Depth axis as the TPR data for a specified field size.
Versus Displays the X axis on the graph as the field size and the
Field Y axis as the TPR data for a used selected depth.
Reviewing and Approving MLC TPR Beam Data

1. Click the TPR step. By default, measured TPR beam data appears.
2. Review the measured beam data to ensure that the appropriate data was
imported to the data server and that the data was successfully loaded in the
Accuray Precision System. If reference data exists, select the same field
size reference beam data for comparison.
3. After reviewing and verifying the measured beam data, select Interpolated
from the Type drop-down list. Review the interpolated TPR beam data.
NOTE: The extrapolation depth (600 mm) is automatically set and you
cannot be change it. The method used for Extrapolation is exponential.
4. To view data by field size, click the Versus Field icon. To go back to the
default view, click the Versus Depth icon.
NOTE: When viewing the data by field size, the x axis displays field size and
the y axis displays TPR. Each line represents a different depth.
5. If the measured and interpolated data are correct, click the Approved
button.
6. (Optional) To change the field size (depth mode) or depths (field view) in the
graph(s) go to the top box of the legend and click in a check box next to the
field size (depth mode) or depths (field view) of your choice. If reference
data is available, go to the bottom box of the legend and click on a check
box next to the field size (depth mode) or depths (field view) of your choice.
To correct the data, re-measure or reprocess the data, then re-import the
data back into iDMS System for review in the Accuray Precision System.
NOTE: When viewing the data by field size, the x axis displays field size and
the y axis displays TPR. Each line represents a different depth.
If the data is not accurate, it may fail the Beam Data Import utility data range
check.
 MLC OF Step
Use OF step to view the measured output factor beam data for different field
sizes and compare it to reference data (if loaded). You can also compare
the interpolated output factor beam data to reference data. When you
switch to the OF step, output factor beam data is interpolated automatically.
If the results are acceptable, you can then approve the beam data.
MLC OF Screen
The OF step displays a graph of measured interpolated output factor
values.
OF step - MLC, Measured, Approved
The top portion of the legend shows the display color for each SAD (mm) in
the graph. Select the check box to view the SAD display.
NOTE: Only 800 mm SAD is allowed for the interpolated and measurement
data.
shows the SADs for reference data. Use the check boxes to select the
SADs to display for reference data.
Control Area for the OF step
Data Type Displays current data type (Measured or Interpolated).

drop-down If reference data generated by Accuray is available,
list Reference also appears as an option. The table values
change depending on the selected option.
Measured Approve Click to approve all of the OF beam data.

Data button
Legends Measured, Interpolated, and Reference (Reference

only appears when it is loaded).
You can select the display color for each SAD in the
graph. Use the check boxes to select the SADs to
display.
Reviewing and Approving MLC OF Beam Data

1. Click the OF step. By default the measured output factor beam data
appears on the graph and in the charts.
2. Review the measured data to ensure that the appropriate data was
imported to the data server and that the data was successfully loaded into
the Accuray Precision System.
NOTE: If reference data exists, compare the measured data with the
reference data.
3. After reviewing the measured data, select Interpolated from the Type
drop-down list. Review the interpolated output factor beam data.
4. If the measured and interpolated data are correct, click on the Approve
button.
NOTE: In the chart, the 100 x 100.1 and the 115 x 100.1 output factors must
be > 1.00. There is a check within iDMS to ensure that this number is correct.
This is required, because the CyberKnife System uses the 60 mm fixed
collimator as the dose calibration reference field.
 MLC Open Beam Profile Step

The open beam profile scans consists of: a zero-degree profile, a
45-degree profile, a 90-degree profile, and a 135-degree profile. Zero
degrees represents the direction in which the leaf moves. Each column on
the chart represents data for a profile. The data is measured using the same
method as is used for other OCR measurements except that the MLC head
is removed during measurements.
MLC Commissioning Scans as viewed from the source
Item Profiles
135°
90°
45°
0°
MLC Open Beam Profile Screen
The Open Beam Profile step depicts the beam profile without the MLC
attached.
Open Beam Profile step - MLC, Approved
The top portion of the legend shows the display color for each angle in the
graph. Select the check box to view the angle.
The lower portion of the legend is displayed only if reference data is loaded.
It shows the angles for reference data. Select the check boxes to view the
angles for reference data.
Control Area for the Open Beam Profile step
Measured Data Display At The drop-down list is available when the

drop-down measured data is collected at a value other
list than 800 SAD.
Approve Click to accept all of the open beam profile

button data.
Legends Displays color for each angle in the graph and

tables. Use the check boxes to select the open
beam profile data to display.
Reference Data This legend appears only when reference data

is loaded. Reference beam data is a
composite data compiled by Accuray
Incorporated for comparison purposes.
Reviewing and Approving the MLC Open Beam Profile Step

1. Click the Open Beam Profile step. Review the data in the chart and on the
graph.
2. If the open beam profile data is correct, click the Approve button.
3. (Optional) To change which OCR to display, select a check box next to the
color of your choice.
To change the beam data, the data needs to be imported again.
 MLC PB Model Step

Use PB Model step to generate the pencil beam model and approve the
results. You can compare the measured OCR and calculated OCR based
on PB modeling side by side. It also allows you to enter your own criteria for
the comparison. Columns in the chart tell you whether the data passes or
fails. Even if the data fails, you can still approve the output.
The measured data is the same as OCR measurement data. The calculated
data is OCR data calculated based on the pencil beam model.
MLC PB Model Screens

Control Area for the PB Model step
Data Field (mm) Drop-down list of OCR field size data collected.
drop-down list The selection appears in the graphics area.
Depth (mm) Drop down list of the OCR depths for the selected
drop-down list field size. The selection appears in the graphics
area.
Measured Approve button Click to accept the PB Modeling data.

Data
Difference Enter a value to represent the pass/fail criteria for

text box the absolute difference. The default value is 0.05.
The value must be <= 0.05. Difference is the
absolute difference between measured and
calculated values.
% Difference Enter a value to represent the pass/fail criteria for

text box the relative difference. The default value is 5%.
The value must be <= 5%. Percent Difference =
absolute value of (calculated - measured
value)/measured value.
DTA (mm) Enter a value to represent the pass/fail criteria for

text box the distance to agreement (DTA). The value must
be <= 5 mm.
Measured Click to select a color for the measured values.

drop-down
list
Calculated Click to select a color for the calculated values.

drop-down
list
Layouts Compare OCR Displays the measured and the calculated values
Measured using the selected colors for comparison.
/Calculated
Versus Field Shows the X axis on the graph as the field size
and the Y axis as the pencil beam modeling data.
Versus Depth Shows the X axis on the graph as the depth and
the Y axis as the pencil beam modeling data.
Compare OF Shows a comparison of the measured and

Measured/Calcul calculated data for the output factors.
ated
NOTE: When investigating points in the very flat region of the tail, the
displayed DTA values have 4 digit precision, although the true values used in
the DTA algorithm may be more than 4 digit precision. To calculate DTA, the
algorithm must search left or right to find the exact matching number.
Therefore, during floating point comparison, the DTA algorithm may return a
result much higher than expected even though the values are essentially the
same and the DTA should be approximately 0.
PB Model step - MLC, Compare OCR Measured / Calculated, Approved
PB Model step - MLC, Versus Field, Approved
PB Model step - MLC, Versus Depth, Approved
PB Modeling step - MLC, Compare OF Measured / Calculated, Approved
Reviewing and Approving the MLC PB Model Step
1. Click the PB Model step.
2. Select the field size.
3. Enter values in the Difference, % Difference, and DTA (mm) fields. The
default value is 5%. The value must be <= 5%. Percent Difference =
absolute value of (calculated - measured value)/measured value.
4. Use the layouts to review and perform the following tasks:
• Compare OCR Measured/Calculated: Compare the off axis distance (X
axis) and off axis (Y Axis) and approve the model.
• Versus Depth to review the pencil beam modeling parameters as a
function of depth.
• Versus Field to review the pencil beam modeling parameters as a
function of field size.
• Compare OF Measured/Calculated layout to review the calculated
output factors based on the pencil beam modeling before approving the
pencil beam model. A third party tool can be used to load the calculated
OF table and measurement OF table from your local drive for
comparison purposes. The formats available are PDF and .xlsx.
For more information on any of the layouts of parameters, see the Physics
Essentials Guide.
(Optional) To change the colors for any of the graphs, select the check box
next to the color and select a color of your choice from the drop-down list.
5. If the pencil beam modeling parameters and OCR comparison are

acceptable, click the Approve button.
6. The model is now approved for use with phantoms. Verify multiple plans on
a phantom before proceeding to the Final Approval step.
 MLC Final Approval Step for Patient Plans

Use Final Approval step to review the data that have been approved
previously. The green buttons denote approved steps and the yellow
buttons denote steps waiting for approval.
Before you use the Final Approval step, it is highly recommended that you
create a phantom plan and test it to ensure that the MLC is commissioned
correctly. Once that has been completed, go to the Final Approval step to
accept the beam data for patient plan use. After that, deliverable MLC
patient plans can be saved.
MLC Final Approval step with optional MLC Monte Carlo
Control Area for the Final Approval step
Approval Type MLC FSPB option Select to approve the MLC FSPB.
MLC Monte Carlo Select to approve the MLC Monte Carlo.

option (available
only with MLC
Monte Carlo
license)
Approval Approve for Patient Click to approve the FSPB model to be

Plans button used for deliverable patient plans.
Approval Status Data set approval status.
Beam Data Review Beam data approval status.

Summary
Reviewing and Approving the MLC Commissioning
Sequence
1. Click on Final Approval step.
2. Review the status.
3. If the status buttons are correct, click the Approve for Patient Plans button.
Beam Data Final Approval Logon dialog box appears.
4. Enter User ID and Password and click Logon. The Approval Status buttons
will change to green.
Commissioning Tools for Monte Carlo Dose Calculation for
Multileaf Collimator
This section describes the Accuray Precision System user interface for
commissioning Monte Carlo Dose Calculation for Multileaf Collimator. No
additional beam data is required for the Monte Carlo MLC algorithm.
However, the Finite Size Pencil Beam (FSPB) algorithm must be
commissioned before moving forward with Monte Carlo commissioning. For
more information on the Monte Carlo Dose Calculation algorithm, see the
Commissioning steps for the Monte Carlo Dose Calculation become
available sequentially, beginning with the MC Source step. Monte Carlo for
multileaf collimator also has a dependency on Fixed collimator
commissioning status.
 MC Source Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
 MC TPR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
 MC OCR Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
 MC OF Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
 MLC Final Approval Step for Patient Plans . . . . . . . . . . . . . . . . . . . . . 196
NOTE: If the commissioning status for the fixed collimator Monte Carlo
algorithm becomes un-commissioned, the MLC collimator Monte Carlo dose
calculation algorithm will be un-commissioned.
NOTE: If the commissioning status for the MLC collimator FSPB algorithm
becomes un-commissioned, the MLC collimator Monte Carlo dose
calculation algorithm will be un-commissioned.
To print the beam data tables, refer to “Printing the Beam Data Table” (page
158).
 MC Source Step
Use this step to generate a calculated source model for the LINAC radiation
source.
The source model consists of the following three probability distributions
which must all be reviewed before you can approve the model.
• MLC Monte Carlo primary source distribution
• MLC Monte Carlo open beam fluence distribution
• MLC Monte Carlo Energy Spectrum
If the results are acceptable, you can then approve the model. For more
information on how the source model is used in Monte Carlo Dose
Calculation, see the Physics Essentials Guide.
MC Source Screen
Control Area for MLC MC Source step
MC Source Model FWHM (mm) Specify the FWHM (full width at the half
text box maximum) value to be used to model a radial
Gaussian probability distribution.
Calculate Click to calculate and display the probability

button distributions in all three layouts simultaneously.
Approve Click to display the Approve MLC MC Source

button dialog box and approve the calculated
probability distributions in all three layouts
simultaneously.
Layouts
Each layout represents a different probability distribution. All the layouts
need to be reviewed in order to approve the source model.
Icon Description
Displays MLC MC Primary Source Distribution as a function of

off-axis radius, calculated using the FWHM value entered by user.
Both a graph and the values for each Radius (mm) and its
Probability are displayed in a table.
Icon Description
Displays;
• MLC Monte Carlo Open Beam Profile that is measured with four
different angles, horizontal (0 degree), vertical (90 degree), and
two diagonals 45 degree and 135 degree, which are already
measured for FSPB algorithm beam data. These profiles are
displayed as a plot of all the curves.
• Measured Tables: Measured open beam profile.
If the measured data is collected at a value other than 800 SAD,
the drop-down menu is available for Display At, and you can
select the desired data to display.
• Calculated Tables: Calculated open beam profile.
• MLC Monte Carlo Calculated Fluence Distribution Map: is a
display of the 2D fluence. It is a plot of the computed 2D fluence
(probability) factor that is related to the beam intensity as a
function of x and y. The display shows the regions that
correspond to a iso-probability band. This displays the area that
is closest to the source near the central axis as the “hottest” and
then a drop off as you move away from the central axis.
• Probability (P) Color Legend: Legend for the 2D fluence
distribution map.
Displays the MLC Monte Carlo Energy Spectrum with Energy

spectrum probability distribution as a function of energy (MeV).
Beam Hardening check box: This setting corresponds to the
presence of a lead filter in your CyberKnife system. Select this
option to use 11 input energy spectra (6.0 MeV to 7.0 MeV) with a
higher mean output photon energy. See the Physics Essentials
Guide for more details.
Log-linear check box: Select to displays the probability as its log
base 10 value.
Generate the MLC Monte Carlo Primary Source Distribution
Specify a value (in mm) for the photon source full width half maximum
(FWHM) for calculation. Larger values produce a wider distribution with
shallower penumbra for the Monte Carlo calculated OCR curve. Smaller
values produce a narrower distribution with steeper penumbra for the
Monte Carlo calculated OCR curve.
MLC MC Source - Primary Source Distribution layout
In the Open Beam Profile Fluence Distribution layout, the upper-left image
viewer shows a graph of the MLC Monte Carlo Open Beam Profile, and
there is a table of the measured beam data and a table of the calculated
values below. On the right, MLC Monte Carlo Calculated Fluence
Distribution Map appears with the Probability (P) Color Legend below it.
MLC MC Source - Open Beam Fluence Distribution layout
In the Energy Spectrum layout, the image viewer shows a graph of the MLC
Monte Carlo Energy Spectrum. The tables to the right display the measured
beam data and calculated values. You can use the scroll bars on the right
to scroll through the data.You can edit the table of probability for the
selected energy spectrum. After editing, it is labeled as Custom. You also
have the option to select the check box for Log-linear to change the graph
shown as its log base 10 value. For more information on the energy
spectrum, see the Physics Essentials Guide.
MLC MC Source - Energy Spectrum layout
Reviewing and Approving the MC Source Model

1. Click the MC Source step. By default, the Source Distribution layout
appears.
2. Enter a value for the photon source FWHM (mm) and click the Calculate
button. The source model is calculated.
3. Select the Open Beam Fluence layout and review the Open Beam Profile
scans. These are the same scans used in the FSPB algorithm. Review the
calculated 2D Fluence Distribution map.
4. Select the Energy Spectrum layout.
5. Select an Energy Spectrum from the drop-down list, and click the Calculate
button.
6. After reviewing the calculated source distribution on the all three layouts,
click the Approve button. Approve MLC MC Source dialog box appears.
7. Click OK to approve the model. All three layouts are approved
simultaneously.
After the source model is approved, the Approved (Non-Sample) label
appears at the top of the image viewer in all three layouts. Then MC TPR
step and MC OCR steps become available.
NOTE: If you change the value of the photon source FWHM of the Gaussian
method or if you change the beam energy, you must reapprove the source
model. Otherwise, Monte Carlo Dose Calculation will not be available for
treatment planning. Furthermore, any Monte Carlo commissioning work
completed in the MC TPR and MC OF steps subsequent to the original
approval of the source model will be lost.
 MC TPR Step
Use MC TPR step to calculate TPR curve using the Monte Carlo Dose
Calculation algorithm.
You can calculate, review, and accept Monte Carlo calculated TPR curve
for one or more field sizes at a time.You must specify a statistical
uncertainty value for the calculations, as described below. You can also set
the Calculation Depth (mm) for each field size and the Leaf Transmission
(%) .
If you are modifying the Energy Spectrum value in the MC Source step, you
must re-approve the source model before returning to the MC TPR step and
all previously calculated TPR curve will be deleted.
When you accept the TPR calculation results, you are indicating that the
current source model, when used to perform Monte Carlo simulation of your
water phantom beam data measurements, adequately reproduce the
measured beam data. The results of the Monte Carlo TPR calculation is for
review only and are not used for any further dose calculations performed as
part of treatment planning.
Uncertainty Value
You specify a requested uncertainty value for the Monte Carlo TPR and
OCR calculations. The same uncertainty value must be used for all field
sizes. Therefore, if you change the uncertainty value after calculating
curves for a field size, you must recalculate the curves using the new value
before you can complete the acceptance.
After a calculation is performed, the reported average uncertainty is
displayed at the top of the screen above each graph. For Fixed and Iris cone
collimators, the reported uncertainty for Monte Carlo TPR calculations for
any given field size is the average of the top 20 voxels with the highest dose
for all water phantom geometries used to calculate the Monte Carlo
simulated OCR curves. For the MLC collimator, the reported uncertainty for
Monte Carlo TPR calculations is the average at all TPR points except at
dmax, the dose uncertainty at the point and the uncertainty at dmax added
in quadrature. For the MLC Monte Carlo OCR calculations, the reported
uncertainty is the computed uncertainty on the CAX at the given depth. See
Physics Essentials Guide for more details. The Accuray Precision System
scales the number of histories with the depth of the Monte Carlo TPR and
Monte Carlo OCR calculations so that the requested uncertainty is
maintained at each calculation depth. Therefore, the reported uncertainty
tends to be smaller than the requested uncertainty.
At a requested uncertainty of 1% and depths of 15, 100, and 300 mm,
Monte Carlo OCR calculations for all field sizes takes about 2 hours. Monte
Carlo TPR calculation takes about 1 hour. Calculations at shallower depths
require less time. You can perform calculations for all field sizes in a single
operation or perform calculations for a few field sizes at a time. For more
information on the uncertainty value, see the Physics Essentials Guide.
MC TPR Screen
On the MLC > MC TPR step, both measured and calculated curves are
displayed on the same graph for comparison. Measured curves appear as
solid lines. Calculated data points appear as dots. The measured and
calculated beam data depicted in the graph appear in tables below the
image viewer.
MLC > MC TPR step, All Approved.
Control Area for MLC MC TPR step
Settings Leaf Enter Leaf Transmission factor values to be used for

Transmission re-calculation. See Physics Essential Guide for more
(%) details on the leaf transmission.
• Center text box
• End text box
• End Edge text box
• Side Edge text box
Depths button Click to display the Set Calculation Depths dialog box,
and you can specify up to eight depths for
calculations. Depths for measured beam data are
displayed for reference.
Computation Uncertainty % Displays the current requested uncertainty value for

the Monte Carlo TPR calculation.
Calculate Click to display the Field Sizes and Uncertainty dialog

button box and select one or more field sizes for the Monte
Carlo TPR calculation before starting the calculation.
You can set the uncertainty value for the Monte Carlo
calculation. Allowed uncertainty values are from 0.1%
to 4%.
Display Data Field (mm) Select a field size to display.

drop-down
menu
User can set a different threshold to compare

measured TPR with calculated TPR. Defaults are set
as the following:
• Difference text box - absolute difference, default
set at 0.05.
• % Difference text box - percentage difference,
default set at 5.00%.
• DTA (mm) text box - Distance To Agreement.
default set at 5.00 mm.
Measured Select the curve color from the drop-down list.

drop-down list
Calculated Select the curve color from the drop-down list.

drop-down list
Accept button Click to accept the TPR values.
Tabulated Phantom Click to display the Phantom Information for MC

Data button Commissioning dialog box.
Reviewing and Accepting MC TPR Beam Profiles
1. Click the MC TPR step. If the Monte Carlo TPR calculation has not yet been
performed and accepted, the MLC Monte Carlo TPR Not Approved label
appears in yellow at the top of the image viewer.
2. (Optional) Update the Leaf Transmission % factors.
3. On the Display Data, select a file size for the measured and calculated
Monte Carlo TPR beam data for review.
4. To set depths for the Monte Carlo calculation, click the Depths button. The
Set Calculation Depths dialog box appears.
5. To modify depth values, do the following:

• Double-click a text box in the MC Depth (mm).
• Enter a new value for the Monte Carlo calculation depth (mm). The
value will be applied to all field sizes. You can perform the Monte Carlo
calculation for up to eight depths by enabling the check box for each
depth value.
6. Click the Calculate button. The Field Sizes and Uncertainty dialog box
appears. You can select one or more field sizes for each Monte Carlo TPR
calculation.
• To select a field size, select the corresponding check box.
• To omit a collimator size from the calculation, clear the corresponding
check box.
The field size is grayed out if a calculation has been made for the
current calculation configuration (i.e. uncertainty, depths, etc.).
• To select a field size with an existing calculation for recalculation,
double click on check box.
7. Enter an Uncertainty % value, and click OK to start the calculation.
NOTE: The same uncertainty value must be used for all field sizes. If you
change the uncertainty value after performing and/or accepting the
calculation for a field size, you must redo the calculation using the new
uncertainty value.
8. To cancel and retain previously calculated results, click the Cancel button
in the Field Sizes and Uncertainty dialog box. When the calculation begins,
screen controls are disabled and a Cancel button in the status bar on the
lower left of the screen becomes available. The status bar displays updated
status information throughout the calculation process.
9. When the calculation is completed for the selected field size, compare the
Monte Carlo calculated TPR values with the measured beam data plotted
in both layouts. Measured curves are shown as solid lines. Calculated data
points appear as dots.
10. If the calculated TPR curve is satisfactory, click the Accept button. The
Approve MLC MC TPR Table dialog box appears.
11. Click the OK button to accept the results. You can accept partial results for
fewer than 11 field sizes. However all field sizes must be calculated and
accepted in order to move forward to MC OF step.
If the results are not acceptable, see Physics Essential Guide for more
details.
12. Click the Phantom button. The Phantom Information for MC

Commissioning dialog box appears.
13. Review the phantom geometry for each Monte Carlo calculation.
 MC OCR Step
Use MC OCR step to calculate OCR data using the Monte Carlo Dose
Calculation algorithm. This step is not available until the results of the MC
Source step are accepted.
You can calculate, review, and accept Monte Carlo calculated OCR data for
one or more field sizes at a time. You can calculate OCR data for up to five
depths per field size. You must calculate OCR data for all filed sizes and
accept all calculation results before you can proceed to the MC OF step.
You must specify a statistical uncertainty value for the calculations. For
more information, see “Uncertainty Value” (page 182).
If you are using the Gaussian source distribution method, modifying the
value of the photon source FWHM in the MC Source step changes the slope
of the OCR penumbra. If you change the photon source FWHM, you must
reapprove the source model before returning to the MC OCR step and all
previously calculated OCR data will be deleted.
When you accept the OCR calculation results, you are indicating that the
current source model and correction factors, when used to perform Monte
Carlo simulation of your water phantom beam data measurements,
adequately reproduce the measured beam data. The results of the Monte
Carlo OCR calculations are for review only and are not used for any further
dose calculations performed as part of treatment planning.
MC OCR Screen
On the MC OCR step, both measured and calculated data appear on the
same graph for comparison. Measured curves appear as solid lines.
Calculated data points appear as dots.
The measured and calculated beam data in the graph appear in tables
below.
MLC MC OCR step, All Approved
Control Area for MLC MC OCR step
Settings Leaf Enter Leaf Transmission factor values to be used for

Transmission re-calculation. See Physics Essential Guide for more
(%) details on the leaf transmission.
• Center text box
• End text box
• End Edge text box
• Side Edge text box
Depth button Click to display the Set Calculation Depths dialog box,
which allows you to specify up to eight depths for
calculations. Depths for measured beam data are
displayed for reference.
Computation Uncertainty % Displays the current requested uncertainty value for the
Monte Carlo OCR calculation.
Calculate Click to display the Field Sizes and Uncertainty dialog

button box and select one or more field sizes for the Monte
Carlo OCR calculation before starting the calculation.
You can set the uncertainty value for the Monte Carlo
calculation. Allowed uncertainty values are from 0.1%
to 4%.
Display Data Field (mm) Select a field size to display.

drop-down
menu
Depth (mm) Select a depth to display.

drop-down
menu
Set a different threshold to compare measured TPR

with calculated TPR. Defaults are set as the following:
• Difference text box - absolute difference, default set
at 0.05.
• % Difference text box - percentage difference,
default set at 5.00%.
• DTA (mm) text box - Distance To Agreement, default
set at 5.00 mm.

drop-down list

drop-down list
Accept button Click to accept the OCR values.
Tabulated Phantom Click to display the Phantom Information for MC

Data button Commissioning dialog box.
Reviewing and Accepting MC OCR Beam Profiles

1. Click the MC OCR step. If the Monte Carlo OCR calculation has not yet
been performed and accepted, the MLC Monte Carlo OCR Not Approved
label appears in yellow at the top of the image viewer.
2. (Optional) Update the Leaf Transmission % factors.
3. On the Display Data, select a filed size for the measured and calculated
Monte Carlo OCR beam data for review.
4. To set depths for the Monte Carlo calculation, click the Depths button. The
Set Calculation Depths dialog box appears. Only the measured depths are
available for calculation.
5. Select a subset or all depths to be calculated. Click Apply to complete the

selection.
6. Click the Calculate button. The Field Sizes and Uncertainty dialog box
appears.
7. You can select one or more field sizes for each Monte Carlo OCR
calculation.
• To select a field size, select the corresponding check box.
• To omit a collimator size from the calculation, clear the corresponding
check box.
The field size is grayed out if a calculation has been made for the current
calculation configuration (i.e. uncertainty, depths, etc.).
8. Enter an Uncertainty %value, and click OK to start the calculation.
NOTE: The same uncertainty value must be used for all field sizes. If you
change the uncertainty value after performing and/or accepting the
calculation for a field size, you must redo the calculation using the new
uncertainty value.
9. To cancel and retain previously calculated results, click the Cancel button
in the Field Sizes and Uncertainty dialog box.
10. When the calculation begins, screen controls are unavailable and a Cancel
button in the status bar on the lower left of the screen becomes available.
The status bar displays updated status information throughout the
calculation process.
NOTE: Calculations are performed sequentially per field size. If the Cancel
button is clicked or the Accuray Precision System is shut down during the
calculation, data for all field sizes for the current calculation is lost, but
previously calculated and accepted data is retained.
11. When the calculation is completed for the selected field size, compare the
Monte Carlo calculated OCR values with the measured beam data plotted
in both layouts. Measured curves appear as solid lines. Calculated data
points appear as dots.
12. If the calculated OCR curve is satisfactory, click the Accept button. The
Approve MLC MC OCR Table dialog box appears.
13. Click the OK button to accept the results. You can accept partial results for
fewer than 11 field sizes. However all field sizes must be calculated and
accepted in order to move forward to MC OF step.
If the results are not acceptable, see Physics Essential Guide for more
details.
Review the Phantom Geometry
Commissioning dialog box appears. Review the phantom geometry for
each Monte Carlo calculation.
 MC OF Step
Use MC OF step to calculate OF data using the Monte Carlo Dose
Calculation algorithm. You can specify an uncertainty value for the
calculation.
The calculation also generates an absolute dose normalization constant,
Fnormal, to convert the deposited energy to the absolute dose.
When you approve the calculated results on the MC OF step, then the
output data is used for all future Monte Carlo dose calculations performed
as part of treatment planning.
MC OF Screen
On the MC OF step, the measured and Monte Carlo calculated output factor
values are displayed as a function of collimator size at 800 mm SAD. Both
measured and calculated curves appear on the same graph for
comparison. The measured beam data and calculated data appear as solid
lines.
MLC MC OF Step Approved
Control Area for MC OF Step
OF & Absolute Uncertainty Displays the requested uncertainty value for the
Dose % text box Monte Carlo output factor calculation.
Calculate Click to display the MC OF Calculation dialog box.

button The dialog box allows you to modify the current
uncertainty value. Allowed uncertainty values for
the Monte Carlo output factor calculation are from
0.1% to 0.5%.
Fnormal Displays the current calculated value of the

absolute dose normalization factor, Fnormal.
Approve Click to accept the current Monte Carlo calculated

button output factor beam data.
SAD Select the SAD to display.

drop-down
list

drop-down
list

drop-down
list
Tabulated Data Phantom Click to display the Phantom Information for MC

button Commissioning dialog box.
Reviewing and Approving MC OF Values and Fnormal

1. Click the MC OF step. The measured output factor values at 800 mm SAD
appear in the image viewer, and the measured output factor beam data
values are tabulated below it.
If the Monte Carlo output factor calculation has not yet been performed and
approved, the MLC Monte Carlo OF Not Approved label appear at the top
of the image viewer.
2. Click the Calculate button. The MC OF Calculation dialog box appears.

3. If appropriate, modify the uncertainty value for the Monte Carlo output factor
calculation by double-clicking the Uncertainty % text box and entering a
new value.
To ensure adequate baseline results and complete the process of
commissioning the Monte Carlo Dose Calculation algorithm, use 0.2% as
the uncertainty value for MC OF. The duration of the MC OF calculation at
0.2% uncertainty is approximately 13 hours.
4. To apply the current uncertainty value and begin the calculation, click the
Calculate button in the MC OF Calculation dialog box.
When the calculation begins, the screen controls are unavailable and the
calculation status appears below the MC OF Data table with a Cancel
button.
NOTE: If you click the Cancel button or shut down the Accuray Precision
System during calculation, the current calculation terminates and calculation
data is deleted. To reload previously calculated and approved Monte Carlo
output factor values, return to the home page and click the Commissioning
Tools icon. Then switch directly to the MC OF step and continue.
5. If the Monte Carlo calculated output factor data is satisfactory, click the
Approve button. The Approve MLC MC OF Table dialog box appears.
6. Click OK to approve. The calculated output factor values and Fnormal are
approved and the MLC Monte Carlo OF Approved label appears at the top
of the image viewer.
Review the Phantom Geometry
Commissioning dialog box appears.
2. Review the phantom geometry for each Monte Carlo calculation.

This is the final step in commissioning the Monte Carlo Dose Calculation
algorithm.
 MLC Final Approval Step for Patient Plans

Use Final Approval step to review the steps that have been approved
previously. The green buttons denote approved steps and the yellow
buttons denote steps waiting for approval.
Before you use the Final Approval step, it is highly recommended that you
create a phantom plan and test it to ensure that the MLC is commissioned
correctly. Once that has been completed, go to the Final Approval step to
accept the beam data for patient plan use. Then, MLC patient plans can be
saved as deliverable.
Final Approval Screen
MLC Final Approval step with optional MLC Monte Carlo
Control Area for the Final Approval step
Approval Type MLC FSPB Select to approve the MCL FSPB beam
option data to be used for creating patient plans.
MLC Monte Select to approve the MCL Monte Carlo

Carlo option beam data to be used for creating patient
plans.
Approval Approve for When selected, allows the FSPB model to

Patient be used for creation of deliverable patient
Plans plans.
Approval Status (MLC Data set approval status.

MC) • Yellow - Not Approved.
• Green - Approved.
Beam Data Review Beam data approval status.

Summary (MLC Monte • Yellow - Not Approved.
Carlo)
• Green - Approved.
Reviewing and Approving the MLC Commissioning

Sequence for MLC Monte Carlo
1. Click on Final Approval step.
2. Select MLC Monte Carlo from Approval Type.
3. Review the status.
4. If the status are correct, click the Approve for Patient Plans button. Beam
Data Final Approval Logon dialog box appears.
5. Enter User ID and Password and click Logon. The Approval Status buttons
become green.
Chapter 4
QA Plans
Section 4-1
QA Plans for Tomo® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Section 4-2
QA Plans for CyberKnife . . . . . . . . . . . . . . . . . . . . . . . . . 227
1072963-ENG B C h ap te r 4 : Q A Pl a ns 199
Section 4-1
QA Plans for Tomo®
Use QA plan to verify a treatment plan’s dose delivery by making a plan that
overlays a patient treatment plan onto a phantom CT image series. Then
deliver the plan to the phantom and compare the delivered dose to the
planned dose.
About QA Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Register Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Machine Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Phantom Step. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Review Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Confirm Angles Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
MultiSlice Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Loading a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
1072963-ENG B S e c t i o n 4 - 1 : Q A P l a ns f or T o m o ® 201
About QA Plans
A QA plan is created based on two input plans: a patient treatment plan and
a QA template plan. The patient treatment plan must be saved as
deliverable. See “Section 8-1” (page 381) for information on how to create
a patient treatment plan. A QA template plan must be created and saved as
deliverable using a CT set of a phantom or a CT set of the same patient with
a different primary CT. A compatible plan of the same patient as the
selected QA patient plan can be also used as a QA template plan.
When a QA Plan is created, the beam data, robot data, path set, alignment
center, reference point, and anatomy setting from the patient treatment plan
are copied. VOIs, tracking information, density model, and dose calculation
box are copied from the QA template plan.
When a QA Plan is created, the machine instructions, lateral position of the
couch, and the virtual isocenter location from the patient treatment plan are
copied. VOIs, density model, density override, and dose calculation box are
copied from the QA template plan.
The density of the phantom curve should correspond to the CT used for the
phantom scan. The physical density of the phantom does not have to be
identical to the patient’s density information. This variability can result in
discrepancies in maximum dose, prescribed dose, reference dose, and
isodose curves between phantom and patient plans.
 Creating a QA Template Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
 Creating a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
 Auto Registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
NOTE: The Plan Overview Report includes information from both the patient plan
and the QA template plan.
 Creating a QA Template Plan

A QA template plan is a prerequisite for creating a QA plan.
2. Select a phantom patient.
3. Click the Standard icon in the Select Type pane, and then click Next>>.
4. Select CT images of a phantom in Select Exams screen.
NOTE: Accuray Incorporated recommends using a stereotactic dose verification
phantom.
5. Create VOIs for the phantom in Contour > Manual > Tools.
NOTE: Contours on the QA template plan can be used to register the patient plan
with the phantom image series.
6. Select a Treatment Machine on Setup > Machine > Tools. Select Density
Model, Density Overrides, Delivery Mode, Plan Mode, Jaw Mode,
Synchrony Method, and perform Couch-replacement, if applicable.
7. Set the Patient Position and the position of the red lasers on the Setup >
Patient >Tools.
8. Optimize or calculate dose accordingly based on the Delivery Mode and
Plan Mode.
9. Save the plan as deliverable.
 Creating a QA Plan
a QA template plan. Patient plan must be a plan of non-phantom type
patient.
Precision System Home Page.
2. Click a patient name from the patient list on the New Plan screen.
3. Click the QA icon in the Select Type area.
4. Click Next >>. The Select a patient plan for a new QA plan screen appears.
5. Select a patient plan from the Plan Name list. Only non-QA plans appear for
patient plan selection.
The patient plan list only contains plans with a status of Deliverable,
Approved, Completed, Under Treatment, Suspended, or Discontinued. The
QA template plan list contains plans with a status of Deliverable, Approved,
Completed, and Under Treatment.
6. Click Next >>. The Select a template plan for a new QA plan screen
appears. Only phantom patients and the patient selected on the previous
screen appear in the list.
7. Select a patient from the patient list.
8. Select a plan from the plan list. The associated QA template plan must have
a status of Deliverable, Approved, Completed, or Under Treatment.
9. Click Finish.The system loads the data from the patient plan and the QA
template plan, and the Setup > Register step, with the Auto Registration
dialog box, appears.
 Auto Registration
The Auto Registration dialog box automatically appears during QA plan
creation prior to a dose being calculated.
Item Description
Auto register by aligning drop-down • VOI Center: Center of the user selected VOI
list • Align Isocenters: Alignment center
• Align Center: Alignment center
• CT Image Center: Center of the CT volume
Patient plan VOIs drop-down list Available only when VOI Center is selected and there are one
or more VOIs available.
Template plan VOIs (Phantom plan) Available only when VOI Center is selected and there are one
drop-down list or more VOIs available.
OK button Dose will be calculated based on the image translation. Maps

beams from patient plan onto the PTV of the QA template plan.
Cancel button Auto registration is canceled without registering images or

calculating the dose.
Auto Register a Patient Plan Image and QA Template Plan

Image
1. Select the initial registration method of the patient plan image and the QA
template plan image in the Auto Registration dialog box.
2. Click OK. Dose is calculated. Isodose lines are displayed and both DVH
and dose statistics are available.
Register Step
Use Setup > Register step to register all non-zero beams per fraction, robot
data, path set, and anatomy settings from the patient plan to the QA
template plan. Confirm that the isodoses dose volumes are within a
minimum amount.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
 Manual Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Setup > Register Step
 Tools
Auto-Register button Allows alignment of the patient to the phantom by

aligning the VOI center, CT image center, or the align
isocenters.
Undo button Click to discard manual changes made to the patient

image since the Confirm button was last pressed.
Confirm button Click to apply changes and perform a dose calculation

based on the shifted image location.
Manual Displays the amount of the manual adjustment since the

Alignment last auto registration.
Offset
Translation tool Click an arrow to move the CT patient image along the X,
Y, Z axis to align to the phantom. Click an arrow to adjust
translation by a pixel in the direction indicated by the
arrow.
Slider bar Click an end of the slider to step through the series a
slice at a time.
Drag inside the slider bar to the right or left to jump
forward or backward through the image series. The slice
number is displayed above the cursor.
View Options Machine Geometry Select Machine Geometry to display green circles that
check box indicate the gantry bore (large circle) and MLC field of
view (small circle) in the Image Viewer.
TomoDirect Angles Select TomoDirect Angles to display the beam angles

check box (TomoDirect plans only).
 Manual Registration
Manual registration allows fine adjustments of the placement of planned
beams on the QA phantom plan. These adjustments will effect the isodose
distribution within the QA phantom VOI.
For point dose verification, user adjustments can be performed to ensure
that the QA measuring device samples a dose region of interest with a
minimum of dose variation through its sensitive volume.
For a two-dimensional relative dose verification (for example, film), the
dose variation should be seen throughout the region of interest.
1. Click Cancel on the Auto Registration dialog box.
2. On the Register step, evaluate the position of the dose distribution in
relation to the area and VOI in the phantom.
When the Register screen appears, the images are misaligned.
3. Align the images.

• For gross changes, use the mouse to drag the patient image on the 2D
images.
• For fine changes, click the arrows on the fine adjustment tools on the 2D
images.
As the patient image moves, the Manual Alignment Offset updates. The
default value prior to an auto or manual registration is 0,0,0.
NOTE: When you move the patient image, the position of the colored overlay is
updated immediately but the dose distribution is updated only after you click
Confirm.
NOTE: Position the least amount of dose variation of the patient image VOI on the
phantom chamber.
4. Repeat this alignment procedure for all 2D views as appropriate.

5. (Optional) To discard changes and display the original dose alignment, click
Undo.
6. Click Confirm to apply changes and initiate dose calculation.
Once the registration is completed, isodose lines appear and both DVH and
dose statistics are available.
Register Step with Isodose
Machine Step
Use the Machine step to view and select the Density Model, Density
Overrides, and perform Couch Replacement if needed. Machine
Parameters are copied from the QA patient plan and cannot be edited.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Setup > Machine Step
 Tools
Density Model Displays the current density model and a list of alternatives. A
drop-down list typical density model contains a mass density model curve and a
relative electron density model curve. Both curves are displayed
on the graph. The existing dose volume will be deleted when
Density Model or Density Overrides is changed. Dose must be
re-calculated in Evaluate > Review step.
Density Overrides Displays the Density Overrides Table.

button
Machine Displays Treatment Machine, Delivery Mode, Plan Mode, and

Parameters Jaw Mode, and Synchrony Method parameters from the patient
plan and cannot be edited.
Remove/Replace Use to remove or replace the treatment couch. Once the couch is
Couch button removed, the user is not allowed to move to a different Task or
Step without replacing the couch. Dose calculation is
automatically performed each time the couch is replaced.
Phantom Step
Use the Phantom step to view the Patient Position, move the Red Lasers (if
needed), and select View Options.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Setup > Phantom Step
 Tools
Patient Displays patient position. Green lasers (virtual isocenter) is copied

Position from the QA Patient plan and is not editable in this step.
Red Move Red Lasers/ Use to move the red lasers and align with green lasers if desired.
Lasers Align buttons The movable red laser position is set based on the saved absolute
position of the red laser from the QA Phantom Template Plan.
View Machine Geometry Select to display green circles that indicate the gantry bore (large
Options check box circle) and MLC field of view (small circle) in the Image Viewer.
TomoDirect Select to display the beam angles (TomoDirect plans only)

Angles check box
Review Step
Use the Review step to evaluate the dose distribution within the VOI and
recalculate the dose if any adjustments are made.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
 Dose Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
 Calculate Dose Per Beam (TomoDirect Only) . . . . . . . . . . . . . . . . . . . 216
 Saving a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Evaluate > Review step for TomoHelical
 Tools
Final Dose Resolution Lists the available Final Dose Calculation resolution:
drop-down list Very Low, Low, Medium or High.
Clear Final Dose Clears the current dose distribution.

button
Calculate Dose Calculates the dose per beam. Only available for
per Beam button TomoDirect.
Reference Point Use max dose Selects the point of maximum dose as the plan reference
point check box point.
Dose (Gy/cGy) Displays the dose of the current reference point.
Point Go to >> Moves the cross-hair to the current reference point.

button
Set to Cross-hair Sets the reference point value to the coordinates of the
Point button current cross-hair position.
Save Plan Save Plan button Displays the Save Plan dialog box.
View Options Machine Select Machine Geometry to display green circles that
Geometry check indicate the gantry bore (large circle) and MLC field of
box view (small circle) in the Image Viewer.
TomoDirect Select TomoDirect Angles to display the beam angles

Angles check box (TomoDirect plans only).
 Dose Calculation
Dose calculation on the phantom is performed each time the user confirms
a registration in the Register step. Dose is also calculated when the couch
replacement height is adjusted. Dose Calculation on the Register step uses
a low-resolution non-voxel broad beam for the dose calculation method.
The final dose can be cleared and re-calculated in Evaluate > Review step
using higher resolution.
 Calculate Dose Per Beam (TomoDirect Only)

Calculate Dose per Beam is available for TomoDirect QA plan. User can
calculate the dose per beam and export the information in DICOM format.
This dose file is created for each beam and can be used to compare with
the actual delivered dose. Once the calculation is completed, the button
becomes un-available.
 Saving a QA Plan
1. If the dose has been calculated, then click Save Plan. The Save Plan dialog
box appears.
2. Enter the plan name in the Plan Name field.

3. Select Make Deliverable to save the plan as deliverable.
4. Click Save.
NOTE: If a plan with associated QA plans is overwritten, a warning message is

displayed and the QA plans will be deleted.
Confirm Angles Step
This step appears only when the QA template plan has a Synchrony
Method selected.
Use this step to review, change, and validate the imaging angles to be used
in the QA plan. You are allowed to save a QA plan as deliverable even when
the angles do not pass the Validation check.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
 Validate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
CAUTION: Tracking target VOI and the fiducials should be visible for each imaging
angle in the DRR views. If they are not visible for each imaging angle in the DRR
views, it could result in patient mistreatment.
 Tools
Tracking Tumor drop-down list Select a VOI that you want to use to track during
Volume treatment delivery from the drop-down list. The
(For Lung with Respiratory tracking VOI must be a target VOI.
only)
Imaging Angles Presets buttons The icons indicate the numbers of predefined set
of static imaging angles on a circle.
Auto Select drop-down list Select the number of angles that you want the
system to automatically select. Angles are
chosen based on their color on the Score Wheel
and the spacing of the angles around the gantry.
Table The table displays the angular values in degrees

of the added or selected angles and the score as
a color.
Add button Click to add an imaging angle.
Delete button Click to delete the selected angle.
Prevalidate button Click to validate the current imaging angles. See

“Prevalidate” (page 355) for more details.
View Options Fiducials check box Select to display the fiducials that are defined in
(For Fiducial and Fiducial with the Fiducial step.
Respiratory only) 2cm of Motion check box: Select to display a
sphere of 2 cm radius around each fiducial. Use 2
cm of Motion display to visualize whether each
fiducial remains within the Tracking Zone box if
there is up to 2 cm of motion.
Tracking Contour check box Select to display the tracking contour.

(For Lung with Respiratory 2cm of Motion check box: Select to display a
only) uniform 2 cm expansion around the Tracking
Tumor Volume. Use 2cm of Motion display to
visualize whether the Tracking Tumor Volume
remains within the Tracking Zone box if there is
up to 2 cm of motion.
Tracking Centroid check box Select to display the centroid of the tracking
(For Lung with Respiratory tumor in the plus (+) mark.
only) 2cm of Motion check box: Select to display a
sphere of 2-cm radius around the Tracking
Centroid. Use 2 cm of Motion to visualize whether
the Tracking Centroid remains within the
Tracking Zone if there is up to 2 cm of motion.
Tracking Zone check box Select to display the red outlines of the active
imaging area where the fiducial or tracking tumor
volume is tracked. The tracking zone is defined
by your Treatment Delivery System configuration.
Score Wheel check box Select to display the color-coded ring. The colors
are based on the heuristic result. Green indicates
a good imaging angle, and red indicates a low
correlation score and makes a poor imaging
angle.
Green Lasers check box Select to display the green lasers (virtual
isocenter).
DRR Type Displays the DRR of the selected imaging angle.

(For Lung with When the angle is updated through the table or
Respiratory only) the image angle control, the DRR is updated
automatically.
Full Content option Displays a DRR of the full couch replaced CT

image volume.
Tumor Region option Displays a DRR only of the tracking tumor

volume.
 Validate
When you click Validate, the system enforce the following requirements.
If you don’t click Validate, the system will enforce the same requirements
when you save the plan as deliverable.
Use the couch travel slider on DRR to view the couch positions used during
the treatment, and visually verify the validation checks made by the
Validate button.
• The number of angles must be between two and six.

• Angles must be separated by at least 30 degrees.
• At least two angles and their parallel opposed counterparts must have
a separation of 30 degrees or more.
• For plans that use fiducials:
– At least half the fiducials must be visible from all angles for the entire
planned couch travel (i.e., must be visible from beginning and end
couch positions).
• For plans that do not use fiducials:
– Tracking tumor is selected.
– The Tracking Reference Point must be visible from all angles for the
entire planned couch travel (i.e., must be visible from beginning and
end couch positions).
In addition, if you click Validate, the system displays a message if the

following recommendations are not met (this message will not be displayed
if you save the plan as deliverable without clicking Validate):
• The angles should be separated by at least 45 degrees.

– The fiducials should be spaced at least 10 mm apart for all DRR
angles and couch positions.
NOTE: A minimum spacing of 10 mm is recommended for fiducial insertion

in the patient. Depending on the viewing angle and considering beam
divergence (the kV source to isocenter distance is 575 mm, and the kV
source to detector distance is 1134.6 mm), fiducials that are 10 mm apart in
the patient may be 0 to almost 20 mm apart on the panel.
– All fiducials should be located within 5 cm of the centroid of the

prescription VOI.
– All fiducials should be visible from all angles for the entire planned
couch travel.
– The centroid of the tracking volume should be located within 5 cm of
the centroid of the prescription volume.
– The entire Tracking Tumor Volume should be visible from all angles
for the entire planned couch travel (i.e., must be visible from
beginning and end couch positions). If this recommendation is met,
visibility will also be verified with a 2-cm margin around the Tracking
Tumor Volume for expected motion.
– The Tracking Reference Point with 2 cm of margin for expected
motion should be within the Tracking Zone box for all imaging angles
beginning and end couch positions).
MultiSlice Step
Use the Evaluate > MultiSlice step to view the multiple planar slices in axial,
coronal, or sagittal image with several choices of image layouts. The planar
slices contain dose distribution and VOI information.
 View Multiple Planar Slices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Evaluate > MultiSlice Step with the second image of [B Dataset 1] selected
 View Multiple Planar Slices

1. On the MultiSlice > Display step, click the desired layout icon in the
Layouts.
2. On MultiSlice >Tools, select a viewing plane on the Image Orientation
drop-down list.
3. (Optional) Select or clear the optional check boxes below the Image
Orientation control (Show VOIs, Show dose contours, Show min/max
dose).
4. To scroll through the slices, drag the vertical slider on the right side of the
image viewer.
If two images are loaded and registered, the Dataset control is available.
5. To change the image source of all the multi-slice views, select an entry on
the Dataset drop-down list.
Loading a QA Plan
 Load a QA Plan to Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
 Load a QA Plan to Review

Precision System home page.
2. Click a patient name from the list on the panel. The plans associated with
the selected patient appear.
3. Select a patient on the list.
4. Select a QA plan on the Select Plan list. QA plans are identified with QA
Plan in the Type column.
5. Click the Load Plan button to load the selected data.The QA plan is loaded
in Evaluate > Review step.
6. Perform manual fine-tune of the align center if desired in the Setup >
Register step.
7. Rescale and recalculate the QA plan in the Evaluate > Review step.
8. Click Save and save the QA plan as Deliverable.
Section 4-2
QA Plans for CyberKnife
Use QA plan to verify a treatment plan’s dose delivery by making a plan that
overlays a patient treatment plan onto a phantom CT image series. Then
deliver the plan to the phantom and compare the delivered dose to the
planned dose.
About QA Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Register Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Align Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Finetune Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Review Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
MultiSlice Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Beams Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Loading a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
1072963-ENG B S ect ion 4- 2 : QA Plan s fo r Cy be rK nif e 227

About QA Plans
a QA template plan. The patient treatment plan must be saved as
deliverable. See “Section 8-2” (page 425) for information on how to create
a patient treatment plan. A QA template plan must be created and saved as
deliverable using a CT set of a phantom or a CT set of the same patient with
a different primary CT. A compatible plan of the same patient as the
selected QA patient plan can be also used as a QA template plan.
When a QA Plan is created, the beam data, robot data, path set, reference
point, and anatomy setting from the patient treatment plan are copied.
VOIs, alignment center, tracking information, density model, and dose
calculation box are copied from the QA template plan.
The density of the phantom curve should correspond to the CT used for the
phantom scan. The physical density of the phantom does not have to be
identical to the patient’s density information. This variability can result in
discrepancies in maximum dose, prescribed dose, reference dose, and
isodose curves between phantom and patient plans.
 Creating a QA Template Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
 Creating a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
 Auto Registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
NOTE: The Plan Overview Report includes information from both the patient
plan and the QA template plan.
 Creating a QA Template Plan

A QA template plan is a prerequisite for creating a QA plan.
2. Select a phantom patient.
NOTE: Accuray Incorporated recommends using a stereotactic dose

verification phantom.
3. Click the Standard icon in the Select Type pane, and then click Next>>.
4. Select CT images of a phantom in Select Exams screen.
5. Create VOIs for the phantom in Contour > Manual > Tools.
NOTE: Contours on the QA template plan can be used to register the patient
plan with the phantom image series.
6. Define the treatment parameters suitable for the CT image series of the QA
template plan in the Setup > Machine step. Density model can be also
selected in this step.
7. Identify location and region of tracking features in Setup > Align step.
8. Define the align center.
9. Select an appropriate density model in Plan > Settings if you have not
selected it in Setup > Machine step.
NOTE: A sample density model cannot be used to save the plan as

deliverable.
10. Optimize the plan and calculate the final dose, and then save the plan as
deliverable.
 Creating a QA Plan
a QA template plan. Patient plan must be a plan of non-phantom type
patient. A patient plan with multileaf collimator must have a QA template
plan with multileaf collimator.
2. Click a patient name from the patient list on the New Plan screen.
3. Click the QA icon in the Select Type area.
4. Click Next >>. The Select a patient plan for a new QA plan screen appears.

5. Select a patient plan from the Plan Name list. Only non-QA plans appear for
patient plan selection.
The patient plan list only contains plans with a status of Deliverable,
Approved, Completed, Under Treatment, Suspended, or Discontinued. The
QA template plan list contains plans with a status of Deliverable, Approved,
Completed, and Under Treatment.
6. Click Next >>. The Select a template plan for a new QA plan screen
appears. Only phantom patients and the patient selected on the previous
screen appear in the list.
7. Select a patient from the patient list.
8. Select a plan from the plan list. The associated QA template plan must have
a status of Deliverable, Approved, Completed, or Under Treatment.
9. Click Finish.The system loads the data from the patient plan and the QA
template plan, and the Setup > Register step, with the Auto Registration
dialog box, appears.

 Auto Registration
The Auto Registration dialog box automatically appears during QA plan
creation prior to a dose being calculated.
Item Description
Auto register by aligning • VOI Center: Center of the user selected VOI
drop-down list • Align Center: Alignment center
• CT Image Center: Center of the CT volume
Patient plan VOIs drop-down Available only when VOI Center is selected and there
list are one or more VOIs available.
Template plan VOIs Available only when VOI Center is selected and there
(Phantom plan) drop-down are one or more VOIs available.
list
OK button Dose will be calculated based on the image translation.

Maps beams from patient plan onto the PTV of the QA
template plan.
Cancel button Auto registration is canceled without registering

images or calculating the dose.
Auto Register a Patient Plan Image and QA Template Plan Image

1. Select the initial registration method of the patient plan image and the QA
template plan image in the Auto Registration dialog box.
2. Click OK. Dose is calculated. Isodose lines are displayed and both DVH
and dose statistics are available.

Register Step
Use Setup > Register step to register all non-zero beams per fraction, robot
data, path set, and anatomy settings from the patient plan to the QA
template plan. Confirm that the isodoses dose volumes are within a
minimum amount.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
 Manual Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Setup > Register Step
 Tools
Auto-Register Allows alignment of the patient to the

button phantom by aligning the VOI center, CT
image center, or the align isocenters.
Undo button Click to discard manual changes made to the

patient image since the Confirm button was
last pressed.
Confirm button Click to apply changes and perform a dose

calculation based on the shifted image
location.
Manual Displays the amount of the manual

Alignment adjustment since the last auto registration.
Offset
Translation tool Click an arrow to move the CT patient image
along the X, Y, Z axis to align to the phantom.
Click an arrow to adjust translation by a pixel
in the direction indicated by the arrow.
Slider bar Click an end of the slider to step through the

series a slice at a time.
Drag inside the slider bar to the right or left to
jump forward or backward through the image
series. The slice number is displayed above
the cursor.
 Manual Registration
Manual registration allows fine adjustments of the placement of planned
beams on the QA phantom plan. These adjustments will effect the isodose
distribution within the QA phantom VOI.
For point dose verification, user adjustments can be performed to ensure
that the QA measuring device samples a dose region of interest with a
minimum of dose variation through its sensitive volume.
For a two-dimensional relative dose verification (for example, film), the
dose variation should be seen throughout the region of interest.
1. Click Cancel on the Auto Registration dialog box.
2. On the Register step, evaluate the position of the dose distribution in
relation to the area and VOI in the phantom.
When the Register screen appears, the images are misaligned.
3. Align the images.

• For gross changes, use the mouse to drag the patient image on the 2D
images.
• For fine changes, click the arrows on the fine adjustment tools on the 2D
images.
As the patient image moves, the Manual Alignment Offset updates. The
default value prior to an auto or manual registration is 0,0,0.

NOTE: When you move the patient image, the position of the colored overlay
is updated immediately but the dose distribution is updated only after you
click Confirm.
NOTE: Position the least amount of dose variation of the patient image VOI
on the phantom chamber.
4. Repeat this alignment procedure for all 2D views as appropriate.

5. (Optional) To discard changes and display the original dose alignment, click
Undo.
6. Click Confirm to apply changes and initiate dose calculation.
Once the registration is completed, isodose lines appear and both DVH and
dose statistics are available.
Register Step with Isodose
Align Step
Use the Setup > Align step to review the registered align centers and
fiducial locations.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
 Define the Alignment Center. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
WARNING: If fiducials are being used for tracking, verify that fiducial
markers are visible in the DRRs.
NOTE: The DRRs are quickly generated and should only be used to verify
visibility. The fiducial centroid positions may not be displayed clearly.
NOTE: Moving the image center during this step may lead to inaccurate
treatment.

 Tools
Section Label Function
Current Center (IECp) X, Y, and Displays the coordinates of the current

Z alignment center.
Confirmed Center (IECp) X, Y, and Displays the coordinates of the current

Z confirmed alignment center.
Spine Supine ROI Height Defines the default tracking search range
(mm) slider (ROI) used during delivery for Synchrony
Spine Tracking. The value is for the height of
ROI in millimeter that is displayed as a blue
mesh on the DRR images.
Patient Position • Head First Supine (HFS)

• Head First Prone (HFP)
• Feet First Supine (FFS)
• Feet First Prone (FFP)
Confirm button Saves the new alignment center position.
Reset to Default button Discards the changes and uses the original
alignment center coordinates.
Fiducials (mm IECp) Displays the coordinates of the fiducials in the

template plan. The selected fiducial shows in
green in the DRR images. Column v (view)
shows which DRR (A, B, or AB) each fiducial
is visible. This column is updated live if you
drag the crosshairs in the image viewer.
Display tracking zone Select to display the border where the

check box fiducials are tracked within.
 Define the Alignment Center
WARNING: Prior to confirming the alignment center, verify that the

appropriate information is visible within the DRR per the alignment
guidelines described in the Treatment Delivery Manual.
If any changes are made to the alignment center during or after plan
generation, the plan must be recalculated in medium or high resolution for
Ray-Tracing and FSPB, and low, medium, or high for Monte Carlo. Then
prescribe again before saving the plan as deliverable.
1. Click Align step on the Setup task.
The two DRRs at the top of the display panel are generated using the
coordinates of the current alignment center. The coordinates of the current
alignment center are displayed in the Current Center area on the control
panel.
The 2D views at the bottom of the display panel are generated using the
current alignment center.
NOTE: The algorithm used to generate these DRRs is optimized for

generating instant updates of the DRRs. As a result, the image quality is not
as detailed as that on the treatment delivery system.
2. Evaluate the position of the alignment center on each DRR.

• For skull tracking, align the CT image so that the silhouette of the patient
has a 10-15 mm gap at the superior and anterior sides of the patient
anatomy in each view. A gap of 10 mm results in more accurate tracking
than does a larger gap.
• For fiducial and Synchrony System tracking, ensure that all required
fiducials for the plan are within the field of view and within the tracking
border. Make sure that the fiducials are visualized on both DRRs. For
fiducial tracking, the alignment center position is defined automatically.
NOTE: The fiducials may not be visible in the live image due to a shift in
patient alignment/fiducials, or if there is an angle difference in the DRRs
generated on the Treatment Delivery System. Treatment cannot proceed
without the required number of trackable fiducials.
3. To save the new alignment center position, click Confirm.

The image display and the plan are updated according to the new alignment
center coordinates. The coordinates in the Current Center and Confirmed
Center boxes on the control panel are both set to the current confirmed
coordinates.
After you click Confirm, if you move the alignment center, the new
coordinates are displayed in the Current Center area on the control panel.
4. To discard changes and use the default (original) alignment center

coordinates, click Reset to Default.
The image display and the plan are updated according to the original
coordinates.

Finetune Step
Use the Setup > Finetune step to review the existing treatment beams for
MLC QA plan and make changes to beam properties.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
 BEV Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
 Finite Size Pencil Beam Dose Calculation . . . . . . . . . . . . . . . . . . . . . . 244
 List Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
 Nominal Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Finetune step for MLC QA plan
 Tools
3D Beam Display Show Beams Select a category to show 3D beams:

options • None
• All
• With Dose
• Selected
• Blocked
BEV Display BEV Controls Views from the perspective of looking through the
button beam onto the patient which allows you to see
the outline of the beam over the patient anatomy.
Dose Calculation Algorithm Displays the current dose calculation algorithm

drop-down and a drop-down list of alternatives, if any.
menu
Resolution Displays the current resolution and a drop-down

drop-down list of alternatives. (Low, Medium, or High).
menu
Uncertainty Sets the uncertainty level used for calculating

(%) dose. (0.1% - 4.0%)
(Monte Carlo
only.)
Lateral Select Lateral Scaling check box to apply the

Scaling check lateral scaling to the FSPB algorithm. The lateral
box for FSPB scaling broadens the kernel based on local
only regional density. The broadened kernel improves
the agreement between measurement and
calculation in low-density regions like the lung
and directly upstream from the low density.
Calculate Calculates dose for the plan.

Final Dose
button
List Tools Sort button Sorts the beam list in ascending or descending
order based on the selection made from the Sort
by drop-down list.
Select button Select allows selection of beams with the user

selected criteria.
Nominal Moves all beams to the nominal position.

Position
button

Beam List Pane Invert Reverses the selection status of the beams from
Selection selected to clear and vice versa.
button
Show • All beams

drop-down • Beams with MU (non-zero MU)
menu • Selected beams (check boxes in the Selected
Column)
Total Beams Displays the number of beams selected.

Selected
Total Beams Displays the total number of beams in the plan.
Beams (MLC Selected (top Selects or clears all beams.

only) level)
Check box Selects or clears an individual beam.

(beam level)
Beam Valid If all segments of a beam are valid, the beam is

valid.
Path/Node Displays the path and node number of the beam.
MU Displays number of monitor units in a text box.
Critical Displays number of critical intersections. The

Intersections tooltip displays the name of each intersected
critical VOI.
Used in QA Check the box if the beam is used in the QA Plan.

Plan
Segments (MLC Segment Key A unique number identifying a particular

only.) segment. This value appears on reports used to
identify individual segments.
Segment Displays whether the segment has a valid set of

Valid leaf openings. If the segment is invalid, an error
will display what needs to be changed.
% The segment’s percentage contribution of MU to

the beam that it is a part of.
Used in QA Check the box if the segment is used in the QA

Plan Plan.
Eq Sq Length The side of the equivalent square field

(mm) corresponding to the irregular field that is used to
look up the pencil kernel and TPR parameters.
Leaf Positions Bank X1 & X2 The side of the MLC collimator the leaf is located.
(MLC only.)
Pos (mm) Number of mm away from the center line of the
MLC, measured at SAD at which each leaf is
positioned.
Layouts The following layouts are available for MLC:
 BEV Display
BEV Display allows you to see the outline of the beam over the patient
anatomy.

• DRR Project: Turns on a projection of the DRR.
• VOI Projection: Turns on a projection of a VOI.
NOTE: VOI Projection will turn off VOI projections even if the VOI Visibility
Option is set as on, but will not show VOI projections of VOIs whose VOI
visibility is turned off.
• Collimator Projection: Turns on a projection of a collimator shape.

• Reticle: Turns on the cross hair which provides an indication of distance
on the 800 mm SAD plane for the selected beam.
 Finite Size Pencil Beam Dose Calculation

After making changes on the Finetune step, you must calculate the dose
based on the current beam data. You can perform a Finite Size Pencil
Beam dose calculation low, medium, or high resolution. To save the plan as
deliverable, you must perform a Finite Size Pencil Beam medium or high
resolution dose calculation.
 List Tools
Sort
Use the Sort dialog box to sort the beam list in ascending or descending
order based on the criteria displayed on the Sort By drop-down list.
The order of sorting is maintained from one sort to another. For example, if
you sort by Path/ Node and then sort by MU, the result displays beams
sorted by MU and each group of beams with the same MU is sorted
internally by Path/Node.
Sorting Beams
1. Click the Sort button from List Tools.
2. Select a sorting criterion on the Sort by drop-down list.
3. Select the option for a sorting order (Ascending or Descending).
4. Click Sort.
Examples
• Selection in ascending order: The deselected beams are grouped at the
top and the selected beams are grouped at the bottom.
• Path/Node in ascending order: The beams are sorted by Path ID first.
Then, beams with the same Path ID value are sorted by Node ID.
• Blocked in ascending order: The unblocked beams are grouped at the
top and the blocked beams are grouped at the bottom. The Yes and No
strings are sorted in alphabetical order.
Select
Use the Select dialog box to select beams.
• Path
• Critical VOI
• MU (Inequality constraints derived from the number of MUs)

Select a Group of Beams
1. Click the Select button from List Tools.
2. Specify some criteria for beam selection.
3. Click Select to select all beams that meet the criteria.
4. Click Deselect to deselect all beams that meet the criteria.
5. Click Clear Fields to reset the Path and Critical VOI values to the default
value <any> and clear the other values.
Each iteration of a group selection is performed on the current beam select
state.
Example
A plan has a total of five beams and the first three are selected. Specify a
criterion that is met by the last three beams. Click Select. All five beams are
selected because no changes were made to the current select state of the
two items that did not meet the criteria and only the beams that did meet the
criteria are updated.
The MU and side edit boxes accept five digits before the decimal point and
one digit after the decimal point. If both MU text boxes are displayed and
populated, the system checks that the value in the left-hand text box is not
greater than or equal to the value in the right-hand text box.
Select a Beam Displayed in the 3D Image Viewer

1. Double-click the tip of a beam displayed on the 3D image.
The beam changes to orange, indicating it is the currently selected beam.
Its entry is checked and displayed in the visible area of the beam list panel.
2. If you double-click the tip of another beam, it turns orange, indicating it is
the currently selected beam. Its entry is checked and displayed in the visible
area of beam parameters table. All other selected beams are yellow.
 Nominal Position
When reorienting a beam to its nominal position in the robot coordinate
system, the Accuray Precision System will set the geometry of the beam in
such a way that the source point of the beam is 800 mm straight above the
machine center, and the target of the beam is the machine center, with no
rotation in any direction.
After accepting Nominal Position, all of the segments will have the exact
same geometry. A beam contains all segments that share the same source
and target position (geometry). Therefore, after the nominal position is
achieved, there will be only a single beam, containing all of the segments.
The Beams table will display a single beam, while the Segments table will
expand to include all of the segments.
To use Nominal Position:
1. Click the Nominal Position button. A Caution dialog box appears to indicate
that the beams will be repositioned and delivered from the nominal position.
2. Click Yes to move all of the beams to the nominal position.

Review Step
Use Evaluate > Review step to calculate dose, rescale MU, change the
reference point and save the plan.
The dose is initially displayed in low resolution and needs to be calculated
in medium or high resolution. Evaluate the dose distribution within the VOI
and recalculate the dose if any adjustments are made.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
 Rescaling the MUs for a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
 Saving a QA Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Evaluate > Review step for Fixed and Iris collimator
Evaluate > Review step for Multileaf collimator
 Tools
Dose Algorithm Displays the current dose calculation algorithm

Calculation drop-down list and a drop-down list of alternatives, if any.

drop-down list list of alternatives. (Low, Medium, or High).
Lateral Scaling Select Lateral Scaling check box to apply the

check box for lateral scaling to the FSPB algorithm. The
FSPB only lateral scaling broadens the kernel based on
local regional density. The broadened kernel
improves the agreement between measurement
and calculation in low-density regions like the
lung and directly upstream from the low density.
Uncertainty (%) Sets the uncertainty level used for calculating

Monte Carlo only Monte Carlo dose. (0.1% - 4.0%) The
Uncertainty setting is enabled after you select a
Monte Carlo dose calculation.

Size to fit • CT button: Sets the dose calculation box to

the size of entire CT Volume
• Skin button: Sets the dose calculation box to
the size of Skin VOI.
Skin VOI must be predefined.
• VOIs button: Sets the dose calculation box to
encompass all VOIs.
Calculate Final Calculates the dose for the plan using the
Dose button selected dose calculation settings.
Rescale MU Rescale MU Displays the Rescale MU dialog box to rescale

button the MU for the QA plan.
Scaling Factor text Displays the current scaling factor.

box
Reference Use max dose Select the check box to use the point of
Point point check box maximum dose as the plan reference point.
Dose (Gy/cGy) Displays the current dose of the reference point.

field
Point (mm IECp) Click the button to set the cross-hair to the
current reference point. The field below the Go
to >> button updates to show the X, Y, and Z
Go to >> button coordinates of the reference point.
Set to Cross-hair Click to set the reference point value to the

Point button coordinates of the current cross-hair position.
Save Plan Save Plan button Click to open the Save Plan dialog box.
 Rescaling the MUs for a QA Plan
Once a QA plan is created, the MUs of all the beams for the QA plan (equal
to a single fraction of the patient plan) can be rescaled using a rescaling
factor. If the rescaling factor is greater than 1, it must be an integer, if it is
less than 1, it can be fraction.
1. Click Rescale MU button. The Rescale MU dialog box appears.
2. Enter a value. If greater than 1, then it must be an integer, otherwise less

than 1 is a fraction.
For multi-fraction patients, rescaling the MU increases the dose delivered
to a QA plan by a multiple greater than or equal to 1.
3. Click the OK button to rescale the beams. The MU will be recalculated and
the plan statistics pane is updated.
NOTE: If, as a result of rescaling, a beam's MU falls below the system's

minimum MU, the MU will be increased to the minimum MU allowed by the
system and the user will be notified of the number of beams with their MU
increased.

 Saving a QA Plan
1. If the dose has been calculated, then click Save Plan. The Save Plan dialog
box appears.
2. Enter the plan name in the Plan Name field.

3. Select Make Deliverable to save the plan as deliverable.
4. Click Save.
NOTE: If a plan with associated QA plans is overwritten, a warning message

is displayed and the QA plans will be deleted.
MultiSlice Step
Use the Evaluate > MultiSlice step to view the multiple planar slices in axial,
coronal, or sagittal image with several choices of image layouts. The planar
slices contain dose distribution and VOI information.
Evaluate > MultiSlice Step with the second image of [B Dataset 1] selected

1. On the MultiSlice > Display step, click the desired layout icon in the
Layouts.
2. On MultiSlice >Tools, select a viewing plane on the Image Orientation
drop-down list.
3. (Optional) Select or clear the optional check boxes below the Image
Orientation control (Show VOIs, Show dose contours, Show min/max
dose).
image viewer.
If two images are loaded and registered, the Dataset control is available.

5. To change the image source of all the multi-slice views, select an entry on
Beams Step
Use the Evaluate > Beams step to view the list of beams and geometric
parameters associated with them. The controls enable you to perform hand
calculations to verify that the reference dose for each beam is consistent
with the number of MUs for that beam. For additional information, see the
 About the Beams Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
 Print the Beam Data List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Beams step for MLC
 About the Beams Step

To validate the dose calculation, you can perform an independent check of
the dose calculation on individual beams. The Beams step provides
geometric and dose parameters for a beam and a reference point in the
dose calculation grid. The reference point is the point of maximum dose or
a point defined by the user on Review step.
The Beams step also provides the SAD, beam depth, radius, the dose at the

reference point, the number of monitor units for each beam, and Dose/MU.
You can use this data and the beam data stored in the datafiles to
independently verify that the dose at that point is consistent with the number
of monitor units.
The Monte Carlo Dose Calculation algorithm requires a different approach

to the secondary MU check as compared with the Ray-Tracing algorithm.
For information about performing an independent check of the dose
calculation on individual beams, refer to the chapter on Algorithms for Dose
Calculation and Display in the Physics Essentials Guide.
 Print the Beam Data List

1. From Evaluate > Review step, click the Print icon.
The Reports Viewer with the available reports is launched.
2. Choose a report:
• Double-click Beam Data List from the report list.
without modifying the parameters.
parameters and click View Report.
Sorting Order of Beams

The list of beams in a plan appears as follows:
• The Beams list on the Evaluate > Beams step.
• The printed Beam Data List.
• The printed Path Check List.
The content of all three lists is the same. The content can be
cross-referenced by template Path ID/node number (TmPID/NID),
collimator size, and Beam Key (for fixed Collimator or Iris Collimator) or
Segment Key (for MLC).
The sorting methods for each list are based on the collimator type.
• Fixed Collimator: The beams are sorted first by template path ID, then
by collimator size, and then by node number.
• Iris Collimator (Option): The beams are sorted first by template path ID,
then by node number, and then by collimator size.
• Multileaf Collimator (Option): The beams are sorted first by template
path ID, then by node number, and the Equivalent Square Length (mm)
field.

Loading a QA Plan
 Load a QA Plan to Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
 Load a QA Plan to Review

2. Click a patient name from the list on the panel. The plans associated with
the selected patient appear.
3. Select a patient on the list.
4. Select a QA plan on the Select Plan list. QA plans are identified with QA
Plan in the Type column.
5. Click the Load Plan button to load the selected data.The QA plan is loaded
in Evaluate > Review step.
6. Perform manual fine-tune of the align center if desired in the Setup >
Register step.
7. Rescale and recalculate the QA plan in the Evaluate > Review step.
8. Click Save and save the QA plan as Deliverable.
Chapter 5
Fuse Task
The Fuse task displays tools for registering the primary (CT) image series
with a secondary image series. Register each secondary image series
individually to the primary image series to display the common information
from both image series in a single volume.
The Fuse task is available after loading the primary image series and at
least one secondary image series.
Setup Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Register Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Manual Fuse Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
WARNING: If images are registered from two different patients, it could result in
serious injury to the patient during treatment delivery. Be certain that the images
being registered are for the same patient.
WARNING: When registering images, verify that the images being registered
contain sufficient anatomic features to ensure proper registration to prevent patient
mistreatment.
WARNING: Always confirm registration visually before proceeding to prevent

patient mistreatment.
1072963-ENG B C h a p t e r 5 : F us e T as k 259
Setup Step
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Setup step
 Tools
The following tools are available on the Setup step.
Item Description
Already registered If the loaded image series have already been registered, this check box is
check box checked. Additionally, the user may check this box to indicate to the system that
the primary and secondary image series are acquired in a common coordinate
space.
Clear the check box to turn on the seed point selection and begin the Register step
again.
Auto Centering When using fiducials as seed points, use Auto Centering to instruct the system to
check box automatically identify the center of each fiducial.
Item Description
Dataset A buttons Delete last: Deletes the most recently created seed point in the primary image
series. To delete several seed points, click Delete last repeatedly.
Delete all: Deletes all seed points in the primary image series.
Dataset B buttons Delete last: Deletes the most recently created seed point in the secondary image
series. To delete several seed points, click Delete last repeatedly.
Delete all: Deletes all seed points in the secondary image series.
Layouts The following layouts are available:
ROI box The ROI (region of interest) box defines the area of the primary (CT) image to be
used for image-to-image registration. Intensity matching is performed only for the
user-defined region within the ROI box.
Modify the ROI box on an Axial/Sagittal or Axial/Coronal view.
Register Step
The Accuray Precision System provides several methods for registering
images:
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
 Loading Pre-registered Image Series. . . . . . . . . . . . . . . . . . . . . . . . . . 263
 Registration Using Seed Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
 Rigid Image Registration (Seedless) . . . . . . . . . . . . . . . . . . . . . . . . . . 267
 Deformable Image Registration (Optional). . . . . . . . . . . . . . . . . . . . . . 268
 Copying a Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Register step
 Tools
Seed Point Translation Select the check box to perform registration based solely on seed
Registration and Rotation points. This procedure does not use intensity data. This procedure
check box give a registration transform which is the rotation and translation that
minimizes the RMS distance between corresponding seed points.
NOTE: Adjustments to fusion can be made in the Manual step.
Translation Available only when two or more image series are loaded. Select the
Only check check box to perform registration for translations only. Typically, this
box setting is used for 4D Planning (no longer available in Accuray
Precision). This procedure gives a registration transform which is the
translation matching the centroids of the seed points.
Rigid Image Start /Continue Click to start the Rigid Image Registration. The word on the Start
Registration button button changes to Continue when Pause button is clicked. Click
Continue to resume the registration process.
Pause button Click the Pause button to suspend the registration process.
Copy Displays the Copy Registration dialog box. Allows you to copy
Registration registration information from an existing image fusion and apply the
button registration information to a user-defined pair of images.
Deformable Start button Click to start the Deformable Image Registration. This is available
Image after Rigid Image Registration is complete or when the Already
Registration Registered on Fuse > Setup Step is selected and the secondary
image allows deformable fusion.
Smoothing Select one smoothing level.

Level • Low Smoothing:This allows more flexibility in the deformation and
drop-down list may be useful for datasets containing large deformations.
• Medium Smoothing: Default and recommended setting.
• High Smoothing: This is more rigid and may be more appropriate
for datasets with limited contrast to noise ratio or low spatial
resolution.
 Loading Pre-registered Image Series

In some cases the primary and secondary image series are already
registered. This is most likely to occur if the result of a previous fusion was
saved. In this case, the Already Registered check box is selected when you
load the images.
Additionally, you may check the Already Registered check box when the
primary and secondary image series are known to have been acquired in
the same coordinate space. The registration procedure will be skipped, and
the primary and secondary image series are considered by the system to
be in a common coordinate space.
To modify the registration of a pre-registered image series, clear the
Already Registered check box to allow seed point selection and perform the
Register step again.
Failed Registration
In some cases, the refinement process fails and the two images move
completely out of alignment during refinement. Common causes of failed
registration include:
• The seed points were not placed in the same sequence on both images.
• The locations of seed points do not correspond closely enough between
the primary and secondary image series.
Correct a Failed Intensity-based Registration
1. Click the Setup step.
2. Clear the Already Registered check box.
3. Place seed points more precisely.
Ensure that the seed points on the primary and secondary image series are
correctly labeled and placed.
4. Click the Register >Tools step.

5. Click the Start button.
WARNING: The intensity-based algorithm finds the optimal registration between

the two images based on a specific mathematical model. The user is responsible
for assuring that the final registration is clinically acceptable for target and critical
volume delineation. Use the overlay, split screen, and checkerboard display modes
to visually check that the algorithm has adequately registered the two images.
NOTE: Fine adjustments to fusion can be made in the Manual Fuse step.
 Registration Using Seed Points

This section describes the basic procedures for placing and modifying seed
points and for performing Seed Point Registration.
Place and Modify Seed Points

1. On Fuse > Setup > Display, select an appropriate layout for the current
case.
NOTE: The 3D layout can be used for placement of seed points when there are
identifiable features on the skin surface.
NOTE: The 2D layout can be used for placement of seed points when there are
identifiable features on the axial, sagittal, or coronal views.
2. (Optional) Use the global tools to enhance the view of the anatomy of
interest.
3. With the Pointer tool active, place cursor over a feature on the primary
image series and double-click to place a seed point.
On a 2D view, a seed point is created at the desired position and displayed
on both image planes.
On a 3D view, a seed point is created at the surface point closest to the

cursor position.
4. Click over the same landmarks on the secondary image series.
NOTE: The positions of seed points on the primary image series must match the
positions of those on the secondary image series, and must be placed in the same
sequence on each image series.
5. Repeat Steps 3 and 4 to create up to eight pairs of seed points on the

primary and secondary image series.
6. Seed points can be placed on all secondary image series. To select another
secondary image series, click the B label in the upper left corner of the
secondary image panel and drag downward to select from the list.
7. (Optional) To modify the position of a seed point, place cursor over the seed
point number to click and drag the seed point marker to a new location.
8. (Optional) To delete the last seed point on the primary or secondary image
series, click the appropriate Delete last button on the control panel.
9. (Optional) To delete all the seed points on the primary or secondary image
series, click the appropriate Delete all button on the control panel.
Registration Method Dialog Box

If at least one pair of seed points have been defined and a current
registration exists for datasets A and B not related to the defined seed
points, the Registration Method dialog box will automatically be displayed
and the user will be required to select one of the two available options as a
registration starting point.
• Use the selected seed points so that the seed points will be used to
determine the starting point of automatic registration.
• Use the current registration results so that the current registration will
be used as the starting point for automatic registration.
Once a selection is made, the OK button becomes available.
Registration Method dialog box
Seed Point Registration Options

Seed Point Registration has the following two options:
• Translation and Rotation
• Translation Only
Translation and Rotation Registration
This registration method is used if three or more pairs of seed points are
present. The starting point for the registration process is calculated using
the seed points. If three or more pairs of seed points are present in the
primary and secondary image series, this starting point is the rotation and
translation that minimizes the RMS error between corresponding seed
points. If one or two pairs of seed points are present, the starting point is the
translation that aligns the centroids of the seed points. Given this starting
estimate, the rotation and translation components of the registration
transfer are refined in such a way that the Normalized Mutual Information of
the two images is maximized.
Translation Only Registration
This registration method is used primarily with the 4D Planning Option (no
longer available in Accuray Precision). It requires at least one pair of seed
points. The registration process is performed based on translations only
(without rotational registration) and the resulting image data is displayed.
Perform Translation and Rotation or Translation Only
Registration
1. On Fuse > Register >Tools, select Translation and Rotation or Translation
Only.
As soon as a selection is made, images are automatically registered.
When the progress bar reaches the end of the scale, the word Done
replaces the progress bar.
2. To evaluate the quality of the registration:

• Drag the cross-hair image partition in any of the 2D views (split screen,
overlay, or checkerboard).
• Drag an end of the image partition to rotate it.
The position of the partition in the 3D view is automatically updated when
the partition is moved or rotated in the 2D views.
NOTE: If you select a Seed Point Registration check box after you have completed
a registration, the previous result is deleted and cannot be restored.
 Rigid Image Registration (Seedless)

This registration method applies calculations based on the relative
intensities of image data to maximize the common information from both
images into one volume and performs automatic registration on the primary
and secondary image series.
1. On Fuse > Setup > Display, select an appropriate layout for the current
case.
2. Adjust the ROI box on the Setup step, as necessary.
3. Select the VOIs to be displayed on the VOIs tab, as necessary.
4. Use the Manual Fuse step to perform a manual registration that can be
used as a starting point of the automatic registration, as necessary.
NOTE: If the field of view is substantially different between the two images, the
results of the seedless fusion may be unacceptable. To optimize the results, use
the Fuse > Manual Fuse step to set the starting point of the auto registration so that
the corresponding anatomies are located near each other or use seed points.
5. On Fuse > Register > click Tools.
The 2 images will be displayed in their original position if manual
registration has not been performed, or in the last registered state if manual
registration has been performed.
6. Click Start to perform Rigid Image Registration.

If manual registration has not been performed, the initial position will
automatically be set based on the centroids of the datasets A and B. Also,
the patient position and image orientation of the two datasets are used to
determine this initial registration position.
7. To evaluate the quality of the registration in progress:

8. (Optional) Click the Pause button to suspend the registration process, and
then click Continue to resume the registration process.
When the progress bar reaches the end of the scale, the word Done
replaces the progress bar. The Continue and Pause buttons are disabled
and the registration is complete.
 Deformable Image Registration (Optional)

Rigid Fusion only allows for rigid transformations (rotation and translation),
Deformable Fusion allows smooth non-rigid transformations to capture
deformations of the underlying anatomy. It estimates the image
deformation field subject to smoothness regularization.
Select a Smoothing level between Low, Medium, and High deformation
smoothing settings. Medium smoothing is the default and recommended
setting. High smoothing is more rigid, and may be more appropriate for
datasets with limited contrast to noise ratio or low spatial resolution. Low
smoothing allows more flexibility in the deformation and may be useful for
datasets containing large deformations.
1. Click the Start button for Rigid Image Registration on the Register > Tools
step.
The Start button for Deformable Image Registration is available when Rigid
Image Registration is completed.
2. Select a smoothing level (Low, Medium, High) from the drop-down list for
Deformable Image Registration.
3. Click the Start button to perform Deformable Image Registration.
NOTE: Deformable image registration cannot be interrupted. The process should

take around 20 seconds for common applications.
When the registration is complete, the Start button changes to Delete

Deformed Image.
4. To evaluate the quality of the registration in progress:

5. If you want to export the Deformable Vector Field (DVF) used for image
registration in DICOM format, use the Export DICOM data on the Global
Tool Bar.
 Copying a Registration
An image registration contains information about the registration of a
secondary image series to the primary image series. When you create a
new plan, you can load multiple secondary image series of any supported
imaging modality. See “About Loading Images” (page 62) for more
information.
After you fuse a secondary image series to the primary image series, you
can copy the registration information from the existing image fusion and
apply it to another secondary image series.
NOTE: Copy Registration is not available for deformed datasets.
Prerequisites
• Two or more secondary images
• One or more seed points defined on the primary image and on at least
one secondary image
Copy a Registration to an Image Pair
1. On the Register >Tools step, click Start for Rigid Image Registration.
2. When the registration is complete, Done is displayed at the bottom of the
screen.
3. Verify that the registration is adequate. See “Manual Fuse Step” (page 271)
for more information.
4. Click Copy Registration. The Copy Registration dialog box appears.
Copy Registration dialog box
The source dataset list displays all secondary image series that have been
registered to the primary image series, by either seed point registration or
manual fuse.
Each dataset name includes an abbreviation that represents the imaging

modality.
5. Select a source dataset on the Select source registered dataset drop-down

list.
6. Select the check box for a target dataset on the Select target dataset(s)
panel.
To select all target datasets, select the top check box.
7. Click Copy.
The source registration is copied to the target image dataset, resulting in a
new image fusion.
8. Click Close to return to the Register step.
Manual Fuse Step
Update the registration of the primary and secondary image series by
performing a manual fusion.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
 Perform a Manual Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Manual Fuse step
 Tools
The following tools are available on the Manual Fuse step.
Item Description
Rotation and translation Fine motion is controlled with the rotation and translation tool at the bottom
tool right of each planar view. This tool is comprised of the translation and
rotation components depicted and described below.
The resolution of the transformation is based on screen pixel resolution. To
achieve finer movements, zoom in on the image.
Item Description
Translation tool Click an arrow to adjust translation by a pixel in the direction indicated by the
arrow.
Rotation tool Click an arrow to adjust rotation by a pixel in the direction indicated by the
arrow.
Slider bar Click an end of the slider to step through the series a slice at a time.
Drag inside the slider bar to the right or left to jump forward or backward
through the image series. The slice number is displayed above the cursor.
The faint circle indicated by the arrow on the secondary image series
defines the boundary of the translation and rotation portions of the screen.
• Drag inside the faint green circle to adjust the translations.
• Drag outside the faint green circle to adjust the rotation.
• Drag the cursor to make gross changes to the transformation.
Undo button Click to discard changes and display the original images.
Confirm button Click to apply changes and display the updated images.
 Perform a Manual Fusion

1. Use the Pointer tool to drag the secondary image series (color overlay) until
visually aligned with the primary image series in all 2D planes.
2. Click Undo to discard changes and display the previous image positions.
3. Click Confirm to apply changes.
Chapter 6
Contour Task
The Contour task provides tools that allow you to outline target tissue and
critical structures by creating volumes of interest (VOIs). VOIs are used to
optimize the dose distribution. In addition, you can define other structures
for a patient plan or Ball-cube plan, and view and modify the display
properties of VOIs.
Manual Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Autosegmentation Step . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Skin Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Spine-Tracking Step. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Ball-cube Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
NOTE: To modify the default display properties of VOIs, go to the Contour >
Display tab.
1072963-ENG B C h ap te r 6 : C o nt ou r T ask 273

Manual Step
A VOI is a user-defined region on medical images. In general, each VOI
should represent a distinct anatomical feature. You can create one or more
contour on a slice. Accuray Precision System supports 200 or more VOIs in
a plan.
A single VOI can contain both a solid contour and a cavity contour. This
allows creation of hollow VOIs (shell structures), which are especially useful
for planning.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
 Image Viewer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
 Appearance of Contours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
 Select VOI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
 Drawing Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
 VOI Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
 Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
 Import VOIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
 Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
 Import Dataset. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
 Create VOI from Isocurve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
 Guideline to Avoid Unexpected Skin Reactions. . . . . . . . . . . . . . . . . . 297
Contour > Manual Step
 Tools
The following tools are available on the Manual step.
In addition to creating a skin VOI in Contour > Skin step, you can use some
of the following tools. Skin VOI must be a critical VOI and cannot be a
boundary VOI.
• Select Skin check box in VOI Properties dialog box.
• From Contour > Manual, VOIs tab, click the type drop-down list and
select S for skin.
• From VOI Visibility dialog box, select Skin from the Type drop-down list.
Select VOI Filter/search Use to filter or search for a VOI to be displayed in the list. Type in
text box one or more characters, and the list will display the VOI names that
contain the typed text.
List The list displays VOI name, type (Target or Critical or Skin), and the
color. Type in the VOI name in the text box or scroll down to select a
VOI. VOIs that have been delineated are indicated with a solid color
box. The empty VOIs are indicated by a gray color.
Click the top row or small arrow to sort the VOI list by ascending or
descending order.
Create VOI: Displays the VOI Properties dialog box. Create a new
VOI by entering a Name, and select the Type, Plane, and Color.
Optionally set the VOI type to Boundary. Select the Auto Interpolate
check box to turn on the automatic interpolation between
user-delineated contours. Select Skin to create a skin VOI.
Delete VOI: Deletes the displayed contours for the selected VOI.
Delete VOI can be undone using Undo.
VOI Properties: Displays the VOI Properties dialog box. View and
modify the Name, Type, Plane, and Color of the selected VOI.
Optionally set the VOI type to Boundary. Select the Auto Interpolate
check box to turn on the automatic interpolation between
user-delineated contours. Select Skin to designate a VOI as Skin
(S).
Move Up: Move the selected VOI up in the list. The VOI list is
initially sorted by creation order.
Move Down: Move the selected VOI down in the list.
VOI Visibility Options: Displays VOI Visibility Options dialog box.

Drawing Tools See “Drawing Tools” (page 284).
Options Smart curve Turns on the smart curve fitting tool, which modifies the effect of the
fitting check Pencil, Line, Ellipse, and Bumper tools. See “Smart Curve Fitting”
box (page 294).
Display all Click to display all VOIs. When cleared, displays only the current
VOIs check VOI.
box
Display Click to display all isocurves. When cleared, isocurves are not
isocurves displayed.
check box
Bumper Size Modifies the diameter of the Bumper tool. The Bumper Size slider
slider switches to the Minimum leakage allowed slider when either the 2D
or 3D magic wand is active.
Import VOIs Click to display the Import VOIs dialog box which contains a list of
button available RT structures associated with the current patient and
primary image that can be imported into the current plan.
Template Click to display the Select VOI Set Template dialog box, and select
button a template for the plan. Applying a template adds empty VOIs as
defined in the selected template.
Import Click to display the Import Dataset dialog box. You can import an
Dataset additional image dataset that are available to an existing plan. This
button option excludes importing DCE MR images. See “Import Dataset”
(page 296) for more details.
Create VOI Click to display the Create VOI from Isocurve dialog box. This
from Isocurve button is only available when a dose volume exists for the plan.
button When an isocurve is selected or a dose % value is entered, a
default VOI name is displayed. See “Create VOI from Isocurve”
(page 297).
 Image Viewer
The image viewer contains a large 2D axial (default) view of the drawing
plane with the other planar views directly to the right.
To make any 2D planar view fill the screen, press Ctrl and double-click in
the 2D view (axial, sagittal, or coronal). To undo, repeat the process by
pressing Ctrl and double-clicking.
The displayed images series can be changed to primary (A), secondary (B),
split (A/B), overlay (A&B), and checkerboard (A+B) views.
Right-click anywhere in the image viewer to access a shortcut menu . More
layout options are available depending on the number of modalities you
have fused.
Right-click Menu - Layout Examples
 Appearance of Contours
The system distinguishes among drawn, interpolated, and extrapolated
contours.
Type of Contour Appearance
Drawn Solid outline
Interpolated Fine dotted outline
Extrapolated Dashed outline
Drawn Contours
Drawn contours appear as solid outlines. This can be drawn from an empty
VOI or by editing an extrapolated or interpolated contour. Creating a
contour from scratch does not generate any interpolated contours on other
slices.

Interpolated Contours
Interpolated Contours appear as fine dotted outlines. They interpolate
between two other contours, called the reference contours, for the
interpolated contour. There is no automatic interpolation between a single
contour on one slice and multiple contours on another. When you edit an
interpolated contour, it becomes a drawn contour (solid line). The
neighboring interpolated contours in the same stack are now interpolated to
it.
Auto Interpolation
The Auto interpolation check box on the VOI Properties dialog box is
selected by default.
1. Create a contour on an image slice.
2. Create a contour on another non-consecutive image slice.
The intermediary contours are interpolated automatically using linear
interpolation.
If you modify an interpolated contour, the other interpolated contours are

updated in two directions:
• From the modified slice or contour to the previous drawn and confirmed
contour.
• From the modified slice or contour to the next drawn and confirmed
contour.
Extrapolated Contours
An extrapolated contour provides a visual indication of the shape and
location of the closest drawn contour. Extrapolated contours have the same
shape as the nearest drawn contour. The extrapolated contour outlines
appear as dashes in the same shape as interpolated contours.
You can edit an extrapolated contour just as you edit a drawn or
interpolated contour. Once it’s edited, the contour becomes a drawn
contour, and interpolated contours are generated in one direction towards
the closest drawn contour.

Editing Contours From Earlier Versions of Accuray Precision
If you edit a plan that was created using an earlier version of Accuray
Precision prior to version 2.0. x, each VOI is kept in the previous format until
the VOI is selected for editing. If a VOI is selected for editing, some types
of VOIs are converted to the new format.
The following two cases applies:
• It was possible for one VOI to have some contour sets that used
interpolation and some that did not use the interpolation. When such a
VOI is selected for editing, all contours that were interpolated before are
converted into non-interpolated contours so that they appear as solid
rather than dotted curves. Then, the entire VOI has Auto Interpolate
turned off. This means that the updated VOI is identical in terms of its
shape and size. The only difference is that it has no dotted contours
when you edit it.
• In earlier versions, different contour sets could overlap each other. In
the current version, the contours merge during editing if you cause them
to overlap. When a VOI with overlapping contour stacks is selected for
editing, all overlapping contours are merged. The shape and size are
almost identical, but represented differently. For instance, instead of
two contours that overlap, there will be a single contour representing the
boundary of the overlapping regions. The reason the shape will not be
perfectly identical is that there is rounding when the new boundary
curves are calculated. Any changes would be subtle and should not be
clinically significant.
Left: Multiple contours in a VOI before the conversion. Right: VOI after the conversion.
 Select VOI
Under the Select VOI area, you can create VOIs, delete VOIs, and modify
or review contours.
Create a VOI
1. On the Manual step, click the Create VOI icon. The VOI Properties
dialog box appears.
2. Assign a name, and select the Type, Plane, and Color.
3. Optionally, select Auto Interpolate or Boundary (available for critical VOI
only).
NOTE: Only one boundary structure is allowed per slice. A new contour
cannot be created on the same slice as an existing boundary VOI.
4. Click OK. A VOI is created and selected, and the remaining controls are
available.
5. To create the first contour of a VOI, select a drawing tool and begin
delineating the contour.
6. Scroll through the slices to delineate the contour throughout the CT volume.
View or Modify the Display Properties of the Selected VOI

1. Select the VOI on the Select VOI list.
2. Click the Gear icon. The VOI Properties dialog box appears.

VOI Properties dialog box
3. Confirm or modify the Name, Type, Plane, and Color of the selected VOI.
NOTE: If you draw contours and then change from one plane to another, all
contours are deleted.
4. If you select Critical on the Type drop-down list, the Boundary check box is
available. Select the check box to create a boundary VOI.
5. Click OK to apply changes.
NOTE: The maximum length for a VOI name is 64 alphanumeric characters,

excluding backslash and control characters.
VOI Properties controls
Item Description
Name The name of the VOI. Use the default name or enter a new name in the
Name text box.
Type The type of the VOI: Target (default) or Critical.
Item Description
Plane The plane of delineation for the VOI: Axial (default), Sagittal, or Coronal.
All contour sets inside a VOI must be in the same plane. All edits must be
done on the original plane.
Color Select the color of the VOI from the list. To create a custom color, select
the last line in the list and use the color palette.
Boundary check box The volume of interest includes the pixels on the boundary of the VOI. A
boundary VOI does not include the structure it encloses, only the actual
contour line. Boundary VOIs can be used to contain dose and achieve
better conformality.
NOTE: Only available for critical structures.
Auto Interpolate check box Select to automatically interpolate between user-delineated contours.
NOTE: Cavity cannot be interpolated automatically.
Skin check box Select to designate the VOI as skin (S). Skin cannot be a Boundary, and
the VOI Type must be Critical.
Turn Off Auto Interpolation

Clear the Auto interpolation check box. Only the contours that you draw
appear and included in the VOI. Auto interpolation mode is selected by
default. Contours must be drawn on consecutive slices if auto interpolation
is turned off.
Create a Cavity
A cavity is created when a contour is drawn inside of another existing
contour. Cavity contours appear with a thick solid outline and cannot be
interpolated automatically. Use VOI Operations if you want to create a large
cavity across numerous CT slices.

 Drawing Tools
The control panel on the Manual step displays a palette of drawing tools.
Use the mouse to hover over an icon to view the tooltip. Click the icon to use
the drawing tool.
WARNING: The 2D magic wand, 3D magic wand, and smart curve tools use the
current settings of window, level and image intensity to define boundaries. These
contours may not always accurately match the volume boundary, compromising the
quality of the plan. Always perform visual inspection of each contour to ensure that
it defines the intended volume.
Item Tooltip Description
Pencil Creates a free-form contour. Use the pencil or mouse button to drag the
structure to be contoured. The contour closes automatically and
intersecting regions are eliminated.
Line Creates a contour with individual line segments.

Segment Click in the image to create the first point. To add vertices, click the
mouse at points along the boundary of the region being contoured. To
end the contour, double-click. The contour closes automatically and
intersecting regions are eliminated.
To delete the contour, right-click before ending the contour.
Ellipse Creates an elliptical VOI.

Click in the image and drag to the opposite side. To end the contour,
release the mouse button.
To create a round contour, hold down the CRTL key and drag over the
image.
Bumper Modifies the outline of a VOI. When the Bumper tool is active, the
cursor appears as a circle in the 2D views.
To modify the diameter of the Bumper tool, use the Bumper Size slider
at the bottom of the control panel. The curvature of the Bumper tool is
determined by the size of the circle relative to the zoom level of the
image. For more precise control, zoom in on the image.
Drag the cursor around the inside or outside of the contour to push the
boundary inward or outward.
The Bumper Size slider switches to the Minimum leakage allowed slider
when either the 2D or 3D magic wand is active. This magic wand
leakage protection option allows a setting between 0 to 20 pixels. When
the value is greater than 0, the leakage protection is available for the
following 2D and 3D magic wand operations.
When the magic wand detects a contour, it utilizes a seed filling
algorithm based on the initial point you selected. Since gaps typically
appear on the edge of the current filling area, the algorithm may leak to
areas not intended to be contoured. Selecting this option allows the
algorithm to detect the gap and prevent leaking. The value of the slider
defines the maximum size in pixel counts of the gap that can be
protected. Using this setting will smooth the final contour and the curve
may have less accuracy.

Item Tooltip Description
3D Magic Automatically generates a contour of a closed region of interest across

Wand the entire image volume.
Adjust the Window/Level for the image so that the region of interest has
high contrast in comparison with the surrounding anatomy. Click at the
approximate center of the region. A contour is defined automatically.
2D Magic Automatically generates a contour of a closed region of interest on a

Wand single 2D slice.
Adjust the Window/Level for the image so that the region of interest has
high contrast in comparison with the surrounding anatomy. Click at the
approximate center of the region. A contour is defined automatically.
VOI Opens the VOI Operations dialog box that provides a tool to manipulate
Operations existing VOIs and create new VOIs. See “VOI Operations” (page 289).
Move and Displays a square with eight rescale vertices surrounding the selected
rescale VOI, and two yellow control points inside the square. Select a control
contour point to rescale or move a contour. See “Move and Rescale Contour”
(page 287) for more details.
Contour Displays the Contour Cleanup dialog box. This tool provides two
Cleanup options, remove and smooth, to remove specified small internal
segments. See “Contour Cleanup” (page 288) for more details.
Delete Deletes contours. When Delete contour is selected, the cursor appears
contour as an X in the 2D views. Click on the contour to delete it.
If a drawn contour is between two other drawn contours, deleting
replaces it with an interpolated contour to create a gap in the VOI.
Delete All Deletes all the contours from all slices of the selected VOI.
Copy Copies the contour on a single slice.
Paste Pastes the copied contours onto another slice.
Undo Discards the previous drawing action performed. This button can be
pressed multiple times if needed.
Redo Reinstates a drawing step you have undone.
Move and Rescale Contour
A square with eight rescale vertices surrounds the selected VOI. Two
yellow control points are inside the square. Select a control point to rescale
or move a contour. You can move the entire VOI by holding the Shift key
while using the mouse.
Rescale Control Point

Point to the rescale control point. The cursor changes appearance when the
control is available. To rescale the contour, drag the point. The contour
grows or shrinks as you drag away from or toward the center. The rescale
is proportional to the center point.
Move Control Point
The move control point is a yellow point at the center of the Move and
rescale contour bounding box.
Point to the move control point. The cursor changes appearance when the
control is available. To move the contour, drag the move control to a new
position.
Rescale Control Point
Point to the rescale control point. The cursor changes appearance when the
control is available. To rescale the contour, drag the point. The contour
grows or shrinks as you drag away from or toward the center. The rescale
is proportional to the center point.
Move Control Point
The move control point is a yellow point at the center of the Move and
rescale contour bounding box.
Point to the move control point. The cursor changes appearance when the
control is available. To move the contour, drag the move control to a new
position.

Contour Cleanup
Each VOI is composed into contiguous stacks of contours. You can clean
up the small internal contour stacks that are not visible by selecting one of
the following options.
• Select Remove volumes less than to remove any internal contour
stacks with a volume smaller than the specified cubic mm.
• Select Smooth with smoothing value to smooth out any small filaments
or separate pieces that are smaller than the specified diameter.
Copying 2D Contours
Copy 2D contours as a quick method of creating multiple contours for a
uniform structure. You can modify individual contours.
1. Select a VOI.
2. Scroll to the slice that contains the contour(s) you want to copy.
3. Click Copy.
4. Scroll to the destination slice.
5. Click Paste. The copied contours are pasted onto the destination slice at
the same location as where they were copied.
Deleting All Contours of a VOI

1. Select a VOI from the Select VOI list.
2. Click the Delete All icon.
Delete a Contour on a Single Slice

1. Click the Delete contour icon.
2. When the pointer becomes an X, select the contour outline on the slice that
you want to delete.
Edit or Delete Portions of a Contour on a Single Slice
1. Select the Bumper tool.
2. Drag across the contour outline where you want to modify a portion of the
VOI.
3. To delete a larger portion and retain a smaller portion, modify one or more
smaller portions.
NOTE: When an interpolated contour is modified, the changes can affect the entire
interpolated component of the VOI. Interpolated aspects of a contour appear as a
fine dotted outline.
Extrapolated Contour and Interpolation

You can choose to use auto interpolation for each VOI. Auto interpolation
speeds up the generation of VOIs. Auto Interpolate is selected by default in
the VOI Properties dialog box.
 VOI Operations
The VOI Operations dialog box provides a tool to manipulate existing VOIs
and create new VOIs. Multiple VOI operations can be staged sequentially
to produce complex results such as a shell encompassing single or
combined VOIs.
The following examples of the VOI Operations functionality are provided:
• “Create a Dilated or Eroded Isotropic Copy of an Existing VOI” (page
291).
• “Create an Isotropic Shell From an Existing VOI” (page 292).
• “Combine Two Existing VOIs” (page 293).
VOI Operations dialog box

The following tools are available in the VOI Operations dialog box.
NOTE: Drop-down lists are activated by first clicking in the working row to produce
the menu field, and then clicking the menu button to access the drop-down list.
Item Description
# Numbered position of VOI operation in the list.
VOI A drop-down list First VOI to be used in the operation.
Operator drop-down list Selection of VOI operation to perform:

Plus: Combines VOI A and VOI B.
Minus: Subtracts VOI B from VOI A.
Copy: Makes a copy of VOI A.
Intersect: Creates new VOI from overlap of VOI A and VOI B.
Resize: Grow VOI A in place.
If defined, Grow operation is performed prior to the VOI operation.
VOI B drop-down list Second VOI to be used in the operation.
Effect on Destination Defines result of the VOI operation on the destination:

drop-down list Add To: Combines result of the VOI operation with the existing destination
VOI.
Replace: Removes any contours from the existing destination VOI, and
creates new destination VOI with result of the VOI operation.
Limited to Replace when:
Grow is defined.
Selected Destination is the same as either VOI A or VOI B.
Destination drop-down Name for destination VOI of the VOI operation. Limited to VOI A when Grow
list is defined. You can also select Create VOI from the drop-down list and create
a new VOI as destination. The destination cannot be a Boundary VOI.
Grow drop-down list Selection of VOI, both or none, to grow:

VOI A
VOI B
Both
Copies of VOI A, VOI B, or both are grown prior to the VOI operation. Limited
to VOI A when Resize is the selected operation.
Isotropic check box Constrains growth values to be identical in all directions. Disabled when Grow
is undefined.
Item Description
Ant (mm) / Post (mm) / ± 100mm: Growth values in patient anterior, posterior, right, left, superior, and
Right (mm) / Left (mm) / inferior directions. All fields are populated with a single value when Isotropic
Sup (mm) / Inf (mm) is selected. Positive growth values produce dilation; negative values produce
erosion. Disabled when Grow is undefined.
Move Up button Moves position of selected VOI operation up in the list.
Move Down button Moves position of selected VOI operation down in the list.
Delete button Deletes selected VOI operation.
OK button Approves VOI operations, and closes the dialog box.
Cancel button Cancels VOI operations, and closes the dialog box.
Create a Dilated or Eroded Isotropic Copy of an Existing VOI

1. Click VOI Operations. The VOI Operations dialog box appears.
VOI Operations dialog box showing operation to expand existing VOI
2. Select an existing VOI from the VOI A drop-down list.

3. Select Copy from the Operator drop-down list.
4. Select Replace from the Effect on Destination drop-down list.
5. Select Create VOI from the Destination drop-down list. VOI Properties
dialog box appears.
6. Enter a name, and select its properties.
7. Select VOI A from the Grow drop-down list.
8. Select the check box in the Isotropic column, and enter the desired amount
by which to resize the target contour in all directions.

• To produce dilation, enter a positive value.
• To produce erosion, enter a negative value.
9. Click OK to initiate the operation. The resulting VOI appears in the image
viewer.
Create an Isotropic Shell From an Existing VOI

VOI Operations dialog box showing operation to create a shell from an existing VOI
2. In row 1, select an existing VOI from the VOI A drop-down list.

3. Select Copy from the Operator drop-down list.
5. Select Create VOI from the Destination drop-down list. VOI Properties
dialog box appears.
6. Enter a name, and select its properties.
7. Select VOI A from the Grow drop-down list.
8. Select the check box in the Isotropic column, and enter the amount to be
added to the VOI A contour in all directions to produce the desired outer
dimensions of the shell.
9. In row 2, select the VOI created in step 5 from the VOI A drop-down list.
10. Select Minus from the Operator drop-down list.
11. Select the VOI specified in step 2 from the VOI B drop-down list.
13. Select the VOI created in step 5 from the Destination drop-down list.
14. Select VOI B from the Grow drop-down list.
15. Select the check box in the Isotropic column, and enter an amount less than
the amount specified in step 8 to be added to the VOI B contour in all
directions to produce the desired inner dimensions of the shell.
16. Click OK to initiate the operation. The resulting VOI appears.
NOTE: If the source is a Boundary VOI, then the destination is automatically

an isotropic shell one pixel thick.
Combine Two Existing VOIs

VOI Operations dialog box showing operation to combine existing contours
2. Select an existing VOI from the VOI A drop-down list.

3. Select Plus from the Operator drop-down list.
4. Select an existing VOI from the VOI B drop-down list.
6. Create or select a target VOI from the Destination drop-down list.
7. Click OK to initiate the operation. The resulting VOI appears in the image
viewer.

 Options
Smart Curve Fitting
The Pencil, Line segment, Ellipse, and Bumper drawing tools can be used
with the Smart curve fitting option.
1. Select the Smart curve fitting on the control panel.
2. Use the Window/Level tool to maximize contrast between the volume you
will contour and the surrounding anatomy.
3. Click the Pencil, Line segment, Ellipse, or Bumper tool.
4. Draw just inside the volume you want to contour.
The curve adjusts to fit the boundary based on the contrast in the image
display.
NOTE: For the most accurate delineation, ensure that the starting contour is fully
inside the region you want to draw.
5. (Optional) To modify a contour, use the Bumper tool.

6. (Optional) Press and hold the Alt key while contouring to quickly toggle the
Smart curve fitting settings. For example, if you have Smart curve fitting
selected on the current VOI but you don’t want to use it for a particular slice,
just hold down the Alt key while contouring.
NOTE: The automated drawing tools use the displayed image modality to
determine boundaries. Set the modality by clicking the indicator at the top left of the
2D image display.
NOTE: The magic wand, 3D magic wand, and smart curve tools use the current
settings of window, level and image intensity to define boundaries. These contours
may not always accurately match the volume boundary, compromising the quality
of the plan. Always perform visual inspection of each contour to ensure that it
defines the intended volume.
Display All VOIs

Select the Display all VOIs check box.
Display Isocurves
Select the Display Isocurves check box.
The display of isocurves is useful for creating tuning structures to tailor
results during conformal inverse planning.
 Import VOIs
To import VOIs of RT structure sets associated with a plan’s primary image
stored in the iDMS System:
1. Click Import VOIs to open the Import VOIs dialog box.
2. Select an RT structure set from the Import VOIs list, and click OK.
 Templates
1. Click the Templates button. The Select VOI Set Template dialog box
appears.
2. Select a template from the drop-down list and click Apply.

• If there is no contour in the current VOI set, the list of VOI names are
replaced by the VOI names from the template.

• If an existing VOI has a defined contour, that VOI name is retained. All
others are replaced by the names in the template.
For information on viewing and modifying VOI templates, see “Chapter 11”
(page 623).
 Import Dataset
Use Import Dataset dialog box to add more image datasets to an existing
plan. You can add one dataset at a time up to the limit described in “Criteria
for Secondary Image Series” (page 62).
DCE MR cannot be imported using this feature. DCE MR can only be
loaded using New Plan wizard.
1. Click the Import Dataset button. Import Dataset dialog box appears.
2. Select an exam which you want to add to the plan you are creating, and click
OK.
3. (Optional) Click Import Dataset and add more image set if necessary.
4. Go to Fuse task, and then review and fuse the images. Continue planning.
5. (Optional) Use Include Registration Images to add patient registration
datasets. e.g. MVCT/kVCT.
 Create VOI from Isocurve
1. Click Create VOI from Isocurve. The Create VOI from Isocurve dialog box
appears.
2. Select an isodose curve from the Select Isodose Curve drop-down list, or
enter an isodose % value in the % text box. The default VOI name appears
in the Name of VOI to Create text box.
3. (Optional) Rename the VOI in the Name of VOI to Create text box.
 Guideline to Avoid Unexpected Skin Reactions

Accuray Incorporated uses an inverse planning system to create IMRT or
3D Conformal treatment plans. Clinicians need to recognize the potential
for skin overdose and take appropriate precautions. Clinicians who are
accustomed to forward planning systems need to pay special attention to
these guidelines.
The following may lead to skin burns:
• Contouring too close to the skin surface.
• Assigning dose to voxels in air.
• Optimizing on voxels that are too large.
• Patient setup errors.
To avoid skin burns:
• Target contours must not include air voxels.
• Retract contours at least 2 mm from the skin surface, or 1 optimization
resolution voxel rounded up to the nearest mm, whichever is greater.
• When deciding how far to retract contours from the skin surface,
consider the size of an optimization resolution voxel.
• For best control over the dose distribution, optimize on the highest
resolution grid. (For best spatial information, calculate final dose on the
highest resolution grid as well.)

• Skin folds (for example, in the neck) make the skin effectively thicker,
reducing or eliminating the skin sparing effect. Where the skin folds in
on itself, retract contours at least the minimum distance beyond the
folds of skin that are most internal to the patient.
• Bolus is usually not needed for TomoTherapy®or Radixact® treatments.
Before deciding to add bolus, measure the skin dose with
thermoluminescent dosimeter or other skin dosimeters. If bolus will be
used during treatments, bolus should be included in the planning image.
In the planning image, check for any air voxels between the bolus and
skin, and replace them with tissue/bolus density.
Refer to the Physics Essential Guide for more details.
Autosegmentation Step
The Autosegmentation step provides tools for automatically segmenting
common structures of the following human anatomies: Brain, Male Pelvis,
and Head and Neck.
 Brain Autosegmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
 Male Pelvis Autosegmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
 Head and Neck Autosegmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
 Brain Autosegmentation
Brain Autosegmentation provides the tools to automatically generate
contours of up to 160 anatomical brain structures. The workflow requires a
a T1-weighted MR image in addition to the patient's planning CT image.
The CT and MR images must be fused in order for the Brain
Autosegmentation to be enabled. If multiple secondary datasets are
available, the T1-weighted MR image must be selected as the active
secondary image after entering the Autosegmentation step.
In order to obtain optimal segmentation results, the following imaging
technique guidelines are recommended:
• The CT image must be scanned in the HFS patient position.
• The CT image resolution should be 1.0 x 1.5 x 1.0 mm or better.
• The T1-weighted MR image resolution should be 1.25 x 1.5 x 1.25 mm
or better.
• The MR image must cover the entire head of the patient.
Tools
Anatomic Supported anatomies for Autosegmentation are listed. If MR is

Region loaded, Brain, Male Pelvis and Head and Neck are available. If
drop-down list MR is not loaded, only Male Pelvis and Head and Neck are
available.

Select/Setup Setup button Displays the VOI Selection Setup dialog box allowing you to
VOIs change the VOI associated with an autosegmentable
anatomical structure.
Structure (VOI) The Structure (VOI) panel allows you to select available
structures and the corresponding VOI for automatic
segmentation.
check box Turn on/off automatic segmentation of the structure and

corresponding VOI.
Color Displays the color of the VOI.
Tooltip Displays the full string of Structure (VOI) descriptions.
Autosegment/Edit Autosegment Begins autosegmentation using the currently enabled

button autosegmentation VOIs.
Create a New Plan Using Brain Autosegmentation
WARNING: Review all automatically segmented VOIs, even those manually

modified to prevent patient mistreatment.
1. Click the New Plan icon on the Accuray Precision System home page.
2. On the New Plan page, select a patient record, click the Standard Plan icon,
and click Next >>.
3. On the Select Exams page, select the CT and T1-weighted MR exams, and
click Finish >>.
4. In the Register step of the Fuse task, register the CT and MR images. For
more information, see “Fuse Task” (page 259).
When registration processing is done, examine the split view images to
confirm accuracy of the registration.
Registered split view image
5. Select a layout from Contour > Autosegmentation > Display.

6. In the Autosegmentation step of the Contour task, select Brain from the
Anatomic Region drop box. The VOI Selection Setup dialog box appears,
listing all the supported structure names.

VOI Selection Setup dialog box
7. Select the structures to be segmented.

• VOI names are filled in automatically.
• VOIs that are designated “Critical” are renamed to match the structure
they represent.
• The system needs at least one selected structure for an automatic
segmentation.
• Select the check box at the top of the column to select all structures.
NOTE: A VOI can be associated with only one Structure Name.
8. Click OK to close the window.

9. Click the Autosegment button to start autosegmentation.
• Contours for the selected VOIs will automatically be generated.
• If an automatic segmentation has been completed for an auto
segmentation VOI, the contours associated with that VOI will be
replaced with the newly generated contours.
• If an automatically generated VOI does not accurately represent the
anatomical structure, use the drawing tools in the Manual step to
manually adjust the automatically generated contours.
 Male Pelvis Autosegmentation

Male Pelvis Autosegmentation allows segmentation of the prostate,
seminal vesicles, bladder, urethra, rectum and femoral heads.
For Autosegmentation, CT images are required and should not contain
contrast or a significant amount of metal (such as hip replacements or
brachytherapy seeds), since they can cause difficulty in producing
acceptable segmentations. The CT images can contain implanted fiducial
markers per Accuray Incorporated guidelines, as long as the resulting
artifacts are not severe in the volumes of interest.
The Autosegmentation algorithm employs a model-based approach that
includes shape variation, image intensity information, and relationships
with other organs for each supported organ. The algorithm uses the models
of each organ, optionally with initialization points created by the user, to
automatically segment each structure. When initialization points are
provided, they are used to create an initial estimate of the organ’s shape
and position, and to define the boundary at the specified points.
Initialization points however are not required for any structure (except for
urethra segmentation with no catheter), but specifying them can give a
more accurate initial result, especially if the image data is ambiguous or has
significant artifacts.
The algorithm uses only the CT image intensity information; however users
may place and adjust initialization points on MR for all organs where
initialization points are applicable. For the prostate, the CT image intensity
information is often ambiguous in the region of the prostate boundary and
therefore placing initialization points on the MR is both helpful and does not
lead to conflicts between the initialization points and the CT image data
being used by the algorithm. For other structures, the registration, size, and
shape may be different between the CT and MR images, so placing
initialization points that do not correspond to clear boundaries in the CT
image may confuse the algorithm and lead to poor results. In this case,
additional initialization points or manual editing can be used to override the
CT information as needed.
NOTE:The autosegmentation activities can be performed in the background during

new plan creation using a template. For information on setting up a template, see
“Background Autosegmentation” (page 315).

Male Pelvis Autosegmentation
Tools
Select/Setup VOIs Setup button Displays the VOI Selection Setup dialog box allowing you to
change the VOI associated with an autosegmentable
anatomical structure. See “VOI Selection Setup” (page 306).
Structure (VOI) The Structure (VOI) panel allows you to select available
automatically segmentable structures and the corresponding
VOI for automatic segmentation.
check boxes Enables automatic segmentation of the structure and

corresponding VOI.
Color Displays the color of the selected VOI.
Initialization Points Show Point List Displays the Initialization Points dialog box for automatic
button segmentation. See “Initialization Points” (page 310). The
initialization points are the same color as selected for
Structure (VOI).
Click to set initialization points.
Autosegment/Edit Autosegment Begins autosegmentation using the current autosegmentation

button VOIs and initialization points.
Update button Click the Update button to apply the edits to the currently
selected VOI.
Autosegmented Contour Pencil Tool button: Creates a

free-form contour once the structure is auto-segmented. When
this tool is active, the cursor appears as a pencil in the 2D
views. Draw around the structure to be contoured. The
contour closes automatically. After the Update button is
pressed, the Autosegmentation algorithm will resegment the
same region on slices close to the edited slice.
In the Autosegmentation step, one or more contours can be
drawn on a slice using the Contour Pencil Tool.
Edits can be made to every third to fifth slice and the
Autosegmentation feature will automatically correct all slices
in between the edits.
Autosegmented Contour Bumper Tool button: Creates or

modifies the outline of a VOI. When the Bumper tool is active,
the cursor appears as a circle in the 2D views. Once edits
have been made, click the Update button and review the
resulting contours. The button can be clicked after a single or
multiple edits. Drag the cursor around the inside or outside of
the contour to push the boundary inward or outward. This tool
also allows editing of a few slices and automatic correction of
many. Edits can be made to every third to fifth slice and the
Autosegmentation feature will automatically correct all slices
in between the edits.
Autosegmented Contour Delete Tool button: Deletes the

contours for the currently selected VOI from the slice.
Discards the previous drawing action performed. This icon can

be pressed multiple times if needed.
Reinstates a previously undone drawing step.
Options Bumper Size To modify the diameter of the Bumper tool, use the Bumper
Size slider below the drawing tools on the control panel. The
curvature of the Bumper tool is determined by the size of the
circle relative to the zoom level of the image. For more precise
control, zoom in on the image.
Male Pelvis Autosegmentation Dependencies

VOIs for Autosegmentation have the following dependencies:

• Bladder depends on prostate.
• Rectum depends on bladder.
• Seminal vesicles depend on rectum.
• Urethra depends on prostate (only if initialization points do not exist).
• Femoral heads depend on prostate.
VOIs can be segmented simultaneously, but will be processed in
dependency order. Attempting to segment the VOI out of dependency order
by selecting a subset where dependencies are not met will result in an error
message.
Using Manually Contoured VOIs with Autosegmentation

If the user prefers to manually segment a VOI supported by
Autosegmentation, segment that VOI prior to performing automatic
segmentation. Map the manually segmented VOI to the proper anatomic
structure name. If the VOI comes before another VOI in the dependency list,
any automatically segmented VOIs with a lower priority will not overlap the
manually segmented VOIs.
Do not define initialization points for manually segmented VOIs. To
automatically segment a VOI that was already manually segmented, place
initialization points and run AutoSegmentation. This will replace the
manually segmented VOIs with automatically segmented VOIs.
NOTE: For a patient with prostatectomy, manually segment the prostate in its
pre-operative position roughly. Then run the autosegmentation with it.
VOI Selection Setup

The VOI names of the study can be matched to the autosegmentation
anatomical structure names by clicking on the Setup button to access the
VOI Selection Setup dialog box. When the Contour > Autosegmentation >
Anatomic Region > Male Pelvis is accessed for the first time, the VOI
Selection Setup dialog box automatically appears.
Change the Autosegmentation VOI
1. Click the Setup button. The VOI Selection Setup dialog box appears.
VOI Selection Setup dialog box
2. Click the VOI Name row to select a VOI of the current plan from the
drop-down list associated with a specific Structure Name.
3. Select a VOI Name for each Structure Name.
NOTE: A VOI can only be associated with one Structure Name.
4. Click the Bladder contains air and/or catheter check box when the patient
has a catheter or air is in the bladder.
5. Click the OK button once all Structure Names have been associated with a
VOI.
The user is warned about the contours being replaced when the
Autosegment button is pressed. It does not happen when the Setup dialog
changes mappings.

Perform Automatic Segmentation for Male Pelvis
1. Click Contour > Autosegmentation.
2. Select Male Pelvis for the Anatomic Region.
• If VOI name matching between the plan and Autosegmentation is not
complete, the VOI Selection Setup dialog box appears. The VOI
Selection Setup dialog box allows the names of anatomical structures
to be matched to VOI names. All anatomical structures must be
matched to a VOI prior to clicking the OK button.
• Once VOI name matching has been completed for a treatment plan, it
can be saved in a plan template. When creating a new plan, the plan
template with the desired name matching can be used and the name
matches will be automatically applied.
3. Select anatomical structures to be automatically segmented from the
Structure (VOI) list in the control panel.
NOTE: If the urethra is selected for autosegmentation and the Bladder contains air
and/or catheter check box is not selected, 3 initialization points must be defined.
4. If desired, place initialization points to provide a starting position for

automatic segmentation. Initialization points are not required, but may
provide a more accurate initial result.
5. Click Autosegment.
NOTE: An Autosegmentation VOI error message may appear when too few or too
many initialization points have been selected. If this occurs, follow the instructions
to correct the issue and cancel the Autosegmentation process.
• Contours for the selected VOIs will automatically be generated. If an

automatic segmentation has been completed for an autosegmented
VOI, the contours associated with that VOI will be replaced with the
newly generated contours.
• If an association was previously made to a VOI with manually drawn
contours, a warning appears. Click OK to keep the defined mappings
and delete the contours for that VOI, or click Cancel to discard the
mapping changes and keep the contours.
NOTE: If the contours are deleted, they will immediately be deleted. To restore the
contours, click the Undo button from Autosegment/Edit.
During automatic segmentation, the progress bar is updated with the

approximate percentage completed. After the process is complete, the
contours appear for the VOIs.
NOTE: An error message may also appear if the inter-autosegmented VOI
dependencies are not met. This means an autosegmented VOI may depend on the
existence of another VOI. For example, the prostate must be automatically
segmented before the bladder can be automatically segmented. See “Male Pelvis
Autosegmentation Dependencies” (page 305) for more information on
dependencies.
Completed Autosegmentation
6. Review each automatically generated VOIs.

If an automatically generated VOI does not accurately represent the
anatomical structure, you can modify initialization points and perform
automatic segmentation.
• Use the Autosegmentation VOI editing tools to adjust contours.

• Use the Manual step to manually adjust invalid contours.


Initialization Points
Initialization points, which are optional, provide the autosegmentation
algorithm with an initial starting position. For fused images, initialization
points can be placed on either the A or B image set.
The selected VOI name appears as the name of the Initialization Points
dialog box.
Initialization Points dialog box for Prostate
Item Description
Show When selected, displays the initialization points for each of the
initialization selected VOI. Hiding initialization points allows automatically
points on generated contours to be reviewed without the visual obstruction of
images check the initialization points.
box
Delete button Deletes initialization points on the displayed slice for the selected
contour set for the selected VOI.
Delete All Deletes initialization points from all slices of the selected contour set
button for the selected VOI.
Close button Closes the dialog box.
Prostate
Initialization points are not required, but if provided, the minimal set is as
follows:
• 4 points on 3 axial slices
– Select a slice 1/4 to 1/3 of the prostate length from the base.
– Select a slice 1/4 to 1/3 of the prostate length from the apex.
– Select a slice midway between the first two slices selected above.
• 1 point on 2 slices
– Select a slice at the very end of the prostate base in the center.
– Select a slice at the very end of the prostate apex in the center.
Place Points on Prostate Slices
1. Click the row associated with the prostate in the Structure (VOI) panel.
Previously defined initialization points appear in the Initialization Points
table.
2. Confirm that the Initialization Point Placement Tool is selected and
navigate the image views to a slice 1/4 to 1/3 of the prostate length from the
base.
3. Place 4 points on the axial slice.
One point should be placed at the top of the center boundary of the
prostate, a second at the bottom center boundary, a third point on the left
center boundary, and a fourth point on the right center boundary. More
points may be placed if the shape of the prostate is highly irregular.
NOTE: If a point is incorrectly placed, click and hold the initialization point in order
to drag the point to the desired location.
NOTE: To permanently delete a point placed on an incorrect slice, select the point
from the Initialization Points table and click the Delete button.

Prostate initialization points
4. Repeat the point placement procedure for a third axial slice that is midway
between the first two slices of the prostate.
5. Add a point in the center of the very end of the base of the prostate and a
point in the center of the very end of the apex of the prostate.
Seminal Vesicles
The right and left seminal vesicles are treated as a single structure. Select
three axial slices for placing multiple points around the organ boundary.
Initialization points are not required for the seminal vesicles, but if provided,
the minimal set is as follows:
• 4-8 points on each axial slices, depending on complexity
– Select the most inferior slice where seminal vesicles are visible and
place 4 points at left, right, top, and bottom extents of the seminal
vesicles.
– Select the most superior slice that has substantial thickness but is not
further than 2.5 cm from the most inferior slice. Place 4-8 points
around the boundary. With the exception of extreme lateral points,
each point on the anterior boundary should be opposite a point on the
posterior boundary.
– Select a slice midway between the first two slices and place 4-8 points
on that slice (6 points are usually sufficient).
Place Points on Seminal Vesicles Slices
1. Click the row associated with the seminal vesicles in the Structure (VOI)
panel. Previously defined initialization points appear in the Initialization
Points table.
2. Confirm that the Initialization Point Placement Tool is selected and
navigate the image views to the desired slice.
3. Start at the most inferior extent of the seminal vesicles where the seminal
vesicles are visible and place 4 points around the boundary as indicated
above.
4. Scroll superiorly until you find the last slice where the seminal vesicle is
clearly and cleanly visualized but not farther than 2.5 cm and place 4-8
points.
5. Select a slice that is midway between the superior and inferior marked
slices and place 4-8 points.
Bladder
The bladder does not require initialization points, but points may be placed
on the boundary in order to fine-tune the generated contours. If the bladder
contains air as a result of a catheter, click the Bladder contains air check
box in the VOI Selection Setup.
Rectum
The rectum does not require initialization points, but points may be placed
for the rectum to constrain how the contours are generated. If points are
specified, 4-6 points on 3 slices are usually sufficient. The rectum
autosegmentation is confined to a region 1 cm superior to 1 cm inferior to
the prostate.
Femoral Heads
The femoral heads segmentation is automatic and does not require
initialization points. However, if Autosegmentation fails, a 2 cm contour
along the boundary of the femoral head can be drawn using the
Autosegmentation editing tools.
Urethra
If the urethra is selected for autosegmentation and the Bladder contains air
and/or catheter check box is not selected, 3 initialization points must be
defined, each at the center of the urethra: one in the prostate base axial
slice, one in the apex slice, and one near the middle.
Autosegmentation Editing Tools

The Autosegmentation editing tools allow the user to correct regional
issues with the Autosegmentation result. The Autosegmented Contour
Pencil Tool creates a free-form contour (dashed), while the Autosegmented
Contour Bumper Tool can be used to move existing contours. Both tools
provide inputs into the Autosegmentation algorithm.

Edit the organs in the following order of dependence:
• Prostate
• Bladder
• Rectum
• Seminal vesicles
• Femoral heads
The urethra can be edited independently, but it is not adjusted automatically
after changes to the prostate or other structures when the Update button is
pressed.
If a given structure does not require edits, it is not necessary to modify it.
However, if, for example the prostate/seminal vesicle boundary is incorrect
after editing the prostate, an edit on the seminal vesicles near the interface
will cause the seminal vesicles to correct to the new prostate boundary
based on relationship encapsulated in the seminal vesicles model. This
concept applies to all other organs and their inter-organ relationships.
NOTE: For non-axial slice edit, if multiple slices are edited, all slices but the last
are ignored when the Update button is clicked. If you need to make non-axial edits
both on anterior and posterior, you must make the edit on the same contour.
Use the Autosegmentation Editing Tools

1. Complete an AutoSegmentation for a given VOI.
2. Select the structure to be edited from the Structure (VOI) panel by clicking
on the row corresponding to the desired structure.
3. Select the desired editing tool, either the Autosegmented Contour Pencil
Tool or Autosegmented Contour Bumper Tool.
Use the selected tool to modify the region of the selected VOI where the
contours are incorrect. Large bladder and rectum edits should be done in a
“coarse to fine” progression for best results. If extensive changes must be
made, add a few edit contours on one or more non-consecutive slices and
press Update. Once gross changes have been made, refine the smaller
details. Sagittal edits with the pencil tool can be used to refine systematic
errors in rectum segmentation. In other cases, edit every 3rd to 5th slice in
the region where changes are desired.
The bumper and pencil tools can be used to extend a VOI onto slices where
the VOI does not yet exist. Navigate to an axial slice without a VOI, but
where a projection of the VOI from the nearest slice where the VOI exists
appears as a sparsely dotted line. Click the bumper tool to extend the VOI
to that slice. The contour will be displayed as a densely dotted line. Press
Update to commit the change and resegment the structure.
Some autosegmented objects have limitations on how far they can be

extended. If results are not acceptable, click Undo.
Modification using the editing tool
4. After each set of editing inputs, click the Update button and repeat as
needed until the contours are acceptable.
5. Review the contours in the region where the changes were desired.
NOTE: If attempts to make small edits are not realized, after all edits have been
completed using the Autosegmentation editing tools, proceed to the Manual step
and utilize the manual editing tools to make final adjustments. However, once the
manual editing tools have been used, the Autosegmentation editing tools cannot be
used unless Autosegmentation is re-executed. This will result in the loss of any
edits for a given VOI.
6. Repeat steps 1-5 for all VOIs.
Background Autosegmentation
Since initialization points are optional, prostate Autosegmentation can be
performed without user input. As a prerequisite, you must have created a
template which:
• Uses VOIs with prostate structure names.
• Selects the Perform Autosegmentation check box.

• Selects the Anatomic Region as Male Pelvis.
• Selects the “Bladder contains air” check box.
Perform Background Autosegmentation

1. Click the New Plan icon on the Accuray Precision System home page.
2. On the New Plan page, select a patient record, click the Standard Plan icon,
and click Next >>.
3. On the Select Exams page, select the CT to be included in the plan
template, and click Next >>.
4. On the Select Optional Plan Template page, confirm that the abdomen of
the template selection icon is highlighted, select the plan template and a
treatment machine, and click Next >>.
NOTE: If plans with and without catheters will be created, two template plans will be
required so that you can select the appropriate one. A simple sample template is
provided, but you can create custom templates as desired.
Select Optional Plan Template page
5. On the Use Plan Template page, click Use Template.
The process is initiated in the background, but the contours generated by
background autosegmentation are not automatically incorporated until you
click the AutoSegment button.
While background autosegmentation is running, autosegmentation

progress can be monitored on the status bar. If autosegmentation is still
running, “Running Autosegmentation...” appears. Once autosegmentation
is complete, the status bar displays “Autosegmented VOIs are ready. Press
the Autosegment button to continue.”
When autosegmentation is completed and you have clicked the

Autosegment button, the contours appear.
6. (Optional) In the Manual step of the Fuse task, click Start to register the CT
and MR images. When registration processing is done, examine the split
view images to confirm accuracy of the registration.
If you leave the Contour task, the autosegmentation process will be halted.
Return to Contour > Prostate and click Autosegment to restart the process.
 Head and Neck Autosegmentation

The Head and Neck Autosegmentation automatically contours the following
structures: brainstem, spinal cord, spinal canal, parotids, mandible, larynx,
skin, eyes, lenses, optic nerves, optic chiasm.
For best results with Head and Neck Autosegmentation, use the following
recommended image data:
• Resolution (if possible): 1.2 x 1.2 mm voxel size in-slice or smaller: slice
thickness: <= 2mm.
• Axial extents: Top of head to top of lungs.
• Contrast: None (neither IV nor CSF).
• Additional images if available: MR images (helpful for segmenting when
registered with CT).
• HFS patient orientation only.
For Head and Neck autosegmentation, the following contouring constraints
apply:
• The parotids cannot overlap the mandible.
• The top slice of the spinal cord must be adjacent to the bottom slice of
the brainstem.
• The spinal cord must be contained within the spinal canal.
• The optic nerves cannot overlap the eyeball or the chiasm.
• The lenses must be contained within the eyeballs.

Perform Automatic Segmentation for Head and Neck

1. Click Contour > Autosegmentation.

2. Select Head and Neck for the Anatomic Region.
• If VOI name matching between the plan and Autosegmentation is not
complete, the VOI Selection Setup dialog box appears. The VOI
Selection Setup dialog box allows the names of anatomical structures
to be matched to VOI names. All anatomical structures must be
matched to a VOI prior to clicking the OK button.
• Once VOI name matching has been completed for a treatment plan, it
can be saved in a plan template. When creating a new plan, the plan
template with the desired name matching can be used and the name
matches will be automatically applied.
3. Select anatomical structures to be automatically segmented from the
Structure (VOI) list in the control panel.
4. Click AutoSegment.
• Contours for the selected VOIs will automatically be generated. If an
automatic segmentation has been completed for an autosegmented
VOI, the contours associated with that VOI will be replaced with the
newly generated contours.
• If an association was previously made to a VOI with manually drawn
contours, a warning appears. Click OK to keep the defined mappings
and delete the contours for that VOI, or click Cancel to discard the
mapping changes and keep the contours.
NOTE: If the contours are deleted, they will immediately be deleted. To restore the
contours, click the Undo button from Autosegment > Edit.
During automatic segmentation, the progress bar is updated with the

approximate percentage completed. After the process is complete, the
contours appear for the VOIs.
NOTE: For non-axial slice edit, if multiple slices are edited, all slices but the last
are ignored when the Update button is clicked. If you need to make non-axial edits
both on anterior and posterior, you must make the edit on the same contour.
Completed Autosegmentation

Skin Step
The Skin structure is a visualization tool that depicts the surface of the
patient and the upper and lower limits of the image series. The Skin
structure is displayed with the VOIs and can be useful in evaluating the
distribution of beams in relation to the patient’s skin and the first and last
slices of the image series.
You can define only one skin structure per plan. Use the skin structure to
display the dose inside of the skin itself, and avoid beams entering from the
top or bottom CT slice.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
 Assigning and Modifying Skin Structures . . . . . . . . . . . . . . . . . . . . . . . 321
Skin step
 Tools
The following tools are available on the Skin step.
Assign Skin drop-down list Select a structure to represent the patient’s skin surface.
Create VOI: Displays the VOI Properties dialog box. Create a new
VOI by entering a Name, and select the Type, Plane, and Color.
Select the Auto Interpolate check box to turn on the automatic
interpolation between user-delineated contours.
Detection Maximum Drag the slider bar to modify the maximum number of contours per
Options contours per slice for the selected Skin structure. (1-8)
slice slider
Skin HU Drag the slider bar to modify the HU number that differentiates
threshold patient anatomy from air. (-900 to -100)
slider
Min contour Drag the slider bar to modify the minimum number of voxels that
size (voxels) can be used to create a Skin structure. (0 - 500)
slider
Commands Auto Detect Click to detect the Skin structure automatically.

button
 Assigning and Modifying Skin Structures

Assign a Skin Structure Manually
1. Go to Contour > Skin.
2. Select the name of the Skin structure on the Select VOI drop-down list or
create a new VOI by clicking the Create VOI icon.
3. (Optional) Modify the Maximum contours per slice.
Examples: 1 for a contiguous solid; 3 for a torso and arms.
4. (Optional) Modify the Skin HU Threshold.

5. (Optional) Modify the Min contour size (voxels).
6. Click Auto Detect.
Modify a Skin Structure

1. Go to Contour > Manual.
2. Select the name of the Skin structure on the Select VOI drop-down list.
3. Use the tools on the Manual step to refine the Skin structure.

Spine-Tracking Step
Use the Spine-Tracking step to delineate a spine tracking VOI.
The default layout on the Spine -tracking step includes three images, an
axial view and a coronal view on the right, and an expanded sagittal view
on the left.
 Delineate a Spine Tracking Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
INOTE: This step is unavailable for sites that only have a Tomo System installed.
Spine Tracking Volume step
 Delineate a Spine Tracking Volume
IMPORTANT: Do not adjust a spine tracking volume on the Manual step. To ensure
correct delineation of the spine tracking volume, make adjustments on the Spine
Tracking Volume step only.
IMPORTANT: Adding dose constraints to Spine Tracking Volume may result in
unexpected plan results. Do not add constraints to the Spine Tracking Volume.
NOTE: For complete coverage, modify both the first and last slice in the series.
NOTE: Excluding beams from the Spine Tracking Volume may result in unexpected
plan results. Do not select the option to exclude beams from the Spine Tracking
Volume.
1. On the Contour task, click Spine-Tracking > Tools.

The default layout on the Spine-Tracking step includes three images, an
axial view and a coronal view on the right, and an expanded sagittal view
on the left.
2. To accurately visualize the spine in all views, scroll through the slices and
select the image in each view with the maximum amount of spine displayed.
3. Select the VOI to use as the spine-tracking volume. A blue outline appears
in all three views.
4. Select the control in the center of the contour in the axial view to center it
over the spine volume.
5. Scroll through all slices in the axial view and make appropriate adjustments.
Positions between adjusted slices are interpolated. For reference, a control
point is placed on the sagittal view for each slice you adjust.

Ball-cube Step
Procedures for delineating the Ball-cube target on the Ball-cube step are
performed during quality assurance testing. Typically, quality assurance
testing is performed by your site’s medical physicist.
 Delineate the Ball-cube. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
NOTE: This step is unavailable for sites that only have a Tomo System installed.
 Delineate the Ball-cube

1. Load a CT of the Ball-cube phantom.
2. Go to the Contour > Ball-cube > Tools.
3. Select a VOI on the Select VOI drop-down list.
4. On the lower panel, drag the cross-hair to the approximate center of the
ball-cube.
5. Click the Auto Detect button. The shape of the mouse cursor changes to the
3D Magic Wand cursor.
6. Click inside the Ball-cube. The Ball-cube is detected on all slices
automatically.
7. To modify delineations, go to the Manual step.
For more information on using the Ball-cube step, see the Physics
Essentials Guide.

Chapter 7
Setup Task
Section 7-1
Setup Task for Tomo® . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Section 7-2
Setup Task for CyberKnife . . . . . . . . . . . . . . . . . . . . . . . . 357
1072963-ENG B C ha pt er 7 : S et up T as k 327
Section 7-1
Setup Task for Tomo®
The Setup task includes the following steps:

• Machine step: This step includes the Tools for selecting Density
Models, Density Overrides, Machine Parameters, and performing
Couch Replacement.
• Patient step: This step includes the Tools for Patient Position and Red
Lasers. The View Options are provided for additional views of Machine
Geometry and TomoDirect Angles. Both Machine and Patient steps
include a VOIs tab for managing VOIs.
Fiducials step and Angles step appear based on the selected Synchrony
Method. Synchrony Method is a licensed option, and it is only available for
Helical plans.
Machine Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Patient Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Synchrony Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Fiducials Step. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Angles Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
1072963-ENG B S ect ion 7- 1: S et up T as k f or T o m o ® 329

Machine Step
Use the Machine step to view the current density model, select a density
model, enter/modify density overrides, select the machine parameters, and
indicate where couch insertion should occur. If you have multiple treatment
delivery systems at your site, select a Treatment Machine for the plan.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
 Density Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
 Couch Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Machine step
 Tools
The following tools are available on the Machine step. Machine Parameters
become available after you select Tomo delivery system.

Density Model Displays the current density model and a list of alternative.
drop-down list
Image Viewer Displays the current density model as a graph. A typical density
model contains a mass density model curve and a relative
electron density model curve. Both curves are displayed on the
graph.
NOTE: The Density Model for Tomo plans only requires mass
density values.
The X-axis has the following options to display density model
range:
Plan Range displays the range between the lowest HU (-1024)
to the highest value in the scan. Max HU in the plan is displayed
as a red dashed-line. Plan Range is the default display during
the plan creation.
Model Range displays the range between the lowest HU (-1024)
to the highest value defined in the selected density model.
Full Range displays the range between the lowest HU (-1024) to
the highest value that Accuray Precision System supports.
Density Displays the Density Override Table. See “Density Override

Overrides button Table” (page 337) for details.
Machine Treatment Lists the available Treatment Delivery Systems. Once a

Parameters Machine treatment machine is selected, the machine settings for the
drop-down list selected treatment machine are displayed.
Planning Method Classic: Select to create a plan using the standard optimization
methods for IMRT inverse planning, 3D Conformal planning, or
Forward Planning.
Delivery Mode If both TomoDirect and TomoHelical are licensed, the system
drop-down list selects TomoHelical as default. The user is required to select
one Delivery Mode for the plan. If only one is licensed, it is
automatically selected. When a selection is made, the planning
workflow is adjusted. TomoDirect mode requires the user to
define beam angles for the plan.
Plan Mode Plan Mode options are IMRT, 3DCRT, and Forward Planning
drop-down list (licensed feature). The optimization or dose calculation workflow
is adjusted based on the selected Plan Mode.
IMRT: An IMRT plan is designed to deliver highly conformal
dose to complex targets.This planning mode takes full
advantage of the optimization power of the system, giving the
user access to all available planning variables, such as
modulation factor, constraints for targets, constraints and
blocking for critical VOIs, and importance rankings for targets
and critical VOIs.
3DCRT: Use 3DCRT to quickly plan and treat less complex
cases.
A 3DCRT plan is designed for use when a target is a simple
shape and/or is isolated from the critical VOIs. A 3DCRT plan
does not allow the assignment of constraints, though critical
VOIs may be blocked to avoid dose. Rather than the modulation
offered by IMRT, a 3DCRT plan uses an electronic compensator,
set to low or high beamlet weighting, to work toward a
homogeneous dose in the target volume. To determine which
compensation level to use in a plan, consider surface
topography, target shape, target depth, and beam
arrangements. Consider a 3DCRT plan when highly conformal
dose may not be required. In such cases, sensitive structures
surrounding the target are minimal or the prescription dose to the
target does not reach the dose limit of the surrounding critical
VOIs.
Forward Planning: Forward Planning is for use withTomoDirect
mode only. It allows a user to create a treatment plan without
defining target or ROIs and it prescribes to the user defined point
or a VOI.

Jaw Mode If Dynamic Jaw mode is licensed, the Jaw Mode options are
drop-down list either Dynamic or Fixed.
Dynamic: The TomoEDGE Dynamic Jaws are capable of
sharpening the cranial/caudal dose penumbra. Jaws sweep
across the field, opening and reducing on the leading and trailing
edge of the target to create an effective field width from as small
as 1-cm up to the selected field width of 2.5-cm or 5.0-cm. With
its greater precision, TomoEDGE can significantly improve
throughput.
Fixed: In Fixed Jaw mode, the jaw width does not vary during
radiation delivery and the jaw opening is always symmetrical
about the plane of gantry rotation. Fixed Jaw mode may be
selected with any of the field width settings.
Synchrony Displays the Synchrony methods determined by the

Method configuration of the Treatment Delivery System and Accuray
drop-down list Precision System, as well as the previously selected treatment
parameters.
(For Delivery • None

Mode: Helical • Fiducial
only) • Fiducial with Respiratory
• Lung with Respiratory
Couch- Remove/Replace Use to remove a simulation CT couch and replace it with an

replacement Couch button Accuray Couch. See “Couch Replacement” (page 340).
Accept button Accepts the couch as the plan couch and turns on Patient step.
Cancel button Cancels the couch replacement.
 Density Models
Density models are used to calibrate a specific CT scanner's grayscale
image values to real-world density values. These models are used by dose
calculation algorithms to translate pixel values from a CT series into density
values. This calibration ensures that the dose calculation algorithm is using
the proper density information when calculating dose and in turn that the
dose calculated is accurate. A density model should be created for each CT
scanner or scanning technique that the physicist has chosen for use.
Density Models can be set or modified from the Home Page using Planning
Settings > Planning Parameters.
When creating a treatment plan, select the density model corresponding to
the CT scanner where the primary CT series originated. Though the
Accuray Precision System provides CT density sample models for the
purposes of dose calculation, it will not allow patient treatment plans that
were generated with sample density models to be saved as deliverable
plans as this may lead to an incorrect dose distribution. A treatment plan
requires a patient-specific density model. You can save phantom plans as
deliverable using sample density models.
The Density Model for treatment plans only requires Mass Density. During
dose calculation for Tomo plans, the software uses the HU to Mass Density
table for all voxels, except those for which there is a density override by a
VOI. For voxels covered by VOIs with density overrides, the Mass Density
override for those voxels is used.
Mass density values are used for all voxels in the planning CT, not just for
density overrides.
MVCT and kVCT Density Models

Tomo Systems have their own imaging beam. The list of density models will
include the density models that correspond to each imaging beam or group
of imaging protocols on the Tomo Systems.
The first 10 density models on the drop-down list are standard density
models that are intended to be used to characterize pixel data from external
(non-Accuray) CT scanners. Density models for MVCT and kVCT that are
associated with each Tomo System appear below the first 10.
The dose calculation on the merged image for Adaptive Monitoring uses
the density model for the specific Radixact System and imaging protocol
group used to acquire the daily image.
The names of density models associated with specific Tomo Systems
cannot be edited.
WARNING: Failure to use the appropriate CT density model may result in incorrect
dose distributions. Use a standard density phantom to derive the CT density curve.
Select a Density Model

When you load a plan, if the density model of the plan is not found on the
current Accuray Precision System, the new plan density model is added to
the Density Model list. The name of the new model is the original model
name with a prefix ([plan]). If you are in a patient plan, the custom model is
set as the default for that patient only.
1. Select an entry from the Density Model list.
2. Re-optimize and recalculate the plan.
NOTE: If you change the model after optimization or dose calculation, the dose
volume is deleted. You can compute dose with the newly-selected density model.

3. Drag over the Density Model graph to view the mass density value and
relative electron density value for a given HU value.
4. Change the Density Model Range options to Plan, Model, and Full to view
the models in different scales.
5. Continue planning as usual and then save the plan. If a density model is
modified after being saved with a plan, when that plan is loaded again the
system loads the saved density model, not the modified model.
6. Print the Plan Overview Report to view the density model applied to the
plan, including the values in that model. If a density model is modified after
being saved with a plan, when that plan is loaded again the system loads
the saved density model, not the modified model.
Density Model section in Setup > Machine step
Density Table
The Density table matches HU (Hounsfield Unit) values generated by the
CT scanner to the measured physical density (in grams per cubic
centimeter) of objects scanned. This table is used during optimization and
dose calculation (Convolution Superposition method) to convert image
values to density values.
NOTE: HU value of -1024 is automatically added in the graph to a density of 0 when

creating a new density model. Air should be measured to obtain a density model
point near -1000 HU and 0.001 g/cm3. If no density model point for air is defined,
the -1000 HU value will be linearly interpolated between -1024 HU and the closest
density model point (often near water).
Extension Method
From the drop-down list on the Density Table, select either Extrapolate or
Flat.
Extrapolate extends the mass/electron density curve up to the maximum
HU number by extrapolating via slope between the last two user entries.
Flat extends the mass/electron density curve up to the maximum HU
number by repeating the last user entries.
Density Override Table
Density overrides allow the user to correct problems that may occur when
HU values map to incorrect or unrealistic density values used in the current
density model. These problems can occur, for example, when the CT image
is intentionally modified using contrast agents or when metallic objects in
the image cause display artifacts. Density overrides allow the user to assign
new density values to be used instead of those typically provided by the
current density model. This allows the user to compensate for the HU
values not mapping to realistic electron or mass densities. All density
override values must exist on the currently selected density model. The
Accuray Precision System will prevent the user from entering values that
are outside the bounds of the currently selected density model. In addition,
the Accuray Precision System will prevent changing to a density model that
does not contain all of the currently specified density override values.When
entering density overrides for Tomo plans, only mass density values need
be entered. When the mass density value is entered, the relative electron
mass density value will automatically be populated with the value from the
same location in the currently selected density model.
When entering density overrides, both relative electron and mass density
values must be entered. When the first value is entered, the second value
will automatically be populated with the value from the same location in the
currently selected density model. However, both values can be changed
independently and do not have to map to the same location in the currently
selected density model.
Except for the special case of Outside All VOIs, density overrides are
associated with VOIs. Density overrides can only be specified for currently
existing VOIs. Removing a VOI with a density override will discard the
density override.
VOIs can be contoured so that they overlap one another. When two VOIs
overlap, the density values of any VOI with a density override will be used
in the overlapping region. If two VOIs with density overrides overlap, the
density values of the VOI with the higher priority will be used in the
overlapping region.
If a Skin VOI exists, the Accuray Precision System will automatically include
an Outside All VOIs entry in the Density Override Table. Outside All VOIs
will always be prioritized last in the Density Overrides Table, and Skin will
be prioritized second to the last.
NOTE: Density override values greater than 0.001 for Outside All VOIs are not
allowed.
NOTE: Density override values less than air threshold (-801HU) for Skin VOI are
not allowed.

Tools
Item Description
Priority Indicates which density override values will be used when VOIs overlap.
When two VOIs overlap, the density values of the VOI with the higher
priority will be used in the overlapping region.
Override check box When checked, the electron and mass density override properties of this
VOI will be applied.
Name The name of selected VOI.
Color Display color of selected VOI.
Relative Electron Density The relative electron density value used during dose calculation for the
selected VOI.
Mass Density (g/cm3) The mass density value used during dose calculation for the selected
VOI.
Move Up button Adjusts the priority by moving the selected density override one row
higher in the list.
Item Description
Move Down button Adjusts the priority by moving the selected density override one row
lower in the list.
Move to Top button Adjusts the priority by moving the selected density override to the top of
the list.
Move to Bottom button Adjusts the priority by moving the selected density override to the bottom
of the list. If the Skin and Outside All VOIs exist in the list, they are always
listed at the bottom.
OK button Dismisses the Density Override Table and applies the current value.
Cancel button Dismisses the Density Override Table and discards any changes that
were made after the dialog was opened.
Density Corrected Images

Density corrected images based on the selected dose calculation algorithm
are available for review by clicking the options on the upper left corner of
the image display. These images have density model and density overrides
applied.

 Couch Replacement
Accurate dose calculation requires replacing the CT couch with the Accuray
Couch in the plan image data set.
Couch with red replacement positioning line
Replace the Couch

1. Drag the red line to position it at the top of the couch.
NOTE: You can select the Couch W/L from the right-click menu.
2. Click Replace Couch. All image elements below the red line are replaced
with the new couch image.
3. Click Accept when you are satisfied with the new image. Wait for the
modified image to be generated. Once the couch is replaced, the default
display view is switched to mass density.
WARNING: If the Accuray Couch is not correctly inserted in the planning image
volume, dose calculation accuracy can be affected during optimization.
Couch inserted

Patient Step
Use the Patient step to position the patient and red lasers and to select
viewing options.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
 Move Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
 Move Red Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Patient step
 Tools
Section Control Function
Patient Move Patient Activates green laser lateral, longitudinal, and vertical movement
Position button controls within the 2D image viewers.
NOTE: If you have a large treatment field (1.2 meters or more), you
can adjust the patient image volume in the longitudinal direction.
Doing so will maximize the full range of longitudinal couch
movement.See “Move Patient” (page 344).
NOTE: Also, if the Move Couch with Patient option is checked, then
only lateral movement is activated.
Align to CT Aligns the patient to the CT center.

Center button
Green Lasers Lateral, longitudinal, and vertical movement controls are activated
Position (IECp) when the Move Patient button is clicked. Move the green crosshairs
on any of the three displayed images to adjust the green lasers
position. The laser coordinates are updated automatically.
Move Couch with When selected, moves couch tabletop with the patient image
Patient check box laterally up to ±15 mm.
Couchtop Offset Displays the adjustments made to the couch tabletop in the lateral
X (X) direction in mm.
Revert button Restores the image volume to the last saved position.
Accept Patient Accepts adjustments made to the patient position.

Position button
Red Lasers Move Red Lasers Enables movement of red laser lines. Move the red laser lines to the
button patient's fiducials (or another easily-identified anatomical
landmark). Use the axial, coronal, and sagittal views to move the
red laser lines to the desired position.
Align button Use to reset the red laser lines (fiducial indicators) at the virtual
isocenter (green laser lines).
Red Lasers Dynamically displays offset coordinate values with red laser
Offset (IECf) movement.
Revert button Restores the last accepted position of the red lasers before you
made adjustments.
Accept Red Accepts the current positions of the red lasers.

Lasers button

Section Control Function
View Machine Select Machine Geometry to display green circles that indicate the
Options Geometry check gantry bore (large circle) and MLC field of view (small circle) in the
box Image Viewer.
TomoDirect Select Fixed Angles to display the beam angles (TomoDirect plans
Angles check box only).
NOTE: Adjustments to the patient image volume affect the patient position at
treatment. Before you accept the position, ensure that the patient will fit comfortably
on the couch in the gantry bore.
 Move Patient
Click Move Patient to activate the Position controls. Use the Position
controls to properly image or treat a patient, when for example:
• The anatomy to be imaged falls out of the approximate 40-cm scan field
of view (SFOV), which is represented by the smaller green circle
displayed in the Machine Geometry.
• The beam expansion in air for a TomoDirect plan requires a greater
margin between the patient and the SFOV.
• The distance of the red laser position is greater than 18 cm from the
green laser position, prompting a shift in patient position.
NOTE: If you change the position of the patient after you accept red lasers, position
the red lasers again to ensure they are aligned with the patient fiducial marks.
 Move Red Lasers

To facilitate patient setup for treatment, align the red lasers with the patient
fiducial marks (or another easily-identified anatomical landmark) and then
accept their positions.
During patient setup, the red lasers will move based on their accepted
positions.
The therapist uses the red lasers to position the patient in the planned setup
position. Image registration is then performed to verify the setup position of
the patient.
Synchrony Method
Fiducials step and Angles step appear based on the selected Synchrony
Method. Synchrony Method is a licensed option, and it is only available for
Helical plans.
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
 Simulation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
 Overview
Observe the following guidelines when you create a plan with Synchrony
Method.
• The planning image must be a kVCT. CTrue™ (MVCT) images cannot
be used to create Synchrony plans.
• Collect the planning kVCT at a high resolution, such as 1 mm slice
thickness, a 50 cm field of view, and 512 x 512 pixels. If the patient
exceeds a 50 cm field of view, use a larger field of view.
• Position the target within a 10 cm radius of isocenter in the transverse
plane. If the target cannot be positioned within 10 cm of isocenter, verify
that your kV imaging angles can see the target. In general, it is helpful
to position the target as close as possible to isocenter to ensure that the
target and fiducials can be seen in the radiographs.
• Acquire an end-exhale scan for the best visualization of the target and
fiducials.
IMPORTANT: Consecutive or long motion synchronization procedures may cause

the kV imaging subsystem to overheat. All motion synchronization procedures
accumulate some heat in the kV imaging subsystem. Overheating is more likely in
cases with a higher number of images per rotation, higher power radiograph
settings (for example pelvis or larger patient), or a longer procedure time.
 Simulation Plan
Use Simulation Plan to test a plan with Synchrony Methods before using it
for patient treatment. The system records and treats a simulation plan
exactly the same way it does a Helical plan, except that the radiation beam
is off during the delivery.

Create a Tomo Simulation Plan
1. On the Setup > Machine step, select a Synchrony Method for your plan.
This enables the Simulation Plan check box.
2. Select the Simulation Plan check box. Continue planning as a standard

plan and complete the optimization and final dose calculation.
3. On the Evaluate > Review step, save the plan as Deliverable. Plan is saved
as Simulation plan type. Note that the option for Make Deliverable and
Approve for Treatment is not available for Simulation Plan.
Plan Overview report displays the Plan Type as Simulation when a plan is
saved with the Simulation Plan check box selected.
4. Complete all necessary quality assurances in Tomo Treatment Delivery

System. The plan status becomes Under-treatment. Refer to the Treatment
Delivery Manual for more information.
5. Once you are satisfied with the simulation result and if you want to use the
plan for patient treatment, load the plan again. On the Setup > Machine
step, clear the Simulation Plan check box.
6. Confirm all VOI contours, plan settings, and dose to be used for patient
treatment.
7. On the Evaluate > Review step, open Save Plan dialog box. Save the plan
as Deliverable and approve for patient treatment.
IMPORTANT: If simulation plan is used and copied, you must save the plan
under a new name in order to save as deliverable and approve for
treatment.

Fiducials Step
The Fiducials step appears when you select Fiducial or Fiducial with
Respiratory as a Synchrony Method. This step displays tools for placing
fiducial markers. You must identify at least one fiducial to use the fiducial
tracking.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
WARNING: Delivery accuracy depends on correct identification of fiducial

locations. If fiducial settings are inaccurate, dose could be delivered incorrectly
during treatment. Be careful to correctly identify the locations of the fiducials.
 Tools
Locate Fiducials Auto Center Select to automatically locate the center of the fiducial at the
check box center of the grayscale intensity in a small volume around the
user-identified fiducial location.
Add button Click to add a fiducial selected in the image viewer.
Finetune Automatically adjusts the position of the fiducial based on

Position button intensity.
Fiducials (mm IECp) XYZ coordinate Displays the coordinates of the fiducial markers.
list
Delete button Click to delete the fiducial selected in the XYZ coordinate list.
Delete Last Click to delete the most recently placed fiducial.

button
Delete All Click to delete all fiducials.

button

Angles Step
The Angles step appears when you select a Synchrony Method on the
Setup > Machine. This step is not available if you select None. This step
displays the tools for setting and validating the imaging angles to use during
treatment.
If you select Lung with Respiratory, you must select a Tracking Tumor
Volume.
The default layout displays the planning images in the axial, sagittal, and
coronal views, and the DRR of the selected angle.
A vertical slider for couch movement is shown next to the DRR which
estimates the couch motion over the sum of all target VOIs in addition to half
a max jaw width on each side.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
 Imaging Angles - Presets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
 Imaging Angles - Display Colors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
 Prevalidate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
 View Options - Score Wheel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Angles Step with Fiducials
Angles Step with Lung with Respiratory

 Tools
Tracking Tumor drop-down list Select a VOI that you want to use to track during
Volume treatment delivery from the drop-down list. The
(For Lung with Respiratory tracking VOI must be a target VOI.
only)
Imaging Angles Presets buttons The icons indicate the numbers of predefined set
of static imaging angles on a circle.
Auto Select drop-down list Select the number of angles that you want the
system to automatically select. Angles are
chosen based on their color on the Score Wheel
and the spacing of the angles around the gantry.
Table The table displays the angular values in degrees

of the added or selected angles and the score as
a color.
Prevalidate button Click to validate the current imaging angles. See

“Prevalidate” (page 355) for more details.
View Options Fiducials check box Select to display the fiducials that are defined in
(For Fiducial and Fiducial with the Fiducial step.
Respiratory only) 2cm of Motion check box: Select to display a
sphere of 2 cm radius around each fiducial. Use 2
cm of Motion display to visualize whether each
fiducial remains within the Tracking Zone box if
there is up to 2 cm of motion.
Tracking Contour check box Select to display the tracking contour on the
(For Lung with Respiratory DRR.
uniform 2 cm expansion around the Tracking
Tumor Volume. Use 2cm of Motion display to
visualize whether the Tracking Tumor Volume
remains within the Tracking Zone box if there is
up to 2 cm of motion.
Tracking Centroid check box Select to display the centroid of the tracking
(For Lung with Respiratory tumor in the plus (+) mark on the DRR.
sphere of 2-cm radius around the Tracking
Centroid. Use 2 cm of Motion to visualize whether
the Tracking Centroid remains within the
Tracking Zone check box Select to display the red outlines of the active
imaging area where the fiducial or tracking tumor
volume is tracked. The tracking zone is defined
by your Treatment Delivery System configuration.
Score Wheel check box Select to display the color-coded ring. The colors
are based on the heuristic result. Green indicates
a good imaging angle, and red indicates a low
correlation score and makes a poor imaging
angle.
Green Lasers check box Select to display the green lasers (virtual
isocenter).
DRR Type Displays the DRR of the selected imaging angle.

(For Lung with When the angle is updated through the table or
Respiratory only) the image angle control, the DRR is updated
automatically.
Full Content option Displays a DRR of the full couch replaced CT

image volume.
Tumor Region option Displays a DRR only of the tracking tumor

volume.

 Imaging Angles - Presets
Accuray Precision provides preset angle sets. You can edit the angles in
the axial view by dragging the beam on the image to the desired angle, and
the value is automatically updated on the table. You can also edit the
numeric values in the table to change the angles. The selected angle
appears as a green dashed line.
Item Angles Description
90°, 180° AP (anteroposterior) & Lateral; one angle from below to

minimize patient dose and maximize field-of-view; and one
angle from the right to maximize field-of-view to the left
(patient left in HFS).
180°, 270° AP & Lateral; one angle from below to minimize patient
dose and maximize field-of-view; and one angle from the
left to maximize field-of-view to the right (patient right in
HFS).
135°, 225° A pair of oblique angles that are useful to see around
anatomy such as the hip bones in prostate treatments; a
view from below to minimize dose and maximize
field-of-view.
45°, 135°, 225°, Four oblique angles that are useful to view an anatomy
315° such as the hip bones in prostate treatments. This set has
four angles for increased imaging frequency.
0°, 90°, 180°, 270° A generic set of four equally spaced angles.
0°, 60°, 120°, 180°, A generic set of six equally spaced angles.
240°, 300°
 Imaging Angles - Display Colors

The imaging angles appear in the following colors.
• Blue - Unselected, valid
• Yellow - Unselected, warning but valid
• Green - Selected, valid or invalid
• Red - Unselected, invalid
 Prevalidate
Click Prevalidate to receive a feedback message about the placement of
fiducials and the angle selection. The following are checked:
• Angles must be separated by at least 30 degrees (45 degrees
recommended). The 30 degree separation ensures adequate time
separation between images required by the imaging hardware.
• Parallel opposed angles may be helpful if the gantry period is slow, but
at least two angles and their parallel opposed counterparts must have a
separation of 30 degrees or more.
– All fiducials should be within the Tracking Zone box for all imaging
angles over an estimated range of couch positions. If this
recommendation is met, visibility will also be verified with a 2 cm
margin around each fiducial for expected motion.
– The entire Tracking Tumor Volume should be within the Tracking
Zone box for all imaging angles over an estimated range of couch
positions. If this recommendation is met, visibility will also be verified
with a 2 cm margin around the Tracking Tumor Volume for expected
motion.
– The Tracking Centroid with 2 cm of margin for expected motion
should be within the Tracking Zone box for all imaging angles over an
estimated range of couch positions.

On the Setup > Angles step, DRRs and Prevalidate check the imaging
angles for DRRs calculated over an estimated range of couch travel
sufficient to treat all target VOIs with a 2.5-cm field width. The information
on the Setup > Angles step can help you begin to evaluate the suitability of
the patient for tracking before making the effort to optimize a plan.
The actual range of couch positions for the delivery is taken into account at
the Evaluate > Confirm Angles Step, and the official validation checks are
performed when you save the plan as deliverable.
 View Options - Score Wheel

The Score Wheel displays the scores as a color intensity map versus the
angle in the polar coordinate system with 0 at the top and positive direction
in the clockwise direction. Green scores indicate good imaging angles for
tracking while red colors indicate poor angles. This Score Wheel centers
around the isocenter.
Imaging angle lines appear in yellow in Axial view if the angles are between
30 and 45 degrees apart and appear in red if the angles are less than 30
degrees apart.
Section 7-2
Setup Task for CyberKnife
Use Setup task for adjusting treatment parameters, identifying fiducials,

defining the alignment center, and reviewing DRRs, as well as selecting
InTempo imaging, if applicable.
Machine Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Fiducials Step. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
Align Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
DRR Review Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
1072963-ENG B Se ct io n 7 - 2: Se tu p T a sk fo r Cy be rK nif e 357

Machine Step
Use the Machine step to view the current density model, select a density
model, enter/modify density overrides, select a treatment machine, number
of fractions, collimator, treatment anatomy, template path sets, and the
tracking method.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
 Density Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
 InTempo Adaptive Imaging System (Option) . . . . . . . . . . . . . . . . . . . . 366
 Synchrony Methods and Patient Positions. . . . . . . . . . . . . . . . . . . . . . 368
Machine step before treatment machine is selected.
 Tools
The following tools are available on the Machine step. Machine Parameters
become available after you select CyberKnife treatment delivery system.
Density Model Displays the current density model and a list of alternative.
drop-down list
Image Viewer Displays the current density model as a graph.A typical density
model contains a mass density model curve and a relative
electron density model curve. Both curves are displayed on the
graph.
The X-axis has the following options to display density model
range:
Plan Range displays the range between the lowest HU (-1024)
to the highest value in the scan. Max HU in the plan is displayed
as a red dashed-line. Plan Range is the default display during
the plan creation.
Model Range displays the range between the lowest HU
(-1024) to the highest value defined in the selected density
model.
Full Range displays the range between the lowest HU (-1024)
to the highest value that Accuray Precision System supports.
Density Overrides Displays the Density Override Table. See “Density Models”
button (page 361).

Machine Treatment Lists the available Treatment Delivery Systems. Once a

Parameters Machine treatment machine is selected, the machine settings for the
drop-down list selected treatment machine are displayed.
Planning Method: Select either Sequential/Isocentric or VOLO as the planning

drop-down list method for your plan.
Number of Enter the number of fractions to be delivered.

Fractions text
box
Set button
Collimator Displays current collimator types and a drop-down list of

drop-down list available collimators.
If the Accuray Precision System is not licensed for either the Iris
Collimator or MLC Collimator, Fixed appears.
Treatment Displays current area to be treated and a drop-down list of

Anatomy available treatment areas stored in the data files. Each
drop-down list anatomical area is associated with one or more unique
template path sets.
InTempo Imaging When selected, the InTempo Adaptive Imaging System path
(Option) check box sets will be used. The check box will not be enabled unless the
CyberKnife System obtains a license for the InTempo System
and “body” is selected in Treatment Anatomy.
If the InTempo Imaging check box is selected, the Tracking
Method must include fiducial tracking, and the Template Path
Set will default to an InTempo System specific path set.
Template Path Set Displays current template path set and a drop-down list of
drop-down list available paths based on the selected treatment anatomy.
Synchrony Method Displays the tracking methods determined by the configuration

drop-down list of the CyberKnife System and Accuray Precision System, as
well as the previously selected treatment parameters.
Depending on your plan, available options are Skull, Fiducial,
Fiducial with Respiratory, Spine Supine, Spine Prone with
Respiratory, and Lung with Respiratory.
 Density Models
Density models are used to calibrate a specific CT scanner's grayscale
image values to real-world density values. These models are used by dose
calculation algorithms to translate pixel values from a CT series into density
values. This calibration ensures that the dose calculation algorithm is using
the proper density information when calculating dose and in turn that the
dose calculated is accurate. A density model should be created for each CT
scanner or scanning technique that the physicist has chosen for use.
Density Models can be set or modified from the Home Page using Planning
Settings > Planning Parameters.
When creating a treatment plan, select the density model corresponding to
the CT scanner where the primary CT series originated. Though the
Accuray Precision System provides CT density sample models for the
purposes of dose calculation, it will not allow patient treatment plans that
were generated with sample density models to be saved as deliverable
plans as this may lead to an incorrect dose distribution. A treatment plan
requires a patient-specific density model. You can save phantom plans as
deliverable using sample density models.
WARNING: Failure to use the appropriate CT density model may result in incorrect
dose distributions. Use a standard density phantom to derive the CT density curve.
Ray-Tracing and Finite Size Pencil Beam Calculations

The Ray-Tracing and FSPB dose calculation algorithms uses the relative
election density to determine the effective depth for any beam at any point
in the patient anatomy. A density model with a valid mass density curve is
required when you select MLC as Collimator on the Machine step
regardless of Lateral Scaling selection.
The relative election density is defined as the electron density value for a
given HU value relative to the electron density of water.
The beam list on the Evaluate > Beams step reports both this effective
depth and the central axis (CAX) depth. The CAX depth is the Euclidean
distance along the beam between the surface of the patient and the point in
the patient anatomy.
The surface point, which is the intersection of each beam with the patient,
is detected by applying an intensity threshold to the HU values. The
minimum threshold is a HU value of -800. Therefore, all relative electron
density curves should set the relative electron density to zero (0) for HU
value -801 or less. See the Physics Essentials Guide for more information.
Monte Carlo Dose Calculation

The Monte Carlo Dose Calculation algorithm uses the mass density to
model energy dissipation and scale the tracks while particles move through
the patient. The Mass Density is defined as the mass per unit volume in

units of g/cm3. This algorithm does not use an effective depth. Nor does it
require that the system determine the intersection point of the central axis
of each beam with the patient anatomy. A threshold HU value is not needed
for the transformation of the HU value to the mass density. Therefore, when
the Monte Carlo Dose Calculation algorithm is used, all HU values will
generally have a non-zero value for the mass density. (The default curves
use 0.001 g/cm3 for an HU value of -1000 and lower) See the Physics
Essentials Guide for more information.
Select a Density Model

When you load a plan, if the density model of the plan is not found on the
current Accuray Precision System, the new plan density model is added to
the Density Model list. The name of the new model is the original model
name with a prefix ([plan]). If you are in a patient plan, the custom model is
set as the default for that patient only.
1. Select an entry from the Density Model list.
NOTE: If you change the model after optimization or dose calculation, the dose
volume is deleted. You can compute dose with the newly-selected density model.
3. Drag over the Density Model graph to view the mass density value and
relative electron density value for a given HU value.
4. Change the Density Model Range options to Plan, Model, and Full to view
the models in different scales.
5. Continue planning as usual and then save the plan. If a density model is
modified after being saved with a plan, when that plan is loaded again the
system loads the saved density model, not the modified model.
6. Print the Plan Overview Report to view the density model applied to the
plan, including the values in that model. If a density model is modified after
being saved with a plan, when that plan is loaded again the system loads
the saved density model, not the modified model.
Density Model section in Setup > Machine step
Density Table
The Density table matches HU (Hounsfield Unit) values generated by the
CT scanner to the measured physical density (in grams per cubic
centimeter) of objects scanned. This table is used during optimization and
dose calculation to convert image values to density values.
NOTE: HU value of -1024 is automatically added in the graph to a density of 0 when

creating a new density model. Air should be measured to obtain a density model
point near -1000 HU and 0.001 g/cm3. If no density model point for air is defined,
the -1000 HU value will be linearly interpolated between -1024 HU and the closest
density model point (often near water).
Extension Method
From the drop-down list on the Density Table, select either Extrapolate or
Flat.
Extrapolate extends the mass/electron density curve up to the maximum
HU number by extrapolating via slope between the last two user entries.
Flat extends the mass/electron density curve up to the maximum HU
number by repeating the last user entries.
Density Override Table

Density overrides allow the user to correct problems that may occur when
HU values map to incorrect or unrealistic density values used in the current
density model. These problems can occur, for example, when the CT image
is intentionally modified using contrast agents or when metallic objects in
the image cause display artifacts. Density overrides allow the user to assign
new density values to be used instead of those typically provided by the
current density model. This allows the user to compensate for the HU
values not mapping to realistic electron or mass densities. All density
override values must exist on the currently selected density model. The
Accuray Precision System will prevent the user from entering values that

are outside the bounds of the currently selected density model. In addition,
the Accuray Precision System will prevent changing to a density model that
does not contain all of the currently specified density override values.
When entering density overrides, both relative electron and mass density
values must be entered. When the first value is entered, the second value
will automatically be populated with the value from the same location in the
currently selected density model. However, both values can be changed
independently and do not have to map to the same location in the currently
Except for the special case of Outside All VOIs, density overrides are
associated with VOIs. Density overrides can only be specified for currently
existing VOIs. Removing a VOI with a density override will discard the
density override.
VOIs can be contoured so that they overlap one another. When two VOIs
overlap, the density values of any VOI with a density override will be used
in the overlapping region. If two VOIs with density overrides overlap, the
density values of the VOI with the higher priority will be used in the
overlapping region.
If a Skin VOI exists, the Accuray Precision System will automatically include
an Outside All VOIs entry in the Density Override Table. Outside All VOIs
will always be prioritized last in the Density Overrides Table, and Skin will
be prioritized second to the last.
Automatically generated VOIs such as the Spine Tracking VOI, Ball-cube
VOI, and VOI shells automatically generated during planning will not be
included in the Density Override Table and cannot have density overrides
associated with them.
NOTE: Density override values greater than 0.001 for Outside All VOIs are not
allowed .
NOTE: Density override values less than air threshold (-801HU) for Skin VOI are
not allowed.
Tools
Item Description
Priority Indicates which density override values will be used when VOIs
overlap. When two VOIs overlap, the density values of the VOI with
the higher priority will be used in the overlapping region.
Override check box When checked, the electron and mass density override properties
of this VOI will be applied.
Name The name of selected VOI.
Color Display color of selected VOI.
Relative Electron Density The relative electron density value used during dose calculation for
the selected VOI.
Mass Density (g/cm3) The mass density value used during dose calculation for the
selected VOI.
Move Up button Adjusts the priority by moving the selected density override one
row higher in the list.

Item Description
Move Down button Adjusts the priority by moving the selected density override one
row lower in the list.
Move to Top button Adjusts the priority by moving the selected density override to the
top of the list.
Move to Bottom button Adjusts the priority by moving the selected density override to the
bottom of the list. If the Skin and Outside All VOIs exist in the list,
they are always listed at the bottom.
OK button Dismisses the Density Override Table and applies the current
value.
Cancel button Dismisses the Density Override Table and discards any changes
that were made after the dialog was opened.
Density Corrected Images

Density corrected images based on the selected dose calculation algorithm
are available for review by clicking the options on the upper left corner of
the image display. These images have density model and density overrides
applied.
 InTempo Adaptive Imaging System (Option)
WARNING: The InTempo System is only designed for prostate treatments and its
use for other anatomical locations is not supported.
The InTempo Adaptive Imaging System is a target tracking technology

used to compensate for intrafraction prostate motion during treatment
delivery. It allows the user to manage image age, which is the elapsed time
from when a pair of x-ray images are taken to when a beam is completely
delivered. If prostate motion exceeds a preset limit, the InTempo System
enables automatic increased imaging frequency.The InTempo System
requires the use of fiducial tracking. For InTempo System plans, fiducial
placement must be in accordance with the following guidelines:
The InTempo System requires the use of fiducial tracking. For InTempo
System plans, fiducial placement must be in accordance with the following
guidelines:
• In order to compute rotations, at least three fiducials with the following
must be present:
– A minimum spacing between each other of 18 mm.
– A minimum angle between the lines connecting the fiducials of 15
degrees.
• The distance between the geometric centroid of the fiducial set and the
geometric centroid of the target must be 50 mm or less.
A fiducial validation warning appears when the fiducials do not meet the
placement requirements.
For a more detailed description regarding use of the InTempo System, refer
to the Treatment Delivery Manual.

 Synchrony Methods and Patient Positions
The following table lists supported and unsupported Synchrony methods and
patient positions.
Supine Prone
Head First Feet First Head First Feet First

Synchrony Method (HFS) (FFS) (HFP) (FFP)
Fiducial Yes Yes Yes Yes
Fiducial with Respiratory Yes Yes Yes Yes
Skull Yes No No No
Spine Supine Yes Yes No No
Spine Prone with Respiratory No No Yes Yes
Lung Tracking with Respiratory Yes No No No
Lung 1-View A (B) with Respiratory Yes No No No
NOTE: If the Spine Prone feature is licensed, select Spine Prone with Respiratory
for Head First Prone (HFP) or Feet First Prone (FFP) cases.
To define treatment parameters:

1. Click the Setup task. The Machine step appears.
2. Double-click and enter a value in the Number of Fractions field (1 - 50). The
entire patient treatment is divided into equal fractions.
3. Click Set.
4. Select the collimator type from the Collimator Type drop-down list.
5. (Optional) To enable InTempo Imaging, select the InTempo Imaging check
box.
6. Select an entry on the Treatment Anatomy drop-down list.
7. Select an entry on the Template Path Set drop-down list.
WARNING: Never use the template path set for one anatomical site to treat another
anatomical site. Using the wrong template path set creates a risk of collision with
the patient because the couch model might not accurately represent the patient
position.
8. Select an entry on the Synchrony Method drop-down list.
NOTE: The defined treatment in the proceeding steps shows the entire treatment,
not the fraction.

Fiducials Step
The Fiducials step is available only if the tracking method selected on the
Setup > Machine is either Fiducial or Fiducial with Respiratory, or if the
InTempo System is enabled.
The Fiducials step displays tools for placing fiducial markers. To use
fiducial tracking, you must identify at least one fiducial. The display view
consists of a 3D view and three planar views (axial, coronal, and sagittal)
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
 Identify Fiducials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
NOTE: Rotations cannot be tracked if only one or two fiducials are used. When
three or more fiducials are identified, all combinations of three fiducials must form a
triangle where each angle is greater than or equal to 15 degrees, further, at least
one pair of fiducials must be at least 18 mm apart.
Fiducial step
 Tools
The following tools are available on the Fiducials step.
Locate Fiducials Auto Center Instructs the Accuray Precision System to locate the
check box center of the fiducial at the center of the grayscale
intensity in a small volume around the
user-identified fiducial location.
Add button Allows the user to add a fiducial selected in the

image viewer.
Finetune Automatically adjusts the position of the fiducial

Position button based on intensity.
XYZ coordinate Displays the coordinates of the fiducial markers.

list
Delete button Deletes the fiducial selected in the XYZ coordinate

list.
Delete Last Deletes the most recently placed fiducial.

button
Delete All button Deletes all fiducials.
 Identify Fiducials
1. Click the Fiducials step.
2. To add a fiducial, choose a method:
• Double-click over the center of the fiducial.
• Click once over the center of the fiducial and click Add.
3. Click the center of a fiducial to mark it. The fiducial location is depicted by a
magenta marker on the 2D views.
WARNING: Delivery accuracy depends on correct identification of fiducial

locations. If fiducial settings are inaccurate, dose could be delivered incorrectly
during treatment. Be careful to correctly identify the locations of the fiducials.
4. Scroll through the image series to view the fiducials.

5. To adjust the position of a fiducial, choose a method:
• Automatic: Click the row of coordinates on the XYZ list and click the
Finetune Position.

• Manual: Scroll through the image series until the marked fiducial is
centered in each view, then drag the fiducial marker to a new location,
or use the slider tool at the bottom of each planar view to adjust the
planar view until the marked fiducial is centered in each view.
6. To delete one or more fiducials, choose a method:
• Click the coordinates on the XYZ list and click Delete.
• Click Delete Last.
• Click Delete All.
7. (Optional) To enable auto centering, select the Auto Center check box.
NOTE: When auto centering is enabled, place the fiducial marker at the center of
the fiducial to ensure that the entire fiducial is included in the search for the center
of grayscale intensity.
When auto centering is disabled, the Accuray Precision System locates the
center of the fiducial at the user-identified fiducial location.
Align Step
Use Align step to define the alignment center to ensure that the diagnostic
X-ray system can function accurately during treatment delivery.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
 Define the Alignment Center. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
WARNING: If fiducials are being used for tracking, verify that fiducial markers are
visible in the DRRs.
NOTE: The DRRs are quickly generated and should only be used to verify visibility.
The fiducial centroid positions may not be displayed clearly.
NOTE: Moving the image center during this step may lead to inaccurate treatment.

 Tools
The following tools are available on the Align step.
Current Center (IECp) X, Y, and Z Displays the coordinates of the current alignment
center.
Confirmed Center (IECp) X, Y, and Z Displays the coordinates of the current confirmed
alignment center.
Spine Supine ROI Height (mm) Defines the default tracking search range (ROI) used
slider during delivery for Synchrony Spine Tracking. The
value is for the height of ROI in millimeter that is
displayed as a blue mesh on the DRR images.
Patient Position • Head First Supine (HFS)

• Head First Prone (HFP)
• Feet First Supine (FFS)
• Feet First Prone (FFP)
Confirm button Saves the new alignment center position.
Reset to Default button Discards the changes and uses the original alignment
center coordinates.
 Define the Alignment Center
WARNING: Prior to confirming the alignment center, verify that the appropriate
information is visible within the DRR per the alignment guidelines described in the
Treatment Delivery Manual.
1. Click Align step on the Setup task.

The two DRRs at the top of the image viewer are generated using the
coordinates of the current alignment center. The coordinates of the current
alignment center are displayed in the Current Center area on the control
panel.
The 2D views at the bottom of the image viewer are generated using the
current alignment center.
NOTE: The algorithm used to generate these DRRs is optimized for generating
instant updates of the DRRs. As a result, the image quality is not as detailed as that
on the treatment delivery system.
2. Evaluate the position of the alignment center on each DRR.
• For skull tracking, align the CT image so that the silhouette of the patient
has a 10-15 mm gap at the superior and anterior sides of the patient
anatomy in each view. A gap of 10 mm results in more accurate tracking
than does a larger gap.
• For fiducial and Synchrony System tracking, ensure that all required
fiducials for the plan are within the field of view and are visualized on the
DRRs. For fiducial tracking, the alignment center position is defined
automatically.
• For more information, see “Synchrony® Spine Tracking (CyberKnife
Option)” (page 665) and “Synchrony® Lung Tracking™ with Respiratory
Modeling (CyberKnife Option)” (page 675).
3. To save the new alignment center position, click Confirm.
The image display and the plan are updated according to the new alignment
center coordinates. The coordinates in the Current Center and Confirmed
Center boxes on the control panel are both set to the current confirmed
coordinates.
After you click Confirm, if you move the alignment center, the new
coordinates are displayed in the Current Center area on the control panel.
4. To discard changes and use the default (original) alignment center

coordinates, click Reset to Default.
The image display and the plan are updated according to the original
coordinates.
NOTE: You must confirm the alignment center before you can go to the Plan task.
NOTE: If any changes are made to the alignment center during or after plan
generation, the plan must be recalculated in high resolution and prescribed again
before saving the plan as deliverable.

DRR Review Step
Use DRR Review step to ensure the tumor is visible and the fiducials are
visible in the DRRs.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
 Default Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
 Generating DRR Images. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
NOTE: The DRR Review step is available when the Lung with Respiratory is
selected as Synchrony Method.
 Tools
Tracking Tumor Displays a list of tumor tracking volumes.

drop-down list
Treatment CT Center Displays the X Y Z coordinates of the

selected tumor tracking volume.
Display Contour Displays the contour of the tumor.

check box
Invert DRR Inverts DRR images black to white and

Images check box white to black.
Reset to Default Resets to the default Window/Level.

W/L button
DRR Type Full Content Displays the full content DRR images.
option
Spine Removed Displays the DRR images with the spine

option removed.
Tumor Region Displays the DRR images only of the

option region surrounding the tumor.
 Default Mode
If only one VOI is defined as a target in the Contour task, that VOI is
automatically selected as the tumor tracking volume in the DRR Review
step.
On the DRR Review step, the default DRR type is Full Content. The name
of the tumor tracking volume and the centroid position point in CT space are
displayed on the left of the screen.
If multiple targets are defined in the Contour task, the DRR views are blank
when you switch to the DRR Review step. You must select a VOI as the
target from the Tracking Tumor drop-down list before DRR images can be
generated.
 Generating DRR Images

1. Select a VOI on the Tracking Tumor drop-down list.
The X Y Z coordinates for the selected target are displayed in the Treatment
CT Center section of the control panel.
The DRR images are generated based on the centroid of the target VOI.
Therefore, the target VOI is always displayed at the center of the DRR
images.

2. Select the Display Contour check box to display the contour. The full
content DRR image appears.
The Full Content option is selected by default.
3. Select the Invert DRR Images check box to invert the DRR images on the
display.
4. Click the Spine Removed option to generate DRR images with the spine
removed.
5. Click the Tumor Region option to generate DRR images with just the tumor
region showing.
6. If the tumor is clearly visible, click the Full Content option and click the Apply
button.
The DRR images have been confirmed.
NOTE: To save a plan as deliverable, you must first confirm the DRR.
NOTE: If DRR images are not defined, the VOI center may be beyond the imaging
center of the scan, and slices may need to be deleted before proceeding.
Chapter 8
Plan Task
Section 8-1
Plan Task for Tomo® . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Section 8-2
Plan Task for CyberKnife . . . . . . . . . . . . . . . . . . . . . . . . . 425
1072963-ENG B C ha p te r 8 : P l an T as k 379
Section 8-1
Plan Task for Tomo®
Use Plan task for Plan Setup, Optimization, and Final Dose Calculation.
The processes for Plan task vary in complexity according to the
requirements of the case and the quality and complexity of the image series
available.
Plan Task Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Optimize Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
3DCRT Dose Calculation . . . . . . . . . . . . . . . . . . . . . . . . . 410
TomoDirect Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Forward Planning (TomoDirect Only) . . . . . . . . . . . . . . . 417
1072963-ENG B S e c t i o n 8 - 1 : P l a n T as k f or T o m o ® 381
Plan Task Controls
The following controls may appear on any step of the Plan task, depending
on the conditions of the current plan.
 Isocurves Legend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
 Isocurves Pane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
 Prescription Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
 Dose Volume Histograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
 Plan Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
 Display Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
 Isocurves Legend
The isocurves legend displays the color and defined dose percentage or
absolute value for each isocurve. You can change the isocurve settings at
any time in any 2D image that contains this vertical bar. If no isocurve is
available, the Config Isocurve label appears instead.
Item Description
NOTE: When the status’ background color is yellow, the plan cannot be saved as deliverable.
Status prefix indicates:
• Opt for IMRT.
• Calc for 3DCRT and Forward Planning
• Final for final dose calculation.
Very Low Indicates the optimization process was performed at very low resolution.
Low Indicates the optimization process was performed at low resolution.
Medium Indicates the optimization process was performed at medium resolution.
High Indicates the optimization process was performed at high resolution.
Item Description
Very Low Indicates the final dose calculation was performed at very low resolution.
Low Indicates the final dose calculation was performed at low resolution.
Medium Indicates the final dose calculation was performed at medium resolution.
High Indicates the final dose calculation was performed at high resolution.
Hide the Isocurves Legend

1. Click the isocurves legend to view the Isocurves panel.
2. Clear the top check box in the Isocurves area. All check boxes are cleared.
3. To close the Isocurves panel, click on the image viewer outside the
Isocurves panel. The Isocurves panel closes.
The isocurves legend is closed, and the Config Isocurve label appears in its
place. The dose calculation resolution label also appears.
 Isocurves Pane
Click the Isocurves legend to display the Isocurves pane. The Isocurves
pane displays the color, dose percentage relative to the normalization
mode set in the Isocurves pane, and line thickness for each isocurve. The
default is to display dose as absolute dose, in cGy or Gy as determined by
the dose units setting on the server for Tomo plans. This can be changed
by the user on a plan-by-plan basis. Use the Min/max dose check box to
view or hide the minimum and maximum dose for each VOI.
Item Description
Check box column When selected, the corresponding isocurve appears. When at least one
check box is selected, the top check box is available. To select or clear all
individual check boxes, select or clear the top check box.
Color Indicates the color of the isocurve associated with the dose.
Dose Gy/cGy Displays the absolute dose in Gy/cGy.
Dose % Displays the relative dose in %.
Line Indicates the thickness of the isocurve.
P Indicates the relative or absolute value of the prescription isocurve (% or

Gy/cGy) (not editable).
Gy/cGy option When selected, display the absolute dose in Gy/cGy.
% option When selected, display the relative dose in %.
Min/max dose check box When selected, displays the minimum and maximum dose values for
each VOI and for the plan.
Normalize relative dose to Select Rx Dose or Max Dose to normalize the dose to.
drop-down list
Show dose outside of skin When selected, displays the dose distribution outside the skin.
check box
Lines check box Displays the isodose lines.
Item Description
Overlay check box Displays the dose differences in color wash.
Fill option Overlay color wash option that fills the entire interior of the isocurve lines.
Grid option Overlay color wash option that fills the interior of the isocurve lines
voxelized to the current dose calculation grid.
Dose Opacity slide bar Control the opacity of the color washes.
Modify the Isocurve Display Settings

1. Click the isocurves legend to open the Isocurves panel. If the isocurve
legend is not visible, double-click Config Isocurve.
2. To modify color:
• Click a row in the Color column.
• Click the drop-down list that appears.
• Select a color.
3. To modify the dose of an isocurve, click the value in the adjacent Dose
column and enter a new value.
4. To modify the display thickness of an isocurve, click the value in the Line
5. To display minimum and maximum dose for each VOI and for the plan,
select the Min/max dose check box.
6. To hide or display an individual isocurve, clear or select the adjacent check
box.
7. To close the Isocurves panel, click anywhere outside the panel.
8. To modify the dose display, choose a method:
• To display absolute dose, select the Gy/cGy option.
• To display the relative dose values, select (%) option.
 Prescription Dose
P on the Isocurves legend displays the prescription isocurve.
Click the Prescription button to open the Prescription dialog box to change
prescription dose percentage.
Modify the IMRT Prescription Dose Percentage (P) of an
Isocurve
1. Go to Plan > Optimize.
2. Edit % Volume, Median, Maximum, and Minimum values in the Prescription
section.
IMRT Prescription section
 Dose Volume Histograms

The Accuray Precision System calculates a Dose Volume Histogram (DVH)
for each VOI that is defined in a plan.
The DVH calculation divides the minimum to maximum dose range for each
VOI into 256 evenly spaced bins.
The DVH image viewer displays a DVH for each delineated target and
critical VOI. When you perform optimization in the Optimize step, the DVH
image viewer is updated after each iteration is processed.
All DVH for contoured VOIs appear on the DVH image viewer. You can click
and view point/dose information for the active curve selected from the
drop-down list.
Item Description
DVH Properties button Click to view the DVH Properties dialog box.
Selected DVH Displays the current active DVH VOI. Select available DVHs from the
drop-down list drop-down list. To display dose (percentage and Gy/cGy) for each point on
the active curve, click on a curve and drag the point or vertical bar across the
panel.
DVH Displays
1. Select a structure from the Selected DVH drop-down list or click on the
corresponding curve in the graph to make it as active curve on DVH panel.
By default, the X-axis display relative dose (%).
2. (Optional) To modify the X-axis display, click the isocurves legend.

Select the cGy (or Gy) check box in the Isocurves pane to display, and then
dismiss the Isocurves pane. The X-axis on the DVH image viewer is
updated to display absolute isocurve (Gy/cGy) for all VOIs.
3. Click the graph to view statistics for the active DVH:
• Dose in Gy/cGy corresponding to a given percentage dose.
• Amount of coverage of the displayed dose percentage.
When you click a point on the active isocurve, a vertical bar intersecting the
point and data for that point are displayed. Drag the bar or the point to a new
position on the curve. The display color for the vertical bar and isocurve
corresponds to the setting in the DVH Properties dialog box.
Soft Tissue DVH

The Soft Tissue is a special VOI formed by subtracting the other VOIs from
the Skin VOI. If there is no Skin VOI, Soft Tissue subtracts the volume of all
other VOIs from the volume of the dose calculation box.
DVH Properties
Use the DVH Properties dialog box to select the display options.
Item Description
Background Color Select a background color on the DVH image viewer.

drop-down list
Check box column Select a check box to display the DVH.
VOI Name Displays available target and critical VOIs.
Color Displays the color for lines and curves for each VOI on the DVH image
viewer.
Constraints and Hide All: Neither constraints nor objectives appear.

Objectives Display Show All: Constraints appear as “X” and objectives appear as arrows. The
colors are the same as the contour and the goal is positioned at the volume
and the dose.
Show only for Active DVH: Appears only for the active DVH.
Snap dose value to When selected, snaps dose value to nearest whole percent when
nearest whole percent interrogating values in relative dose mode.
when interrogating
values in relative dose
mode check box
Manage display of VOI When the check box is cleared (the default), the VOI check boxes in the DVH
DVHs independent of Properties dialog box are synchronized with those in the VOIs tab. When
VOI Visibility Settings selected, the VOI check boxes in the DVH Properties dialog box are
check box independent of those in the VOIs tab.
View and Modify DVH Properties

1. Click the DVH Properties button. The DVH Properties dialog box appears.
2. Make changes and click OK to save changes.
 Plan Statistics
For both TomoDirect and TomoHelical, the plan statistics panel displays the
Beam on Time (sec) and Actual Modulation Factor for IMRT plans and
Beam on Time (sec) for 3DCRT plans. For TomoHelical Estimated Gantry
Period (sec) and Active Rotations are also displayed for IMRT plans.
Plan statistics panel for TomoHelical
Plan statistics panel for TomoDirect IMRT
Plan statistics panel for TomoDirect 3DCRT
Item Description
Beam on Time Displays the estimated beam on time.
Actual Modulation Displays the actual modulation factor.

Factor
Estimated Gantry To determine the gantry period for a single rotation, the leaf with the longest
Period duration of open time (greatest non-zero intensity value) is multiplied by the
number of projections per rotation (51) and rounded up to an integer number
of seconds per rotation. If this value is less than the minimum allowed gantry
speed, the minimum allowed gantry speed is used.
Active Rotations An active rotation is defined as a gantry rotation that has at least one leaf
intensity value greater than zero.
Calculate the Estimated Treatment Time
Important: Accuray Incorporated recommends that you strive for a gantry period of
20 seconds. This results in the following:
• Shorter treatment duration.
• More efficient performance of the Tomo System during irradiation.
• Helps reduce unnecessary stress on Tomo System components.
The estimated treatment time helps you determine whether or not your desired
gantry period will require significant Modulation Factor adjustments.
• Use the Active Rotations (AR) that you recorded when the protocol was
optimized using Scatter.
Estimated treatment time:

T=Total treatment time
AR=Number of active rotations
RP=The desired gantry period
 Display Tab
Before working on plan optimization and dose calculation, go to Plan >
Optimize > Display tab to select the display layout to use.
Available options are the followings. For the layout symbol description, refer
to “Display Layouts” (page 52).
Display options example
Optimize Step
Optimize step provides tools for Scripts, Plan Setup, Optimization
Resolution, and Final Dose Calculation.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
 Saving a Script . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
 Loading a Script . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
 Match VOI Names. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
 Deleting a Script . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
 Field Width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
 Pitch. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
 Modulation Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
 Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
 Target Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
 Critical Constraints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
 Dose Statistics Table, Dx Vx Values, Plan Information and Dose Points .
404
Optimize step
 Tools
The following tools are available on the Optimize step.
Script Displays the Save Script dialog box. Saves a new or modified script.
Displays the Load Script dialog box. Loads a previously saved script.
Displays the Delete Script dialog box.
Plan Setup Jaw Mode If the Dynamic Jaw mode is licensed, Jaw Mode consists of Dynamic
drop-down and Fixed. Otherwise, only Fixed is available.
list
Field Width All field widths commissioned for the machine are listed.
drop-down
list
Pitch text Pitch determines the amount of primary beam overlap along the Y axis.
field The maximum pitch allowed is 0.500.
Modulation Modulation Factor determines the optimizer's limit for the range of leaf
Factor text intensity values allowed in the optimized treatment plan. The default
field value is 2.0
Optimization Displays the selected resolution to use for optimization and a drop-down
Resolution list of alternatives (Very Low, Low, Medium, or High).
Start button Click to start the optimization. This button changes to Pause after
optimization starts. This button changes to Resume when the
optimization is paused.
Cancel Click to cancel the optimization.

button
Initiate Final (check box) Select to start the final dose calculation automatically after
Dose After the user specified number of iterations are completed.
(text input field) Enter a desired number of optimization iterations to be
performed before initializing the final dose calculation.
Show VOI This option is only available when Optimization Dose is being displayed.
Overlap When selected, all the views (including DVHs, Statistics and image
Effect check views) are updated to reflect the VOI overlap priorities as seen by the
box optimizer, not the normal VOI display overlap priorities specified in the
VOIs tab (or VOI Visibility Options dialog box).
Final Dose Displays the selected resolution to use for final dose and a drop-down
Resolution list of alternatives (Very Low, Low, Medium, or High).
Calculate Click to start the final dose calculation. This button changes to Cancel
Final Dose when dose calculation starts. This button changes to Clear Final Dose
button when dose calculation is completed.
Show Updates and displays the DVH, isodose, statistics, Dx Vx Values, leaf
Optimizatio open times, and dose points.
n Results
button
 Saving a Script
The Save Script button allows you to save the following optimization
parameters currently set in the Optimize step as a script. The saved script
can be re-loaded and used for a similar plan and may contain the following
parameters: Delivery Mode, Plan Mode, Jaw Mode, Fractions, Pitch,
Synchrony Method, Final Dose Resolution, Modulation Factor,
Optimization Resolution, Initiate Final Dose After, and Constraints.
1. Click the Save Script button.
2. In the Save Script dialog box, type in a script name in the Script Name field.
3. (Optional) Type a script description in the Script Description section.
4. Click the Save button to save the script.
Save Script Dialog box
 Loading a Script
Use the Load Script button to load a saved script that can be used for a
similar plan.
Load Script dialog box
1. Click the Load Script button.

2. In the Load Script dialog box, select a script name from the Script Name
drop-down list.
3. To ensure the script is appropriate for the current case, review the
description in the Script Description field and the script contents in the
Script Summary field. The Script Description and Script Summary are not
editable when loading an existing script.
4. Click Load. The Match VOI Names dialog box appears.
 Match VOI Names
When you load a script, the Accuray Precision System compares the
names of the VOIs in the script to those in the current plan and attempts to
match the VOIs based on their names and types (Target or Critical). Review
the information displayed to ensure the matching is accurate.
Match VOI Names dialog box
 Deleting a Script
Use the Delete button to delete a saved script from the Precision
System. A deleted script is not recoverable.
Delete Script dialog box
1. Click the Delete Script icon.

2. In the Delete Script dialog box, select a script name from the Script Name
drop-down list.
3. To ensure the script is the one you want to delete, review the description in
the Script Description field and the script contents in the Script Summary
field.
4. Click Delete.
 Field Width
Field Width is the longitudinal thickness of the treatment field (nominal full
width at half maximum) at the machine isocenter. Select a treatment field
width from the Field Width drop-down list. All field widths commissioned for
the machine are listed. 1 cm field width is available only for the Fixed Jaw
Mode.
Field Width
(cm) Fixed Dynamic
1.0 cm - Jaws x
(0.35, -0.35)
2.5 cm - Jaws x x
(1.00, -1.00)
5.0 cm - Jaws x x
(2.10, -2.10)
 Pitch
Pitch determines the amount of primary beam overlap along the Y axis
(longitudinal extent).
For TomoHelical plans, pitch is the couch distance traveled per gantry
rotation/field width.
For TomoDirect, pitch is the couch distance traveled per projection (in cm).
The default pitch value is determined by the selected field width.
TomoDirect field width and pitch values
Field Width (cm) Pitch
5.0 0.500 (maximum pitch allowed)
2.5 0.250
1.0 0.100
 Modulation Factor
NOTE: You can adjust the Pitch and Modulation Factor values to improve treatment
time.
NOTE: Modulation Factor is for IMRT plans only. For 3DCRT plans, there is no
modulation factor.
Modulation Factor determines the optimizer's limit for the range of leaf
intensity values allowed in the optimized treatment plan. The modulation
factor applies if the plan includes one or more sensitive structures. The
default value is 2.0.
Accuray Incorporated suggests an initial value of 2.0 for the Modulation
Factor for TomoHelical and TomoDirect protocols.
Modulation factor = (RP x GRotS)/dose per fraction.
Variable Description
RP The desired gantry period.
GRotS Gray x Rotations per second.
Dose Per Fraction The intended dose for each fraction to treat the target defined by the protocol.
 Prescription
Use the Prescription fields to prescribe dose to a target based on a
percentage of the target volume or on volume statistics. Specify the
prescription target, prescription dose, and number of treatment fractions.
Prescription area with Volume Percentage Option
Prescription area with Volume Statistics Option
Item Description
% Volume drop-down list Select % Volume to prescribe dose to a target based on the percentage
specified in the % will receive field that should receive at least the
Prescribed Dose.
Maximum, Median, Select Maximum, Median, or Minimum to base the prescription on volume
Minimum drop-down list statistics.
Select Median if 50% of the structure should receive at least the Prescribed
Dose.
Select Maximum if the structure should not receive more than the
Prescribed Dose.
Select Minimum if the structure should receive at least the Prescribed Dose.
For drop-down list Use to select the prescription Target.
% will receive The Volume Percentage field displays the percentage of the structure that
will receive at least the Prescription Dose (0.01 to 120 Gy or 12000 cGy). If
you choose %Volume, type the percentage dose in the field. If you choose
Maximum, Median, or Minimum, the field displays the calculated value.
Gy (or cGy) in Type the prescription dose (0.01 to 120Gy or 1 to 12000 cGy) for the
prescription target.
Fraction Type the number of fractions that will be used to deliver the prescribed
dose.
 Target Objectives
Use the options in the Target Objectives area to specify dose prescriptions
and constraints for Targets.
For Importance, Max Dose Penalty, Min Dose Penalty, the weights of these
constraints are relative to those of other VOIs. Values are compared
against those of other structures.
Target Objectives area
Target Objectives and Critical Constraints share several of the same
controls. In the following table the controls apply to both unless otherwise
indicated:
Item Description
Color Displays the color of the VOI set in Contour task or VOI Visibility Options.
Name Lists the names of the target VOIs.
Overlap Priority When two or more structures of the same type overlap, the number in the Overlap
Priority column indicates which structure has priority (the lower the number, the
higher the priority). For each overlap, the calculation applies the dose and
constraints of the structure having the greatest priority.
Use Select the Use check box for a VOI if you want its constraint settings included in
the optimization process. By default, all VOIs are selected.
Importance The optimization process uses Importance as a relative weight to update leaf
intensity values with each iteration. The scale can range from 1 (the least
important) to over 2 billion.
For Target Objectives, this influences the Max Dose and Min Dose objectives.
For Critical Constraints, this influences Max Dose and DVH objectives.
Max Dose Use Max Dose (Gy/cGy) to specify the desired maximum dose that an VOI
(Gy/cGy) receives. You can specify a maximum dose up to 120 Gy.
Max Dose Penalty The optimization process uses Max Dose Penalty as a relative weight to update
leaf intensity values with each iteration. The scale can range from 1 (the lowest
penalty) to over 2 billion. This enforces the Max Dose (Gy/cGy) value.
DVH Vol (%) For a point on the DVH chart, DVH Vol (%) indicates the percentage of the overall
Target that should receive the specified DVH Dose (Gy/cGy).
DVH Dose Indicates the dose that the specified percentage (DVH Vol %) of the Target overall
(Gy/cGy) volume should receive.
Min Dose (Gy/cGy) Use Min Dose (Gy/cGy) to specify the desired minimum dose that a Target
(Target Only) receives.
Min Dose Penalty The optimization process uses Min Dose Penalty as a relative weight to update
(Target Only) leaf intensity values with each iteration. The scale can range from 1 (the lowest
penalty) to over 2 billion. This enforces the Min Dose (Gy/cGy) value.
DVH Constraint Use the DVH Constraint to create the point for the prescription dose and dose
volume. You can add up to two more points if you want the optimizer to attempt to
achieve a specific dose for a volume of the Target. The prescription point is the
only one that is guaranteed by the optimizer.
Add button Click to add a row for an additional DVH constraint. A VOI can have up to three
DVH constraints.
Item Description
Remove button Click to remove a row.
 Critical Constraints
Use the options in the Critical Constraints area to define and modify VOIs
for optimization. Once the constraints and other parameters are defined,
the plan is ready for Optimization.
Critical Constraints area
NOTE: For Importance, Max Dose Penalty, and DVH Penalty, the weights of these
constraints are relative to those of other VOIs. Values are compared against those
of other structures.
Target Objectives and Critical Constraints share several of the same

controls. The controls described in the following table apply only to Critical
Constraints.
Item Description
Beam Intersection Allowed: Allows beams to intersect the listed VOI.
Never: Does not allow beams to intersect the listed VOI.
Exit Only: If a beam segment intersects the listed VOI before it intersects the
target, it will be disabled.
NOTE: Beam/VOI intersection check is performed at projection plane at 800

mm depth.
Item Description
DVH Penalty The optimization process uses DVH Penalty as a relative weight to update
leaf intensity values with each iteration.The scale can range from 1 (the
lowest penalty) to over 2 billion. This enforces the DVH point specified by
DVH Dose (Gy/cGy) and DVH Vol (%).

and Dose Points
There are five tabs below the Dose Statistic panel:
• The Dose Statistics Table tab displays a table of dose statistics for each
VOI of the Active plan.
• The Dx Vx Values tab displays a table of Dx and Vx customizable
values for each selected VOI in the Active plan.
• The Plan Information tab displays plan information for Active plan.
• Leaf Open Times displays the percentage of leaves open for the
duration specified on the horizontal axis.
• The Dose Points tab displays dose point name, dose value, and the
location.
Dose Statistics Table

The target volumes in the Dose Statistics Table have calculations for the
parameters listed.
Item Description
Name List of VOIs names. Double-click a VOI name to move the cross-hairs
to the centroid of the corresponding VOI.
Min (Gy/cGy) Minimum dose in Gy or cGy for each VOI. Double-click a Min dose
value to move the cross-hairs to that min dose point of the
corresponding VOI.
Mean (Gy/cGy) Mean dose in Gy or cGy for each VOI.
Max (Gy/cGy) Maximum dose in Gy or cGy for each VOI. Double-click a Max dose
value to move the cross-hairs to that max dose point of the
corresponding VOI.
CI (Conformality Index) The ratio of total tissue volume that receives the prescription isodose to
tumor volume that receives the prescription isodose or more.
nCI (New Conformality Index) The Conformality Index multiplied by the ratio of the total tumor volume
to the tumor volume that receives the prescription isodose or more.
HI (Homogeneity Index) The ratio of the maximum dose in each VOI to the prescription dose.
For the current configuration of the Accuray Precision System, the
maximum dose is always 100% isodose.
Coverage (%) The volume of the tumor that receives the prescription dose divided by
the total volume of the tumor times 100.
Dx Vx Values
Dx Vx Values tables for customizable dose-to-volume analysis are
available wherever dose statistics are shown. In the Optimize, Calculate or
Forward Planning step, you can perform dose-to-volume analysis on active
plan VOIs, All Target Regions, or Soft Tissue. After selecting an option from
the drop-down list, enter one (of four) values to track: Dose (in Gy/cGy or
%) or Volume (in cm3 or %). The other three values are automatically
calculated. Entered values appear as bold text.
Item Description
Name Select VOIs names from the drop-down list to display Dx and
Vx values. Double-click the color box to move the cross-hairs
to the centroid of the corresponding VOI, and move the DVH
probe to the point on the DVH graph corresponding to the
current Dx Vx values (if specified).
Dose (Gy or cGy) Displays the dose of the selected VOIs in Gy or cGy. Entered
values appear in bold text.
Dose (%) Displays the dose of the selected VOIs in %. Entered values
appear in bold text.
Volume (cm3) Displays the volume of the selected VOIs in cm3. Entered
Volume (%) Displays the dose value of the selected VOIs in %. Entered
Criteria (double-click Double click to open the Edit DxVx Criteria dialog box, and
to edit) enter values to augment each DxVx value which you want to
evaluate against the active plan.
DxVx Criteria
Use the Edit DxVx Criteria dialog box to augment each DxVx value to
evaluate against the current active plan results. The evaluation results are
shown with pass, fail, and warning indicators.
You can specify dose/volume quantity, VOI mean dose or Cl (conformality
Index), relative comparison (<, <=, >, >= or within range), and min/max
warning values (optional).
Indicator Description
Pass - Criteria is met. Place the mouse over the icon to view
the value used for the evaluation.
Warning - The main criteria is not met, but the value meets an
enabled warning min/max setting.
Fail - Criteria is not met. Place the mouse over the icon to view
Performing Customized Dose-to-volume Analysis

1. Select a VOI or All Target Regions or Soft Tissue from the Name drop-down
list.
2. In a Dose or Volume field, enter the value you want to analyze.
3. Use Criteria field to edit the DxVx values you entered to augment each
DxVx value for further evaluation against the current active plan results.
4. Start the optimization. The other three values for the Dose or Volume fields
are automatically calculated.
5. The evaluation results are displayed based on the criteria and actual value.
 Optimization Procedures (IMRT)

Optimization provides a detailed method for managing the settings of a
plan.
1. (Optional) Load an existing script or template, or create a new script.
2. (Optional) Modify settings.
3. (Optional) Select the check box for Initiate Final Dose After, and enter the
number of desired iterations before the final dose calculation.
4. Select Optimization Resolution, and click Start to initialize the optimization.
• If the final dose resolution was not set before starting optimization, click
the Pause button to stop the optimization when the optimization results
meet the goals.
– Evaluate the quality of the plan and modify the target objectives,
overlap priorities, critical constraints, and modulation factor to meet
the goal.
– Select the Final Dose Calculation Resolution from the drop-down
menu, and click Calculate Final Dose to initiate the final dose
calculation.
OR...
• If the final dose resolution was set before starting optimization, when
the optimization results meet the goals, click Calculate Final Dose.
When the final dose calculation is complete, the Calculate Final Dose
button becomes Clear Final Dose.
6. To switch the display results, do one of the following:
• Click Show Optimization Results to switch the display to the
optimization results.
• Click Show Final Dose Results button to switch the display to the final
dose calculation results.
3DCRT Dose Calculation
When 3DCRT is selected as the Plan Mode in Setup > Machine step,
Plan > Optimize step becomes Calculate step.
A 3DCRT plan is ideal when the Target is a simple shape and/or is isolated
from critical VOIs. A 3DCRT plan does not allow the assignment of
constraints, though critical VOIs may be blocked to avoid dose. Rather than
the modulation offered by IMRT, a 3DCRT plan uses an electronic
compensator, set to low or high beamlet weighting, to work toward a
homogeneous dose in the target volume. To determine which
compensation level to use in a plan, consider surface topography, target
shape, target depth, and beam arrangements. Consider a 3DCRT plan
when highly conformal dose may not be required. In such cases, sensitive
structures surrounding the Target are minimal or the prescription dose to
the Target does not reach the dose limit of the surrounding critical VOIs.
Only Overlap Priority, DVH VOI% and DVH Dose (Gy/cGy) can be set for
Target Objectives. Only the Beam Intersection can be set for Critical
Constraints.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
 Perform 3DCRT Dose Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Plan > Calculate step for 3DCRT
 Tools
The following controls are available for 3DCRT, Plan > Calculate step.
Plan Compensation Compensation refers to the level of beam intensity variation allowed for the
Setup drop-down list plan. A higher level of compensation may produce more conformal dose
distributions but will usually require longer delivery times.
Select Low compensation for your initial calculation. Low compensation
may result in optimal treatment duration.
Select High compensation if DVH results from your initial calculation are
not acceptable. High compensation may result in more acceptable DVH
curves and longer treatment duration.
Calculation Options are: Very Low, Low, Medium, and High.

Resolution
drop-down list
Calculate button Click to start the calculation. The calculation cannot be paused. User
needs to wait for the calculation to be completed, modify the parameters,
and re-calculate if necessary.
Cancel Click to cancel the calculation.

drop-down list
Normal Tissue Select the Normal Tissue Dose Uniformity check box if you want the
Dose Uniformity calculator to attempt to prevent hotspots from forming in normal tissue. A
check box skin VOI must be defined in order to use Normal Tissue Dose Uniformity.
Show VOI This option is only available when Optimization Dose is displayed. When
Overlap Effect the option is selected, all the views (including DVHs, statistics and image
check box views) are updated to reflect the VOI overlap priorities as seen by the
optimizer, not the normal VOI display overlap priorities specified in the
VOIs tab or VOI Visibility Options dialog box.
 Perform 3DCRT Dose Calculation

1. (Optional) Load an existing script or template, or create a new script.
2. (Optional) Modify settings.
3. (Optional) Select the check box for Normal Tissue Dose Uniformity.
4. Select the resolution for Calculate Resolution, and click Calculate to start
the dose calculation.
• You cannot pause the 3DCRT dose calculation. Use Cancel button to
cancel the calculation process.
• When the dose calculation is complete, Calculate Final Dose button is
available.
5. Evaluate the quality of the plan and modify the target objectives, overlap
priorities, critical constraints, pitch, and Compensation values to meet the
goal.
6. Select the Final Dose Calculation Resolution from the drop-down list, and
click Calculate Final Dose button to initiate the final dose calculation.
• When the final dose calculation is complete, the Calculate Final Dose
button becomes Clear Final Dose.
• Use Show Optimization Result button to switch the display to the
optimization results.
• Use Show Final Dose Results button to switch the display to the final
dose calculation results.
TomoDirect Plans
A TomoDirect plan delivers dose to the Target with fixed beam angles. Both
IMRT and 3D Conformal (3DCRT) are available for TomoDirect plans.
 Beam Angle Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
NOTE: Forward Planning plans are also TomoDirect plans, but don't use the Beam
Angle and Optimize/Calculate steps and are therefore described separately in this
manual. See “Forward Planning (TomoDirect Only)” (page 417),
 Beam Angle Step

Beam Angle step is available in Plan task when Direct is selected as the
Delivery Mode in Setup > Machine step.
Beam Angles step
The following tools are available in the Beam Angles > Tools step.
Angles Reset Angles button If you make any changes after the angle is applied,
you can click the Reset button to go back to the state
where the angle was applied.
Apply Angles button Click to apply the angle defined in the Angle table.
Script Save Script To save, load, or delete a script, click the appropriate
Load Script button.
Delete Script buttons
Notice text area If one of more of the following occur, a notice appears.
• One or more angles pass through the couch before
reaching the Target.
• One or more angles do not have the necessary
leaves to apply +/- Xg settings from at least one
projection.
• The beam expansion (+/- Xg setting) for one or
more angles is blocked by the current Beam
Intersection settings. An asterisk appears in the
affected angle’s Xg field.
Show Lines and Wash option Select to display the beams in lines and wash.
Lines Only option Select to display the beams in lines only.
Wash Only option Select to display the beams in wash only.
Entire Treatment check Once all the beams have been applied, this check box
box becomes available to display the beams angles for the
entire treatment.
Machine Geometry Select the check box to display the machine geometry.
check box
Lasers check box Select the check box to display the green and red
lasers.
Plan Setup Jaw Mode drop-down If the Dynamic Jaw mode is licensed, Jaw Mode
list consists of Dynamic and Fixed. Otherwise, only Fixed
is available.
Field Width drop-down Lists the field widths commissioned for the machine.
list Select a treatment field width from the Field Width
drop-down list.
Pitch Type in the desired Pitch value in this box.
Angle Management Click to add an angle.

Area
Click to add a parallel opposed angle.
Click to remove the selected angle.
Name Define the name of the angle, or use the default.
Angle Add the angle value in the cell, and the beam moves to
the defined angle. Or, drag the beam on the image to
the desired angle, and the value is automatically filled
on the table.
-Xg (leaves) Select the amount of beam expansion leaves you want
to attempt to add from the -Xg (leaves) drop-down list.
You can add up to 5 leaves (beamlets) on the following
edge of the beam angle.
+Xg (leaves) Select the amount of beam expansion leaves you want
to attempt to add from the +Xg (leaves) drop-down list.
You can add up to 5 leaves (beamlets) on the leading
edge of the beam angle.
Status States displayed are: Pending, Modified, Applied.
VOIs check box All target VOIs whose objectives are marked as Used
on the Optimize step have check boxes.
Create TomoDirect Plans

1. Select Direct as Delivery Mode in Setup > Machine step.
2. Go to Plan > Beam Angles step, and click the Add Angle icon to add a
new row. The status of the newly added angle becomes “pending.”
NOTE: Beam angles are listed in the order in which they are added. The maximum
number of beam angles per plan is determined by the Beam Number license which
could have the values of 9, 12, or 15.
A target VOI requires minimum of two beam angles.
3. (Optional) Enter name for the added angle.

4. Add the value for the Angle in the table, or just drag the beam on the image.
5. If needed, extend the beam to either edge of the beam angle by editing the
value on the table or using the slide bars on the image.
Beam angle slider
• Select the amount of beam expansion leaves you want to attempt to add
from the +Xg (leaves) drop-down list. Up to 5 leaves can be added.
• Select the amount of beam expansion leaves you want to attempt to add
from the -Xg (leaves) drop-down list. Up to 5 leaves can be added.
6. Click Apply Angles button to apply the angle.
NOTE: For TomoDirect plans, when beam angles are applied, a notice is displayed
indicating the beam angle of any beams that pass through or intersect with the
couch. Ensure that these beams will not result in significant differences between
planned and delivered dose.
• You can make changes after the angle has been applied. However,
you'll need to re-apply the angles after you modify the beam angle. Use
the Reset Angles button to go back to where the angle was applied.
• To delete a beam angle, select the angle and click the Remove Angles
button.
NOTE: To ensure that the beam angles sufficiently cover the prescribed area,
select the Entire Treatment check box to view the full longitudinal extent of the
beam (including beam expansion) in the Image Viewer.
7. For IMRT plans, go to Plan > Optimize step. Follow the Optimization
procedure, optimize and run the final dose calculation.
For 3DCRT plans, go to the Plan > Calculate step and follow the 3DCRT
Calculate procedure.
Forward Planning (TomoDirect Only)
Forward Planning step is available in Plan task when Forward Planning is
selected as the Plan Mode in Setup > Machine step.
No target or critical VOI is required for this feature.
 Beam Angle and Field Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
 Beams Eye View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
 Dose Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
 Display Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
 Create a Plan Using Forward Planning . . . . . . . . . . . . . . . . . . . . . . . . 423
Forward Planning Step
 Beam Angle and Field Tables
Click to add an angle.
Click to add a parallel opposed angle.
Click to remove the selected angle.
Dose Groups button Click to open the Dose Group dialog box. Dose Group allows
the user to select the group of angles that will be weighted
together.
Add Dose Point Move the crosshair to a point where you want to prescribe the
button dose, and click the Add Dose Point button to add a dose point.
Angle Table Displays and allows editing of data describing the beam angles.
Defines the currently selected angle.
Name Define the name of the angle, or use the default.
Angle Add the angle value in the table, and the beam moves to the
defined angle. Or, or drag the center line of the beam image to
define the angle.
Group drop-down list Select a Dose Group from the drop-down list.
Weight Percent relative weight of this angle relative to the total fluence
from all angles in the same Dose Group.
Locked check box Indicates that the relative weight of the field will not change
when a weight changes for another field in the Angle.
Click to add a field.
Click to copy a field.
Click to delete a field.
Fields Table Displays and allows editing of data describing the fields of the
selected angle. There is a list of fields for each beam angle.
When a field is selected the user is able to draw curves to
define the blocks that determine fluence.
Name The name of the field with a unique name here, or use the
default names.
Weight Percent relative weight of the field relative to the total fluence
from all fields in the same Angle.
Locked check box Indicates that the relative weight of the field will not change
when a weight changes for another field in the Angle.
 Tools
The following tools are available in the Forward Planning > Tools step.
Plan Setup Jaw Mode If the Dynamic Jaw mode is licensed, Jaw Mode consists of
drop-down list Dynamic and Fixed. Otherwise, only Fixed is available.
Field Width Lists the field widths commissioned for the machine. Select a
drop-down list treatment field width from the Field Width drop-down list.
Pitch Type in the desired Pitch value in this box.
Fractions Type the number of fractions that will be used to deliver the
prescribed dose.
Approximate Very Low, Low, Medium, and High.

Dose
Resolution Calculate Click to start the dose calculation.
drop-down list Approximate Dose
button
Clear Click to clear the calculated result.
Final Dose Calculate Final Click to start the final dose calculation.
Resolution Dose button
Show Approximate Click to switch the DVH display to Approximate Results.

Results button
Field Selection Tool: Select curve for editing.

Definition
Pencil: Draw a field curve by dragging the mouse.
Line Segment: Draw a field curve as a series of line segments.
Bumper: Modify the currently selected curve.
Open Field check Select the check box to draw within a blocked region.
box
Delete: Delete the selected curve.
Delete All: Delete all curves.
Control the opacity of the field areas.
Bumper Size slide Control the size of the bumper tool.
Capture ISO Line as Click to open the dialog box that allows the user to select a ISO
Block button dose curve to use as a block.
Capture VOI as Click to open the dialog box that allows the user to select a VOI
Block button to use as a block.
 Beams Eye View

Beams Eye View displays patient DRR, beam extent, and fields for the
current beam angle. User can shape the beam by adjusting the purple lines.
Purple line moves with the resolution of one leaf.
NOTE: Beams Eye View is available from the layouts in Display tab for any
TomoDirect plans.
Define BEV Display Properties

On the BEV view, right click to open the BEV Display Properties dialog box.
View Projections of Leaf Openings
1. On the BEV image, right click to open the BEV Display Properties dialog
box.
2. In the BEV Display Properties dialog box, select the Projections check box.
3. Use the up and down arrow keys to view the leaf openings.
BEV leaf openings projections
 Dose Group
Use Dose Group to prescribe dose to a desired area.
There are two types. Use Dose Point to specify a particular point to receive
a certain dose level. Use DxVx to scale the dose so that a certain VOI’s
volume receives a specified dose value.
 Display Tab
Click the Forward Planning > Display tab for available layouts.
Available layouts for Forward Planning
 Create a Plan Using Forward Planning

1. In Plan > Forward Planning > Tools, complete the Plan Setup.
2. Click the Add Angle icon to add an angle. As soon as an angle is
added, Beams Eye View is displayed.
3. Edit the beam angle by entering the values in the table or drag the beam on
the image.
4. Shape the beam by adjusting the purple lines in Beams Eye View.
5. If necessary, add more beam angles and assign weights to each beam
angle.
6. Move the crosshair to where you want to set the Dose Point, and click Add
Dose Point. The dose point is added to the all the image views.
7. Click the Dose Groups button and click Add Group button. Prescribe dose
to the dose group.
Each defined angle needs to be assigned to a dose group.
8. Select the dose resolution and click Calculate Approximate Dose.

9. (Optional) Use Capture ISO Line as Block and Capture VOI as Block to
adjust the dose distribution and remove hot spots.
10. Select the Final Dose Resolution from the drop-down list, and click
Calculate Final Dose to run the final dose calculation.
Section 8-2
Plan Task for CyberKnife
Use the Plan task to create, evaluate, refine, and review treatment plans.
The processes of creating, evaluating, refining, and saving a plan vary in
complexity according to the requirements of the case and the quality and
complexity of the image series available. This chapter describes plan setup
and optimization using the Ray-Tracing and Monte Carlo Dose Calculation
(Option) algorithms for use with fixed and Iris Collimators; and Finite Size
Pencil Beam (FSPB) and Monte Carlo dose calculation algorithm used only
with the multileaf collimator (MLC) which is an optional feature of the
CyberKnife System.
Plan Task Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Settings Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Isocentric Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Sequential Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
VOLO Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
1072963-ENG B S ec t i on 8- 2 : Pl a n T a s k fo r Cy be rK ni f e 425
Plan Task Controls
The following controls appear on any step of the Plan task, depending on
the optimization method and the conditions of the current plan.
 Dose Calculation Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
 Isocurves Legend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
 Collimators (Fixed and Iris Collimators Only) . . . . . . . . . . . . . . . . . . . . . . . 434
 Scripts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436
 Auto-shells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
 Dose Volume Histograms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
 Plan Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
 Dose Statistics Table, Dx Vx Values, Plan Information and Dose Points . . 447
 Prescription. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452
 Dose Calculation Box
WARNING: If the dose calculation box does not cover all defined structures or the
entire patient surface, then it is possible to miss regions of dose that may be higher
than clinically desired. Always enlarge the calculation box before completing plan
evaluation and approval to ensure adequate review of the dose throughout the
entire patient. You can modify the dose calculation box on the Plan task or Review
and Finetune step on the Evaluate task.
Use the dose calculation box to define the volume within which dose is
calculated at the currently selected algorithm (Ray-Tracing or FSPB),
resolution (High, Medium, or Low), and from which constraint points are
extracted for each VOI used for optimization.
Accuray Precision System maintains separate dose calculation boxes for
the optimization and final dose calculation. The dose calculation box used
for optimization appears as dotted lines in Evaluate > Review step and the
final dose calculation box appear as solid lines.
If you run a final dose calculation in Evaluate > Review or Finetune step and
go back to the Plan task, the dose calculation box used for optimization
appears in solid lines and the dose calculation box used for final dose
calculation appears in dotted lines.
NOTE: VOLO Optimization does not use the dose calculation box. Dose calculation
box is used for the final dose calculation after VOLO optimization is completed.
NOTE: Monte Carlo dose calculation box is not editable and always corresponds to
the entire volume defined by the primary CT image series.
NOTE: Only structures that are wholly or partially inside the dose calculation box
have dose displayed in the DVH panel and Dose Statistics Table.
Size to Fit Buttons

Use the Size to fit buttons (CT, Skin, VOIs) to set the dose calculation box
size.
• CT: Sets the dose calculation box to the size of entire CT volume.
• Skin: Sets the dose calculation box to the size of skin VOI. Skin VOI
must be predefined.
• VOIs: Sets the dose calculation box to encompass all VOIs.
Manually Modify the Dose Calculation Box

1. Choose a method:
• Resize: On a 2D view, drag a control to a new location.
• Move: Drag an edge of the box to a new location.
2. Review all planar views.
3. Ensure that all target and critical structures that should be constrained
during dose calculation are inside the dose calculation box.
NOTE: If you resize or move the dose calculation box, any existing dose volume is
deleted. Recalculate the dose volume on Isocentric, Sequential, or VOLO step on
Plan task, or Review or Finetune step on Evaluate task.
For information regarding the dose calculation box, see the Physics
Essentials Guide.
Evaluate a Treatment Plan

To ensure that a treatment plan is properly evaluated, perform the following
actions in the Evaluate > Review step.
1. Increase the size of the dose box to include the entire patient volume, not
just the contoured anatomy.
2. Recalculate the dose at high resolution.
3. Examine the treatment plan to ensure that applicable organs at risk are
accounted for.
 Isocurves Legend
NOTE: The isocurves legend and Isocurves panel do not appear on the Setup step
for a new plan. They appear when a plan has beams with dose.
The isocurves legend displays the color and defined dose percentage or
absolute value for each isocurve. You can change the isocurve settings at
any time in any 2D image that contains this vertical bar. If no isocurve is
available, the Config Isocurve label appears instead.
Item Description
NOTE: When the status’ background color is yellow, the plan cannot be saved as
deliverable. Text indicates either Opt for optimization or Final for final dose calculation.
Ray Low Indicates the Ray-Tracing dose calculation process was performed
at low resolution.
Ray Medium Indicates the Ray-Tracing dose calculation process was performed
at medium resolution.
Ray High Indicates the Ray-Tracing dose calculation process was performed
at high resolution.
Ray Low (C) Indicates the low-resolution Ray-Tracing dose calculation process
was performed with Contour correction turned on.
Ray Medium (C) Indicates the medium-resolution Ray-Tracing dose calculation

process was performed with Contour correction turned on.
Ray High (C) Indicates the high-resolution Ray-Tracing dose calculation process
was performed with Contour correction turned on.
MC Low Indicates the Monte Carlo dose calculation process was performed
at low resolution.
MC Medium Indicates the Monte Carlo dose calculation process was performed
at medium resolution.
MC High Indicates the Monte Carlo dose calculation process was performed
at high resolution.
Low Indicates the low-resolution Finite Size Pencil Beam dose

calculation process was performed.
Medium Indicates the medium-resolution Finite Size Pencil Beam dose

High Indicates the high-resolution Finite Size Pencil Beam dose

Hide the Isocurves Legend

1. Click the isocurves legend to view the Isocurves panel.
2. Clear the top check box in the Isocurves area. All check boxes are cleared.
3. To close the Isocurves panel, click on the image viewer outside the Isocurves
panel. The Isocurves panel closes.
The isocurves legend is closed, and the Config Isocurve label appears in its
place. The dose calculation resolution label also appears.
Isocurves Pane for Ray-Tracing and Finite Size Pencil Beam

Algorithms
Click the Isocurves legend to view the Isocurves pane. The Isocurves pane
displays the color, dose, dose percentage (relative to the maximum dose),
and line thickness of each isocurve. Use the Min/max dose check box to view
or hide the minimum and maximum dose for each VOI.
Item Description
Check box column Select to view the corresponding isocurve. When at least one
check box is selected, the top check box is available. To
select or clear all individual check boxes, select or clear the
top check box.
Color Indicates the color of the isocurve associated with the dose.
Dose Gy/cGy Displays the absolute dose in Gy/cGy.
Dose % Displays the relative dose in %.
Item Description
P Indicates the relative or absolute value of the prescription

isocurve (% or Gy/cGy) (read-only).
Gy/cGy option Select to view the absolute dose in Gy/cGy.
% option Select to view the relative dose in %.
Min/max dose check Select to view the minimum and maximum dose values for
box each VOI and for the plan.
Normalize relative dose Select Rx Dose or Max Dose as a value to normalize the
to drop-down list relative dose to.
Show dose outside skin Select to view the dose distribution outside the skin.
check box
Lines check box Select to view isodose lines.
Overlay check box Select to view dose differences in color wash.
Fill option Select to view an overlay color wash option that fills the entire
interior of the isocurve lines.
Grid option Select to view an overlay color wash option that fills the
interior of the isocurve lines voxelized to the current dose.
Dose Opacity vertical Move the slider to control the opacity of the color washes.
slider
Isocurves and MC Dose Panes

The MC Dose pane displays smoothing information and settings for the
Monte Carlo algorithm, and the Show uncertainty check box. Use the Show
uncertainty to view or hide the uncertainty level as a color wash over the
image.
Item Description
Show smoothed option Select to view smoothed dose only.
Show raw option Select to view raw dose only.
Show both option Select to view both smoothed and raw dose.
Smoothing Method drop-down list Displays current smoothing method. Select to view another
smoothing method: Average, Weighted, Gaussian, Clipped
Gaussian, or Desparkled Only.
Sigma drop-down list This drop-down list is only available if the Smoothing Method
selected is Gaussian or Clipped Gaussian. Select the Sigma level
(0.10 - 3.0).
Show uncertainty check box When selected, displays the uncertainty level as a color wash on
the 2D image display.
For mathematical details of the smoothing methods, refer to the Physics

Essentials Guide.
Modify the Isocurve Display Settings

1. Click the isocurves legend to open the Isocurves panel. If the isocurve
legend is not visible, double-click Config Isocurve.
2. To modify color:
• Click a row in the Color column.
• Click the drop-down list that appears.
• Select a color.
3. To modify the dose of an isocurve, click the value in the adjacent Dose
4. To modify the display thickness of an isocurve, click the value in the Line
5. To display minimum and maximum dose for each VOI and for the plan,
select the Min/max dose check box.
6. To hide or display an individual isocurve, clear or select the adjacent check
box.
7. To close the Isocurves panel, click anywhere outside the panel.
8. To modify the dose display, choose a method:
• To display absolute dose, select the Gy/cGy option.
• To display the relative dose values, select (%) option.
NOTE: Changing between absolute (Gy/cGy) and relative (%) Isocurve mode can
slightly change the Isocurve values to maintain the display accuracy with respect to
the actual isocurve lines.
Prescription Dose
P on the Isocurves legend displays the prescription isocurve.
Click the Prescription button to open the Prescription dialog box to change
prescription dose percentage.
Uncertainty Legend (Monte Carlo Only)

The uncertainty legend appears when you select Show uncertainty in the MC
Dose panel. It depicts the display color of each uncertainty level for the dose
calculation. The uncertainty levels appear as colorwash overlays. The
assigned color for the corresponding uncertainty colorwash cannot be
modified.
If the plan contains a dose volume, the uncertainty legend appears on the
lower-right side of each 2D view.
 Collimators (Fixed and Iris Collimators Only)

Define settings for collimators in the Collimators dialog box.
Path Set Displays the currently selected path set (read-only).
Collimator Displays the current collimator type: Fixed or Iris (read-only).
Automatic Target Displays the list of target VOIs for the current plan.
Collimator drop-down list
Selection
Method Displays the list of methods for the current plan.
drop-down list • Conformality (2 collimators)
• Homogeneity (2 collimators)
• Conformality (3 collimators)
Apply button Click to apply the Target and Method settings.
Target Boundary Target Displays the selected target.

Distance table
Target Enter a value between -10mm and + 10mm as a target
Boundary boundary distance.
Distance text
box
Collimator Select up to 3 collimators per target and per path with Fixed
(mm) collimators and up to 12 collimators per target and per path with
the Iris collimator.
TmP1 TmP2 Displays check boxes for collimators per template path.
TmP3
All Selects all Iris Collimator openings (5 mm to 60 mm).
OK button Click to save settings, close the Collimators dialog box, and
generate a set of zero-dose beams for the plan.
Cancel button Click to cancel the settings.
Show Select to view the selected collimator sizes graphically on the

Collimator main anatomical view as a guide.
Overlay check
box
Output Factor
Although the Iris Collimator is designed and capable of collimating beams
down to a 5 mm diameter at 800 mm SAD, it is advantageous to limit the
use of 5 mm Iris collimated beams. See the Physics Essentials Guide for
more details.
 Scripts
Saving a Script
Click the Save Script icon to save the parameters for future use.
The following values are saved. Collimator size is not saved in the script.
Collimator selections and Beam Intersection settings can be saved in the
Plan Template.
Sequential VOLO (Fixed/Iris) VOLO (MLC)
• MU Limits • Collimator Type • Collimator Type

• Auto-shell settings • Max Nodes • Max Nodes
• Dose Constraints • Total MU Penalty • Total MU Penalty
• Dose Objectives • Optimization Iterations • Optimization Iterations
• Auto-shell settings • Auto-shell settings
• Max Beams • Adaptation Iterations
• Max Beam MU • Fluence Smoothness Penalty
• Min Beam MU Per Fraction • Max Segments Per Beam
• Target Goals (Target • Max Segments
Boundary Distance, • Max Segment MU
Sampling, and DVH Goals)
• Max Beamlet MU
• Critical Goals (Sampling,
• Min Segment MU Per Fraction
DVH Goals and NTO)
• Target Goals (Target Boundary
Distance, Sampling, and DVH
Goals)
• Critical Goals (Sampling, DVH
Goals and NTO)
1. Click the Save Script icon. The Save Script dialog box appears.
2. Enter a unique name in the Script Name text box.
3. Enter a description in the Script Description text box.
4. Review the settings for the active plan on the Script Summary panel.
5. Click Save. The script is saved and the Save Script dialog box is closed.
Loading a Script
Click the Load Script icon to load a script that has been saved. The script
can be used for a similar plan.
1. Click the Load Script icon. The Load Script dialog box appears.
2. Select a script from the Script Name drop-down list.
NOTE: The Script Name drop-down list of Load Script and Delete Script are filtered
to display only scripts related to the currently selected collimator type.
3. To ensure the script is appropriate for the current case, review the Script
Description and Script Summary.
4. To ensure the settings are appropriate for the current case, review the
settings in the Script Summary dialog box.
5. Click Load. The VOI names in the script are matched to those in the plan.
The Match VOI Names dialog box appears.
Match VOI Names
When you load a script, the Accuray Precision System compares the
names of the VOIs in the script to those in the current plan and attempts to
match the VOIs based on their names and types (Target or Critical). Review
the information displayed to ensure the matches are accurate.
For those VOIs in the script that are not automatically matched, the VOIs
need to be manually selected from the drop-down list for each VOI before
the script can load. The OK button is available only after all the script VOIs
are matched with the plan VOIs.
VOLO allows multiple plan VOIs to be assigned to a single script VOI.
Deleting a Script
Click the Delete Script icon to delete a saved script. A deleted script is
not recoverable.
1. Click the Delete Script icon. The Delete Script dialog box appears.
2. Select a script from the Script Name drop-down list.
to display only scripts related to the currently selected collimator type.
3. To ensure the script is the one you want to delete:

• Review the description in the Script Description field.
• Review the script contents in the Script Summary field.
4. Click Delete. The script is deleted and the dialog box is closed.
 Auto-shells
Click the Auto-shells button to add, delete, or modify auto-shells for the
current plan. Auto-shells settings are saved with the script and are used to
recreate the auto-shells when you load the script for a plan and during a
subsequent Sequential Optimization procedure. Auto-shells are visible on
the image viewer. Dose statistics and DVHs are calculated for auto-shells.
Typically, auto-shells are used to control dose distribution both close to and
farther away from a target. An auto-shell close to a target can control
conformality. A shell distant to a target can be used to control low dose
distribution or remote hot spots.
Item Description
Source Sets the source VOI for the auto-shell.
Auto-shell Name Sets the name of the auto-shell. The name is generated
automatically and cannot be edited.
Symmetric When selected, applies one value to all directional parameters.
Anterior (mm) Set directional parameters for the dimensions of the auto-shell.
Posterior (mm) Enter a unique dilation value per parameter or select
Symmetric to apply one value to all parameters for the
Right (mm) auto-shell.
Left (mm)
Inferior (mm)
Superior (mm)
Add Click to add a new auto-shell.
Delete Click to delete the selected auto-shell.
OK Click to save the settings for the auto-shells. After you click
OK, auto-shells are created and the Auto-shells dialog box is
closed.
Cancel Click to cancel the auto-shell settings and return to the

Sequential step screen.
 Dose Volume Histograms
The Accuray Precision System calculates a Dose Volume Histogram (DVH)
for each VOI that is defined in a plan. DVH is only calculated within the dose
volume which covers the dose calculation box for a Ray-Tracing and FSPB
plan, and the entire CT volume for a Monte Carlo plan. Voxels of a VOI that
are outside of the dose volume are not counted in the DVH for that VOI
either as dose or volume.
The DVH calculation divides the minimum to maximum dose range for each
VOI into 256 evenly spaced bins.
The DVH image viewer displays a DVH for each delineated target and
critical VOI that are used for optimization goals. When you perform
Sequential Optimization, the DVH image viewer is updated after each
iteration of the optimization process or every 20 seconds, whichever is
longer. Refer to “Dose-Volume Histogram in Sequential Step” (page 485)
for more details.
In the VOLO step, the DVH graph shows each DVH goal as a triangle
marker pointing right for a “Min” dose goal and pointing left for a “Max” dose
goal. You can manipulate the triangle markers in the DVH graph by
dragging them into a new position. Refer to “Interactive Dose Volume
Histogram in VOLO Step” (page 504) for more information.
All DVH for contoured VOIs that are included in the optimization goals
appear on the DVH image viewer. You can click and view point/dose
information for the active curve selected from the drop-down list.
Item Description
DVH Properties button Click to view the DVH Properties dialog box.
Selected DVH Displays the current active DVH VOI. Select available DVHs from the
drop-down list drop-down list. To display dose (percentage and Gy/cGy) for each point on
the active curve, click on a curve and drag the point or vertical bar across the
panel.
DVH Displays
1. Select a structure from the Selected DVH drop-down list or click on the
corresponding curve in the graph to make it as active curve on DVH image
viewer. By default, the X-axis displays relative dose (%).
2. (Optional) To modify the X-axis display, click the isocurves legend. Select
the cGy (or Gy) check box in the Isocurve panel to display and close the
Isecurve panel. The X-axis on the DVH image viewer updates to display
absolute isocurve (Gy/cGy) for all VOI.
When you click a point on the active isocurve, a vertical bar appears. Drag
the bar or the point to a new position on the curve. The display color for the
vertical bar and isocurve corresponds to the setting in the DVH Properties
dialog box.
Soft Tissue DVH

other VOIs from the volume of the dose calculation box.
DVH Calculation for Monte Carlo Dose Calculation

If the smoothed isodose curves or both smoothed and raw isodose curves
are shown, DVH curves and dose statistics for the Monte Carlo algorithm
are based on the smoothed dose volume.
If only the raw isodose curves are shown, DVH curves and dose statistics
for the Monte Carlo algorithm are based on the raw dose volume.
DVH Properties
Use the DVH Properties dialog box to select the display options. Refer to
“DVH Properties for VOLO” (page 506) for DVH Properties for VOLO
optimization.
Item Description
Background Color drop-down Select a background color on the DVH image viewer.
list
Check box column Select a check box to display the DVH.
VOI Name Displays available target and critical VOIs.
Color Displays the color for lines and curves for each VOI on the DVH
image viewer.
Item Description
Constraints and Objectives Hide All: Neither constraints nor objectives appear.
Display Show All: Constraints appear as “X” and objectives appear as arrows.
The colors are the same as the contour and the goal is positioned at
the volume and the dose.
Show only for Active DVH: Appears only for the active DVH.
Snap dose value to nearest When selected, snaps dose value to nearest whole percent when
whole percent when interrogating values in relative dose mode.
interrogating values in relative
dose mode check box
Manage display of VOI DVHs When the check box is cleared (the default), the VOI check boxes in
independent of VOI Visibility the DVH Properties dialog box are synchronized with those in the
Settings check box VOIs tab. When selected, the VOI check boxes in the DVH Properties
dialog box are independent of those in the VOIs tab.
View and Modify DVH Properties

1. Click the DVH Properties button. The DVH Properties dialog box appears.
2. (Optional) Select Soft Tissue from the DVH layout column in order to view the
DVH of all tissue within the dose calculation box that is not delineated as a
target or critical VOI.
3. Make changes and click OK to save changes.
 Plan Statistics
The plan statistics area displays the number of nodes, number of non-zero
beams, maximum dose (Gy/cGy), total monitor units (MU), minimum
non-zero and maximum MU of all currently existing beams. Isocentric
beams are included in these calculations. These statistics are updated at
the end of each planning iteration during iterative optimization, and at the
end of each update interval or step during Sequential Optimization. For
VOLO, Plan Statistics are only displayed for the delineated target and
critical VOIs that are used as optimization goals. The full set of VOIs are
displayed once final dose is calculated.
The plan statistics area also displays the estimated treatment time per
fraction based on the Accuray Precision System’s default setup time and
the image time interval for a given tracking method. The treatment time
estimate appears read-only when the treatment plan dose information is
available.
For multileaf collimator, the plan statistics area displays Segments.
Segments are defined as unique radiation deliveries by the MLC which
share the same source and target points but have different leaf positions.
These segments have different leaf positions. Beams for the MLC are
defined as a collection of all segments with the same source and target
points.
Setting the Estimated Treatment Time Per Fraction

Click the Estimated Treatment Time Inputs icon to modify the estimated
setup time and imaging frequency time for a specific plan.
NOTE: The setup time is applied only to the first path. For additional paths, setup
time is not included in the treatment time estimation. In addition, the time spent
handling E-Stops is also not included in the time estimation.
1. Click the Estimated Treatment Time Inputs icon. The Estimated Treatment Time
Inputs dialog box appears.
2. Set the new treatment times as necessary.
If InTempo Imaging has been selected in Setup > Machine step, the InTempo
check box is available.
3. Click OK to save the treatment time inputs. The new treatment time settings
will be used when the treatment plan is saved.

and Dose Points
In the default layout for the Sequential and VOLO step, there are 4 tabs below
the Dose Statistic panel:
• The Dose Statistics Table tab displays a table of dose statistics for each
VOI of the Active plan.
• The Dx Vx Values tab displays a table of Dx and Vx customizable values
for each selected VOI in the Active plan.
• The Plan Information tab displays plan information for Active plan.
• The Dose Points tab displays dose point name, dose value, and the
location.
Dose Statistics Table

parameters listed.
NOTE: Minimum, mean, and maximum dose statistics for auto-shells generated
during the sequential planning process appears in the Dose Statistics Table. The
conformal shell icon is indicated by a green rectangle.
Item Description
Name List of VOIs names. Double-click a VOI name to move the cross-hairs
to the centroid of the corresponding VOI.
Min (Gy/cGy) Minimum dose in Gy or cGy for each VOI. Double-click a Min dose
value to move the cross-hairs to that min dose point of the
corresponding VOI.
Mean (Gy/cGy) Mean dose in Gy or cGy for each VOI.
Max (Gy/cGy) Maximum dose in Gy or cGy for each VOI. Double-click a Max dose
value to move the cross-hairs to that max dose point of the
corresponding VOI.
CI (Conformality Index) The ratio of total tissue volume that receives the prescription isodose to
tumor volume that receives the prescription isodose or more.
nCI (New Conformality Index) The Conformality Index multiplied by the ratio of the total tumor volume
to the tumor volume that receives the prescription isodose or more.
HI (Homogeneity Index) The ratio of the maximum dose in each VOI to the prescription dose.
For the current configuration of the Accuray Precision System, the
maximum dose is always 100% isodose.
Coverage (%) The volume of the tumor that receives the prescription dose divided by
the total volume of the tumor times 100.
Dx Vx Values
Dx Vx Values tables for customizable dose-to-volume analysis are available
wherever dose statistics are shown. In the Isocentric, Sequential, or VOLO
step, you can perform dose-to-volume analysis on active plan VOIs, All
Target Regions, or Soft Tissue. After selecting an option from the
drop-down list, enter one (of four) values to track: Dose (in Gy/cGy or %) or
Volume (in cm3 or %). The other three values are automatically calculated.
Entered values appear as bold text.
Item Description
Name Select VOIs names from the drop-down list to display Dx and
Vx values. Double-click the color box to move the cross-hairs
to the centroid of the corresponding VOI, and move the DVH
probe to the point on the DVH graph corresponding to the
current Dx Vx values (if specified).
Dose (Gy or cGy) Displays the dose of the selected VOIs in Gy or cGy. Entered
Dose (%) Displays the dose of the selected VOIs in %. Entered values
Volume (cm3) Displays the volume of the selected VOIs in cm3. Entered
Volume (%) Displays the dose value of the selected VOIs in %. Entered
Criteria (double-click Double click to open the Edit DxVx Criteria dialog box, and
to edit) enter values to augment each DxVx value which you want
to evaluate against the active plan.
DxVx Criteria
Use Edit DxVx Criteria dialog box to augment each DxVx value to evaluate
against the current active plan results. The evaluation results are shown
with pass, fail, and warning indicators.
You can specify dose/volume quantity, VOI mean dose or Cl (conformality
Index), relative comparison (<, <=, >, >= or within range), and min/max
warning values (optional).
Indicator Description
Pass - Criteria is met. Place the mouse over the icon to view
Warning - The main criteria is not met, but the value meets an
enabled warning min/max setting.
Fail - Criteria is not met. Place the mouse over the icon to view
Performing Customized Dose-to-volume Analysis

1. Select a VOI or All Target Regions or Soft Tissue from the Name drop-down
list.
2. In a Dose or Volume field, enter the value you want to analyze.
3. Use Criteria field to edit the DxVx values you entered to augment each
DxVx value for further evaluation against the current active plan results.
4. Start the optimization. The other three values for the Dose or Volume fields
are automatically calculated.
5. The evaluation results are displayed based on the criteria and actual value.
Plan Information
The Plan Information table displays the following parameters for the active
plan:
• Plan Name
• Plan Type
• Prescription
• Treatment Machine
• Number of Fractions
• Final Total MU
• Fraction MU
• Dose Calculation Algorithm
• Density Model
• Density Overrides (electron, mass)
• Dose Calculation Resolution
• Dose Volume Spacing (mm)
• Dose Volume Size (voxels)
• Treatment Anatomy
• Template Path Set
• Synchrony Method
• InTempo Imaging
• Collimator Type
• Collimators Used (mm) - Fixed and Iris only
• Number of Segments - MLC only
• Number of Beams- Fixed and Iris only
• Number of Nodes
• Minimum MU/Beam- Fixed and Iris only
• Maximum MU/Beam- Fixed and Iris only
• Minimum MU/Segments- MLC only
• Maximum MU/Segments- MLC only
• Estimated Treatment Time (min)
• Add Fraction Original Plan Name
Dose Points
The Dose Points tab contain the dose points that you have defined for the
active plan.
• Click Add to add dose points.
• Click Delete to remove dose points that you have added.
• Click Update to update dose points that you have added.
 Prescription
Use the Prescription dialog box to define the isocurve-based prescription
dose parameters. Or, click the Target Coverage button to prescribe dose to
a target based on a percentage of the target volume in the Set Isocurve
Prescription from Target VOI Coverage dialog box.
Isocurve-based Prescription
Item Description
Number of Fractions Displays the number of fractions defined in the Setup > Machine step. You can
text box edit the number of fractions here to scale the final segment/beam weights
resulting from the optimization to achieve the prescribed dose.
Prescribed Isocurve Enter a numeric value to set the prescribed isocurve percentage of max dose.
text box
Prescribed Dose text Enter a numeric value to set the prescribed dose (Gy/cGy) for the prescribed
box isocurve percentage.The allowable range for the absolute dose field is 0.01 to
120 Gy (or 1 to 12,000 cGy). Its initial displayed value is the current prescribed
dose value if a target VOI is specified.
Target Coverage Click to open the Set Isocurve Prescription from Target VOI Coverage dialog
button box.
Set button Click to save values displayed and re-normalize the dose based on the
prescription.
Cancel button Click to discard changes and close the Prescription dialog box.
Target Coverage Prescription

Target Coverage option converts user-defined target coverage parameters
into the equivalent isocurve-based prescription dose.
NOTE: The parameters entered in the Set Isocurve Prescription from Target VOI
Coverage dialog box are not saved with the plan.
Item Description
% Volume text box Enter a numeric value to set the percentage of a VOI volume, which
applies to the selected Target from the drop-down list in order to receive
the prescribed dose.
Target drop-down list Select a target VOI from the drop-down list to apply the prescription.
Gy (or cGy) Enter a numeric value to set the prescribed dose (Gy/cGy). The allowable
range for the absolute dose field is 0.01 to 120 Gy (or 1 to 12,000 cGy).
Set button Click to save values displayed and re-normalize the dose based on the
prescription.
Cancel button Click to discard changes and close the Set Isocurve Prescription from
Target VOI Coverage dialog box.
Settings Step
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
 Setting Step Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
 Overview
Use the Settings step to:
• View the current density model.
• Select a density model.
• Enter or modify density overrides.
• Select the contour correction.
• Define the beam intersection options for each VOI.
• Evaluate and modify the location and the size of the dose calculation
box.
 Tools
Density Model drop-down list Displays the current density model.Select from a list of
alternatives. A typical density model contains a mass
density model curve and a relative electron density model
curve. Both curves are displayed on the graph.
graph display Displays the current density model as a graph.
Density Overrides Displays the Density Override Table.

button
Contour Correction For Ray-Tracing algorithm only: When selected, applies a

check box correction to off-axis rays to account for patient surface
obliquity.
Detect Padding When selected, the Accuray Precision System checks

Pixels in CT that beam intersections with the patient are performed
Images check box inside the region of the padded pixels. This setting helps
assure that beams do not intersect the patient at a point
that is not seen in the CT image, especially if the patient
is larger than the CT field of view. (CT Scanners add
padded pixels to convert the circular scan to a
rectangular image.)
Do not select this check box for computer generated CT
series that are used for QA purposes.
Dose Calculation Box Size to Fit • CT: Sets the dose calculation box to the size of entire
CT Volume.
• Skin: Sets the dose calculation box to the size of Skin
VOI. Skin VOI must be predefined.
• VOIs: Sets the dose calculation box to encompass all
VOIs.
Beam Intersection Displays a list of VOIs and the options for beam
intersection.
• Allowed: Allows beams to intersect the listed VOI.
• Never: Does not allow beams to intersect the listed
VOI.
• Exit Only: If a beam or segment intersects the listed
VOI before it intersects the target, it will be
unavailable.
For segments, only the portion that intersects with the
VOI is blocked, not the whole segment.
Ray-Tracing and Finite Size Pencil Beam Calculations
The Ray-Tracing and FSPB dose calculation algorithms uses the relative
election density to determine the effective depth for any beam at any point
in the patient anatomy. A density model with a valid mass density curve is
required when you select MLC as Collimator on the Machine step regardless
of Lateral Scaling selection.
The relative election density is defined as the electron density value for a
given HU value relative to the electron density of water.
The beam list on the Evaluate task reports both this effective depth and the
central axis (CAX) depth. The CAX depth is the Euclidean distance along
the beam between the surface of the patient and the point in the patient
anatomy.
The surface point, which is the intersection of each beam with the patient,
is detected by applying an intensity threshold to the HU values. The
minimum threshold is a HU value of -800. All relative electron density
curves should set the relative electron density to zero (0) for HU value -801
or less. See the Physics Essentials Guide for more information.

The Monte Carlo Dose Calculation algorithm uses the mass density to
model energy dissipation and scale the tracks while particles move through
the patient. The Mass Density is defined as the mass per unit volume in
units of g/cm3. This algorithm does not use an effective depth. Nor does it
require that the system determine the intersection point of the central axis
of each beam with the patient anatomy. A threshold HU value is not needed
for the transformation of the HU value to the mass density. Therefore, when
the Monte Carlo Dose Calculation algorithm is used, all HU values will
generally have a non-zero value for the mass density. (The default curves
use 0.001 g/cm3 for a HU value of -1000 or lower.) See the Physics
Contour Correction
Contour Correction is an option for the Ray-Tracing algorithm. When Contour
Correction is available, it estimates the off-axis effective depth for each
beam at each calculation point by modeling changes in depth over the
cross-section of the beam. In a plan that has beams with oblique angles to
the patient surface, or large-diameter beams that pass through
inhomogeneous tissue, contour correction improves the accuracy of the
dose calculation.
The Monte Carlo algorithm implicitly accounts for surface obliquity;
therefore, no contour correction option is necessary. See the Physics
Detect Padding Pixels in CT Images
This setting is only available when the CT images have padding pixels. CT
Scanner can add padded pixels to convert the circular scan to a rectangular
image. When this check box is selected, the Accuray Precision System
checks the beam intersection within the region of the padded pixels. This
helps to assure that beams do not intersect the patient at a point that is not
seen in the CT image, especially if the patient is larger than the CT field of
view.
Beam Intersection
The Accuray Precision System provide you with the options to determine
which critical VOIs can be intersected by beams during plan optimization.
There are following beam intersection options. The default is Allowed.
• Allowed: The beam intersection is not restricted.
• Exit Only: Allows the beam intersection only after the beam exits a target
VOI.
• Never: Beam intersection is not allowed.
 Setting Step Procedures

Apply a Density Model
Density Model can be set or modified by going to Planning Settings > Planning
Parameters from the Home page. Density model cannot be edited while
creating a plan or when a plan is loaded.
The default density model for a new plan is Body Standard.
NOTE: When you load a plan, if the density model of the plan is not found on the
current Accuray Precision System, the new plan density model is added to the
Density Model list. The name of the new model is the original model name with a
prefix ([plan])
1. Select a Density Model from the drop-down list.

When a plan is loaded and the density model is changed, all beams in the
plan are preserved but the dose is deleted.
View Density Model Data for a HU Value
CAUTION: Using a density model that is inappropriate for a plan can cause
unexpected results in planning. Review the density model carefully to ensure it is
appropriate for the current plan.
Point anywhere over the density model graph to view the mass density
value and relative electron density value for a given HU value.
Select Contour Correction (Ray-Tracing Only)

Select the Contour Correction check box. The Contour Correction setting is
applied to all beams in the plan during dose calculation.
Select Detect Padding Pixels in CT Images
CAUTION: Do not select this check box for computer generated CT series that are
used for QA purposes.DICOM padding tags are not present.
Select the Detect Padding Pixels in CT Images check box to verify that the
beams do not intersect the patient at a point that is not visible in the CT
image.
Set the Dose Calculation Box

Set the Dose Calculation Box size using the Size to fit buttons or manually
drag the control point or the edge of the box to a new location.
Set the Beam Intersection for each VOI
CAUTION: For previously saved deliverable plans, if you change the intersection
property of a VOI to Never or Exit Only, the dose of any non-zero intersecting beam
may be changed to zero, which can degrade the quality of the plan.You must
re-optimize the plan in order to save it as deliverable. To assign zero dose to
beams that intersect a critical structure after the plan has been generated, go to the
Evaluate > Finetune. step.
The default beam intersection option for each critical VOI is Allowed.
Highlight the VOI and select the beam intersection option from the
drop-down list.
Isocentric Step
Use the Isocentric step to create an isocentric plan. There are two kinds of
isocentric plans: isocentrically targeted beams equally and weighted and
isocentrically targeted beams with conformal weights
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
 Isocentric Planning Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
NOTE: The isocurves legend is displayed only when the plan has beams with dose.
 Tools
Isocenter drop-down list Displays the current isocenter.Select a different isocenter from
the drop-down list for the current plan.
Use TmP 1 When selected, includes template path during generation of

Use TmP 2 beams. Each node on a selected path contributes a single beam
to the isocenter.
Use TmP 3
check boxes
Color drop-down Select the display color for the isocenter, for both the circle on the
list 2D views and the 3D object on the 3D view. Does not affect
planning.
Dose (Gy or cGy) Set the beam weights so that the total dose at the isocenter
text box matches the value you enter.
New button Click to create a new isocenter at the selected location.
Delete button Click to delete the current isocenter.
All Isocenters Conformal Weights Select to generate isocentric beams and allow conformal
check box weighting of dose for the isocentric beams.
The beam geometry (the target and collimator size of the beam
set) is created on the Isocentric step and the beam weights are
assigned on the Sequential step.
Apply button Click to generate beam set for each selected isocenter.
Display Layouts The following layouts are available for isocentric planning on
Display tab:
 Isocentric Planning Procedures

Create an Isocenter
1. Go to the Plan > Isocentric.
2. Drag the cross-hair on a 2D image to the desired location for the isocenter.
3. Evaluate the position on the planar views and modify as needed to locate
the center of the target structure.
4. Click New. A circle appears on the image with a legend for the collimator
size used for the beams that comprise the new isocenter.
The new isocenter appears on the Isocenter drop-down list.
5. To change the display color of the collimator, select a new color from the
Color drop-down list. The color appears as a circle on the 2D views and as
a 3D object on the 3D view.
6. To change the size of the isocenter, drag an edge of the selected isocenter
to a new location.
As you drag the isocenter, the size of the circle and the collimator size
legend change in increments according to the set of available collimator
sizes. The minimum and maximum isocenter sizes are constrained by the
smallest and largest collimator sizes.
7. To move the isocenter, drag it to a new location.
Modify the Placement of an Isocenter

1. Point to the isocenter indicator on the image viewer. When the cursor is
shaped like a hand, it is selected.
2. Drag the isocenter to the new location.
Select an Isocenter
Select an entry on the Isocenter drop-down list. The selected isocenter
becomes activate and appears in color on the 2D images.
Modify the Size of a Collimator

Select a control point on the perimeter of the collimator and drag toward or
away from the center of the circle.
Create an Isocentric Plan

1. Select an isocenter from the Isocenter drop-down list.
• The Template Path Set determines the number of template paths.
• Each node on a selected template path contributes a single beam to the
isocenter.
• Nodes on the cleared paths do not contribute beams to the isocenter.
2. On the All Isocenters section, select a process for determining beam weights
on the Isocentric step. Note that beam geometry is the target and collimator
size of the beam set.
• Clear the Conformal Weights check box to create beam geometry and
assign equal beam weights.
• Select the Conformal Weights check box to create beam geometry and
assign beam weights on the Conformal step.
3. To set the dose at the center of the beam, enter a value in the Dose (Gy/cGy)
text box.
• The beam weights at the center of the active isocenter are set to the
value you enter.
• Existing dose from other isocenters and conformal planning is
considered during this calculation.
NOTE: The Dose (Gy/cGy) setting cannot be used in conjunction with the
Conformal Weights selection. When the Conformal Weights check box is selected,
the Dose (Gy/cGy) text box is unavailable.
4. To generate beams, click Apply.
If the existing dose at the center is already higher than the selected value,
all beam weights are set to zero for the active isocenter.
Delete an Isocenter
NOTE: After you delete an isocenter, do not add, delete, or modify an isocenter
until the light stops flashing in the status bar.
1. Select an isocenter from the Isocenter drop-down list.

2. Click Delete. The beam set for this isocenter is deleted and the dose distribution,
if calculated, are updated.
Sequential Step
 About Sequential Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
 Display. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
 MLC Settings (MLC only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
 Relaxed Convergence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
 Time Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
 Beam Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
 Node Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
 Segment Reduction (MLC only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
 Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
 Dose-Volume Histogram in Sequential Step . . . . . . . . . . . . . . . . . . . . 485
 Data Saved in a Sequential Optimization Plan . . . . . . . . . . . . . . . . . . 488
 Sequential Optimization Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 489
NOTE: For more information on Sequential Optimization and dose calculation

algorithms, see the Physics Essentials Guide.
 About Sequential Optimization

The Sequential Optimization option is comprised of a series of individual
optimization steps, which are performed in a defined sequence. Each step
corresponds to a clinical objective. The steps and user-defined constraints
comprise a script.
A Sequential Optimization script is created in the following manner:
• Define maximum dose and dose volume constraints for the VOIs.
• Define maximum MUs for each beam, for each robot position (node),
and for the entire treatment plan (Total MU).
• Define an objective and a relaxation value for each optimization step
and the order in which the steps will be performed.
When the script is played, the result of each step represents the optimal
achievable value for the objective of the step given the existing constraints
and relaxation values. Each result is applied as an additional constraint for
each subsequent step. Thus, the treatment plan is built up one clinical
objective at a time, with a gradual improvement observed after each step.
In addition, a beam reduction tool allows the script to be run using a smaller
number of beams.
The appropriate sequence of optimization steps for a typical clinical
application can be saved as a script. The script can be loaded for use with
a similar clinical case. Each script contains the MU limits, auto-shells
settings, maximum dose and dose volume constraints, and an ordered list
of optimization objectives (steps). For fixed and Iris Collimator plans,
collimator(s) must be selected for each plan. Collimator settings are not
saved with the script. A script can be modified during planning to address
the specific requirements of a given case. For MLC plans, set parameters
to generate leaf shapes. These parameters are saved and then reloaded
with the script.
During Sequential Optimization, you can pause, review progress, jump to
the next step, and restart the process from the beginning after modifying the
script.
 Display
Go to Plan > Sequential > Display tab to select the display layout to use.
 Tools
Collimators Fixed and Iris Collimators only: Click to open the Collimators
button dialog box.
Script Click to save a new or modified script.
Click to load a previously saved script.
Click to delete the script selected on the Delete Script dialog

box.
MU Limits Click to open the MU Limits dialog box.

button
Auto-shells Click to open the Auto-shells dialog box.

button
Constraints Click to open the Constraints and Steps dialog box.

and Steps
button
MLC Settings Click to open the MLC Settings dialog box, which allows you to
button (MLC set the maximum number of nodes for the plan and the leaf
only) segment generation methods.
Relaxed Select to apply convergence criteria for the sequential

Convergence optimization steps that reduce the optimization time.
check box
VOI, Displays the name of VOI and its dose objectives that you have
Objective defined in the Constraints and Steps. You can select a step to
run or run all the steps continuously in the order. If you select the
Pause at end in Constraint and Steps, the check box is selected
in the pause column to indicate that the optimization pauses at
the end of the step.
Resets the Sequential Optimization process to the beginning.

Choose to retain existing beams and weights or delete existing
beams and weights.
Play: Starts or resumes the Sequential Optimization process.

When the script is executing, the Stop button is available.
Quits the current step and starts the next step. Step Forward
cannot be used during the final step of a script.
Time Click to open the Treatment Time Reduction dialog box. This
Reduction button is only available when a dose volume exists and contains
button one or more beams with the number of MU greater than 0. Set a
goal delivery time per treatment fraction. The number of beams
and nodes in the solution will be reduced iteratively.
Stop Time Reduction is available during the optimization phase

of Treatment Time Reduction. This button stops the time
reduction process during the time reduction optimization phase,
but not during the beam node pruning or beam retargeting
phases of time reduction.
Node Click to open the Node Reduction dialog box. Set the desired
Reduction number of nodes and re-optimize.
button
Beam Fixed and Iris Collimators only: Click to open the Beam
Reduction Reduction dialog box. Set a cutoff (MU), delete beams with MU
button below the cutoff, and re-optimize.
Segment MLC only: Click to open the Segment Reduction dialog box.
Reduction
button
Dose Calculation Algorithm Displays the current dose calculation algorithm.Select an

drop-down list alternative, if any, from the drop-down list.
Resolution Displays the current resolution.Select an alternative from the

drop-down list drop-down list. (Low, Medium, or High).
Uncertainty Monte Carlo only: Sets the uncertainty level used for calculating
(%) text box dose. (0.1% - 4.0%)
The Uncertainty setting is available after you perform a
Ray-Tracing dose calculation and select Monte Carlo on the
Algorithm drop-down list.
Prescription Click to open the Prescription dialog box.

button
MU Limits
Use the MU Limits dialog box to set and view Total MU for the plan, Max MU
per Beam (Max MU per Segment for MLC), and Max MU per Node. These
settings are used as constraints and applied to all steps in the script. The
plan will not exceed these limits.
Control Description
Total MU Enter value for maximum total MU for the plan.
Max MU per Beam For Ray-Tracing and Monte Carlo: Enter value for maximum MU per beam.
Max MU per Segment For MLC only: Enter value for maximum MU per segment.
Max MU per Node Enter value for maximum MU per node.
OK button Click to save the settings for MU limits. After you click OK, the MU limits are
set and the MU Limits dialog box is closed.
Cancel button Click to cancel the entered MU limit settings and return to the Sequential step
screen.
Constraints and Steps

Use the Constraints and Steps dialog box to define and modify VOI
constraints (maximum and dose volume), step definitions for Sequential
Optimization, and sampling used for optimization.
WARNING: Adding dose constraints to Spine Tracking Volume may result in

unexpected plan results. Do not add constraints to the Spine Tracking Volume.
Maximum Dose Constraints and Dose Volume Constraints
A maximum dose constraint can be defined for any target, critical VOI, or
auto-shell. If a maximum dose constraint is not defined for a VOI or an
auto-shell for which a dose volume constraint or dose objective is defined,
the system will automatically create a constraint according to the following
rules when you click the Update or OK button.
• For critical VOIs: The maximum dose will be set to the highest dose
from all steps and constraints.
• For target VOIs: The maximum dose will be set to the highest OHI goal
value if there are OHI steps defined for the VOI. If there are no OHI
steps defined for the VOI, then the maximum dose will be the highest
dose from all steps and constraints multiplied by 1.5.
• For auto-shells: The maximum dose will be the highest dose from all
steps and constraints.
Automatically generated constraints are listed in a message at the right side
of the Maximum Dose Constraints and Dose Volume Constraints table.
Maximum dose constraints are allowed for target and critical VOIs; and
dose-volume constraints are only allowed for critical VOIs. Dose-volume
constraints can be in cm3 or %, the default is %. The maximum dose and
dose-volume constraints are applied to all steps in the script. The plan will
not exceed these constraints subject to dose calculation resolution and
sampling consideration.
Section Control Description
Maximum Dose VOI Name Displays VOIs for the plan.

Constraints and Dose
Volume Constraints Dose Displays dose value to be assigned to a
maximum dose or dose volume constraints for
plan VOIs. When a VOI is selected, the dose
value can be changed.
Volume Displays volume values for plan critical VOI.

When a critical VOI is selected, the volume
may be changed. Dose-volume constraints are
only allowed for critical VOIs.
Volume Unit Displays critical VOI dose-volume constraint

as either % or cm3.
Automatically Generated Displays the VOIs that have automatically

Maximum Dose Constraints generated maximum dose constraints.
Add Click to add the selected VOI.
Delete Click to delete the selected VOI.
Define or Edit Maximum Dose and Dose Volume Constraints for
VOIs
1. Click the Constraints and Steps button. The Constraints and Steps dialog box
appears.
2. To add a VOI to the VOI Name column, click the Add button.
3. In the VOI Name column, select a VOI from the drop-down list.
4. Enter the dose.
5. (Optional) For critical VOIs, select the units from the drop-down list,% or
cm3, and enter volume.
6. To delete a VOI, select the VOI and click the Delete button.
Dose Objectives
Use the Dose Objectives table to set goals for the VOIs, auto-shells, and MU
to be used in the Sequential Optimization steps. A Sequential Optimization
plan can have up to 20 steps. The first step must be for a target VOI
selected from the drop-down list for step 1. All other steps can have either
a target VOI, a critical VOI, an auto-shell, or MU.
The optimization strategies available for a step depend on whether the

objective is a target VOI, critical VOI, auto-shell, or MU. For a description of
these options, see the table below.
For each goal, you can also enter a relaxation value that sets an acceptable
range for the dose or volume objective.
Dose Step Displays the current step number. (read-only)

Objectives
VOI Name Drop-down list displays VOIs, auto-shell, or the MU for the plan.
drop-down list After selecting a name on the VOI Name list, the Objective
drop-down list displays the available objectives for the VOI type,
auto-shell, or the MU for the plan.
Objective Targets
drop-down list Optimize Minimum Dose (OMI): Maximizes the minimum dose
value to be as close as possible to the entered goal.
Optimize Maximum Dose (OMA): Minimizes the maximum dose
to be as close as possible to the entered goal.
Optimize Coverage (OCO): Maximizes the total dose to all
calculation sample points that receive less than the entered dose
goal. As a result, it maximizes the volume that receives at least
the entered goal.
Optimize Homogeneity Index (OHI): Maximizes the total dose to
all calculation sample points that receive less than the entered
dose goal. As a result, it maximizes the volume that receives at
least the entered goal.
Dose Volume Lower Limit (DVL): Optimizes the dose volume
histogram of the target toward the specified dose volume
objective.
Critical Structures
• Optimize Maximum Dose (OMA): Minimizes the maximum
dose to be as close as possible to the entered goal.
• Optimize Mean Dose (OME): Minimizes the total dose to all
calculation sample points that receive greater than the entered
dose goal. As a result, it minimizes the volume that receives
more than the entered goal.
• Dose Volume Upper Limit (DVU): Optimizes the dose volume
histogram of the critical structure toward the specified dose
volume objective.
Auto-shells
Optimize Conformality Index (OCI): Minimizes the maximum dose
to be as close as possible to the entered goal.
MU
Optimize Monitor Units (OMU): Minimizes the total number of
MUs in the plan.
Goal text box Sets the goal dose (Gy/cGy) for targets, critical structures, and
auto-shells, and the goal MU for Total MUs.
Volume text box Displays volume goals for plan target or critical VOIs.
Volume Unit Select to volume goal as either % or cm3.

drop-down list
Relaxation Sets the maximum value by which the script will relax the
Value text box optimized objective for the VOI or the Total MU to be used as
constraints in subsequent steps. If the step objective is either
DVU or DVL, the unit of relaxation is that of the volume unit (% or
cc). For all other objectives the relaxation value is Gy/cGy and
MU for OMU.
Pause at end Select to pause the script after the step has been optimized.
check box
Add button Click to add a step.
Delete button Click to delete the selected step.
Move Up button Click to move the selected step up one row.
Move Down Click to move the selected step down one row.
button
Add a Step for Sequential Optimization
Click the Add button, and select a VOI from the drop-down list in the VOI
Name column.
Define or Edit a Step

1. In the Objective column for the VOI, select an optimization method from the
drop-down list.
2. Enter the dose goal and the volume goal (if applicable) for the VOI.
3. Select the volume unit to use from the drop-down list, % or cm3(if
applicable).
4. Enter the relaxation value for the VOI.
5. Select the Pause at end check box to pause Sequential Optimization after
executing a step.
Rearrange the Order of the Steps

Select a step, and click the Move Up or Move Down button.
Delete a Step from Sequential Optimization

Select a step, and click the Delete button.
Show/Hide VOI Setup

The Show/Hide VOI Setup button shows or hides the VOI setup table. The
table shows all VOIs and auto-shells defined for the plan, It also displays
the total number of sample points for all VOIs, the number of sample points
used for each VOI, and the number of sample points per unit volume (cm3)
for each VOI.
You can change the Boundary Only setting and modify the sampling Skip
Factor to reduce the number of voxels used in optimization. If all voxels
should be included, do not modify these settings.
Sampling Total Number of Displays total number of sample points used for plan VOIs.
Sampling Points
Update button Updates total number of sample points for plan VOIs.
Show VOI Setup/ Click to show or hide the VOI Setup table. The default setting is
Hide VOI Setup Hide VOI Setup. The VOI Setup table appears if Boundary Only is
button selected for one or more VOI or a Skip Factor greater than one is
set for one or more VOI.
VOI Setup Step Lists names of plan VOIs.
VOI Type Lists type of plan VOI, Target or Critical.
VOI Volume (cm3) Lists VOI volumes in cm3.
Boundary Only When selected, constrains a VOI for boundary voxels only.
check box
Skip Factor text Sets the skip factor for changing the sample points-to-volume
box ratio for plan VOIs. At the default skip factor of one, each voxel
where the dose calculation volume overlaps the VOI is
constrained. To reduce the total number of constrained points,
increase the skip factor.
Sample Points Displays the sample points used for a VOI based on all the
constraints defined by you and the system.
Sample Points/ Displays the sample points-to-volume ratio for plan VOIs in units
Volume of 1/cm3.
Use the VOI Boundary Only Option for Sampling a VOI
Select the Boundary Only check box, and then click the Update button. The
total number of sampling points for the plan is recalculated and appears in
the Total Number of Sample Points field.
Change the Skip Factor for Sampling a VOI

Enter a value in the Skip Factor field, and then click the Update button.The
total number of sampling points for the plan is recalculated and appears in
the Total Number of Sample Points field.
 MLC Settings (MLC only)

Set the maximum number of nodes for the plan and the leaf segment
generation method.
Item Description
Maximum Number Set maximum number of nodes used to generate segments that will be optimized.
of Nodes text box The range is determined by the number of nodes in the selected path.
Item Description
Leaf Segment Methods \ Targets: Lists the available segmentation methods. Select the check
Methods box to generate beam segments (Isocentric Conformal and Conformal
Avoidance), set a margin around the target VOI, and set a Leaf Margin (mm) and
a Lead Leaf Justification convention.
Avoidance Control OARs \ Targets: Only active if a target uses Conformal Avoidance segment
generation and the Beam Intersection for the selected VOI is not set to Never.
Use this control to include segments that specifically do not intersect the selected
VOIs.
NOTE: Some segments may intersect the VOIs. If you do not want any segments
to intersect a specific VOI, it should be turned off in the Settings step.
Clear Settings Click to discard the changes and use a default method avoidance control that is
button generated from the constraints and steps in the sequential script.
OK button Click to save the settings. If the settings have changed, any existing beams are
deleted.
Cancel button Click to discard changes and close the MLC Settings dialog box.
 Relaxed Convergence
The Relaxed Convergence applies convergence testing during optimization.
Convergence testing may decrease optimization time by evaluating the
objective value of each step at each update to determine if the objective
value is slowly changing (as it often does when close to the optimum value).
If changes in the objective value are below the change threshold of the
convergence test, optimization of the step will end at the update.
You can select the Relaxed Convergence prior to the optimization, after
optimization has been completed, or during the Pause state. The check box
setting is applied throughout the optimization and the setting does not
change even when you exit the Sequential step and re-enter or when the
plan is saved and reloaded.
 Time Reduction
Time Reduction iteratively reduces the number of available beams and
nodes and runs the Sequential Optimization script to make the plan’s
treatment time less than or equal to the desired treatment time. The solution
space consists of a set number of beams and nodes. The minimum solution
space is determined automatically based on the template path or the
desired treatment time per fraction. If these limits are reached and the
estimated time per fraction is greater than the goal, the time reduction
process terminates. To further reduce time, use either the node or beam
reduction tools.
WARNING: Treatment time reduction of the treatment plan can degrade the quality
of the plan. You must review the treatment plan using Evaluate > Review step.
Item Description
Estimated Treatment Goal: Enter the value for the desired treatment time (in minutes) per
Time Per Fraction fraction.
(minutes) text box NOTE: The minimum goal treatment time, minimum allowed threshold, 10
minutes, plus user-defined patient setup time.
Current: Read-only display of the estimated treatment time per fraction of
the current plan.
Item Description
Solution History button Available only when there are solution records stored from the previous
time reduction process. When clicked, the Treatment Time Reduction
dialog box expands showing the solution records saved during the
previous time reduction process.
The history is cleared in the following instances:
• Collimator settings are modified.
• Reset button is clicked.
• When a treatment plan is deleted outside of Sequential.
• When a new time reduction is started.
Index: Identifies the solution records saved during the time reduction
process. Index 0 indicates the treatment plan state before the time
reduction process begins. Index 1 indicates the solution record after
iteration 1 has completed, etc.
Time (minutes): Estimated delivery time of the solution record.
Set Highlighted as Current and Load:button: When this button is clicked,
the system sets the highlighted solution record as the current solution
record and reloads the saved beams and weights. Then dose is
recalculated.
Reduce and Optimize Click to validate the goal value. If valid, the time reduction process starts.
button
Cancel button Click to discard changes and close the Treatment Time Reduction dialog
box.
 Beam Reduction
Beam Reduction reduces the total number of beams in the treatment plan.
Set a cutoff value for MU per beam to exclude beams below the MU cutoff.
Select to remove those beams and calculate dose for the remaining beams,
or remove those beams and then repeat the optimization script using the
remaining beams.
NOTE: Typically, the resulting minimal MU per beam is higher than that in the
original plan. However, the re-optimization option can cause the MU value for some
remaining beams to be below the Beam Reduction MU Cutoff value.
NOTE: If the MU cutoff is set too high, it can result in a significant degradation of
the quality of the plan.
Item Description
Beam Reduction Enter minimum value (MU) for beams to be retained in the plan. All beams with
MU Cutoff text box dose below this value will be removed from the current plan.
Calculate button Click to calculate the beam and node statistics resulting from application of the
beam reduction with the entered MU cutoff. No beams are removed by this
calculation.
Reduce button Click to accept changes, remove beams whose MU are below the cutoff, and
recalculate the remaining non-zero beams without re-optimization. If the
optimization was previously in a Paused state, this will result in going back to the
Ready state with the step being reset to 1.
Reduce and Click to accept changes, removes beams whose MU are below the cutoff, and
Optimize button start re-optimization with the first step.
Cancel button Click to discard changes and close the Beam Reduction dialog box.
 Node Reduction
Node Reduction reduces the total number of nodes in the treatment plan.
You can delete nodes based on the Lowest MU or Lowest Area-Weighted MU.
Item Description
Desired Number of Enter the desired number of nodes to be retained in the plan.
Nodes text box
Calculate button Click to calculate the number of beams, nodes, and monitor units that will be
removed for the desired number of nodes. No nodes are removed by this
calculation.
Delete Nodes Based On • Lowest MU: Delete nodes that have the lowest total MU.
options • Lowest Area-Weighted MU: Delete nodes that have the lowest product of
beam area multiplied by the beam MU.
Reduce and Optimize Click to accept changes, remove nodes according to the lowest MU or the
button lowest area-weighted MU, and start re-optimization with the first step.
Cancel button Click to discard changes and close the Node Reduction dialog box.
 Segment Reduction (MLC only)

Segment Reduction reduces the total number of segments in the treatment
plan.
Item Description
Segment Reduction Enter minimum value (MU) for segments to be retained in the plan. All beams
MU Cutoff text box with dose below this value will be removed from the current plan.
Calculate button Click to calculate the segments and node statistics resulting from applying beam
reduction with the entered MU cutoff. No segments are removed by this
calculation.
Reduce button Click to accept changes, remove the segments whose MU are below the cutoff,
and recalculate the remaining non-zero segments without re-optimization. If the
optimization was previously in a Paused state, this will result in going back to the
Ready state with the step being reset to 1.
Reduce and Click to accept changes, remove segments according to lowest MU or lowest
Optimize button area-weighted MU, and start re-optimization with the first step.
Cancel button Click to discard changes and close the Segment Reduction dialog box.
 Status Indicators
During Sequential Optimization, color is applied to the steps on the VOI,
Objective list to indicate the status of each step.
Color Status Actions
Blue Default The step is in default status before you click Play.
Green Running Indicates the step is running.
Yellow Paused Indicates the step is paused, either after you click Pause or at the end of a
step.
Black Completed Indicates the step has run successfully.
Orange Invalid Indicates the step failed validation. An invalid step does not meet
requirements. Modify the step and click Play to perform validation again.
 Dose-Volume Histogram in Sequential Step

When you perform Sequential Optimization in the Sequential step, the DVH
image viewer includes indicators for constraints and maximum, minimum,
and dose-volume optimization steps. There are no indicators for mean,
homogeneity, coverage, conformality, or MU optimization steps. The DVH
image viewers are updated after each iteration of the optimization process
or every 20 seconds, whichever is longer.
In the DVH image viewer, a constraint is shown as an ”x”. A goal is shown
as an arrow indicating which direction the step should push the DVH curve.
Item Description
DVH Properties Click to open the DVH Properties dialog box.

button
Selected DVH Displays the current active DVH VOI.Selectan available DVH from the drop-down
drop-down list list. To display dose (percentage and Gy/cGy) for each point on the active curve,
click a point on a curve, and a vertical bar appears. Drag the point or the vertical bar
across the image viewer.
View DVH Displays

1. Select a structure from the Selected DVH drop-down list. The VOI curve is
now active on the DVH image viewer. By default, the X-axis displays
relative dose (%).
2. (Optional) To modify the X-axis display, click the isocurves legend. The
Isocurves panel appears.
3. Select the Show absolute dose check box and dismiss the Isocurves panel.
The X-axis on the DVH image viewer updates to display absolute dose
(Gy/cGy) for all VOI.
When you click a point in the active DVH, a vertical bar appears. The
display color for the vertical bar and isocurve corresponds to the setting in
the DVH Properties dialog box.
DVH Properties Dialog Box
In the Sequential step, the DVH Properties dialog box displays settings and
controls for the display properties of VOIs on the DVH image viewer. It also
gives options to hide all, show all, or only active DVH for constraints and
objectives.
Item Description
Background Color From the drop-down list, select a background color for the DVH image
viewer (gray, white, or black).
Check box column Select a check box to view the DVH.
VOI Name Displays the available target and critical VOIs.
Color Displays the color for lines, curves, and text for each VOI on the DVH
image viewer.
Constraints and Objectives • Hide All: Neither constraints nor objectives appear.
Display options • Show All: Constraints appear as “x” and objectives appear as arrows.
The colors are the same as the contour and the goal is positioned at
the volume and the dose.
• Show only for Active DVH: Only appears for the active DVH.
Item Description
Snap dose value to When selected, snaps dose value to nearest percent when interrogating
nearest whole percent values in relative dose mode.
when interrogating values
in relative dose mode
check box
Manage Display of VOI When the check box is clear (the default), the VOI check boxes in the
DVHs independent of VOI DVH Properties dialog box are synchronized with those in the VOIs tab.
Visibility Settings check When the check box is selected, the VOI check boxes in the DVH
box Properties dialog are independent of those in the VOIs tab.
 Data Saved in a Sequential Optimization Plan

When you save a Sequential Optimization plan, the following information is
saved with the plan.
Setting Data Saved
Collimators Fixed and Iris Collimator only: Collimator selection information, Target
Boundary Distance for each target VOI.
MU Limits Maximum total MU for the plan, Max MU per Beam, Max MU per Node.
Auto-shells Auto-shell generation settings: Source, symmetry setting, and dilation

distance for each dilation direction.
Maximum Dose and Dose Maximum Dose and Dose Volume Constraints setting including the VOI
Volume Constraints names, Dose, Volume and Volume Units.
Dose Objectives Steps settings including the VOI Names, Objectives, Goals, Volumes
Volume Units, Relaxation Values, and Pause at the End settings.
Sampling Sampling setting including the boundary only and the skip factor.
Relaxed Convergence Relaxed Convergence setting.
MLC Settings MLC only: Maximum number of nodes for the plan and the leaf segment
generation methods.
Dose Calculation Monte Carlo only: Dose Calculation setting including algorithm, resolution,
uncertainty.
Prescription Prescription setting including the number of fractions, the prescribed

Percentage and the prescribed Dose.
Estimated Treatment Estimated Treatment Time Inputs including the Estimated Patient Setup
Time Inputs Time and the Estimated Image Time Interval.
Setting Data Saved
Dx Vx VOI dose, volume data, and criteria settings as entered and calculated.
 Sequential Optimization Procedures

Defining Collimator Settings (Fixed and Iris Collimators
Only)
If you change a collimator size selection during the planning process, all
existing beams are deleted, and new beams are created based on the new
collimator size settings and target boundary distance.
NOTE: The collimators are selected according to the Method that you select. The
selected collimators appear with check marks on the Collimator list in Collimators
dialog box. These can be edited manually if necessary.
1. Click the Collimators button. The Collimators dialog box appears.

2. Define the Collimator settings. Ensure that the Path Set and Collimator type
are appropriate for the current plan.
3. For Fixed collimators, do one of the following:
• Manual collimator selection: Select up to three collimators per template
path.
• Automatic collimator selection: Select from the Target drop-down list
and from the Method drop-down list. Click Apply.
4. For Iris Collimator, do one of the following:
• Manual collimator selection: Select up to 12 collimators per template
path.
5. In the Target Boundary Distance box, modify the default values for the
displayed target if necessary.
6. Click OK.
A zero-dose beam set is generated for the defined collimators. During beam
generation, the cursor takes the form of an hourglass.
7. (Optional) Select the Show Collimator Overlay check box to view the selected
collimator sizes graphically on the main anatomical view as a guide.
Loading a Script
1. Click the Load Script button. The Load Script dialog box appears.
2. Select a script on the Script Name drop-down list. The Script Name
drop-down list is filtered to display only scripts specific to the selected
collimator type.
Description and Script Summary, which are read-only when loading an
existing script.
4. To ensure the settings are appropriate for the current case, review the
settings in the Script Summary dialog box.
5. Click the Load button. The Match VOI Names dialog box appears.
The VOI names in the script are matched to those in the plan.
Creating a New Script

Follow the steps below to create a script that reflects the specific
requirements of the current case. You can save the resulting script for use
with similar cases.
Defining MU Limits
1. Click the MU Limits button. The MU Limits dialog box appears.
2. For each category you want to use, select the check box and enter a value.
3. Click OK. The settings are saved and the MU Limits dialog box is closed.
Creating Auto-shells
1. Click the Auto-shells button. The Auto-shells dialog box appears.
2. Click the Add button. A new row for an auto-shell appears.
3. To select a different target VOI, select an entry on the Source drop-down list.
4. To create a symmetrical auto-shell, select the check box in the Symmetric
column. When you enter a value in a text box, the value is applied to all
direction. The range for dilations is 0 mm to 100 mm.
5. To delete an auto-shell, select the row and click Delete.
6. Click OK. The settings are saved, and the auto-shells are generated.
Defining Maximum Dose and Dose Volume Constraints
1. Click the Constraints and Steps button. The Constraints and Steps dialog box
appears.
2. In the Maximum Dose Constraints and Dose Volume Constraints table, click Add
button to add a VOI to the VOI Name column.
3. In the VOI Name column, select a VOI from the drop-down list.
4. Enter dose for each VOI.
5. (Optional) For a critical VOI, select the volume unit from the drop-down list,
% or cm3, and enter the volume.
Defining Dose Volume Objectives

1. In the Dose Objectives table in the Constraints and Steps dialog box, select a
target VOI from the drop-down list. The first step must be a target VOI.
2. Select an entry on the Objective drop-down list.
The result of any single optimization step is used as input for the
subsequent optimization step. Therefore, the sequence in which the steps
are performed is a key factor in determining the effectiveness of a given
plan.
3. Enter a value in the Goal field. DVU and DVL require values for Volume and
Volume Unit for dose-volume objectives.
4. (Optional) Enter a value in the Relaxation column.

5. (Optional) Select the Pause at End check box to review plan status after the
step.
6. Click Add to add more steps.
7. To change the sequence of steps, select a step and click Move Up or Move
Down.
8. To delete a step, select the step and click Delete.
Steps objectives
Objective Application
• Optimize Minimum Dose (OMI) Target

• Optimize Coverage (OCO)
• Optimize Homogeneity Index (OHI)
• Optimize Maximum Dose (OMA)
• Dose Volume Lower Limit (DVL)
Objective Application
• Optimize Maximum Dose (OMA) Organ at Risk

• Optimize Mean Dose (OME)
• Dose Volume Upper Limit (DVU)
• Optimize Conformality Index (OCI) Auto-shell
• Optimize Monitor Units (OMU) Total Plan MU
Modifying VOI Sample Points Used in Optimization

Calculations (Optional)
By default, all VOIs and their sampling points for the current plan are
hidden.
Show the VOI Setup Table
1. Click the Show VOI Setup button in the Constraints and Steps dialog box.
2. For each VOI, select a method based on the VOI type (see the table below)
for reducing the number of voxels for optimization to shorten optimization
time.
3. Click the Update button to update the display of total sample points for the
plan.
If all voxels should be calculated, do not select a method.
VOI Type Method Result
Target, Critical Structure, Enter a Skip Factor value Defines the relative number of voxels to be
or Auto-shell sampled. If you enter 5, only one in 5
voxels will be sampled during
optimization.
Target or Critical Structure Select the Boundary Only Only boundary voxels will be calculated for
check box the selected VOI.
MLC Settings (MLC only)

1. To optimize the plan, set the Maximum Number of Nodes to generate beams.
The nodes are assigned randomly to evenly sample the complete
workspace of the selected pathset.
2. Determine which target VOIs to use to shape beams.
3. Select methods to generate beam segments:
• Isocentric Conformal: Creates conformal segments in which all segments
have the same isocenter. That isocenter is the geometric center of the
target VOI. Because only one isocenter is allowed per target, the target
projection must not be bigger than the maximum projected MLC field
dimensions. The target used is the selected target minus any
unavailable VOI. (The unavailable VOIs are selected in Plan > Settings.)
Options for avoiding other VOIs or using other generation methods
(peripheral, eroded, or random) are unavailable.
• Conformal Avoidance: Allows multiple isocenters per target. This allows
selection of a VOI that some segments will avoid. (An avoidance VOI
would be selected for which dose should be limited, but its geometric
position is such that you cannot fully treat the target if no segments
could pass through that VOI.) This method allows you to select the other
generation methods. If Conformal Avoidance is selected, the apertures
for beams can be added.
4. Set the Leaf Margin (mm), which is the distance outside (positive) or inside
(negative) the target VOI that forms the conformal edge.
5. Set the Leaf Justification.
• Leading Edge: the furthest outside intersection with the target VOI.
• Trailing Edge: the most inside intersection with the target VOI.
• Middle: the midpoint projection between the Leading Edge and the
Trailing Edge.
6. If the method to generate beam segments is Conformal Avoidance for a target
VOI, one or more Critical VOI(s) can be selected to avoid. Some segments
will be shaped to not intersect with the user-selected avoidance VOI.
7. Select OK to saves the settings.
Saving the Script (Optional)

After defining all the optimization parameters, you can save all those
settings as a script. Click the Save Script icon to save the script.
Playing the Script

Click the Play icon. Steps are highlighted with color to indicate their status.
Pausing the Script

The Pause at end check box must be selected in the Constraints and Steps
dialog box to pause a script after the selected step has been optimized.
Resume Playing the Script

Click the Play icon to resume.
Changing Script Settings
Click the Stop icon to stop the script, and then make the changes. When you
click the Play icon again, the script will start from the beginning.
Stepping Forward
Click the Step Forward icon to jump forward to the next step. When the last
step is in Play mode, clicking Step Forward has no effect.
Restarting the Script

The Reset icon can be selected during pause or after the script is
completed. While paused, Reset Options dialog box appears. Select one of
the options, and click OK.
When the Reset icon is selected after the script stops, a caution message
appears stating that the beams will be deleted.
After reset, the script must be run from the first step.
Performing a New Treatment Time Reduction

1. Click Time Reduction button. The Treatment Time Reduction dialog box
appears.
2. Enter the desired treatment time per fraction in the Goal text box.
3. Click Reduce and Optimize. The Treatment Time Reduction dialog box closes.
The beams and nodes revert to the previous state and a Ray-Tracing dose
calculation is performed at the resolution indicated from the Resolution
drop-down list.
The plan is optimized and the Estimated Treatment Time per Fraction updates.
4. (Optional) To stop the time reduction process, click the Stop Time Reduction
icon. It may take a few minutes for the process to stop. The optimization
stops and uses the currently-displayed plan.
Restore a Previous Solution Record

1. Click Time Reduction button. The Treatment Time Reduction dialog box
appears.
2. Click Solution History to expand the dialog box. The solution records list
appears in the Solution History area of the dialog box.
3. Highlight a solution record and press the Set Highlighted as Current and Load
button. The beams and nodes revert to the previous state and a
Ray-Tracing low dose calculation is performed.
Reducing the Number of Nodes

Nodes removed through Node Reduction are not used during optimization.
Subsequent Sequential Optimization steps are performed using the
reduced nodes.
1. Click Node Reduction. The Node Reduction dialog box appears.
2. Enter the desired number of nodes in the Desired Number of Nodes text box.
3. Select the Lowest MU or the Lowest Area-Weighted MU option.
4. Click Calculate. The predicted reductions appear in the text boxes below.
Predicted beam and node reductions are calculated based on the Desired
Number of Nodes value and the selected MU type.
5. If the predicted reductions are unacceptable:

• Modify the value in the Desired Number of Nodes text box.
• Select Lowest MU or Lowest Area-Weighted MU.
• Click Calculate again.
6. When the predicted reductions are acceptable, click Reduce and Optimize.
All nodes above the desired number are removed from the plan. The plan
is re-optimized beginning with the first step.
Reducing the Number of Beams (Fixed and Iris Only)

Beams that are removed through Beam Reduction are not used during
optimization. Subsequent Sequential Optimization steps are performed
using the reduced beam set. The removed beams will not be used unless
you delete the existing (reduced) beam set and create a new beam set. This
option is only available when a dose volume exists and contains one or
more beams with MU greater than 0.
1. Click Beam Reduction. The Beam Reduction dialog box appears.
2. Enter a value in the Beam Reduction MU Cutoff text box.
3. Click Calculate. The predicted reductions appear in the text boxes below.
Predicted beam reductions are calculated based on the Beam Reduction MU
Cutoff value.
4. If the predicted reductions are unacceptable, modify the value in the Beam
Reduction MU Cutoff text box, and click Calculate again.
5. When the predicted reductions are acceptable, click either Reduce or

Reduce and Optimize. All beams below the cutoff are removed from the plan.
The plan is only recalculated when Reduce is selected. When Reduce and
Optimize is selected, the plan is re-optimized beginning with the first step.
Reducing the Number of Segments (MLC Only)

Segments that are removed through Segment Reduction are not used during
optimization. Subsequent Sequential Optimization steps are performed
using the reduced segment set. The removed segments will not be used
unless you delete the existing (reduced) beam set and create a new beam
set. This option is only available when a dose volume exists and contains
one or more segments with MU greater than 0.
1. Click Segment Reduction. The Segment Reduction dialog box appears.
2. Enter a value in the Segment Reduction MU Cutoff text box.
3. Click Reduce. The predicted reductions appear in the text boxes below.
Predicted segment reductions are calculated based on the Segment
Reduction MU Cutoff value.
4. If the predicted reductions are unacceptable, modify the value in the

Segment Reduction MU Cutoff text box and click Reduce again.
5. When the predicted reductions are acceptable, click either Reduce or

Reduce and Optimize. All segments below the cutoff are removed from the
plan.
The plan is only recalculated when Reduce is selected. When Reduce and
Optimize is selected, the plan is re-optimized beginning with the first step.
Setting the Prescription Dose
1. Click the Prescription button. The Prescription dialog box appears.
2. Accept the current value or enter a new value for Number of Fractions,
Prescribed Percentage, and Prescribed Dose (Gy/cGy).
3. Click Set. Prescription dose values are applied to the plan, and beam
weights are scaled.
When the plan is acceptable, go to the Evaluate > Review step to perform
more detailed evaluation and modifications.
VOLO Step
 About VOLO Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
 Display. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
 Tools for Multileaf Collimator (MLC) . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
 Tools for Fixed and Iris Collimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
 Plan Setup - Max Nodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
 Interactive Dose Volume Histogram in VOLO Step . . . . . . . . . . . . . . . 504
 VOLO Optimization for Multileaf Collimator (MLC) . . . . . . . . . . . . . . . 508
 VOLO Optimization for Fixed and Iris Collimators . . . . . . . . . . . . . . . . 515
 VOLO Optimization Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 520
VOLO Step for Multileaf Collimator
 About VOLO Optimization

VOLO optimization is a plan generation method in which the user-defined
goals are weighted and combined into a single cost function.
For the multileaf collimator, VOLO optimization has two phases. The first
phase is the fluence map optimization (FMO). A fluence map is a
rectangular grid of beamlets. The FMO optimizes the intensities of each
beamlet. The second phase begins with sequencing of the fluence map into
apertures and then optimizing the dose intensity for these apertures.
VOLO optimization for Iris and fixed collimators has only the single beam
optimization phase.
For VOLO optimization, you define the maximum number of nodes, and set
the maximum and minimum dose goals for target VOIs and maximum dose
goals for critical VOIs. These goals can either be absolute goals or goals for
specified volumes of a VOI.
For Iris and fixed collimators, you also need to specify the collimator
diameters to use for each target VOI. As with Sequential Optimization, you
can create and optimize the dose to conformality shells around any target
VOI.
During optimization only the VOI to be optimized are sampled and those
VOI have DVH and dose statistics generated. You can also see another
VOI's DVH and statistics by adding that VOI to the goal list and specifying
its type as "Stats Only”.
For more details on VOLO optimization and algorithm, refer to the Physics
Essentials Guide.
 Display
Go to Plan > VOLO > Display tab to select the display layout to use. For more
details on the display layout options, see “Display Layouts” (page 52).
 Tools for Multileaf Collimator (MLC)
The following tools are available at Plan > VOLO > Tools.
Script Click to save a new or modified script from the Save

Script dialog box.
Click to load a previously saved script from the Load

Script dialog box.
Click to delete the script selected from the Delete

Script dialog box.
Auto-shells button Click to open the Auto-shells dialog box.
Plan Setup Max Number of Enter a value for desired max nodes to be used for
Nodes text box the plan. The allowed range for the selected robot
path appears next to the text box.
Optimization > Fluence Click to start Fluence optimization. At least one

“Min” goal and one “Max” goal are required to start
the fluence optimization.
Click to pause the Fluence Optimization.
Click to clear the Fluence optimization results.
Auto Proceed Select to automatically initiate the proceeding

check box Segments optimization phase after the fluence
optimizer has converged and is then automatically
paused.
Optimization > Segments Click to start Segments optimization.
Click to stop Segments optimization.
Click to clear Segment optimization results.
Prescription Prescription button Click to open the Prescription dialog box.
Dose Calculation Algorithm Displays the current dose calculation algorithm.

drop-down list Select an alternative from the drop-down list, if any.
Resolution Displays the current resolution. Select an alternative

drop-down list from the drop-down list. (Low, Medium, or High).
Uncertainty (%) Monte Carlo only: Sets the uncertainty level used for
text box calculating dose. (0.1% - 4.0%)
Lateral Scaling Select to apply the lateral scaling to the FSPB

check box algorithm. The lateral scaling broadens the kernel
based on local regional density. The broadened
kernel improves the agreement between
measurement and calculation in low-density regions
like the lung and directly upstream from the low
density.
Size to fit buttons Use the Size to fit buttons (CT, Skin, VOIs) to set the
dose calculation box size.
Calculate Final Click to start the dose calculation.

Dose button
 Tools for Fixed and Iris Collimator
Collimators Collimators Fixed and Iris Collimators only: Click to open the
button Collimators dialog box.
Script Click to save a new or modified script from the

Save Script dialog box.
Click to load a previously saved script from the

Load Script.dialog box.
Click to deletes the script selected from the Delete

Script dialog box.
Auto-shells Click to open the Auto-shells dialog box.

button
Plan Setup Max Number of Enter a value for desired max nodes to be used for
Nodes text box the plan. The allowed range for the user-selected
robot path appears next to the text box.
Optimization > Optimize Click to start the beam optimization.
Click to stop the beam optimization. The start

button changes to the stop button when
optimization begins.
Click to clear the optimization results.
Dose Calculation Algorithm Displays the current dose calculation algorithm.

drop-down list Select an alternative from the drop-down list, if any.
Resolution Displays the current resolution. Select an

drop-down list alternative from the drop-down list. (Low, Medium,
or High).
Uncertainty (%) Monte Carlo only: Sets the uncertainty level used
text box for calculating dose. (0.1% - 4.0%)
Size to fit Use the Size to fit buttons (CT, Skin, VOIs) to set
buttons the dose calculation box size.
Calculate Final Click to start the dose calculation.

Dose button
 Plan Setup - Max Nodes

You can specify the maximum number of nodes to be used for the plan.
Based on the selected CK Path Set, a valid range of values are displayed
on the screen. This field is read-only while the optimizer is running.
NOTE: Double-check the displayed range on the screen. The range may vary
depending on your treatment machine configuration.
Treatment Anatomy Template Path Set Max Number of Nodes (range)
head_iris-fixed Full_Path 1 - 179
Short_Path 1 - 64
Even_Paths Not supported with VOLO

optimization.
with InTempo Imaging InTempo 1 - 120
InTempo_Short 1 - 38
body_iris-fixed Full_Path 1 - 117
Short_Path 1 - 87

optimization.
Prostate 1 - 101
Prostate_Short 1 - 73
Reduced_Prostate 1 - 23
with InTempo Imaging Prostate_InTempo 1 -70
Prostate_InTempo_Short 1 - 49
Reduced_Prostate_InTempo 1 - 20
InTempo 1 - 82
QA_Iris-fixed AQA90deg 1-2
SingleBeam 1-1
head_mlc Full_Path 1 - 171
Short_Path 1 - 73

optimization.
with InTempo Imaging InTempo 1 - 116
Treatment Anatomy Template Path Set Max Number of Nodes (range)
body_mlc Full_Path 1 - 102
Short_Path 1 - 76

optimization.
Prostate 1 - 91
Prostate_Short 1 - 69
Reduced_Prostate 1 - 24
with InTempo Imaging Prostate_InTempo 1 - 64
Prostate_InTempo_Short 1 - 50
Reduced_Prostate_InTempo 1 - 23
InTempo 1 - 71
 Interactive Dose Volume Histogram in VOLO Step

When dosimetric results are available, the DVH graph shows each DVH
goal as a triangle marker pointing right for a “Min” dose goal and pointing
left for a “Max” dose goal.
While Fluence optimization is running, you can drag the triangle markers in
the DVH graph, and you can also edit the DVH goals for VOIs in the goal
tables.
The intermediate fluence results appear as dashed curves in the DVH
graph.
Use the Mouse and Keyboard to Manipulate the DVH
• Dragging a triangle marker moves in discretized dose steps of 0.1 Gy
and 0.1% of the VOI volume.
• Point to the triangle markers on the DVH graph to view the current
absolute dose and volume % value.
• Press Shift and move a triangle marker on the DVH graph to limit the
drag to be either all horizontal (dose change only) or all vertical (volume
change only).
• Press Alt and click in the DVH graph to add a new DVH goal. The point
for the VOI is represented by the currently selected DVH curve except
for the All Target Regions and Soft Tissue curves. The goal is a “Min” goal
for a Target, and a “Max” goal for critical. Alt + Ctrl and click removes an
existing DVH goal.
DVH Displays
1. Select a structure from the Selected DVH drop-down list. The VOI curve is
now active on the DVH image viewer. By default, the X-axis displays
relative dose (%).
2. (Optional) To modify the X-axis display, click the isocurves legend. The
Isocurves panel appears.
3. Select the Gy (or cGy) option and dismiss the Isocurves panel. The X-axis on
the DVH image viewer updates to display absolute dose (Gy/cGy) for all
VOI.
• Amount of coverage of the displayed dose percentage in both % and
cm3.
When you click a point on the active DVH, a vertical bar appears. The
display color for the vertical bar and isocurve corresponds to the setting in
the DVH Properties dialog box.
DVH Properties for VOLO

Use the DVH Properties dialog box to adjust DVH display settings.
VOLO Step - DVH Properties Dialog Box for Multileaf Collimator
Item Description
Background Color Displays selections for the background color on the DVH image viewer
drop-down list (gray, white, or black).
Item Description
Check box column Select a check box to view the DVH.
VOI Name Displays the available target and critical VOIs.
Color Displays the color for lines, curves, and text for each VOI on the DVH
image viewer.
Target and Critical Goals Select a category to show optimization goal markers for VOI:
Display options • Hide All: No target or critical goals are displayed.
• Show All: Both target and critical goals are displayed as arrows. The
colors are the same as the contour, and goals are positioned at the
volume and the dose.
• Show only for Active DVH: Displays goal markers for the active DVH
only.
Hide Fluence when Dose is Select to hide the Fluence DVH when dose is displayed. The intermediate
displayed check box (MLC fluence results are displayed as dashed curves in the DVH graph.
only)
Snap dose value to nearest Select to snap dose value to nearest percent when interrogating values in
whole percent when relative dose mode.
interrogating values in
relative dose mode check
box
Manage Display of VOI When the check box is clear (the default), the VOI check boxes in the DVH
DVHs independent of VOI Properties dialog are synchronized with those in the VOIs tab.
Visibility Settings check When the check box is selected, the VOI check boxes in the DVH
box Properties dialog are independent of those in the VOIs tab.
 VOLO Optimization for Multileaf Collimator (MLC)
Goals
The Tools > Goals screen displays two tables, one for Target Goals and the
other for Critical Goals. Use these tables to specify DVH goals for each VOI
and sampling resolution.
You can specify up to five Max and/or Min goal types per VOI.
VOI Drop-down list displays the available target VOIs

for the Target Goals table and critical VOIs for the
Critical Goals table. Select a VOI from the
drop-down list to add to the goals table.
Sampling Select Low, Medium, High, or Boundary from the

drop-down list. The sampling resolution defaults to
High resolution for a newly added VOIs. The
Boundary option samples along the bounding edge
of a VOI.
Goal Type For Target Goals, select Min or Max from the
drop-down list.
You can specify up to five Min and/or Max DVH
goals for each VOI. New DVH goals for a VOI
defaults to a Min goal type for targets and a Max
goal type for critical.
For Critical Goals, you can select Mean dose,
which optimizes the mean dose for the VOI. When
Mean option is selected, the volume fields are
disabled and the mean value does not appear in
DVH.
When you select the Stats Only option as a goal
type, this indicates that the VOI does not participate
in optimization. However, the intermediate
dosimetric results are calculated and displayed.
When Stats Only is selected, no other goals can be
set for that VOI.
Weight Assign a weight for each DVH Goal between 0 to

1000. Weight represents the relative contribution of
that goal to the overall optimization cost function.
Specified Dose Enter a desired dose based on the selected Goal

(Gy/cGy) Type.
Achieved Dose Displays a read-only dose value of the Achieved

(Gy/cGy) Dose (Gy/cGy) for each VOI in the Target Goals
and Critical Goals tables.
Volume (%) Set the volume (%) of the selected VOI, the volume
(cm3) is automatically calculated.
Volume (cm3) Set the volume (cm3) of the selected VOI, the
volume (%) is automatically calculated.
NTO On/Off - Displays the NTO status. The name of the

selected NTO VOI is also displayed when the NTO
is on.
Total Samples Displays an estimate total number of sample points

of all VOI optimization goals.
VOI Add button Click to add a new VOI to the goal table.
Remove button Click to remove the selected VOI from the goal
table.
DVH Goal Add button Click to add a new DVH Goal to a selected VOI.
Remove button Click to remove a selected DVH Goal from the

table.
NTO (Normal Tissue Objective)

Use the NTO tab to create a simple objective to control the dose gradient
outside the target VOI. The goal is applied within a user defined critical VOI
and you can set the falloff function. See Physics Essentials Guide for more
details.
Normal Tissue Normal Tissue Select a VOI to use as the normal tissue
Objective VOI drop-down representation.
list
Normal Tissue Displays the number of sample points used for

Sample Points NTO. This field is filled only after optimization
starts.
Weight Enter a value (0-1000) to scale the NTO when it is

added to the total objective function.
Distance Form • Start: Enter the distance from which the dose
Target (mm): falloff function starts.
• Mid: Enter an intermediate distance between the
start and end distances used to define the shape
of the dose falloff function.
• End: Enter the distance to which the dose falloff
function ends.
Dose (%) • Start: Enter the relative dose at the start

distance used to define the shape of the
exponential dose falloff function.
• Mid: Enter the relative dose at the mid distance
used to define the shape of the exponential dose
falloff function.
• End: Enter the relative dose at the end distance
falloff function.
Parameters
Define the following additional parameters to be used for optimization in the
Tools > Parameters tab. These parameters provide nominal defaults and
enforced range checking of valid ranges, which are editable when the
optimization is not running.
Parameter Range Default Description
Fluence Smoothness 0-10 1 Controls the amount of intensity

Penalty modulation.
Total MU Penalty 0-10 1 Controls the plan efficiency by reducing the

MUs and thereby indirectly reduce the
number of segments.
# of Optimization Iterations 50-500 50 Defines the maximum number of

(For Segment optimization optimization iteration.
only)
# of Adaptation Iterations 0-5 3 Defines the number of adaptation iteration.

Each adaptation allows leaf position to vary
within one beamlet’s extents.
Max Segments per Beam 1-50 5 Limits the number of segments that can be
generated from each fluence map.
Max Segments 20-500 300 Controls the pruning that is done after each
segment weight optimization. If the number
of non-zero segment is greater than the
specified number, segments with the least
product of MU and area are pruned.
Max Segment MU 100-5000 500 Applies the upper limit on segment MU

during each segment weight optimization.
Max Beamlet MU 120-6000 600 Applies the upper limit om Beamlet MU

during fluence optimization.
Min Segment MU per 2-100 2 Controls the pruning after each segment
Fraction weight optimization. Segments below this
value are removed.
Beam Intersection
Use Beam Intersection tab to define the beam intersection option for each
VOI. You can also set the beam intersection options at Plan > Settings step.
• Never: Does not allow beams to intersect the listed VOI.
• Exit Only: If a beam or segment intersects the listed VOI before it
intersects the target, it is unavailable.
For segments, only the portion that intersects with the VOI is blocked, not
the whole segment.
Fluence Optimization
The Fluence optimization controls consists of two buttons and one check
box options.
• The goals tables (Target Goals and Critical Goals) must be fully
populated, and at least one Min and one Max goal must be specified to
start the fluence optimization. Any pre-existing segments results and/or
final dose results are discarded when fluence optimization begins.
• Select the Auto Proceed check box to automatically initiate the segments
optimization phase after the fluence optimizer is automatically paused.
• The status bar indicates the progress of the optimization including
informing you when it has converged.
• While the Fluence optimizer is running, the intermediate dosimetric

results are being updated continuously on-screen. If Accuray Precision
System is waiting for input changes, you can edit the DVH goals for
VOIs already in the goals table by either editing the fields in the goals
tables or dragging the triangle markers in the DVH graph on the fly. This
on the fly edit mode dynamically updates in response to DVH goal
changes. All other optimization controls and parameters remain
unavailable for edit while the optimization is running.
Segments Optimization
Segments optimization is available when fluence results are available and
the optimizer is paused.
• The Segments optimization runs to completion (unless manually

stopped or an error occurs) and updates the screen with intermediate
dosmetoric results while the optimizer is running.
• The status bar displays the progress.
• The DVH graph displays paused Fluence optimization results with

dashed line curves and the latest Segments results with solid line
curves.
Dose Calculation
At the end of Segments optimization, the final dose with the current dose
calculation box is automatically calculated. If the dose calculation resolution
is set to Medium or High, you can proceed to the Evaluate task and
immediately save the plan as deliverable without needing to re-compute the
dose again.
• You can also use the Calculate Final Dose button to re-calculate final
dose after changing the Dose Calculation Algorithm, Resolution, or
Uncertainty in the case of Monte Carlo dose calculation.
• When you select Monte Carlo as the dose calculation algorithm for
VOLO, the Monte Carlo algorithm is used as follows:
– Fluence optimization uses FSPB for beamlet dose calculation.

– Segment optimization before adaptation uses FSPB with Lateral
Scaling correction.
– Segment optimization after adaptation uses Monte Carlo for segment

dose calculation.
– Final volumetric dose at the end of optimization uses Monte Carlo.
 VOLO Optimization for Fixed and Iris Collimators

VOLO optimization for Fixed and Iris collimators consists of the following
three workflow phases:
1. Collimator Selection.
2. Beam Optimization.
3. Final Dose Calculation.
You can freely iterate forwards and backwards among these three phases,
editing applicable optimization parameters in between.
Goals
The Tools > Goals screen displays two tables, one for the Target Goals and
the other for the Critical Goals. Use these tables to specify DVH goals for
each VOI and sampling resolution.
You can specify up to five Min and/or Max goals per VOI.
NTO (Normal Tissue Objective)
VOI Drop-down list displays the available target VOIs for

Target Goals table and critical VOIs for the Critical
Goals table. Select a VOI from the drop-down list to
add to the goals table.
Sampling Select Low, Medium, High, or Boundary from the

drop-down list. The sampling resolution defaults to
High resolution for a newly added VOIs. The
Boundary option samples along the bounding edge of
a VOI.
Goal Type Select Min or Max from the drop-down list.

You can specify up to five Min and/or Max DVH goals
for each VOI. New DVH goals for a VOI defaults to a
Min goal type for targets and a Max goal type for
critical.
For Critical Goals, you can select Mean dose, which
optimizes the mean dose for the VOI. When Mean
option is selected, the volume fields are disabled and
the mean value does not appear in DVH.
When you select the Stats Only option as a goal type,
this indicates that VOI does not participate in
optimization. However, the intermediate dosimetric
results are calculated and displayed. When Stats Only
is selected, no other goals can be set for that VOI.
Weight Assign a weight for each DVH Goal between 0 to

1000. Weight represents the relative contribution of
that goal to the overall optimization cost function.
Specified Dose Enter a desired dose based on the selected Goal

(Gy/cGy) Type.
Achieved Dose Displays a read-only display of the Achieved Dose

(Gy/cGy) (Gy/cGy) for each goal in the two tables that indicates
the dose value currently achieved by the optimizer for
the corresponding Volume of the corresponding VOI.
Volume (%) Set the volume (%) of the selected VOI, the volume
(cm3) is automatically calculated.
Volume (cm3) Set the volume (cm3) of the selected VOI, the volume
(%) is automatically calculated.
VOI Add button Click to add a new VOI to the goal table.
Remove Click to remove the selected VOI from the goal table.
button
DVH Goal Add button Click to add a new DVH Goal to a selected VOI.
Remove Click to remove a selected DVH Goal from the table.

button
NTO On/Off - Displays the NTO status.
Total Samples Displays an estimate total number of sample points of

all VOI optimization goals.
Use the NTO tab to create a simple objective to control the dose gradient
outside the target VOI. The goal is applied within a user defined critical VOI
and you can set the falloff function. See Physics Essentials Guide for more
details.
Normal Tissue Normal Tissue Select a VOI to use as the normal tissue
Objective VOI drop-down representation.
list
Normal Tissue Displays the number of sample points used for

Sample Points NTO. This field is filled only after optimization
starts.
Weight Enter a value (0-1000) to scale the NTO when it is

added to the total objective function.
Distance Form • Start: Enter the distance from which the dose
Target (mm): falloff function starts.
• Mid: Enter an intermediate distance between the
start and end distances used to define the shape
of the dose falloff function.
• End: Enter the distance to which the dose falloff
function ends.
Dose (%) • Start: Enter the relative dose at the start

distance used to define the shape of the
exponential dose falloff function.
• Mid: Enter the relative dose at the mid distance
falloff function.
• End: Enter the relative dose at the end distance
falloff function.
Parameters
Define the following additional parameters to be used for optimization in the
Tools > Parameters tab. These parameters provide nominal defaults and
enforced range checking of valid ranges, which are editable when the
optimization is not running.
Total MU Penalty 0-10 1 Controls the plan efficiency by reducing the

MUs and thereby indirectly reduce the
number of segments.
# of Optimization Iterations 50-500 50 Defines the maximum number of

optimization iteration.
Max Beams 20-500 300 Controls the pruning that is done after each
beam weight optimization. If the number of
non-zero beam is greater than the specified
number, beams with the least product of
MU and area are pruned.
Max Beam MU 100-5000 500 Applies the upper limit on beam MU during
each beam weight optimization.
Min Beam MU per Fraction 2-100 2 Controls the pruning after each beam
weight optimization. Beams below this
value are removed.
Beam Intersection
Use Beam Intersection tab to define the beam intersection option for each
VOI. You can also set the beam intersection options at Plan > Settings step.
• Exit Only: If a beam or segment intersects the listed VOI before it
intersects the target, it is unavailable.
For segments, only the portion that intersects with the VOI is blocked, not
the whole segment.
Optimization
If necessary, beam optimization begins with node selection, beam
generation, and dose calculation. Then it proceeds to the beam weight
optimization. The optimization runs to completion unless manually stopped
or an error occurs. Intermediate dosimetric results are updated while the
optimizer is running. The status bar indicates the progress of the
optimization.
Final Dose Calculation

Use the Calculate Final Dose button to initiate the dose calculation. If the
optimization is manually stopped or if you make any changes to the dose
calculation box, dose calculation algorithm or resolution, this button is
available again.
Once final dose has been calculated, all on-screen dosimetric displays are
updated to reflect the final dose results. Isocurves are also displayed on the
image views. You can use the Prescription button to adjust the prescription
for the final dose.
If you run the dose calculation with Medium or High resolution and you are
satisfied with the results, then you can proceed to the Evaluate > Review step
and save the plan as deliverable without re-computing the final dose.
When you select Monte Carlo as the dose calculation algorithm for VOLO,
the Monte Carlo algorithm is used as follows:
• Ray-Tracing is used for the initial set of candidate beams.
• One round of optimization with limited pruning is done.
• Monte Carlo is used to calculate the dose for the remaining beams and
then the optimization continues.
• Monte Carlo is used for the final volumetric dose calculation at the end
of optimization.
 VOLO Optimization Procedures
IMPORTANT: VOLO optimization does not support QuickPlan or multiple path

sets.
Defining Collimators Settings (Fixed and Iris Only)

Define the Collimator settings and ensure that the Path Set and Collimator
type are appropriate for the current plan.
NOTE: The collimators are selected according to the Method you select and appear
on the Collimator table. The collimator size(s) can be edited manually if necessary.
If you change a collimator setting parameter during the planning process, all
existing beams are deleted and new beams are created based on the new
collimator size settings and target boundary distance.
1. Click the Collimators button. The Collimators dialog box appears.

2. For Fixed collimators, do one of the following:
• Manual collimator selection: Select up to three collimators.
3. For Iris collimator, do one of the following:
• Manual collimator selection: Select up to 12 collimators.
4. Use the Target Boundary Distance to modify surface at which the beam is
targeted. Negative values target inside the physical target surface. Positive
values target outside the physical target surface.
5. Click OK to confirm the beam generation configuration to apply.
6. (Optional) Select the Show Collimator Overlay check box to view the selected
collimator sizes graphically on the 2D anatomical view.
Loading a Script
NOTE: Sequential scripts are not available for VOLO. The list only displays the
scripts for the matching collimator type (Fixed/IRIS or MLC).
1. Click the Load Script button. The Load Script dialog box appears.
2. Select a script from the Script Name drop-down list. The Script Name
drop-down list is filtered to display only scripts specific to the selected
collimator type.
Description and Script Summary, which are read-only when loading an
existing script.
4. Click the Load button. The Match VOI Names dialog box appears.
The VOI names in the script are matched to those in the plan.
Creating a New Script

Follow the steps below to create a script that reflects the specific
requirements of the current case. You can save the resulting script for use
with similar cases.
Create Auto-shells (Optional)
1. Click the Auto-shells button. The Auto-shells dialog box appears.
2. Click the Add button. A new row for an auto-shell appears, and the first
target VOI appears.
3. To select a different target VOI, select an entry from the Source drop-down
list.
4. To create a symmetrical auto-shell, select the check box in the Symmetric
column. Then, enter a value in a text box. The value is applied to all
direction. The range for dilations is 0 mm to 100 mm.
5. (Optional) To delete an auto-shell, select the row and click Delete.
6. Click OK. The settings are saved, and the auto-shells are generated.
Define Max Nodes
Enter a value for desired max nodes to be used for the plan. The allowed
range for the selected robot path is displayed right next to the text box.
Define Target Goals and Critical Goals

Populate the goal tables. At least one Min goal and one Max goal must be
defined to start the fluence optimization.
Turn on NTO
1. Click the NTO tab. The NTO becomes On when you select a VOI from the
Normal Tissue VOI drop-down list.
2. Enter the Weight value to scale the NTO.

3. Review the automatically filled default values for Distance From Target (mm)
and Dose %, and edit if desired.
Select Beam Interaction Options
Select beam intersection option for each VOI.
Define Parameters
1. Click the Parameters tab. The sets of additional optimization parameters are
displayed.
2. Review the automatically filled default values, and edit if desired.
Saving a Script
After defining all the optimization parameters, you can save all those
settings as a script. Click the Save Script icon to save the script.
Optimize - Fixed and Iris Collimator

1. Click to start the Beam optimization for Fixed or Iris collimators.
2. (Optional) Manually stop the optimization by clicking to adjust the
optimization goals and parameters, or adjust the dose calculation box size,
algorithm and resolution. Otherwise, the final dose calculation starts
automatically when the optimization completes.
3. (Optional) If the optimization is manually stopped, click Calculate Final Dose
button to start the final dose calculation.
4. Review the results. Repeat the iterations to meet the clinical goals, or
proceed to Evaluate step to save the plan as deliverable if the results are
acceptable.
Optimize - Multileaf Collimator
1. (Optional) Select the Auto Proceed check box if you want to initiate the
segments optimization phase automatically after the fluence optimization
converses.
2. Click to start the Fluence optimization.
If you did not select the Auto Proceed, check the status bar for the
optimization status. The status may indicate that the optimization process
is waiting on your input changes.
3. (Optional) While Fluence optimization is running, drag to manipulate the

triangle markers in the DVH graph, and/or edit the DVH goals for VOIs in
the goal tables if desired.
4. (Optional) Manually pause the Fluence Optimization to edit the addition
parameters in the Parameters tab or Max Nodes if desired.
Segments optimization starts automatically when Fluence optimization
converses if you have selected the Auto Proceed.
5. Click to start the Segments optimization (if you did not select the Auto
Proceed).
6. (Optional) Manually stop the Segments optimization by clicking to

adjust the optimization goals and parameters, or adjust the dose calculation
box size, algorithm, and resolution if desired. Otherwise, Segments
optimization runs until it completes and the final dose calculation starts
automatically.
7. (Optional) If the optimization is manually stopped, click Calculate Final Dose
button to start the final dose calculation.
8. Review the results. Repeat the iterations to meet the clinical goals, or
proceed to Evaluate step to save the plan as deliverable if the results are
acceptable.
Chapter 9
Evaluate Task
Section 9-1
Evaluate Task for Tomo® . . . . . . . . . . . . . . . . . . . . . . . . 527
Section 9-2
Evaluate Task for CyberKnife . . . . . . . . . . . . . . . . . . . . . 561
1072963-ENG B Ch ap te r 9: Eva l ua te T ask 525

Section 9-1
Evaluate Task for Tomo®
Review Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528

Confirm Angles Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
MultiSlice Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Compare and Sum Plans Step . . . . . . . . . . . . . . . . . . . . 544
Image Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
1072963-ENG B S e c t i o n 9 - 1 : E v a l u a t e T as k f or T o m o ® 527
Review Step
Use the Review step to review and modify details of a plan, perform a final
dose calculation using different resolutions, save the plan as deliverable
and authorize for treatment, and print treatment plan reports.
 Review Step - Tools Tab. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
 Display Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
 Viewing and Printing Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
 Review Step - Tools Tab
The following options are available on the Tools tab of the Review step.
Final Dose Resolution Displays the selected resolution. Click the drop-down list to
Resolution drop-down list select another resolution: Very Low, Low, Medium, or High.
Clear Final Dose Click the button to clear the existing dose distribution.
button
Reference Use max dose Select the check box to use the point of maximum dose as the
Point point check box plan reference point.

field
Go to >> button Click the button to set the cross-hair to the current reference
point. The field below the Go to >> button updates to show the
X, Y, and Z coordinates of the reference point.
Set to Cross-hair Click the button to set the reference point value to the
Point button coordinates of the current cross-hair position.
Save Plan Save Plan button Click the button to open the Save Plan dialog box.
View Machine Geometry Select Machine Geometry to display green circles that
Options check box indicate the gantry bore (large circle) and MLC field of view
(small circle) in the image viewer.
TomoDirect Select TomoDirect Angles to display the beam angles

Angles check box (TomoDirect plans only).
Entire Treatment Select the Entire Treatment check box to display the beams
angles for the entire treatment (TomoDirect plans only).
Reference Point
The reference dose for a plan is calculated at the reference point. Use the
Reference Point options to set the reference point manually or
automatically. You can also view the reference point dose and the X, Y, and
Z coordinates of the reference point.
Calculate Dose for the Plan at a Reference Point
Method Instructions
Automatic Select the Use max dose point check box. The reference point is set at the
maximum dose point on the dose grid.
Manual 1. Clear the Use max dose point check box.
2. Drag the cross-hair point on the 2D view to the desired location.
3. Click Set to Cross-hair Point. The reference point is set to the

coordinates of the current cross-hair location.
Save a Plan
A plan can be saved as deliverable if it meets the following criteria:
• Couch image is inserted and accepted.
• Patient position (green laser) and red lasers are set.
• Final dose calculation is completed.
• No inconsistencies have been found. Inconsistencies include a primary
CT study that is tagged with a different medical ID than the patient
medical ID.
After the plan is saved as deliverable, it can be approved for treatment. See
the Data Management Manual for more information.
Save a Deliverable Plan

1. Click Save Plan. The Save Plan dialog box appears.
2. Enter a name in the Plan Name field.

• If the current plan was saved previously, the default name that appears
is the name of the saved plan.

modified to prevent patient mistreatment before saving the plan as Deliverable.
NOTE: When the density of VOIs are changed, review density models before
saving the plan as Deliverable.
3. Select one of the following options:

• Save.
• Make Deliverable.
• Make Deliverable and Approve for Treatment. You can also select the
Enroll plan in PreciseART® check box for Tomo if you select this option.
4. To acknowledge that you have reviewed each of the automatically
generated items prior to saving the plan as deliverable, select the
Autosegmentation check box if the plan's VOIs have been contoured or
created automatically.
Fiducials are automatically identified by the system during prostate
autosegmentation. Select the Fiducial Identification check box if the
fiducials are marked automatically after the prostate autosegmentation.
5. Click Save.
If Make Deliverable or Make Deliverable and Approve Treatment is
selected, a Warning dialog box appears that asks you to confirm that the
density model selected for the plan is appropriate for the CT image that will
used for dose calculation.
6. Review the density model that appears in the Warning dialog box for the
maximum HU value of the image in relation to the points defined in the
density model.
7. Click Yes to confirm the density model to complete the plan saving process.
Overwrite a Previously Saved Plan
WARNING: If you save a copy of a plan under a new name, all fractions in the new
plan are deliverable, regardless of how many fractions were delivered in the
original plan. Delivering more fractions than intended may cause patient injury or
death. Discontinue any fractions that should not be delivered.
If you overwrite a plan that has been previously approved for treatment, the
plan cannot be used for treatment unless you overwrite it and then
re-approve the plan.
If you overwrite a plan that has associated QA plans, a warning message
appears and the QA plans are deleted.
You cannot overwrite a plan for which any dose has been delivered.
Approving Plans for Treatment

A plan can be authorized for treatment while saving a plan. The User ID and
Password of an authorized user is required.
1. After you have selected the Make Deliverable and Approve for Treatment
option and clicked Save, the Approve for treatment dialog box appears.
2. Click Select ICD Code. The Select Treatment Site dialog box appears.
3. Select an appropriate ICD code and click OK.

For more information on Treatment Site ICD Code, refer to the Data
Management Manual.
4. Enter your User ID and Password, and click Approve.

A Warning message appears asking you to confirm that the density model
selected for the plan is appropriate for the CT image to be used for dose
calculation.
5. Review the displayed density model, and click Yes to confirm that the
selected density model is appropriate for the plan.
 Display Tab
Use the Display tab to manipulate the views on the Evaluate > Review step.
The following options are available on the Display tab of the Review step.
Item Description
Select one of the available layout options to view the

corresponding data in the image viewer.
By selecting the layout that includes 3D view, the 3D view
can be used for plan evaluation.
Item Description
Show Isocenters check box Select the check box to show isocenters on the image
viewers.
The 3D View
The 3D view can be used for plan evaluation. For information on modifying
this view, see “3D Filter Step” (page 612).
If two images are loaded and fused, you can switch between the primary,
secondary, and mixed series displays by clicking on the icon in the
upper-left corner of the 3D view.
 Viewing and Printing Reports
WARNING: All treatment plan reports must be approved by trained personnel prior
to plan treatment. Use of treatment planning reports by unqualified personnel could
appropriate data values for any given situation.
TIP: To view the description of a report, click on a report name from the list.
If you double-click the Plan Overview report, the parameters for the report appear.
You cannot print planning reports for new plans that have not been saved.
1. Click Print . The Reports Viewer appears.
2. Review the patient information and plan name, and then select the Optional
Chapters available.
3. Click View Report. The report will be generated according to the specified
parameters and displayed in the report viewer.
Confirm Angles Step
This step appears when you are using a Synchrony Method (licensed
option) in the plan, and it is enabled when the final dose calculation has
been completed. Use this step to confirm the imaging angles you have
defined in the Setup > Angles step. The Tools are exactly the same as what
are provided in Setup > Angles.
One of the differences between the Setup > Angles and this step is the
validation algorithm of the angles. Plan dose and treatment delivery
information are used in this step to validate the imaging angles. You cannot
save the plan as deliverable with invalid imaging angles.
A vertical slider appears next to the DRR which shows the actual couch
motion defined in the final dose calculation.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
 Validate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
Confirm Angles Step for Fiducial and Fiducial with Respiratory Tracking
Confirm Angles Step for Lung with Respiratory Tracking
 Tools
Tracking Tumor drop-down list Select a VOI that you want to track from the drop box. The
Volume (For Lung with tracking VOI must be a target VOI.
Respiratory only)
Imaging Angles Presets buttons The buttons with icons indicate the numbers of angles on a
circle.
Auto Select Select the number of angles that you want the system to
drop-down list automatically select. Angles are chosen based on their color
on the Score Wheel and the spacing of the angles around
the gantry.
Table The table displays the angular values in degrees of the added
or selected angles and the score as a color.
Validate button Click to validate the current imaging angles. See “Validate”
(page 540) for details.
View Options Fiducials check Select to display the fiducials that are defined in the Fiducial
box step.
(For Fiducial and 2cm of Motion check box: Select to display a sphere of 2 cm
Fiducial with radius around each fiducial. Use 2 cm of Motion display to
Respiratory only) visualize whether each fiducial remains within the Tracking
Zone box if there is up to 2 cm of motion.
Tracking Select to display the tracking contour.

Contour check 2cm of Motion check box: Select to display a uniform 2 cm
box expansion around the Tracking Tumor Volume. Use 2cm of
(For Lung with Motion display to visualize whether the Tracking Tumor
Respiratory only) Volume remains within the Tracking Zone box if there is up to
2 cm of motion.
Tracking Centroid Select to display the centroid of the tracking tumor in the plus
check box (+) mark.
(For Lung with 2cm of Motion check box: Select to display a sphere of 2-cm
Respiratory only) radius around the Tracking Centroid. Use 2 cm of Motion to
visualize whether the Tracking Centroid remains within the
Tracking Zone Select to display the red outlines of the active imaging area
check box where the fiducials and tracking volume are tracked within.
The tracking zone is defined by your Treatment Delivery
System configuration.
Score Wheel Select to display the color-coded ring. The colors are based
check box on the heuristic result. Green indicates a good imaging angle,
and red indicates a low correlation score and makes a poor
imaging angle.
Green Lasers Select to display the green lasers (virtual isocenter).

check box
DRR Type Displays the DRR of the selected imaging angle. When the
(For Lung with angle is updated through the table or the image angle control,
Respiratory only) the DRR is updated automatically.
Full Content Displays a DRR of the full CT image volume.

option
Tumor Region Displays a DRR only of the tracking tumor volume.

option
 Validate
When you click Validate, the system enforce the following requirements.
If you don’t click Validate, the system will enforce the same requirements
when you save the plan as deliverable.
Use the couch travel slider on DRR to view the couch positions used during
the treatment, and visually verify the validation checks made by the
Validate button.

• Angles must be separated by at least 30 degrees.
• At least two angles and their parallel opposed counterparts must have
a separation of 30 degrees or more.
– At least half the fiducials must be visible from all angles for the entire
planned couch travel (i.e., must be visible from beginning and end
couch positions).
– The Tracking Reference Point must be visible from all angles for the
entire planned couch travel (i.e., must be visible from beginning and
end couch positions).
In addition, if you click Validate, the system displays a message if the

following recommendations are not met (this message will not be displayed
if you save the plan as deliverable without clicking Validate):
• The angles should be separated by at least 45 degrees.

– The fiducials should be spaced at least 10 mm apart for all DRR
angles and couch positions.
NOTE: A minimum spacing of 10 mm is recommended for fiducial insertion

in the patient. Depending on the viewing angle and considering beam
divergence (the kV source to isocenter distance is 575 mm, and the kV
source to detector distance is 1134.6 mm), fiducials that are 10 mm apart in
the patient may be 0 to almost 20 mm apart on the panel.
– All fiducials should be located within 5 cm of the centroid of the

prescription VOI.
– All fiducials should be visible from all angles for the entire planned
couch travel.
– The centroid of the tracking volume should be located within 5 cm of
the centroid of the prescription volume.
– The entire Tracking Tumor Volume should be visible from all angles
beginning and end couch positions). If this recommendation is met,
visibility will also be verified with a 2-cm margin around the Tracking
Tumor Volume for expected motion.
– The Tracking Reference Point with 2 cm of margin for expected
motion should be within the Tracking Zone box for all imaging angles
beginning and end couch positions).
IMPORTANT: Radixact System v3.x has a more robust algorithm than

Radixact System v2.x for tracking targets that move partly outside the
tracking zone. When you save a plan as deliverable for Radixact v2.x
using Accuray Precision v3.3, make sure to click Validate on the
Evaluate > Confirm Angles tab to review the full list of informational
messages for the selected angles. Consider addressing informational
messages by adjusting angle selections. If the informational
messages are still unresolved, consider returning to the Setup >
Patient step and moving the patient to bring the target closer to
isocenter.
MultiSlice Step
Use the MultiSlice step to choose image viewer layouts using a
combination of multiple planar slices in axial, coronal, or sagittal image
orientations. The planar slices contain dose distribution and VOI
information.

1. On the MultiSlice > Tools step, select a viewing plane from the Image
Orientation drop-down list.
2. If needed, select or clear the optional check boxes:
• Show VOIs.
• Show dose contours.
• Show min/max dose.
image viewer.
4. To change the image source of all the multi-slice views, select an entry from
5. On the Display tab, select the desired layout to display on the image viewer.
You can compare an Active Plan and a previously-saved Reference Plan
that are based on the same patient CT data set. You can also sum dose
distributions when two or more reference plans are loaded. The plan list
displays plans associated with the current patient.
In the default layout mode, when a reference or sum plan is loaded, the
Active Plan appears on the left image viewer, and the Reference Plan or
Sum Plan appears on the right image viewer. The bottom image viewer is
a single DVH chart that compares isodose curves from both plans. Below
the DVH chart are tabs with additional information for plan comparison.
A wide variety of plans can be loaded and compared or summed. Loaded
plans may have VOIs that are not comparable. VOIs are comparable if VOIs
have matching names and contours. The Comp column in the Dose
Statistics Table and the Comparable column in the DVH Properties dialog
box indicate if VOIs from plans are comparable.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
 Perform a Reference Plan Comparison . . . . . . . . . . . . . . . . . . . . . . . . 546
 Perform a Sum Plan Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
 Create a Summation Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
 Tools
Load Reference Click to open the Load Reference Plan dialog box, which lists
Plan button available reference plans to load.
Sum Plans Click to open the Sum Plan dialog box, which lists available
button plans for summation.
Active Plan Max Dose field Displays the Max Dose of the Active Plan.
Rx Dose field Displays the Rx Dose of the Active Plan.
Reference Max Dose field Displays the Max Dose of the Reference Plan.
Plan
Rx Dose field Displays the Rx Dose of the Reference Plan.
Contributing Displays the names of plans used for summation and its
Plans contributing dose of each plan.
NOTE: This area appears when plan summation is completed.
Compare and Sum Plan Tabs
Tab Description
Dose Statistics Dose Statistics Table includes Active and Reference or Sum plan dose
Table statistics that are presented side-by-side. The Comp column indicates if the active
and reference plans are comparable. Plans are comparable if VOIs have matching
names, contours, and density overrides.
Dx Vx Values Dx Vx Values lets you customize dose-to-volume analysis using both the Active
and Reference or Sum VOIs. The user adds a VOI of interest and specifies a VOI
and 1 of 4 values to track or compare:
• Dose (in Gy/cGy or %)
• Volume (in cm3 or %)
The other values are automatically calculated. Any values that you enter appear
as bold text.
Plan Information Displays Active and Reference or Sum plan information side-by-side.
Leaf Open The vertical axis displays the percentage of leaves open for the duration specified
Times on the horizontal axis.
Dose Points Displays the dose points that you have defined on Plan task, Forward Planning
step, or Evaluate > Review step for the active plan.
Display Tab
Additional layouts are available on the Display tab of Compare and Sum
Plans step.
 Perform a Reference Plan Comparison

1. Click Load Reference Plan. The Load Reference Plan dialog box appears.
2. Select a reference plan from the plan list. You can only select a reference
plan that is based on the same primary CT image as the active plan.
3. Click Load Plan. The Reference plan is loaded with all its plan
characteristics maintained and its VOIs displayed on the right image
viewer.
With the Active and Reference plans showing, you can:
• Use the Dose Probe tool to compare dose values at points of interest in
the Active and Reference plans. When a point is selected in one image,
the corresponding point in the other image is also selected and the
difference in dose between the plans is shown.
• Use the normalization modes to synchronize normalization of the
isodose curves in the Active and Reference plans.
• Use the DVH to compare dose-volume values in the Active and
Reference plans.
• Use the following tabs to compare plan data: Dose Statistics Table, Dx
Vx Values, Plan Information, Leaf Open Times, and Dose Points.
 Perform a Sum Plan Comparison
Sum Plans
NOTE: The active plan is not incorporated in the summation of multiple plans. If you
want to include the active plan in the evaluation, you must first save the plan and
then include the saved plan when you select the plans to sum.
1. Click Sum Plans. The Sum Plans dialog box appears.

2. Select contributing plans to sum. You can only select a plan to sum if the
plan is based on the same primary CT image as the active plan.
3. Enter the values for Contributing Dose (Gy/cGy) and Contributing Weight
(%) for the selected plans.
4. Click Sum Plans. The summed plan appears on the right image viewer with
all its plan characteristics maintained and its VOIs.
If the Active plan is one of the plans chosen for the summation, and with the
Active and Sum plans showing, you can:
the Active and Sum plans. When a point is selected in one image, the
corresponding point in the other image is also selected and the
• To scale the summation dose, enter an absolute dose or % of
Prescription in the Isdose Legend Panel. The system will scale the
contribution accordingly.
• Use the DVH to compare dose-volume values in the Active and Sum
plans.
 Create a Summation Report

A summation report is available after summing plans in Compare and Sum
Plans step. The summation report contains summed dose and statistics for
two or more plans based on the same patient and primary CT image.
To generate a summation report:
1. Click Sum Plans to open the Sum Plans dialog box.
2. Select contributing plans to sum and click Sum Plans.
3. Review the results. Accuray Incorporated recommends that you go back to
Evaluate > Review step and save the active plan before generating a report.
4. After reviewing, go back to the Evaluate > Compare and Sum Plans step,
and click Print. The Summation Notes dialog box appears.
5. Enter any notes that you have and click OK. The Reports Viewer appears.
6. Review the patient and plan names, and select any Optional Chapters to
add.
7. Click View Report to create the summation report.
Image Tools
 Dose Probe Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
 Isocurves / Dose Difference Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . 549
 Dose-Volume Histogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554
 Dose Statistics Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
 Dx Vx Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558
 Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
 Leaf Open Times. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
 Dose Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
 Dose Probe Box

In the Compare and Sum Plans step, a Dose Probe box appears on all 2D
images. The Dose Probe box lists the following data about the point:
• HU Value.
• Dose.
• Delta Dose.
• Voxel Indices.
• CT Position in mm IECp.
 Isocurves / Dose Difference Panels

In the Compare and Sum Plans step, when you click the Isocurves legend
on the image viewer, the Isocurves /Dose Difference Map panel appears.
Isocurves Check boxes When selected, the color assigned to a color wash value appears.
When at least one check box is selected, the column header check
box is available. To select or clear all individual check boxes, select
or clear the column header check box.
Color Indicates the color that represents a point in the range of Gy/cGy or
drop-down menu % color wash values.
Dose Gy/cGy Displays the absolute value of the isocurve.
Dose % Displays the relative value of the isocurve.
Gy/cGy option Select this option to update the Isocurves legend and the
corresponding Dose Gy/cGy values in the image viewers.
% option Select this option to update the Isocurves legend and the
corresponding Dose % values in the image viewers.
Min/max dose Select to show the minimum and maximum dose values for each
check box VOI in the corresponding plan.
Normalize Select one of the available options from the drop-down list:
relative dose to • Active Max Dose
drop-down list
• Active Rx Dose
• Ref Max Dose
• Ref Rx Dose
• Custom [100% =]
Gy/cGy field The Gy/cGy field updates in correspondence to what you have
selected from the Normalize relative dose to drop-down list.
Show dose Select the check box to show dose outside the skin.
outside skin
check box
Lines check box Select the check box to show dose lines.
Overlay check Select the check box to show dose overlay.

box • Select this option to view the overlay as a smooth fill of the
• Fill option isocurves.
• Grid option • Select this option to view the overlay as a grid that displays the
dose at its native resolution.
Dose Opacity Use the slider to modify dose opacity.

slider
Dose Check boxes When selected, the color assigned to a color wash value appears.
Difference When at least one check box is selected, the column header check
Map box is available. To select or clear all individual check boxes, select
or clear the column header check box.
Color Indicates the color that represents a point in the range of Gy/cGy or
% color wash values.
Diff Displays the different values (% or Gy/cGy) assigned to each color

and adjusts the values based on the dose normalization mode.
Show dose Displays a dose difference color wash on the image viewers.
difference
check box
The Dose Difference Map defines the colors used in the color wash to
highlight the dose difference between points on Active and Reference
images when the Show dose difference check box is selected. Pixels
shaded in red have higher dose values in the dose distribution relative to
the plan being compared. If the Active plan has higher dose at a given pixel,
that pixel will be shaded with red on the Active plan image, but will be blue
on the Reference plan image.
Color Wash on an Active Plan Image Comparing Dose to the Reference Plan Image
The value assigned to a color is in either Gy/cGy or % depending on the
dose normalization mode selected. When the dose normalization mode is
changed, the Dose Difference Map values are updated to be consistent with
the normalization mode.
Dose Normalization Modes

In the Compare and Sum Plans step, the following dose normalization
modes are available for sum plans.
• Active Max Dose: 100% dose level of isodose contours and isodose
legends corresponds to the max dose value for the active plan. Dose
difference values appear as a relative percentage of the active plan's
max dose.
• Active Rx Dose: 100% dose level of isodose contours and isodose
legends corresponds to the prescription dose value for the active plan.
Dose difference values appear as a relative percentage of the active
plan's prescription dose.
• Ref Max Dose: 100% dose level of isodose contours and isodose
legends corresponds to the max dose value for the reference plan.
Dose difference values appear as a relative percentage of the
Reference plan's max dose.
• Ref Rx Dose: 100% dose level of isodose contours and isodose
legends corresponds to the prescription dose value for the reference
plan. Dose difference values appear as a relative percentage of the
reference plan's prescription dose.
• Custom [100% =]: 100% dose level of isodose contours and isodose
legends corresponds to the dose value displayed in the
Custom [100% =] field. Dose difference values appear as relative
percentages of the value entered in the Custom [100% =] field.
The prescription isodose line is a special case. Regardless of the
normalization scheme selected, the prescription isodose line represents
the prescribed dose for the plan displayed. The Active plan and Reference
plan images always show the prescription isodose line for their respective
prescription doses. Therefore, even when the selected normalization mode
is relative to the Reference plan or a custom max, the calculated
percentage value for the Active plan prescription isodose line represents
the prescription dose of the Active plan. The same is true for the Reference
plan's prescription isodose line when normalization is set to the Active
plan's max or a custom max.
If the prescription doses of the Active and Reference plans do not match,
the Reference plan's prescription dose appears in green to indicate the
lines that represent different absolute doses.
Finally, the Sum plan's first entry in the isodose line list is equivalent to the
prescription dose of the Active plan.
Display a Dose-difference Color Wash on an Image
1. Click the Isocurves legend on the image viewer.
2. Select the Show dose difference check box.
3. Click in the image viewer to close the Isocurves / Dose Difference Map
dialog box.
Change Color Values Assigned in Color Wash

2. Click in the value field assigned to a dose-difference color, and change the
value. The value must be greater than the value of the color below it and
less than the value above it.
dialog box.
 Dose-Volume Histogram
In the Compare and Sum Plans step, the Dose-Volume Histogram (DVH)
chart displays a DVH for each delineated target and critical VOI in the
Active plan and Reference or Sum plan. You can use the DVH chart to
compare the DVHs of VOIs in the plans.
Click on a point in the selected DVH curve to display Active and Reference
or Sum plan dose and volume data (% and Gy/cGy) and the difference
between the two. To move the point along an active curve, drag the vertical
bar left or right.
Item Description
DVH Properties button Click to open the DVH Properties dialog box.
Item Description
Selected DVH drop-down The VOI selected from the Selected DVH drop-down list is the active VOI
list on the DVH chart. Click a point in the selected DVH curve to display Active
and Reference plan dose and volume data (percentage and Gy/cGy) and
the difference between the two. To move the point along an active curve,
drag the vertical bar left or right.
View or Modify DVH Properties
You can set or change the DVH chart properties of the Active and
Reference or Sum plan structures. It includes columns indicating available
structures, the source plan, whether a structure in a Reference or Sum plan
is comparable with a structure in the Active plan, and check boxes to show
structures on the DVH chart.
IMPORTANT: Only the portion of a VOI that is enclosed by the dose calculation
grid is used to determine the DVH and dosimetric statistics. Therefore, if a volume
is partially enclosed by the grid, the apparent total volume of the VOI for DVH
calculation will be less than the volume calculated.
1. Click DVH Properties. The DVH Properties dialog box appears.

2. From the Background Color drop-down list, you can select a different
background color to view the DVH chart.
3. Select one or more Show Active Plan DVH check boxes to view the
corresponding VOIs on the DVH chart.
• Select one or more Show Reference Plan DVH check boxes to view the
• Select one or more Show Sum Plan DVH check boxes to view the
5. If necessary, select the Snap dose value to nearest percent when
interrogating values in relative dose mode check box.
6. If necessary, select the Manage display of DVH curves independent of VOI
Visibility Settings check box.
7. Click OK.
View DVH Displays

1. Select a VOI on the Selected DVH drop-down list. The VOI curve is now the
active curve on the DVH panel.
2. Click a point on the active curve. A navigation bar intersecting the point and
data for that point appears.
The following data are displayed:
• Dose in Gy/cGy corresponding to a given percentage dose for the point

on the active curve and for the equivalent point on the Reference plan
curve.
• The difference between the Active plan volume and the Reference plan
volume at the selected point.
3. To move the point along the active curve, drag the point or vertical bar left
or right, or click a different point on the curve.
 Dose Statistics Table
parameters listed in the following table for Active and Reference or Sum
plans that are compared side-by-side.
NOTE: For sum plans, the CI, nCI, HI, and Coverage statistics for targets will
show as n/a because the statistics require a prescription isodose line and one is
unavailable for a sum plan.
Item Description
Name Lists the name of VOIs in Active and Reference or Sum plans.
Comp Comparable. Indicates whether the VOI from a reference or sum plan is
comparable to the same VOI from the Active plan. VOIs are comparable if they
have matching names and contours.
Min (Gy/cGy) Minimum dose in Gy/cGy for each VOI in the Active plan (Min), Reference
Min r (Gy/cGy) plan (Min r), or Sum plan (Min s).
Min s (Gy/cGy)
Mean (Gy/cGy) Mean dose in Gy/cGy for each VOI in the Active plan (Mean), Reference
Mean r (Gy/cGy) plan (Mean r) or Sum plan (Mean s).
Mean s (Gy/cGy)
Max (Gy/cGy) Maximum dose in Gy/cGy for each VOI in the Active plan (Max), Reference
Max r (Gy/cGy) plan (Max r) or Sum plan (Max s).
Max s (Gy/cGy)
CI, CI r, CI s The ratio of total tissue volume that receives the prescription isodose or more
(Conformality Index) to tumor volume that receives the prescription isodose or more in the Active
plan (CI), Reference plan (CI r) or Sum plan (CI s).
nCI, nCI r, nCI s The CI multiplied by the ratio of the total tumor volume to the tumor volume
(New Conformality that receives the prescription isodose or more in the Active plan (nCI),
Index) Reference plan (nCI r) or Sum plan (nCI s).
Item Description
HI, HI r, HI s The ratio of the maximum dose to the prescription dose. For the current
(Homogeneity Index) configuration of the Accuray Precision System, the maximum dose is always
the100% isodose in the Active plan (HI), Reference plan (HI r) or Sum plan
(HI s).
Coverage (%) The volume of the tumor that receives the prescription dose divided by the total
volume of the tumor times 100 in the Active plan (Coverage), Reference
Coverage r (%)
plan (Coverage r) or Sum plan (Coverage s).
Coverage s (%)
 Dx Vx Values
Dx Vx Values for customizable dose-to-volume analysis are available

wherever dose statistics are shown. You can perform dose-to-volume
analysis on Active and Reference or Sum VOIs, All Target Regions, or Soft
Tissue. After selecting an option from the drop-down menu, you can enter
one of four values to track or compare: Dose (in Gy/cGy or %) or Volume
(in cm3 or %). The other values are automatically calculated. Any values
that you enter appear as bold text.
NOTE: Dx Vx values that are entered are copied from the active plan to the
reference plan with the automatically calculated values derived from the
corresponding DVH curves. As a result, either the dose difference or volume
difference will be always zero for each row.
TIP: Double-click the color box next to the Name column to move the crosshairs on
the images to the centroid of the corresponding VOI and move the DVH graph
cursor to the corresponding point (if the corresponding DVH curve is currently
visible and the selected VOI is not All Target Regions or Soft Tissue).
Item Description
Name Select a VOI,All Target Regions, or Soft Tissue from the drop-down list
to display and customize Dx and Vx fields for dose-to-volume analysis of
Active and Reference or Sum plans.
Item Description
Dose (Gy/cGy) Displays the dose of the selected DVH option in Gy/cGy for the Active
Dose r (Gy/cGy) plan (Dose), Reference plan (Dose r) or Sum plan (Dose s).
Dose s (Gy/cGy)
Dose (%) Displays the dose of the selected DVH option in % for the Active plan
Dose r (%) (Dose), Reference plan (Dose r) or Sum plan (Dose s).
Dose s (%)
Volume (cm3) Displays the volume of the selected DVH option in cm3 for the Active plan
(Volume) and Reference plan (Volume r) or Sum plan (Volume s).
Volume r (cm3)
Volume s (cm3)
Volume (%) Displays the dose value of the selected DVH option in % for the Active
Volume r (%) plan (Volume) and Reference plan (Volume r) or Sum plan (Volume
s).
Volume s (%)
Active-Ref Dose Displays the dose difference in Gy/cGy between the Active and
(Gy/cGy) Reference or Sum plans for the selected DVH option.
Active-Sum Dose
(Gy/cGy)
Active-Ref Volume (cm3) Displays the dose difference in cm3 between the Active and Reference
Active-Sum Volume or Sum plans for the selected DVH option.
(cm3)
To perform customized dose-to-volume analysis:

1. Select a VOI, All Target Regions, or Soft Tissue from the DVH drop-down
list.
2. In a Dose or Volume field, enter the value you want to analyze. The other
values for the Active and Reference or Sum plan are automatically
calculated.
 Plan Information
Plan Information displays information for Active and Reference or Sum
plans side-by side.
 Leaf Open Times
The Leaf Open Times tab displays the percentage of leaves open for the
duration specified on the horizontal axis. A new tab for Leaf Open Times is
added when a reference plan is loaded. Use the right-click menu to:
• Draw Lines
• Draw Points
• Draw Lines and Points
• Point Select
• Zoom
• Pan
• Reset Zoom and Pan
For a single projection, the duration of leaf open time (beamlet intensity) is
primarily determined by the plan's Modulation Factor (IMRT plans only),
ROI constraint settings, prescribed dose, and pitch.
NOTE: If approved, a plan that contains a high count (40-50%) of leaf open times
approaching the minimum limit may create a discrepancy between planned and
delivered dose. Increase (loosen) your pitch value if it is unnecessarily tight (for
example, less than 0.287). This may decrease treatment time without affecting
treatment quality.
 Dose Points
active plan. Dose Points cannot be defined in Compare and Sum Plans
step.
Section 9-2
Evaluate Task for CyberKnife
Review Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562

MultiSlice Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
Compare and Sum Plans Step . . . . . . . . . . . . . . . . . . . . 577
Finetune Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Beams Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
Image Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
1072963-ENG B Sec ti on 9 -2 : E v al u at e T a s k fo r Cy be rK ni f e 561

Review Step
Use the Review step to review and modify details of a plan, perform a final
dose calculation using different resolutions, save the plan as deliverable
and authorize for treatment, and print treatment plan reports.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
 High Resolution Dose Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
 Finite Size Pencil Beam Dose Calculation . . . . . . . . . . . . . . . . . . . . . . 566
 Setting the Plan Prescription Dose. . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
 Reference Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
 Save a Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
 Viewing and Printing Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
 DxVx Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 574
 Tools
Area Option Description
Dose Algorithm Displays the current dose calculation algorithm

Calculation drop-down list and a drop-down list of alternatives, if any.

drop-down list list of alternatives. (Low, Medium, or High).
Uncertainty (%) Sets the uncertainty level used for calculating

Monte Carlo only. Monte Carlo dose. (0.1% - 4.0%)
The Uncertainty setting is enabled after you
select a Monte Carlo dose calculation.
Lateral Scaling Select Lateral Scaling check box to apply the

check box lateral scaling to the FSPB algorithm. The lateral
FSPB only. scaling broadens the kernel based on local
regional density. The broadened kernel
improves the agreement between measurement
and calculation in low-density regions like the
lung and directly upstream from the low density.
Size to fit • CT button: Sets the dose calculation box to

the size of entire CT Volume
• Skin button: Sets the dose calculation box to
the size of Skin VOI.
NOTE: Skin VOI must be predefined.
• VOIs button: Sets the dose calculation box to
encompass all VOIs.
Calculate Final Calculates the final dose for the plan using the
Dose button selected dose calculation settings.
Cancel button Available during dose calculation. Opens a

dialog box that allows you to cancel the dose
calculation. If you cancel the dose calculation,
the dose volume is deleted.
Prescription Prescription Displays the Prescription dialog box.

button

Area Option Description
Reference Use max dose Select the check box to use the point of
Point point check box maximum dose as the plan reference point.

field
Point (mm IECp) Click the button to set the cross-hair to the
current reference point. The field below the Go
to >> button updates to show the X, Y, and Z
Go to >> button coordinates of the reference point.
Set to Cross-hair Click the button to set the reference point value
Point button to the coordinates of the current cross-hair
position.
Save Plan Save Plan button Click the button to open the Save Plan dialog
box.
 High Resolution Dose Calculation

Performing Higher Resolution Ray-Tracing Dose Calculation
NOTE: Accuray Precision System requires Medium or High resolution

Ray-Tracing dose calculation to save the plan as deliverable.
1. Select Ray-Tracing from the Algorithm drop-down list.

2. Select Medium or High on the Resolution drop-down list.
3. Click Calculate Final Dose.
The progress bar on the lower-right area of the screen displays status.
When the progress bar reaches the end, the calculation is complete.
Medium or High resolution dose isocontours and statistics are displayed
and the resolution labels indicate that medium or high resolution was used.
The plan can be saved as deliverable.

Most actions that modify scaling alone, such as changing the prescription
dose or percentage, do not invalidate the high resolution dose volume.
NOTE: The values of the reference point dose and the maximum dose for
Monte Carlo Dose Calculation will be the dose values after any smoothing
has been applied to the raw dose distribution calculation performed by the
Monte Carlo Dose Calculation.
1. Select Monte Carlo on the Algorithm drop-down list.

2. Select a setting on the Resolution drop-down list.
3. Specify an Uncertainty setting (0.1% - 4.0%).
NOTE: A high uncertainty value requires less time to compute.

5. To modify the Isocurves and MC Dose settings, click the Isodose legend on
the upper right of a 2D image. The Isocurves and MC Dose panels appear.
• To change the display of smoothed or raw information, select the
appropriate option on the MC Dose panel: Show smoothed, Show raw,
or Show both.
• To change the Smoothing Method, select a method from the drop-down
list.
• For the Gaussian smoothing method, select a setting from the Sigma
drop-down list.
• To show minimum and maximum dose information, select the Min/max
dose check box.
Artificial Hot Spots
In some cases, a Monte Carlo dose calculation may display one or more
isolated voxels with very high dose in locations where the mass density is
low. These artificial hot spots are present in the raw dose distribution and
could also be present in smoothed dose distributions. To filter out these
artificial hot spots, a desparkling algorithm is applied to the raw volume
before the smoothing operation is performed.
These artificial hot spots occur because the energy cutoff mandates that an
interaction involving a particle whose energy is lower than the cutoff value
deposit all remaining energy locally. Dose in a voxel is calculated as the
energy deposited in the voxel divided by the mass of the voxel. Therefore,
in regions of low density (as over air, bowel, or lung), the Monte Carlo Dose
Calculation algorithm can compute an artificially high dose value. Because
lower numbers of photon histories require a higher normalization factor to
magnify the dose deposition to match the number of photons in the
treatment plan, this effect is most likely to occur when:

• The user specifies a high uncertainty value.
• The dose calculation is performed in a region of high uncertainty in a
dose volume.
The most obvious effect of this phenomenon is that the maximum dose is
significantly increased in comparison to that for the Ray-Tracing
calculation, so all the DVHs are shifted to lower values.
Identify an Artificial Hot Spot
1. Click Evaluate > Review step.
2. Ensure that the point of maximum dose is used as the reference point.
3. Use the Go to >> reference point tool.
4. If you observe artificial hot spots in the raw dose distribution, choose a
response:
• Base the dose prescription and DVH analysis on the smoothed dose
distribution.
• Repeat the calculation with a lower uncertainty setting.
• Ignore the artificial hot spot when analyzing the DVH and setting the
prescription.
 Finite Size Pencil Beam Dose Calculation

Perform Medium or High Resolution Finite Size Pencil Beam
Dose Calculation
1. Select FSPB from the Algorithm drop-down menu.
2. Select Medium or High from the Resolution drop-down list.
3. (Optional) Select Lateral Scaling check box.
The progress bar on the lower-right area of the screen displays status.
When the progress bar reaches the end, the calculation is complete.
Medium or High resolution dose isocontours and statistics are displayed
and the resolution labels indicate that medium or high resolution was used.
The plan can be saved as deliverable.
Most actions that modify scaling alone, such as changing the prescription
dose or percentage, do not invalidate the high resolution dose calculation.
Lateral Scaling
When Lateral Scaling is applied to the FSPB algorithm, the lateral scaling
broadens the kernel based on local regional density. The broadened kernel
improves the agreement between measurement and calculation in
low-density regions like the lung and directly upstream from the low density.
For more details on Lateral Scaling, see the Physics Essentials Guide.
 Setting the Plan Prescription Dose

1. Click the Prescription button. The Prescription dialog box appears.
2. (Optional) Accept the current value or enter a new value for Number of
Fractions, Prescribed Isocurve, and Prescribed Dose (Gy/cGy).
Or, click the Target Coverage button to prescribe dose to a target based on
a percentage of the target volume in the Set Isocurve Prescription from
Target VOI Coverage dialog box.
3. Click Set. The dialog box closes. Prescription dose values are applied to
the plan, and beam weights are scaled.
 Reference Point
The reference dose for a plan is calculated at the reference point. Use the
Reference Point options to set the reference point manually or
automatically. You can also view the reference point dose and the X, Y, and
Z coordinates of the reference point.
Calculate Dose for the Plan at a Reference Point
Method Instructions
Automatic Select the Use max dose point check box. The reference point is
set at the maximum dose point on the dose grid.
Manual 1. Clear the Use max dose point check box.
2. Drag the cross-hair point on the 2D view to the desired

location.
3. Click Set to Cross-hair Point. The reference point is set

to the coordinates of the current cross-hair location.

Dose (Gy or cGy)
The current dose at the reference point appears in the adjacent text box.
For Monte Carlo, the dose value is obtained as follows:
• From the raw dose volume if Show raw is selected on the MC Dose
panel.
• From the smoothed dose volume if Show smoothed or Show both is
selected.
Point (mm IECp) Go to >>
Click Go to >>. The text box below displays the updated X, Y, and Z
coordinates of the reference point.
 Save a Plan
NOTE: The maximum length for a plan name is 24 characters. Use

alphanumeric characters, underscore (_), single dash (-).
A plan can be saved as deliverable if it meets the following criteria:

• The alignment center has been confirmed.
• Medium or High resolution Ray-Tracing or FSPB dose calculation, or
Monte Carlo dose calculation has been performed in Evaluate > Review
step.
• No inconsistencies have been found. Inconsistencies include:
– A primary CT study that is tagged with a different medical ID than the
patient medical ID.
– Any beam with less than the minimum deliverable MU per session.
– A Synchrony Fiducial Tracking plan without identified fiducials.
– Inconsistency between displayed dose and the dose recorded in the
treatment paths.This inconsistency can be detected only when you
are saving a plan. If the inconsistency is detected, a warning appears.
– A plan for an Synchrony Lung Tracking with Respiratory Modeling that
does not include at least one spine tracking volume and one target
VOI.
• For MLC plans, none of the segments can violate the criteria for a valid
segment. An invalid segment is one in which the segments are too small
or positions of given segments are too narrow.
Save a Deliverable Plan
1. Click Save Plan. The Save Plan dialog box appears.
2. Enter a name in the Plan Name field.

• If the current plan was saved previously, the default name that appears
is the name of the saved plan.

modified to prevent patient mistreatment before saving the plan as
Deliverable.
NOTE: When the density of VOIs are changed, review density models before
saving the plan as Deliverable.
3. Select one of the following options:

• Save.
• Make Deliverable.
• Make Deliverable and Approve for Treatment.
4. To acknowledge that you have reviewed each of the automatically
generated items prior to saving the plan as deliverable, select the

Autosegmentation check box if the plan's VOIs have been contoured or
created automatically.
Fiducials are automatically identified by the system during prostate
autosegmentation. Select the Fiducial Identification check box if the
fiducials are marked automatically after the prostate autosegmentation.
5. Click Save.
If Make Deliverable or Make Deliverable and Approve Treatment is
selected, a Warning dialog box appears that asks you to confirm that the
density model selected for the plan is appropriate for the CT image that will
used for dose calculation.
6. Review the density model that appears in the Warning dialog box for the
maximum HU value of the image in relation to the points defined in the
density model.
7. Click Yes to confirm the density model to complete the plan saving process.
Overwrite a Previously Saved Plan
WARNING: If you save a copy of a plan under a new name, all fractions in
the new plan are deliverable, regardless of how many fractions were
delivered in the original plan. Delivering more fractions than intended may
cause patient injury or death. Discontinue any fractions that should not be
delivered.
If you overwrite a plan that has been previously approved for treatment, the
plan cannot be used for treatment unless you overwrite it and then
re-approve the plan.
If you overwrite a plan that has associated QA plans, a warning message
appears and the QA plans are deleted.
You cannot overwrite a plan for which any dose has been delivered.
Approving Plans for Treatment
A plan can be authorized for treatment while saving a plan. The User ID and
Password of an authorized user is required.
1. After you have selected the Make Deliverable and Approve for Treatment
option and clicked Save, the Approve for treatment dialog box appears.
2. Click Select ICD Code. The Select Treatment Site dialog box appears.

3. Select an appropriate ICD code and click OK.
For more information on Treatment Site ICD Code, refer to the Data
Management Manual.
4. Enter your User ID and Password, and click Approve.

A Warning message appears asking you to confirm that the density model
selected for the plan is appropriate for the CT image to be used for dose
calculation.
5. Review the displayed density model, and click Yes to confirm that the
selected density model is appropriate for the plan.
 Viewing and Printing Reports
WARNING: All treatment plan reports must be approved by trained

personnel prior to plan treatment. Use of treatment planning reports by
unqualified personnel could result in patient mistreatment. Users are solely
responsible for determining appropriate data values for any given situation.
NOTE: The Monte Carlo dose listed in reports are smoothed dose values.
TIP: To view the description of a report, click on a report name from the list.
If you double-click the Plan Overview report, the parameters for the report
appear.
You cannot print planning reports for new plans that have not been saved.
1. Click Print . The Reports Viewer appears.
• For deliverable plans, the Plan Overview, Path Check List, Beam Data
List, and Commissioning reports are available. If an MLC plan is loaded,
the Segment Report is also available.
• For non-deliverable plans, only the Plan Overview and Beam Data List
reports are available.
2. Review the patient information and plan name, and then select the Optional
Chapters available.
3. Click View Report. The report will be generated according to the specified
parameters and displayed in the report viewer.

Below the DVH panel is a table of maximum and minimum dose statistics
for each VOI. The target volumes have calculations for the parameters
listed below.
NOTE: Minimum, mean, and maximum dose statistics for auto-shells

generated during the sequential planning process appear in the Dose
Statistics Table. The conformal shell icon is indicated by a green rectangle.
Item Description
VOI List of VOIs.

Item Description
Min (Gy/cGy) Minimum dose in Gy or cGy for each VOI.
Mean (cGy/Gy) Mean dose in Gy or cGy for each VOI.
Max (Gy/cGy) Maximum dose in Gy or cGy for each VOI.
CI (Conformality Index) The ratio of total tissue volume that receives the
prescription isodose or more to tumor volume that
receives the prescription isodose or more.
nCI (New Conformality Index) The CI multiplied by the ratio of the total tumor volume
to the tumor volume that receives the prescription
isodose or more.
HI (Homogeneity Index) The ratio of the maximum dose to the prescription

dose. For the current configuration of the Accuray
Precision System, the maximum dose is always the
100% isodose.
Coverage (%) The volume of the tumor that receives the prescription
dose divided by the total volume of the tumor times
100.
 DxVx Criteria
Dx Vx Values tables for customizable dose-to-volume analysis are
available wherever dose statistics are shown.
Use Edit DxVx Criteria dialog box to augment each DxVx value to evaluate
against the current active plan results. The evaluation results are shown in
pass, fail, and warning indicators. See “Dx Vx Values” (page 448) for more
details.
 Display Tab
Use the Display tab to manipulate the views on the Evaluate > Review step.
The following options are available on the Display tab of the Review step.
Option Description
Select one of the available layout options to

view the corresponding data in the image
viewer.
By selecting the layout that includes 3D view,
the 3D view can be used for plan evaluation.
Show Isocenters check box Select the check box to show isocenters on the
image viewers.

MultiSlice Step
Use the MultiSlice step to choose image viewer layouts using a
combination of multiple planar slices in axial, coronal, or sagittal image
orientations. The planar slices contain dose distribution and VOI
information.

1. On the MultiSlice > Tools step, select a viewing plane from the Image
Orientation drop-down list.
2. If needed, select or clear the optional check boxes:
• Show VOIs.
• Show dose contours.
• Show min/max dose.
image viewer.
4. To change the image source of all the multi-slice views, select an entry from
5. On the Display tab, select the desired layout to display on the image viewer.
You can compare an Active Plan and a previously-saved Reference Plan
that are based on the same patient CT data set. You can also sum dose
distributions when two or more reference plans are loaded. The plan list
displays plans associated with the current patient.
In the default layout mode, when a reference or sum plan is loaded, the
Active Plan appears on the left image viewer, and the Reference Plan or
Sum Plan appears on the right image viewer. The bottom image viewer is
a single DVH chart that compares isodose curves from both plans. Below
the DVH chart are tabs with additional information for plan comparison.
A wide variety of plans can be loaded and compared or summed. Loaded
plans may have VOIs that are not comparable. VOIs are comparable if VOIs
have matching names and contours. The Comp column in the Dose
Statistics Table and the Comparable column in the DVH Properties dialog
box indicate if VOIs from plans are comparable.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
 Perform a Reference Plan Comparison . . . . . . . . . . . . . . . . . . . . . . . . 580
 Perform a Sum Plan Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
 Create a Summation Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582

 Tools
Load Reference Click to open the Load Reference Plan dialog

Plan button box, which lists available reference plans to
load.
Sum Plans button Click to open the Sum Plan dialog box, which
lists available plans for summation.
Active Plan Max Dose field Displays the Max Dose of the Active Plan.
Rx Dose field Displays the Rx Dose of the Active Plan.
Reference Plan Max Dose field Displays the Max Dose of the Reference Plan.
Rx Dose field Displays the Rx Dose of the Reference Plan.
Contributing Displays the names of plans used for

Plans summation and its contributing dose of each
plan.
NOTE: This area appears when plan
summation is completed.
Summed Fields Summed MU Displays the summed MU of contributed plans.
Summed # of Displays the summed number of beams of

Beams contributed plans.
Compare and Sum Plan Tabs
Tab Description
Dose Statistics Dose Statistics Table includes Active and Reference or Sum plan
Table dose statistics that are presented side-by-side. The Comp column
indicates if the active and reference plans are comparable. Plans
are comparable if VOIs have matching names, contours, and
density overrides.
Tab Description
Dx Vx Values Dx Vx Values lets you customize dose-to-volume analysis using

both the Active and Reference or Sum VOIs. The user adds a VOI
of interest and specifies a VOI and 1 of 4 values to track or
compare:
• Dose (in Gy/cGy or %)
• Volume (in cm3 or %)
The other values are automatically calculated. Any values that
you enter appear as bold text.
Plan Information Displays Active and Reference or Sum plan information

side-by-side.
Dose Points Displays the dose points that you have defined on Plan step or
Evaluate > Review step for the active plan.

Display Tab
Additional layouts are available on the Display tab of Compare and Sum
Plans step.
 Perform a Reference Plan Comparison

1. Click Load Reference Plan. The Load Reference Plan dialog box appears.
2. Select a reference plan from the plan list. You can only select a reference
plan that is based on the same primary CT image as the active plan.
3. Click Load Plan. The Reference plan is loaded with all its plan
characteristics maintained and its VOIs displayed on the right image
viewer.
With the Active and Reference plans showing, you can:
the Active and Reference plans. When a point is selected in one image,
the corresponding point in the other image is also selected and the
• Use the normalization modes to synchronize normalization of the
isodose curves in the Active and Reference plans.
• Use the DVH to compare dose-volume values in the Active and
Reference plans.
Vx Values, Plan Information, and Dose Points.
 Perform a Sum Plan Comparison
NOTE: The active plan is not incorporated in the summation of multiple

plans. If you want to include the active plan in the evaluation, you must first
save the plan and then include the saved plan when you select the plans to
sum.
1. Click Sum Plans. The Sum Plans dialog box appears.

2. Select contributing plans to sum. You can only select a plan to sum if the
plan is based on the same primary CT image as the active plan.
3. Enter the values for Contributing Dose (Gy/cGy) and Contributing Weight
(%) for the selected plans.

4. Click Sum Plans. The summed plan appears on the right image viewer with
all its plan characteristics maintained and its VOIs.
If the Active plan is one of the plans chosen for the summation, and with the
Active and Sum plans showing, you can:
the Active and Sum plans. When a point is selected in one image, the
corresponding point in the other image is also selected and the
• To scale the summation dose, enter an absolute dose or % of
Prescription in the Isdose Legend Panel. The system will scale the
contribution accordingly.
• Use the DVH to compare dose-volume values in the Active and Sum
plans.
 Create a Summation Report

A summation report is available after summing plans in Compare and Sum
Plans step. The summation report contains summed dose and statistics for
two or more plans based on the same patient and primary CT image.
To generate a summation report:
1. Click Sum Plans to open the Sum Plans dialog box.
2. Select contributing plans to sum and click Sum Plans.
3. Review the results. Accuray Incorporated recommends that you go back to
Evaluate > Review step and save the active plan before generating a report.
4. After reviewing, go back to the Evaluate > Compare and Sum Plans step,
and click Print. The Summation Notes dialog box appears.
5. Enter any notes that you have and click OK. The Reports Viewer appears.
6. Review the patient and plan names, and select any Optional Chapters to
add.
7. Click View Report to create the summation report.
Finetune Step
Use the Finetune step to review existing treatment beams and make
detailed changes to certain properties of the beams. The Finetune step only
appears when the current treatment plan has one or more beams.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
 3D Beam Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
 BEV Display . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
 Dose Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
 List Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
NOTE: Beams modified on the Finetune step can only be saved as

deliverable using the Save Plan button located on the Evaluate > Review
step.
Finetune Step for MLC

 Tools
Section Control Description
3D Beam Display See “3D Beam Display” (page 588).
Show Beams Select a category to show 3D beams:

options • None
• All
• With Dose
• Selected
• Blocked
BEV Display BEV The view, from the perspective of looking through
Controls the beam onto the patient, allows you to see the
button outline of the beam over the patient anatomy.
Dose Calculation Algorithm Displays the current dose calculation algorithm

drop-down and a drop-down list of alternatives, if any.
menu

drop-down list of alternatives. (Low, Medium, or High).
menu
Calculate Calculates the final dose for the plan.

Final Dose
button
List Tools Sort button Sorts the beam list in ascending or descending
order based on the selection made from the Sort
by drop-down list.
Beam List Panels Invert Reverses the selection status of the beams from
Selection selected to not settled and vice versa.
button
Show • All Beams

drop-down • Beams with MU (non-zero MU)
list • Selected Beams (check boxes in the Selected
column)
Total Beams Displays the number of beams selected.

Selected
Total Beams Displays the total number of beams in the plan.
Fixed and Iris Collimators Only
Dose Calculation Uncertainty (%) Sets the uncertainty level used for
text box calculating dose. (0.1% - 4.0%)
The Uncertainty setting is available after
you perform a Ray-Tracing dose calculation
and select Monte Carlo on the Algorithm
drop-down list.
List Tools Select and Modify Select allows selection of beams with the
button user selected criteria.Modify allows the
target positions and MUs to be modified.
Beam List Panels Frame Displays the current frame of reference and
a drop-down list of available frames of
reference. (CT or Robot)
Beams Selected check box Select this check box to select all beams.
Individual check Select or clear an individual check box for

boxes an individual beam.
Path/Node Displays the path and node number of the

beam.
Collimator (mm) Displays collimator size in millimeters.
MU Displays number of monitor units in a text

box.
Critical Displays number of critical

Intersections intersections.The tooltip displays the name
of each intersected critical VOI.
Blocked Imaging Blocked state of the beam. (No / Yes)
Target coordinates Displays X, Y, and Z coordinates of the

target in an editable text box.
Source coordinates X, Y, and Z coordinates of the LINAC

photon beam source (not editable).

Layouts
MLC Only
Dose Calculation Uncertainty (%) text box Sets the uncertainty level used for calculating
dose. (0.1% - 4.0%)
The Uncertainty setting is available after you
perform a FSPB dose calculation and select
Monte Carlo on the Algorithm drop-down list.
List Tools Select and Modify button Select allows selection of beams with the user
selected criteria.Modify allows the target
positions and MUs to be modified. MU
modifications can be applied to a group of
beams.
Beams Selected check box Select this check box to select all beams.
Individual check boxes Select or clear an individual check box for an

individual beam.
Beam Valid If all segments of a beam are valid, the beam is

valid.
Path/Node Displays the path and node number of the

beam.
Critical Intersections Displays number of critical intersections.The

tooltip displays the name of each intersected
critical VOI.
Blocked Imaging Blocked state of the beam. (No / Yes)
Segments Segment Key A unique number identifying a particular
segment. This value appears on reports used to
identify individual segments.
Segment Valid Displays whether the segment has a valid set of

leaf openings. If the segment is invalid, an error
will display what needs to be changed.
% The segment’s percentage contribution of MU

to the beam it is a part of.
Critical Intersections Displays number of critical intersections.The

tooltip displays the name of each intersected
critical VOI.
Eq Sq Length (mm) The side of the equivalent square field

corresponding to the irregular field that is used
to look up the pencil kernel and TPR
parameters.
Leaf Positions Bank X1 & X2 The side of the MLC collimator the leaf is
located.
Pos (mm) Number of mm away from the center line of the

MLC, measured at SAD at which each leaf is
positioned.
Layouts

 3D Beam Display
Display Options:
• None
• All
• With Dose
• Selected
• Blocked
Individual Modification
Use the beam list to modify MU or Target values. Values that can be edited
on the beam list are displayed with a light background; the read-only items
are displayed with a darker background.
To modify the MU or Target coordinates on the beam list:
1. Click to select a row.
2. Double-click the parameter.
The text box is activated for editing and the current value appears.
3. Modify the current value.

4. Click outside the text box to save changes and close the text box.
When you attempt to modify values on the beam list, the Accuray Precision
System checks certain conditions and displays appropriate error or warning
messages. For more information on these messages, see “Warnings,
Errors, and Messages” (page 735).
 BEV Display
BEV Display allows you to view the outline of the beam over the patient
anatomy.
NOTE: Clear the VOI Projection check box to turn off the VOI projections
even if VOI Visibility Options is turned on. However, VOI Projections does
not show the VOIs that have VOI Visibility Options turned off.
• DRR Projection: View the DRR projection.

• VOI Projection: View the VOI projection on the current DRR when the
same VOIs are turned on the VOI Visibility Options.
• Collimator Projection:View the projection of a collimator shape.
• Reticle: View the cross hair which provides an indication of distance on
the 800 mm SAD plane for the selected beam.
 Dose Calculation
After making changes on the Finetune step, you must calculate the dose
based on the current beam data. You can perform low, medium, or high
resolution dose calculation. To save the plan as deliverable, you must
perform a medium or higher resolution for Ray-Tracing and FSPB dose
calculation.
 List Tools
Sort
Use the Sort dialog box to sort the beam list in Ascending or Descending
order based on the criteria displayed on the Sort by drop-down list.

The order of sorting is maintained from one sort to another. For example, if
you sort by Path/ Node and then sort by MU, the result displays beams
sorted by MU and each group of beams with the same MU is sorted
internally by Path/Node.
1. Under List Tools, click the Sort button. The Sort dialog box appears.
2. Select a sorting criterion from the Sort by drop-down list.
3. Select Ascending or Descending.
4. Click Sort.
Examples
• Selected Beams in ascending order: The beams that are not selected
are grouped at the top and the selected beams are grouped at the
bottom.
• Path/Node in ascending order: The beams are sorted by Path ID first.
Beams with the same Path ID value are then sorted by Node ID.
• Blocked Imaging in ascending order: The unblocked beams are
grouped at the top and the blocked beams are grouped at the bottom.
Yes and No are then sorted in alphabetical order.
Select and Modify

Use the Select and Modify dialog box to select beams and apply MU
modifications to a group of beams.
Select and Modify dialog box for Fixed and Iris collimator
Select and Modify dialog box for Multileaf Collimator
NOTE: For Fixed and Iris Collimators, Modify allows the target positions and
MUs to be modified. For MLC, only MU modifications can be applied to a
group of beams.
NOTE: When using Finetune step for an MLC QA Plan, Modify allows
selection, but no modification.
The following selections are available:

• Frame.
• Path.
• Critical VOI.
• MU.
• Fixed and Iris only - Position of the robot node relative to the patient
anatomy (if CT is selected from the Frame drop-down menu).
Select a Group of Beams

1. Click the Select and Modify button from List Tools.
2. Specify one or more criteria for a beam.
3. Click Select to select all beams that meet the criteria.
4. Click Deselect to clear the selection of all beams that meet the criteria.

5. Click Clear Fields to reset the Path and Critical VOI values to the default
value <any> and clear the other values.
Each iteration of a group selection is performed on the current beam select
state.
Example
A plan has a total of five beams and the first three are selected. Specify a
criterion that is met by the last three beams. Click Select. All five beams are
selected because no changes were made to the current select state of the
two items that did not meet the criteria and only the beams that did meet the
criteria are updated.
The MU and the edit text boxes accept five digits before the decimal point
and two digits after the decimal point. If both MU text boxes are displayed
and populated, the system checks that the value in the left-hand text box is
not greater than or equal to the value in the right-hand text box.
Select a Beam Displayed in the 3D Image Window

Double-click the tip of a beam displayed on the 3D image. The beam
changes to orange, indicating it is selected. Its entry is checked and
displayed in the beam list panel. All other selected beams are yellow.
Modify Selected Beams for Fixed and Iris Collimators
WARNING: To prevent patient mistreatment, do one of the following:

• If a beam set already exists and you wish to zero the dose for beams that
intersect a critical VOI, you must clear the Allow Beam Intersections check
box on Plan > Settings . You must then re-optimize the plan.
• You can also set the dose for these beams to zero in the Finetune step,
however, if you use this method and subsequently use Sequential
Optimization planning to modify the plan, the optimal solution may include
non-zero beams that pass through the critical VOI.
1. Select the beams to modify.

2. Enter new values for the selected beams.
3. To identify the desired target coordinates, perform graphical targeting by:
• Drag the cross-hair on a 2D-view.
• Click Get Cross-hair Point.
The Target X, Y, and Z text boxes are populated with the X, Y, and Z
values from the 2D views.
4. Click Modify to apply changes.
5. (Optional) Click Clear Fields to reset default values.
If you enter invalid values, an error or warning message appears. For more
information on these messages, see “Warnings, Errors, and Messages”
(page 735).
Modify Selected Beams for MLC

1. Select the beams to modify.
2. Enter new values for the selected beams.
3. Click Modify to apply changes.
4. (Optional) Click Clear Fields to reset default values.
Automatic Updates
Dose contours are not displayed after a modification because the current
calculated dose no longer applies to the beam set. Perform a low, medium,
or high resolution dose calculation to view newly-generated dose contours.
The controls are unavailable until the beams have been generated.
When pointing to a critical intersection whose value is greater than 0, the
system displays a tooltip with the names of the critical VOIs intersected by
a beam.

After a new target modification has passed all system checks and is
accepted, the critical beam intersection is updated. If the beam would
intersect a critical structure where dose is not allowed, the beam is set to
blocked state.
Frame
For Fixed and Iris Collimator only, you can display the coordinates in the CT
(default) or Robot frame. The ability to select beams based on the direction
(anterior, inferior, superior, posterior, left and right) of the beam with respect
to the patient CT on the Beams table are hidden in Robot frame and are
visible in CT frame.
When you select a new frame, the system updates the beam list
coordinates and clears all coordinate-related text boxes on the beams and
target coordinates panels to ensure that values entered for one frame are
not mistakenly used for another frame.
Beams Step
The Beams step displays a list of beams and geometric parameters
associated with them. The controls enable you to perform hand calculations
to verify that the reference dose for each beam is consistent with the
number of MUs for that beam. For additional information, see the Physics
Essentials Guide.
 About the Beams Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
 Print the Beam Data List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
 Sorting Order of Beams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596
 About the Beams Step

To validate the dose calculation, you can perform an independent check of
the dose calculation on individual beams. The Beams step provides
geometric and dose parameters for a beam and a reference point in the
dose calculation grid. The reference point is the point of maximum dose or
a point defined by the user on Review step.
The Beams step also provides the SAD, beam depth, radius, dose at the
reference point, the number of monitor units for each beam, and Dose/MU.
You can use this data and the beam data stored in the datafiles to
independently verify that the dose at that point is consistent with the number
of monitor units.

The Monte Carlo Dose Calculation algorithm requires a different approach
to the secondary MU check as compared with the Ray-Tracing algorithm.
For information about performing an independent check of the dose
calculation on individual beams, refer to the chapter on Algorithms for Dose
Calculation and Display in the Physics Essentials Guide.
 Print the Beam Data List

1. From Evaluate > Review step, click the Print icon. The Reports Viewer
appears.
2. Choose a report:
• Double-click Beam Data List (for Fixed and Iris only) from the report list.
• Double-click Segment Report (for MLC only) from the report list.
without modifying the parameters.
parameters and click View Report.
 Sorting Order of Beams

The list of beams in a plan appears as follows:
• The Beams list on the Evaluate > Beams step.
• The printed Beam Data List or Segment Report.
• The printed Path Check List.
The content of all three lists is the same. The content can be
cross-referenced by template Path ID/node number (TmPID/NID),
collimator size, and Beam Key (for fixed Collimator or Iris Collimator) or
Segment Key (for MLC). There are differences in the indexing of Beam List
(Beam) and Path Checklist (SID).
The sorting methods for each list are based on the collimator type.
• Fixed Collimator: The beams are sorted first by template path ID, then
by collimator size, and then by node number.
• Iris Collimator (Option): The beams are sorted first by template path ID,
then by node number, and then by collimator size.
• Multileaf Collimator (Option): The beams are sorted first by template
path ID, then by node number, and the Equivalent Square Length (mm)
field.
Image Tools
 Dose Probe Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
 Isocurves / Dose Difference Panels . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
 Dose-Volume Histogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
 Dx Vx Value. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
 Plan Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
 Dose Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
 Dose Probe Box

In the Compare and Sum Plans step, a Dose Probe box appears on all 2D
images. The Dose Probe box lists the following data about the point:
• HU Value.
• Dose.
• Delta Dose.
• Voxel Indices.
• CT Position in mm IECp.
 Isocurves / Dose Difference Panels

In the Compare and Sum Plans step, when you click the Isocurves legend
on the image viewer, the Isocurves /Dose Difference Map panel appears.

Isocurves Check boxes When selected, the color assigned to a color wash
value appears. When at least one check box is
selected, the column header check box is
available. To select or clear all individual check
boxes, select or clear the column header check
box.
Color drop-down Indicates the color that represents a point in the

menu range of Gy/cGy or % color wash values.
Dose Gy/cGy Displays the absolute value of the isocurve.
Dose % Displays the relative value of the isocurve.
Gy/cGy option Select this option to update the Isocurves legend

and the corresponding Dose Gy/cGy values in the
image viewers.
% option Select this option to update the Isocurves legend

and the corresponding Dose % values in the image
viewers.
Min/max dose Select to show the minimum and maximum dose

check box values for each VOI in the corresponding plan.
Normalize Select one of the available options from the

relative dose to drop-down list:
drop-down list • Active Max Dose
• Active Rx Dose
• Ref Max Dose
• Ref Rx Dose
• Custom [100% =]
Gy/cGy field The Gy/cGy field updates in correspondence to

what you have selected from the Normalize relative
dose to drop-down list.
Show dose Select the check box to show dose outside the skin.
outside skin
check box
Lines check box Select the check box to show dose lines.

Overlay check Select the check box to show dose overlay.

box • Select this option to view the overlay as a
• Fill option smooth fill of the isocurves.
• Grid option • Select this option to view the overlay as a grid
that displays the dose at its native resolution.
Dose Opacity Use the slider to modify dose opacity.

slider
Dose Check boxes When selected, the color assigned to a color wash
Difference value appears. When at least one check box is
Map selected, the column header check box is
available. To select or clear all individual check
boxes, select or clear the column header check
box.
Color Indicates the color that represents a point in the

range of Gy/cGy or % color wash values.
Diff Displays the different values (% or Gy/cGy)

assigned to each color and adjusts the values
based on the dose normalization mode.
Show dose Displays a dose difference color wash on the image

difference check viewers.
box
The Dose Difference Map defines the colors used in the color wash to
highlight the dose difference between points on Active and Reference
images when the Show dose difference check box is selected. Pixels
shaded in red have higher dose values in the dose distribution relative to
the plan being compared. If the Active plan has higher dose at a given pixel,
that pixel will be shaded with red on the Active plan image, but will be blue
on the Reference plan image.
Color Wash on an Active Plan Image Comparing Dose to the Reference Plan Image
The value assigned to a color is in either Gy/cGy or % depending on the

dose normalization mode selected. When the dose normalization mode is
changed, the Dose Difference Map values are updated to be consistent with
the normalization mode.
Dose Normalization Modes

In the Compare and Sum Plans step, the following dose normalization
modes are available for sum plans.
• Active Max Dose: 100% dose level of isodose contours and isodose
legends corresponds to the max dose value for the active plan. Dose
difference values appear as a relative percentage of the active plan's
max dose.
• Active Rx Dose: 100% dose level of isodose contours and isodose
legends corresponds to the prescription dose value for the active plan.
Dose difference values appear as a relative percentage of the active
plan's prescription dose.
• Ref Max Dose: 100% dose level of isodose contours and isodose
legends corresponds to the max dose value for the reference plan.
Dose difference values appear as a relative percentage of the
Reference plan's max dose.
• Ref Rx Dose: 100% dose level of isodose contours and isodose
legends corresponds to the prescription dose value for the reference
plan. Dose difference values appear as a relative percentage of the
reference plan's prescription dose.
• Custom [100% =]: 100% dose level of isodose contours and isodose
legends corresponds to the dose value displayed in the

Custom [100% =] field. Dose difference values appear as relative
percentages of the value entered in the Custom [100% =] field.
The prescription isodose line is a special case. Regardless of the
normalization scheme selected, the prescription isodose line represents
the prescribed dose for the plan displayed. The Active plan and Reference
plan images always show the prescription isodose line for their respective
prescription doses. Therefore, even when the selected normalization mode
is relative to the Reference plan or a custom max, the calculated
percentage value for the Active plan prescription isodose line represents
the prescription dose of the Active plan. The same is true for the Reference
plan's prescription isodose line when normalization is set to the Active
plan's max or a custom max.
If the prescription doses of the Active and Reference plans do not match,
the Reference plan's prescription dose appears in green to indicate the
lines that represent different absolute doses.
Finally, the Sum plan's first entry in the isodose line list is equivalent to the
prescription dose of the Active plan.
Display a Dose-difference Color Wash on an Image

2. Select the Show dose difference check box.
dialog box.
Change Color Values Assigned in Color Wash

2. Click in the value field assigned to a dose-difference color, and change the
value. The value must be greater than the value of the color below it and
less than the value above it.
dialog box.
 Dose-Volume Histogram
In the Compare and Sum Plans step, the Dose-Volume Histogram (DVH)
chart displays a DVH for each delineated target and critical VOI in the
Active plan and Reference or Sum plan. You can use the DVH chart to
compare the DVHs of VOIs in the plans.
Click on a point in the selected DVH curve to display Active and Reference
or Sum plan dose and volume data (% and Gy/cGy) and the difference
between the two. To move the point along an active curve, drag the vertical
bar left or right.
Item Description
DVH Properties button Click to open the DVH Properties dialog box.
Selected DVH drop-down The VOI selected from the Selected DVH drop-down list
list is the active VOI on the DVH chart. Click a point in the
selected DVH curve to display Active and Reference plan
dose and volume data (percentage and Gy/cGy) and the
difference between the two. To move the point along an
active curve, drag the vertical bar left or right.

View or Modify DVH Properties
You can set or change the DVH chart properties of the Active and
Reference or Sum plan structures. It includes columns indicating available
structures, the source plan, whether a structure in a Reference or Sum plan
is comparable with a structure in the Active plan, and check boxes to show
structures on the DVH chart.
IMPORTANT: Only the portion of a VOI that is enclosed by the dose

calculation grid is used to determine the DVH and dosimetric statistics.
Therefore, if a volume is partially enclosed by the grid, the apparent total
volume of the VOI for DVH calculation will be less than the volume
calculated.
1. Click DVH Properties. The DVH Properties dialog box appears.

2. From the Background Color drop-down list, you can select a different
background color to view the DVH chart.
3. Select one or more Show Active Plan DVH check boxes to view the
• Select one or more Show Reference Plan DVH check boxes to view the
• Select one or more Show Sum Plan DVH check boxes to view the
5. If necessary, select the Snap dose value to nearest percent when
interrogating values in relative dose mode check box.
6. If necessary, select the Manage display of DVH curves independent of VOI
Visibility Settings check box.
7. Click OK.
View DVH Displays

1. Select a VOI on the Selected DVH drop-down list. The VOI curve is now the
active curve on the DVH panel.
2. Click a point on the active curve. A navigation bar intersecting the point and
data for that point appears.
The following data are displayed:
• Dose in Gy/cGy corresponding to a given percentage dose for the point

on the active curve and for the equivalent point on the Reference plan
curve.
• The difference between the Active plan volume and the Reference plan
volume at the selected point.
3. To move the point along the active curve, drag the point or vertical bar left
or right, or click a different point on the curve.
Soft Tissue DVH
other VOIs from the volume of dose calculation box.

parameters listed in the following table for Active and Reference or Sum
plans that are compared side-by-side.
NOTE: For sum plans, the CI, nCI, HI, and Coverage statistics for targets will
show as n/a because the statistics require a prescription isodose line and
one is unavailable for a sum plan.
Item Description
Name Lists the name of VOIs in Active and Reference or Sum plans.
Comp Comparable. Indicates whether the VOI from a reference or

sum plan is comparable to the same VOI from the Active plan.
VOIs are comparable if they have matching names and
contours.
Min (Gy/cGy) Minimum dose in Gy/cGy for each VOI in the Active plan
Min r (Gy/cGy) (Min), Reference plan (Min r), or Sum plan (Min s).
Min s (Gy/cGy)
Mean (Gy/cGy) Mean dose in Gy/cGy for each VOI in the Active plan (Mean),
Mean r (Gy/cGy) Reference plan (Mean r) or Sum plan (Mean s).
Mean s (Gy/cGy)
Max (Gy/cGy) Maximum dose in Gy/cGy for each VOI in the Active plan
Max r (Gy/cGy) (Max), Reference plan (Max r) or Sum plan (Max s).
Max s (Gy/cGy)
CI, CI r, CI s The ratio of total tissue volume that receives the prescription
(Conformality Index) isodose or more to tumor volume that receives the
prescription isodose or more in the Active plan (CI), Reference
plan (CI r) or Sum plan (CI s).
Item Description
nCI, nCI r, nCI s The CI multiplied by the ratio of the total tumor volume to the
(New Conformality tumor volume that receives the prescription isodose or more in
Index) the Active plan (nCI), Reference plan (nCI r) or Sum plan (nCI
s).
HI, HI r, HI s The ratio of the maximum dose to the prescription dose. For
(Homogeneity Index) the current configuration of the Accuray Precision System, the
maximum dose is always the100% isodose in the Active plan
(HI), Reference plan (HI r) or Sum plan (HI s).
Coverage (%) The volume of the tumor that receives the prescription dose
Coverage r (%) divided by the total volume of the tumor times 100 in the
Active plan (Coverage), Reference plan (Coverage r) or Sum
Coverage s (%) plan (Coverage s).
 Dx Vx Value
Dx Vx Values for customizable dose-to-volume analysis are available

wherever dose statistics are shown. You can perform dose-to-volume
analysis on Active and Reference or Sum VOIs, All Target Regions, or Soft
Tissue. After selecting an option from the drop-down menu, you can enter
one of four values to track or compare: Dose (in Gy/cGy or %) or Volume
(in cm3 or %). The other values are automatically calculated. Any values
that you enter appear as bold text.
NOTE: Dx Vx values that are entered are copied from the active plan to the
reference plan with the automatically calculated values derived from the
corresponding DVH curves. As a result, either the dose difference or volume
difference will be always zero for each row.
TIP: Double-click the color box next to the Name column to move the
crosshairs on the images to the centroid of the corresponding VOI and move
the DVH graph cursor to the corresponding point (if the corresponding DVH
curve is currently visible and the selected VOI is not All Target Regions or
Soft Tissue).

Item Description
Name Select a VOI,All Target Regions, or Soft Tissue from the

drop-down list to display and customize Dx and Vx fields for
dose-to-volume analysis of Active and Reference or Sum
plans.
Dose (Gy/cGy) Displays the dose of the selected DVH option in Gy/cGy for
Dose r (Gy/cGy) the Active plan (Dose), Reference plan (Dose r) or Sum plan
(Dose s).
Dose s (Gy/cGy)
Dose (%) Displays the dose of the selected DVH option in % for the
Dose r (%) Active plan (Dose), Reference plan (Dose r) or Sum plan
(Dose s).
Dose s (%)
Volume (cm3) Displays the volume of the selected DVH option in cm3 for the
Active plan (Volume) and Reference plan (Volume r) or Sum
Volume r (cm3)
plan (Volume s).
Volume s (cm3)
Volume (%) Displays the dose value of the selected DVH option in % for
Volume r (%) the Active plan (Volume) and Reference plan (Volume r) or
Sum plan (Volume s).
Volume s (%)
Active-Ref Dose Displays the dose difference in Gy/cGy between the Active
(Gy/cGy) and Reference or Sum plans for the selected DVH option.
Active-Sum Dose
(Gy/cGy)
Active-Ref Volume Displays the dose difference in cm3 between the Active and
(cm3) Reference or Sum plans for the selected DVH option.
Active-Sum Volume
(cm3)
To perform customized dose-to-volume analysis:

1. Select a VOI, All Target Regions, or Soft Tissue from the DVH drop-down
list.
2. In a Dose or Volume field, enter the value you want to analyze. The other
values for the Active and Reference or Sum plan are automatically
calculated.
 Plan Information
Plan Information displays information for Active and Reference or Sum
plans side-by side.
 Dose Points
active plan. Dose Points cannot be defined in Compare and Sum Plans
step.

Chapter 10
Utilities Task
The Utilities task provides tools for analyzing the quality of various aspects
of a plan. 3D Filter step displays tools for viewing 3D images in W/L, Color,
and Flythrough layout which provides a unique view of the plan and dose
distribution. Ball-cube Plan step provides tools to create a test plan to be
used to verify the geometric accuracy of the CyberKnife System.
3D Filter Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
Flythrough. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
3D Presets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
Color 3D Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
Ball-cube Plan Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
1072963-ENG B Chapter 10: Utilities Task 611

3D Filter Step
The 3D Filter step displays tools for enabling the color 3D filter, showing
beams on the 3D view for selected VOIs, and merging datasets (for multiple
fused image series). The following layouts, determined by whether single or
multiple image sets are loaded, are available for 3D Filter: W/L, Color, or
Flythrough.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612
3D Filter step
 Tools
The following tools are available on the 3D Filter step.
Layout W/L option Allows the user to adjust window/level based on histogram.
Selection
Color option Allows the user to define customized 3D filter preset.
Flythrough Allows navigation through 3D images from both outside and inside.
option
Synchronize By default, if two or more datasets are loaded, synchronize mode

check box is selected when 3D Filter is accessed. Synchronize allows
side-by-side simultaneous visualization of two 3D views during
Flythrough mode. If not selected, the user can adjust the two 3D
views independently.

Flythrough
Flythrough allows the user to inspect data from both the inside and outside
of the image. A Flythrough 3D image is different from standard 3D image
because of its perspective. This means that objects close to the user will
appear larger than objects further away.
 Use Flythrough Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
 Use Dual or Multiple Data Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Flythrough with single image set loaded
 Use Flythrough Mode

• Drag the mouse to rotate the image to change the image view The
rotations will not alter the dataset, just the display of the data.
• Use the Pan tool to shift the 3D center. Carefully shift in small
increments by releasing the mouse quickly.
• Use the mouse wheel to move in and out.
NOTE: Because the distance between the viewer and object determines the size in
perspective view, the Zoom tool cannot be used with Flythrough.
3D Filter also displays flythrough image sets in synchronized mode. When
two or more image sets are loaded, flythrough mode allows the user to
inspect the image sets from any angle and position either inside or outside
the patient data.
 Use Dual or Multiple Data Mode

• When a single image set is loaded, image controls are applied to the
displayed 3D image.
• When Synchronize mode is selected and two or more image sets are
loaded, image controls are applied to the 3D image of the primary
series. Image controls cannot be independently applied to the 3D image
when Synchronize mode is selected.
• When Synchronize is not selected and two or more image sets are
loaded, the user can adjust the two 3D views independently.

Flythrough synchronized mode
Flythrough not synchronized mode
The following example screen depicts the 3D Filter layout for a plan with two
sets of fused image series. This view displays three volume renderings:
• Primary image series (A)
• Mixed fusion of the primary and secondary image series (A/B)
• Secondary image series (B)
If two images are loaded and fused, you can switch between the primary,
secondary, and mixed image series displays by clicking on the icon in the
top left corner of the image pane.
The prescription dose isocontour and the regions that were selected on the
3D Filter step are rendered in the 3D volume.
3D Filter with two sets of fused image series

3D Presets
 3D Display Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
 3D Display Options
3D Filter allows color 3D filter presets to be defined. Customized presets
can be defined based on factory presets and then saved with a meaningful
name. These presets are then displayed in a preset gallery with a skull
image and labeled with a red "C".
3D Display Options dialog box
Color 3D Filter
With the Color option selected as the Layout Selection, the user can assign
different color and opacity to different intensity value of 3D images. For
example, in certain instances, it may be useful to display vascular
structures in red.
The bottom panel displays the image histograms, color palette selector,
final color bar, histogram scale control, and a curve to represent opacity and
color information.
 Use the Color 3D Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
 Use the Color 3D Filter

1. Drag the cursor on the curve. If the control point is dragged (small square)
on the curve, the control point position will be modified along with the
portion of the curve connected to neighboring control points. If the curve is
dragged, a new control point will be created.
2. The curve y-value represents the opacity value assigned to the intensity
value. Zero opacity will make that voxel with this intensity value fully
transparent in the 3D image. The maximum value (1) opacity will change
that voxel to opaque.
3. Double-click on the color control palette to choose a color.

4. Right double-click on the color palette to assign that color to 3D image
background.
5. Double-clicking on the control points will assign the currently selected color
to that portion of curve. This changes the color of those voxels in the 3D
image to the range of intensity value. The color value will be interpolated
between neighboring control points, if neighboring control points have
different color values.
6. Dragging the control point in a straight line with two neighboring control
points and releasing the mouse will automatically delete that control point.
7. By dragging cyan color lines in histogram scale control area, the histogram
can be scaled so that only that portion of the histogram will be displayed.
8. By pressing U, D, L, and R keys on the keyboard, the entire curve can be
shifted up, down, left, and right. The first and last control points will not be
moved.
9. Click the Save Filter button to save the customized filter into the preset
gallery with a meaningful name and a fixed icon.
10. Load a filter by either clicking the Load Filter button or by right-clicking to
quickly access to 3D Presets gallery in 3D Options dialog box.
Ball-cube Plan Step
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621
 Overview
The Ball-cube plan test procedure is a quality assurance tool that enables
you to create a dose distribution at the center of the film-cube with a
spherical target. Use this test to verify the geometric accuracy of the
CyberKnife System.
For more information on using the Ball-cube Plan step, see the Physics
Essentials Guide.

Chapter 11
Settings Task
The Settings task allows you to set display preferences and defaults for the
The Settings task can be accessed when a plan is being viewed or click
Planning Settings from the home page.
Preferences Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
Maintenance Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
Plan Template Step . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
Plan Template Parameters for Tomo® . . . . . . . . . . . . . . 642
Plan Template Parameters for CyberKnife . . . . . . . . . . . 648
NOTE: To allow data to be shared among Accuray Precision System workstations

associated with the same CyberKnife System or Tomo Treatment Delivery System,
some data created in the Preferences and Plan Templates steps are stored on the
iDMS System. This data includes Isocurve Templates, VOI Set Templates,
Window/Level Presets, Plan Templates, Optimization Scripts, and Density Models.
When a file is in use by another user, an error message appears, indicating that the
file is locked.
1072963-ENG B C ha pt er 1 1: Se tt i ng s T as k 623
Preferences Step
Use the Preferences step to set display and planning parameters.
 Display Parameters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
 Planning Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626
Preferences Display Parameters tab
 Display Parameters
The appearance of the display can be customized by setting the
parameters in the Isocurve Templates, Rendering, and VOI Set Templates
sections.
The following parameters can be set on Preferences > Display Parameters.
Isocurve Use the Isocurve Templates area to set the current isocurve
Templates template or update the default isocurve template. Set the
percentage of the maximum dose for each curve, the isodose line
width, the color, and show/hide setting for any or all of the dose
curves.
Load Factory Click to reset all default Isocurve Templates to factory settings.
Settings button
Rendering Displays the current color selection of Labels on images, Focus

lines, Controls on images, Dose Box, and Secondary Image
Overlays. Use the drop-down lists to change the color.
The color selection in the Secondary Image Overlay drop-down
list controls the color of the Monochrome colormap.
Load Factory Click to reset all color selections to factory settings.

Settings button
Share pan and Select to apply pan and zoom settings to all 2D views on a step.
zoom factors
between 2D views
check box
Default SUV Select the default method for calculating SUV from the drop-down
Method drop-down list.
list
Default Colormap Select the default colormap for CT images.

for CT Images
drop-down list
Default Colormap Select the default colormap for MR images.

for MR Images
drop-down list
Default Colormap Select the default colormap for PET images.

for PET Images
drop-down list
Default Colormap Select the default colormap for XA images.

for XA Images
drop-down list
Load Factory Click to reset all default colormaps to factory settings.

Settings button
VOI Set Use the VOI Set Templates area to select a VOI template set from
Templates a list of saved VOI Set Templates. When you select a template,
the properties update for all VOIs that do not have a defined
contour. If a VOI has been previously delineated, that VOI will
retain its current properties (including the VOI name).
Template Click to select a template from the list of saved VOI Set
drop-down list Templates. By default, Empty template is selected.
Rename button Click to rename the selected VOI template.
Set Default button Click to set the selected VOI template as default.
Add button Click to add a VOI to the selected VOI template.
Delete button Click to remove the selected VOI from the template.
Load Factory Click to reset all default VOI Templates to the factory settings.
Settings button
 Planning Parameters
The planning parameters can be customized by setting the Treatment Time
Parameters (CyberKnife plans only), Density Models, Window/Level
Presets, and Miscellaneous sections.
Planning Parameters Tab for Tomo
Planning Parameters Tab for CyberKnife
Miscellaneous Enable The Accuray Precision System automatically saves the current plan
Auto-save at regular intervals. The interval length can be modified or the
check box function disabled.
NOTE: If Auto-save is disabled, the plan is not saved and any
changes are unrecoverable.
Load Factory Resets the interval time to factory settings.

Settings
button
Expected MIM Displays expected MIM build number.The information only appears
build if PreciseART® or PreciseRTX® is licensed.
Window/Level Add button Click to add a preset.

Presets
Delete button Click to remove the selected preset.
Load Factory Resets all 2D Presets to the factory settings.

Settings
button
Treatment For each tracking method for the CyberKnife System, the default
Time patient setup time and image time intervals are modified here.
Parameters
CyberKnife Load Factory Resets all Treatment Time Parameters to the factory settings.
Only Settings
button
Density Models Create a custom density model, and set a default.

The X-Axis has two options to display the Density Model Range:
• Model Range displays the range between the lowest HU (-1024)
to the highest value defined in the selected density model.
• Full Range displays the range between the lowest HU (-1024) to
the highest value Accuray Precision System supports.
Two Extension Methods are available:
• Extrapolate extends the mass/electron density curve up to the
max HU number by extrapolating via slope between last two
entries.
• Flat extends the mass/electron density curve up to the max HU
number by using repeating last entries.
Density Models
The Model drop-down list in the Planning Parameters tab shows the
following sample models:
• Water/Air (sample)
• Lung Standard (sample)
• Body Standard (sample)
Sample models cannot be changed and cannot be used to create
deliverable patient plans. You can create and name up to seven custom
models for a total of 10 density models.
Density Definitions
• Relative Electron Density: The electron density value for a given CT
number relative to the electron density of water.
• Mass Density: The mass per unit volume in units of g/cm3.
CAUTION: When you are defining the density model, include a point defined as
follows: HU value for air -1000 at air density 0.001 g/cc. Otherwise, there is a risk
that an interpolated value will have too high a density and the beam attenuation in
air will be overestimated. Failure to use the appropriate density model may result in
incorrect dose distributions.
NOTE: If you generate and save a plan that uses a specific density model and then
change the curve associated with that model, when you reload the plan it will reuse
the curve saved with the plan. The name of the density curve in the Plan > Setup
will be bracketed to indicate that the parameters differ from the default density
curve with the same name.
Density Models panel with Model Range
Density Models panel with Full Range
Create or Modify a Density Model

1. Click Settings task.
2. Click Preferences > Planning Parameters.
3. Select a custom model from the Model drop-down list.
4. (Optional) Click Rename.
Enter the new name in the highlighted section and press Enter.
5. (Optional) Click Set Default to set a new density model as the default.
6. Enter values in the HU and Density fields for each point in the model.
• Maximum relative electron density of 10.
• Maximum mass density 22.6.
• Maximum HU value of 31743. Minimum HU value of -1024.
• Model displayed as point to point line segments.
7. (Optional) To delete a point in the model, select the point and click Delete
Point.
8. (Optional) To reset the model to the default system values, click Reset
Model.
IMPORTANT: The initial values of the custom models are quite different from any
real-world model. Therefore, be careful to avoid accidentally resetting any custom
model you enter. There is no confirmation message for the reset model command,
and in the normal planning workflow, there is no display of the model currently in
use.
If you click Reset Model, all values revert to the default values except for the
model name. When you reset a modified model, evaluate the resulting
model carefully before applying that model to a plan.
9. Enter values in any order. The list will automatically be resorted.

• Use -1 if a density will not be defined.
• Enter values in the last row and click Enter to add a new edit row.
Set a Model as the Default Model
1. Click Settings task.
2. Click Preferences > Planning Parameters.
3. Select a custom model in the Model drop-down list.
4. Click Set Default. A Warning message appears.
5. Click Yes to set a new default density model.
6. From the Plan task, confirm that the density model default is the custom
model assigned as the default.
Maintenance Step
Use the Maintenance step to delete images from the workstation if the
image is stored locally on the Accuray Precision System, and delete the
remote host setup for DICOM transfer.
 Delete an Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
 Delete a Remote Host. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
NOTE: Patient images are stored on the iDMS System. The data deleted here is
duplicate data.
Maintenance Step
 Delete an Image
To delete an image, select the patient or patients associated with the
images to be deleted and click Remove.
 Delete a Remote Host
To delete a remote host, select a host name to be deleted and click
Remove.
Plan Template Step
Use the Plan Template step to review, create, edit, and delete plan
templates. Plan templates are saved when leaving the Plan Template step.
Use the Save As function to change a plan template and then save it as a
new plan template. When using Save As, the originally modified plan
template does not change.
 Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636
 Managing Plan Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
 General Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
NOTE: Changes to a plan template are automatically saved either when navigating
away from the Plan Template step or when a different plan template is selected.
Plan Template for Tomo
Plan Template Step for CyberKnife
 Tools
The following controls are available on the Plan Template step.
CAUTION: When a template is loaded, it sets many planning parameters including

the fractionation, density model, and the dose limits for plan optimization. Verify
that each parameter is the desired value for the particular patient whose treatment
you are planning. Inappropriate values may cause unexpected results in planning.
Plan drop-down list Chose from a list of existing templates.

Templates
New button Create a new template.
Delete button Delete an existing template.
Save As button Save a new template from an existing template with

a new name.
Edit button Edit a template.
Load Factory Settings Resets all default values to factory settings.

button
Template Name Displays name of current template.

Properties
Anatomic Region Defines the anatomic region associated with the
drop-down list plan template.
Treatment Machine Lists available treatment machine types.

Type drop-down list
Author Displays name of the template author.
Password Protection Allows you to establish password protection for the

check box current template.
Quick Plan Validation Summary Checks the plan template for use with QuickPlan.
button Not available for Tomo templates.
 Managing Plan Templates

The Accuray Precision System provides capabilities to create, edit, and
delete plan templates. Plan templates can optionally be protected with a
password. The screen for managing plan templates is located in the
Settings >Plan Template. If a template is password-protected, you must
enter the password to edit.
NOTE: The Plan Template step displays tools for managing template contents. For
information on selecting a template for a plan, see “Complete Creating a Standard
Treatment Plan With a Template” (page 71).
The control panel on the Plan Template step displays:

• A list to select any template defined on the Accuray Precision System.
• Control buttons to create, delete, copy, and edit the current template.
• A template properties section that includes name, the anatomical
region, machine type, the author, and the status of password protection.
The plan template view (in the center of the window) displays a series of
tabs that correspond to types of parameters that are part of the plan
template. These parameters can be edited to set different parameters in a
given view.
Create a Plan Template

You can create a new plan template with all the parameters populated from
the currently selected plan, or with all of the parameters empty.
1. Click New from Plan Templates. A dialog box appears to confirm that you
want to continue creating a template based on the current template plan.
If the plan template is being created from a plan that has optimization
parameters set, you will be asked if you want to create a new script. If you
click Yes, the Save Script dialog box appears. If you click No, you can
manually select the script to be associated with the template if desired.
2. Click Yes to create a new template with all the settings of the currently
loaded plan, or click No to create a new empty template.
When a new template is created, an automatically generated name is
assigned to the template. You can change the name in the Name field of
Template Properties.
Copy a Plan Template

You can copy an existing template to a new template.
1. Select the template you want to copy from the template list.
2. Click Save As from Plan Template. The Save Plan Template dialog box
appears.
3. Enter a name for the new template. The template name field cannot be
empty or the duplicate of an existing template.
4. Click OK to create a new template. The new template is added to the
template list and becomes the current template.
If the source template is password protected, you can still copy it to a new
template without typing the password. The password will not be copied to
the new template.
Delete a Plan Template
1. Select the template to delete from the Plan Template drop-down list.
2. Click Delete. If the template is not password-protected, the template is
deleted.
If the template is password protected, the Plan Template Password dialog
box appears. Once the correct password is entered, the template is deleted.
Edit a Plan Template
Plan Template and Template Properties
1. Select the template to edit from the Plan Template drop-down list.
• If the plan is not password protected, you can edit the fields.
• If the plan is password protected, click the Edit button, enter the
password in the password prompt, and click OK.
2. (Optional) Select the Password Protection check box to add password
protection.
You can also replace an existing password by clicking the Change
Password button under the check box.
3. Edit the template fields.
Any changes immediately update the template contents. Changes are not
applied to previously saved plans using the template. To change the
settings saved with a plan, you must update the plan.
 General Tab
The General tab allows you to configure isocurve and VOI definitions and
allows Autosegmentation for a plan template.
The following parameters can be set on the General tab.
Isocurve check boxes Set the isocurves to be displayed, as well as the

Definitions color, dose percentage (relative to the point of
maximum dose), and line thickness for each.
Autosegmentation Perform Select to perform Autosegmentation for this plan

Autosegmentation template. This includes the ability to define a
check box mapping between a VOI name and an
Autosegmentation structure name in the plan
template VOI Name Matching tab.
NOTE: Autosegmentation is currently available for
brain, head and neck, and prostate cases.
NOTE: Brain Autosegmentation requires an MR
image.
Anatomic Region Displays the current selection and drop-down list to

select available automatically segmentable
structures.
Bladder contains Select to indicate that CT image set includes a

air check box catheter and resulting air in the bladder. When
selected, autosegmentation algorithm
compensates for the presence of catheter and the
associated air.
VOI Definitions Displays list of VOI names, types, and colors.
Add VOI button Click to add a VOI to the selected VOI template.
Delete VOI button Click to remove the selected VOI from the
template.
Load Definitions Loads VOI definitions from an existing VOI set

from a VOI Set template.
Template button
Set General Template Parameters
1. Select the Show check box in the Isocurve Definitions section for each
isocurve definition you want displayed for the plan.
2. Click the Load Definitions from a VOI Set Template button if using VOI
definitions from an existing template.
3. Select the Perform Autosegmentation check box if you want automatic
segmentation to be performed.
4. Select Brain, Head and Neck, or Male Pelvis from the Anatomic Region
drop-down list.
5. Select the Bladder contains air check box if CT images show air in the
bladder.
Plan Template Parameters for Tomo®
 Plan Setup Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
 Planning Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
 Evaluate Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645
 VOI Name Matching Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646
 Plan Setup Parameters Tab

Use Plan Setup Parameters tab to select a density model, select density
overrides, and set allowed beam intersections for critical structures.
The following parameters can be set on the Plan Setup Parameters tab.
Density Model drop-down Displays the current density model and a list of alternatives. A typical
list density model contains a mass density model curve and a relative
electron density model curve. Both curves are displayed on the graph.
Tomo plans only require mass density values.
Density Priority Indicates which density override values will be used when VOIs
Overrides overlap. When two VOIs overlap, the density values of the VOI with the
higher priority, in descending order from the top, will be used in the
overlapping region.
Enabled Turns on the ability to define a density override for a VOI.

check box
Move to Adjusts the priority by moving the selected density override to the
Bottom bottom of the list.
button
Move Down Adjusts the priority by moving the selected density override one row
button lower in the list.
Move Up Adjusts the priority by moving the selected density override one row
button higher in the list.
Move to Top Adjusts the priority by moving the selected density override to the top
button of the list.
Beam Name Name of the critical VOIs that beams can intersect.
Intersection
Allow Beam Allowed: Allows beams to intersect the listed VOI.
Intersection Never: Does not allow beams to intersect the listed VOI.
Exit Only: If a beam intersects the listed VOI before it intersects the
target, the beam is disabled.
NOTE: Beam/VOI intersection check is performed at projection plane
at 800 mm depth.
Set Plan Setup Parameters
NOTE: The beam intersection table on the Plan Setup Parameters tab is hidden if a
script is applied to a template. The script’s beam intersection settings have priority
over the template settings.
1. Select the density model for the treatment plan from the Density Model
drop-down list.
2. Select the corresponding Enabled check boxes for density overrides.
3. Set density overrides priorities using the Move buttons.
4. Highlight the VOI and select the beam intersection option from the
drop-down list.
• Exit Only: If a beam intersects the listed VOI before it intersects the
 Planning Parameters Tab

Use the Planning Parameters tab to select a script.
Planning Parameters tab
The following parameters can be set on the Planning Parameters tab.
Treatment Script Name Select from the list of available scripts.

Parameters drop-down list
Script Description saved with the script.

Description
Script Summary The optimization parameters saved in the script.
 Evaluate Parameters Tab
Use the Evaluate Parameters tab to predefine dose volume analysis for
VOIs (all target regions or soft tissue). After selecting a VOI from the
drop-down list, decide which parameter to track and enter a value for one
of the following:
• Dose (Gy/cGy)
• Dose (%)
• Volume (cm³)
• Volume (%)
When a template is applied to a new plan, these values are included. Once
dose has been calculated in the plan, the other three values are
automatically computed based on the DVH for the selected VOI.
Evaluate Parameters tab
The following parameters can be set on the Evaluate Parameters tab.
DxVx Values Name Select VOIs from the drop-down list to display Dx and Vx values.
Dose (Gy/cGy) Displays the dose of the selected VOI in Gy/cGy. Manually entered
Dose (%) Displays the dose of the selected VOI in %. Manually entered values
Volume (cm3) Displays the volume of the selected VOI in cm3. Manually entered
Volume (%) Displays the dose value of the selected VOI in %. Manually entered
Criteria Double click to open the Edit DxVx Criteria dialog box, and enter
(double-click to values to augment each DxVx value which you want to evaluate
edit) against the active plan. See “DxVx Criteria” (page 406) for more
details.
 VOI Name Matching Tab

When a plan is created, there can be as many as four different names for a
given VOI. For a given VOI, the names include:
• The name specified in the Plan Template.
• The name from an Optimization Script which should be associated with
the VOI.
• The name used by Autosegmentation associating the contours
produced by the AutoSegmentation algorithm with the VOI.
• The name for the VOI that is contained in the RTSS imported when the
plan was created.
Autosegmentation and RTSS names can be considered the source of
contours for a VOI. VOI names defined by the Plan Template can be
considered the source of contours for Autosegmentation rules and for the
VOIs used in optimization.
VOI Name Matching tab
The following parameters can be set on the VOI Name Matching tab.
VOI Name Name in VOI names in the template.

Matching template
Name in script VOI names from the Optimization script for

the plan.
Autosegmentati VOI names used by Autosegmentation.

on Structure
Name
The Accuray Precision System automatically matches the VOI names

between the Plan Template and the Optimization script and between the
Plan Template and the VOI names for Autosegmentation.
Matching VOI names between an optimization script and the imported
RTSS can be performed prior to applying a Plan Template in the Use Plan
Template screen.
Plan Template Parameters for CyberKnife
 Planning Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 648
 Plan Setup Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
 Script Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
 Evaluate Parameters Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
 VOI Name Matching Tab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
 QuickPlan Tab. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659
 Planning Parameters Tab

Use the Planning Parameters tab to define treatment parameters, select an
optimization method, set prescription information, and select collimators.
Planning Parameters tab
The following parameters can be set on the Planning Parameters tab.
Planning Parameters tab controls
Treatment Treatment Select a treatment delivery machine. What you select affects what
Parameters Machine other settings are available, depending on the machine
drop-down list configuration and licenses.
Number of Number of fractions to be delivered.

Fractions
Collimator Type Displays current collimator type and a drop-down list of available
drop-down list collimators.If the Accuray Precision System is not licensed for
either the Iris Collimator or MLC Collimator, Fixed appears.
Treatment Displays current area to be treated and a drop-down list of

Anatomy available treatment areas stored in the data files. Each anatomical
drop-down list area is associated with one or more unique template path sets.
InTempo Imaging When selected, the InTempo Adaptive Imaging System path sets
check box will be used. The check box is unavailable unless the CyberKnife
System is licensed for the InTempo System and “body” is selected
in Treatment Anatomy.If the InTempo Imaging check box is
selected, the Tracking Method must include fiducial tracking, and
the Template Path Set defaults to an InTempo System specific
path set.
Template Path Displays the current selection and drop-down list to change the
Set drop-down template path set. Available choices depend on the selected
list treatment anatomy.
Synchrony Displays the Synchrony methods determined by the configuration

Method of the CyberKnife System and Accuray Precision System, as well
drop-down list as the previously selected treatment parameters.
Optimization Optimization Displays the current selection and a drop-down list of available
Resolution resolution settings for the Ray-Tracing dose calculation algorithm,
drop-down list Monte Carlo Dose Calculation, and FSPB dose calculation
algorithm for optimization (Low, Medium, or High).
Prescription Prescription Dose Sets the numerical value for the prescribed dose (Gy/cGy).
(Gy/cGy)
Prescription Sets the numerical value for the prescription dose percentage.
Isocurve (%)
Collimator • If the Collimator Type is Fixed, a max of 3 collimators may be

Selection selected for each treatment path.
• If the Collimator Type is Iris, any number of collimators may be
selected for each treatment path.
• Whenever Treatment Anatomy is changed, Template Path Set
and Synchrony Method are reset to empty and the user must
choose those items again.
• While Template Path Set is empty, no collimators can be
selected.
Name Name of VOIs.
Selection Method Select a Selection Method for each target VOI. If the Selection
drop-down list Method is Manual, set the collimator size for each of the treatment
path (TmP1, TmP2, TmP3).
• Manual
Collimator Size Displays the available collimator sizes.

(mm)
Set Planning Parameters

1. Select a Treatment Machine if there is more than one CyberKnife at the site.
2. Enter the number of plan fractions in the Number of Fractions text box.
3. Select the collimator type from the Collimator Type drop-down list.
4. Select the anatomic region from the Treatment Anatomy drop-down list.
5. (Optional) Select the InTempo Imaging check box if InTempo imaging will
be used in the treatment plan.
6. Select the appropriate path set from the Template Path Set drop-down list.
7. Select the appropriate tracking method from the Synchrony Method
drop-down list.
8. Select Low, Medium, or High from the Optimization Resolution drop-down
list.
9. For Fixed and Iris Collimators, highlight and select the collimators for each
treatment path (TmP1, TmP2...) for the corresponding target in the table
below.
 Plan Setup Parameters Tab
The Plan Setup Parameters tab allows you to select a density model,
enable contour correction, select density overrides, and set allowed beam
intersections for critical structures.
Plan Setup Parameters tab
NOTE: Beam/VOI intersection check is performed at projection plane at 800 mm

depth.
Plan Setup Parameters tab controls
Density Model drop-down list Displays the current density model and a list of alternatives. A
typical density model contains a mass density model curve and a
relative electron density model curve. Both curves are displayed on
the graph.
Contour For Ray-Tracing algorithms only: Select to apply a correction to

Correction off-axis rays to account for patient surface obliquity.
check box
Density Priority Indicates which density override values are used when VOIs
Overrides overlap. When two VOIs overlap, the density values of the VOI with
the higher priority, in descending order from the top, are used in
the overlapping region.
Enabled check Select to define a density override for a VOI.

box
Move to Adjusts the priority by moving the selected density override to the
Bottom button bottom of the list.
Move Down Adjusts the priority by moving the selected density override one
button row lower in the list.
Move Up Adjusts the priority by moving the selected density override one
button row higher in the list.
Move to Top Adjusts the priority by moving the selected density override to the
button top of the list.
Beam Name Name of the critical VOIs that beams can intersect.
Intersection
Intersection • Allowed: Allows beams to intersect the listed VOI.
• Exit Only: If a beam or segment intersects the listed VOI before
it intersects the target, the beam will be disabled.
Set Plan Setup Parameters

1. Select the density model for the treatment plan from the Density Model
drop-down list.
2. Check the Contour Correction check box if you want the Ray-Tracing
algorithm to apply a contour correction.
3. Select the corresponding Enabled check boxes for density overrides.
4. Set density overrides priorities using the Move buttons.
5. Highlight the VOI and select the beam intersection option from the
drop-down list.
NOTE: For segments, only the portion that intersects with the VOI is blocked, not
the whole segment.

• Exit Only: If a beam intersects the listed VOI before it intersects the
 Script Parameters Tab

Use the Script Parameters tab to define parameters related to Sequential
and VOLO optimization scripts.
Script Parameters tab
Script Parameters tab controls
Show Sequential option Select either option to filter the scripts available from the Script
VOLO option Name drop-down list.
Script Name drop-down list Select from the list of available optimization scrips for the
selected optimization method.
Relaxed Appears when the Sequential option is selected. Select this

Convergence check box to apply system-defined convergence criteria at each
check box step of the optimization script.
Script Description of the selected optimization script.

Description
Script Summary Summary of the selected optimization script.
Set Script Parameters
to display only scripts specific to the selected collimator type.
1. Select the optimization method (Sequential or VOLO) that you want to

show.
2. If you select Sequential, select the Relaxed Convergence check box to
apply convergence testing during optimization.
3. Select an appropriate Optimization script from the Script Name drop-down
list. The description and summary of the script appears.
 Evaluate Parameters Tab

The Evaluate Parameters tab provides the ability to predefine dose volume
analysis for VOIs, All Target Regions, or Soft Tissue. After selecting a VOI
from the drop-down list, enter one (of four) values to track: Dose (in Gy/cGy
or %) or Volume (in cm3 or %). When a template is applied to a new plan,
these values will be included. Once dose has been calculated in the plan,
the other three values will automatically be computed based on the DVH for
the selected VOI.
Evaluate Parameters tab controls
DxVx Values Name Select VOIs from the drop-down list to display Dx
and Vx values.
Dose (Gy/cGy) Displays the dose of the selected VOI in Gy or

cGy. User entered values appear in bold text.
Dose (%) Displays the dose of the selected VOI in %.

Manually entered values appear in bold text.
Volume (cm³) Displays the volume of the selected VOI in cm3.

Volume (%) Displays the dose value of the selected VOI in %.

Criteria Double click to open the Edit DxVx Criteria dialog

(double-click to box, and enter values to augment each DxVx
edit) value which you want to evaluate against the
active plan. See “DxVx Criteria” (page 449) for
more details.
 VOI Name Matching Tab
When a plan is created, there can be as many as four different names for a
given VOI. For a given VOI, the names include:
• The name specified in the Plan Template.
• The name from a Optimization Script which should be associated with
the VOI.
• The name used by Autosegmentation associating the contours
produced by the AutoSegmentation algorithm with the VOI.
• The name for the VOI that is contained in the RTSS imported when the
plan was created.
AutoSegmentation and RTSS names can be considered the source of
contours for a VOI. VOI names defined by the Plan Template can be
considered the source of contours for Auto Margin rules and for the VOIs
used in optimization script. The Manual check box and the Generate Skin
Automatically check box are also sources of contours for VOIs.
Before a Plan Template can be valid for use with QuickPlan, all sources of
contours (AutoSegmentation Names, RTSS Names, Automatic Skin
Generation and Manual if checked) must be matched with some VOI name
from the Plan Template. No VOI can have more than one source of
contours. All VOI names from the Plan Template or optimization script must
have a source of contours matched to it.
The QuickPlan Validation Summary specifically indicates where there are
problems involving VOIs that are inadequately matched (either as sources
or destinations of contours).
VOI Name Matching tab controls
VOI Name Name in template Name of the VOI.

Matching
VOI Operation When selected, indicates that the VOI name in this row is the
Destination destination of an VOI Operation defined in the QuickPlan tab.
Manual When selected, manually contour the VOI before QuickPlan can
proceed automatically.
Name in script VOI names from the selected optimization script for the plan.
AutoSegmentation VOI names used by AutoSegmentation.

Structure Name
Matching VOI Names

• If a script is selected, match each name from the selected script with the
desired VOI name in the plan template. The VOI type (Critical or Target)
for the VOI from the script must match with the VOI type for the VOI from
the plan template. The drop-down list for a VOI selected in Script Name
column will only show VOIs that are the same type as the VOIs from the
plan template.
• If AutoSegmentation is selected, match each structure name supported
by AutoSegmentation with the VOI from the plan template where the
automatically generated contours should be placed.
 QuickPlan Tab
The QuickPlan (licensed option) step allows key planning parameters to be
set via a plan template prior to creating a new plan. QuickPlan automates
the treatment planning process by fusing image sets, generating VOIs (if
AutoSegmentation is selected), optimizing beams, and calculating dose.
The newly created plan can then be evaluated and adjusted.
QuickPlan tab controls
VOI Operations If configured, VOI operations completes automatically after

autosegmentation is performed and before leaving the
Contour tab. For further instructions, refer to “VOI
Operations” (page 289)
Skin Generation Generate Skin When selected, QuickPlan generates a skin VOI
Automatically check automatically. When cleared, the Skin VOI drop-down list
box is unavailable.
Skin VOI drop-down Select a structure to represent the patient’s skin.

list
Maximum Contours Enter the number of contour sets for the selected Skin VOI
Per Slice text box (1 - 8).
HU Threshold text Enter a value to modify the HU number that differentiates

box patient anatomy from air. (-900 to - 100).
Min Contour Size Enter a value to modify the minimum number of voxels that
(voxels) text box can be used to create a Skin structure.
Optimization Optimization Dose Set Dose Calculation Box Size button: Click to view the
Calculation Dose Calculation Box Size dialog box to define the size of
the dose calculation box for the Sequential or VOLO step.
This is based on which VOIs should be included and some
margin that is used to dilate the box isotropically.
Monte Carlo Dose Perform Monte Carlo Dose Calculation check box: When
Calculation selected, QuickPlan uses Monte Carlo for optimization
after it has optimized the plan using Ray-Tracing.
Resolution: Displays the current selection and a
drop-down list of resolution settings when Monte Carlo is
performed (Low, Medium, or High).
Uncertainty%: Displays the uncertainty used for
calculating the dose.
Time Reduction for Perform Time Reduction check box: Select to specify a
Sequential desired treatment time per fraction in the Treatment Time
Optimization per Fraction text box and perform a treatment time
reduction.
Treatment Time per Fraction text box: Enter the value for
the desired treatment time (in minutes) per fraction.
Beam Reduction for Perform Beam Reduction check box Select to reduce the
Sequential number of beams in the treatment plan. The Cutoff (MU)
Optimization text box and the Reduce and Reduce and Optimize
options become available,
Cutoff (MU) text box: Enter the minimum MU for beams to
be retained in the plan. All beams with dose below this
value are removed from the plan.
Reduce option: Accepts changes and removes the beams
whose MU are below the cutoff and recalculates the
remaining non-zero beams without re-optimization.
Reduce and Optimize option: Accepts changes, removes
beams whose MU is below the cutoff, and starts
re-optimization with the first step.
Evaluation Perform Dose Calculation check box: Select to perform a

dose calculation in the Evaluate > Review step.
Set Dose Calculation Box Size button: Click to view the
Dose Calculation Box Size dialog box to define the size of
the dose calculation box for the Evaluate > Review step.
This is based on which VOIs should be included and some
margin that is used to dilate the box isotropically.
Algorithm: Displays the current dose calculation algorithm
and a drop-down list of alternatives, if any.
Resolution: Displays the current selection and a
drop-down list of resolution settings when calculation is
performed (Low, Medium, or High).
Uncertainty (%): (Monte Carlo only) Displays the
uncertainty used for calculating the dose.
Lateral Scaling check box: Select to apply the lateral
scaling to the FSPB algorithm. The lateral scaling
broadens the kernel based on local regional density. The
broadened kernel improves the agreement between
measurement and calculation in low-density regions like
the lung and directly upstream from the low density.
General Stop In Fusion Step check box: Select to perform manual

fusion before QuickPlan can proceed automatically;
otherwise fusion without seed points will be used to fuse
secondary datasets to the primary CT.
Set QuickPlan Options

1. Click the Generate Skin Automatically check box.
• Select a skin VOI from the Skin VOI drop-down list.
• Enter the maximum contour per slice, HU Threshold, and minimum
contour size in the Skin Generation text boxes.
2. Define a VOI operation by specifying a VOI A name, an operation, VOI B
name if applicable, effect on destination, destination if not selected by
default, and grow target if desired.
• Enter growth parameters in the VOI Operations section.
3. Click the Set Dose Calculation Box Size button. The Dose Calculation Box
Size dialog box appears where a dose calculation box that includes either
all of the VOIs or a select set of VOIs can be created.
4. If Monte Carlo is used, select the Perform Monte Carlo Dose Calculation
check box. Then, select Low, Medium, or High from the Resolution
drop-down list and set the Uncertainty (%).
NOTE: Ray-Tracing will have been performed prior to performing Monte Carlo
during optimization.
5. If time reduction is desired, select the Perform Time Reduction check box.
6. If beam reduction is desired, select the Perform Beam Reduction check
box.
7. Select the Perform Dose Calculation check box in the Evaluation section to
calculate evaluation dose.
8. Click the Set Dose Calculation Box Size button in the Evaluation section.
The Dose Calculation Box Size dialog box appears.
NOTE: This is only available for Ray-Tracing since Monte Carlo uses the entire CT
volume when calculating dose.
9. Select the algorithm from the Algorithm drop-down list in the Evaluation
section.
10. Select Low, Medium, or High from the Resolution drop-down list in the
Evaluation section.
11. Click Validation Summary to confirm that the plan template is sufficient for
creating a plan using QuickPlan.
If the QuickPlan template is incomplete, a information message will be
displayed.
Chapter 12
Synchrony® Spine Tracking (CyberKnife

Option)
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666
Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Imaging Center Selection. . . . . . . . . . . . . . . . . . . . . . . . . 671
1072963-ENG B Ch ap t er 12 : S y nc hr on y® Sp ine Tr a cking ( Cy be r Knif e Op t io n) 665

Introduction
The Synchrony Spine Tracking enables tracking of skeletal structures in the
spine region for patient positioning and radiation beam delivery without the
need for implanting fiducials. It is capable of tracking throughout the spine
including the cervical, thoracic, lumbar and sacral spinal regions. The
Synchrony Spine Tracking can also track non-rigid deformations typically
observed in vertebrae.
 About the Synchrony Spine Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . 666
 Accuracy of Synchrony Spine Tracking . . . . . . . . . . . . . . . . . . . . . . . . 666
 About the Synchrony Spine Tracking

During treatment planning for the Synchrony Spine Tracking, perform the
following steps.
On the Contour task Spine -Tracking step:
• Spine segmentation (optional).
On the Setup task Align step:
• Define an imaging center in the patient CT image series. A default
region of interest (ROI) is automatically projected onto each of the DRR
images.
• Adjust the ROI size so that it contains the skeletal structures to be
tracked.
While the size of the ROI can be modified on the treatment delivery system,
the position of the imaging center cannot. It is therefore important to choose
the imaging center so that it is close to the target and in a region with
sufficient skeletal features for tracking.
 Accuracy of Synchrony Spine Tracking

The tracking accuracy and stability of Synchrony Spine Tracking is verified
and validated using phantom experiments as well as clinical patient data.
Synchrony Spine Tracking has an accuracy of better than 0.95 mm in
end-to-end phantom experiments. Because of the geometric effect of
rotational errors, the targeting error increases as a function of the distance
between tracking center and treatment center. For example, 0.5 degree of
rotational error translates to 0.1 mm of translational error per 10 mm of
distance between tracking center and treatment center. This accuracy
trade-off should be considered when treating targets with significant
distance from the spine.
Treatment Planning
This section presents features specific to the Synchrony Spine Tracking in
treatment planning.
 Spine Tracking Volume Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . 667
 Tracking Mode Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
 Spine Tracking Volume Segmentation

To segment the spine tracking volume, use the model-based spine
segmentation tool in the Contour > Spine-Tracking step as shown in the
following image. Spine tracking volume segmentation is required when
treating a lesion in the thoracic, lumbar and sacral regions of the spine. Do
not use segmentation for C-spine unless bony anatomy is visible in the ROI.
WARNING: The Spine Tracking Volume limits the portion of the DRR used for
tracking by the Synchrony Spine Tracking. If the Spine Tracking Volume does not
fully encompass the vertebral column, tracking errors may occur during treatment.
Examine the images to ensure that the vertebral column is fully within the Spine
Tracking Volume.

Spine-Tracking Definition
On the Spine-Tracking step, use the Select VOI drop-down list to select the
Spine Tracking VOI. When a different VOI is selected, the previously
selected VOI is reset to a standard VOI, any existing contour set is
removed, and the VOI type is set to be a critical structure.
Spine-Tracking
The spine tracking defines a structure that includes the vertebral column
and the surrounding area. The surrounding area contains information that
helps generate higher quality DRR images.
NOTE: The spine tracking volume should not contain only the vertebral column, but
should also contain the surrounding area.
NOTE: For Synchrony Lung Tracking with Respiratory Modeling, the spine tracking
volume should not include any part of the target VOI. The treatment plan cannot be
saved if any part of the target VOI is included in the spine tracking volume.
The following image illustrates the spine model. The spine model defines a
stack of virtual spine disks. Each virtual spine disk is defined as an elliptical
contour on one of the axial image slices. The position and the size of each
elliptical contour are determined by a center point and two radius vectors.
A spine model contains two or more virtual spine disks. A spine model
includes the following adjustable parameters:
• The number of virtual spine disks.
• The center point and radius of each disk.
Adding a Virtual Spine Disk
In either the sagittal view or the coronal view, click on the spine axis line to
define the center position of the new virtual spine disk.
The radius of the new virtual spine disk is interpolated automatically from
the radii of the neighboring virtual spine disks.
Moving a Virtual Spine Disk

1. In any of the 2D views, click on the center of the virtual spine disk.
2. Drag the virtual spine disk to the new position.
Resizing a Virtual Spine Disk

1. Browse through the axial view to the image slice that includes the virtual
spine disk.
2. Resize the box that encloses the virtual spine disk.
Removing a Virtual Spine Disk

1. In either the sagittal view or the coronal view, click on the center point of the
disk to be removed.
2. Drag the center point of the virtual spine disk over the neighboring virtual
spine disks and release the mouse.
 Tracking Mode Selection

When creating a new plan, select Spine Supine from the Synchrony Method
drop-down list.
NOTE: For Head First Prone (HFP) or Feet First Prone (FFP) cases, select Spine
Prone with Respiratory if the Synchrony Spine Tracking Prone feature is licensed.

Imaging Center Selection
The display panel on the Align step includes five windows. The top windows
are DRRs (left corresponds to Camera B and right to Camera A) of the
patient. The lower images are 2D planar views: axial, coronal, and sagittal.
The intersection of the green lines in the 2D images represent the current
position of the imaging center. The DRRs are based on the current imaging
center.
 Guidelines for Setting the ROI Height . . . . . . . . . . . . . . . . . . . . . . . . . 671
NOTE: DRR quality in the treatment planning system differs from that in the
treatment delivery system.
 Guidelines for Setting the ROI Height

Set the height of the ROI to achieve optimum coverage of the relevant
skeletal structures. The default ROI height is 60 mm and can be adjusted in
the range of 40-100 mm. An aspect ratio of 3:2 is maintained by the system.

ROI Size Setting
To set the ROI size, adjust the ROI height.
1. Move the Spine Supine ROI Height slider bar. The grid displayed on the
DRR images is updated as the slider bar is adjusted.
The ROI height is displayed in millimeters to the right of the slider bar.
2. Click Confirm to save the position of the imaging center and the ROI height.
The Plan task will become active and a new plan can be created.
NOTE: The ROI height set in this step is the default size used during treatment
delivery.
ROI Too Small

If the ROI is too small, pertinent information for achieving optimal tracking
results is excluded.
ROI Too Large
Inclusion of large areas of the background will force the tracking algorithm
to scan a larger area. During treatment delivery, this may slow down the
Lung Optimized Treatment algorithm.
Imaging Center and ROI Positioned Incorrectly
If the imaging center is placed incorrectly for optimum tracking, it may cause
relevant skeletal structures to be excluded from the ROI or overly large
areas of the background to be included.
Proper Imaging Center Placement and ROI Sizing
The following image shows a correctly placed imaging center and an
appropriately sized ROI. The ROI is centered on the relevant skeletal
structures and is sized to minimize the back ground.
Chapter 13
Synchrony® Lung Tracking™ with

Respiratory Modeling (CyberKnife Option)
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
Alignment Center Selection . . . . . . . . . . . . . . . . . . . . . . . 681
1072963-ENG B C h a p t er 1 3 : Sy n c h r o n y L un g T r a c k i n g w i t h R es pi r a t o r y M od el i n g 675
Introduction
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
 About the Synchrony Lung Tracking with Respiratory Modeling . . . . . 676
 Overview
The CyberKnife System with the Synchrony Lung Tracking with Respiratory
Modeling enables accurate patient positioning and radiation beam delivery
without the need for implanting fiducials.
The Synchrony Lung Tracking with Respiratory Modeling is used in
combination with the Synchrony Spine Tracking to perform patient
alignment. During treatment delivery, it is used with the Synchrony System
to track movement of the tumor correlated with patient breathing patterns
translationally.
For more information about the Synchrony System, refer to the Synchrony
Respiratory Tracking (Option) chapter of the Treatment Delivery Manual.
For more information about the Synchrony Spine Tracking, refer to the
“Synchrony® Spine Tracking (CyberKnife Option)” (page 665) and the
Treatment Delivery Manual.
 About the Synchrony Lung Tracking with Respiratory

Modeling
The Synchrony Lung Tracking with Respiratory Modeling can accurately
and automatically track lung tumors that meet the following criteria:
• Tumor diameter greater than 15 mm in every direction.
• Tumor location in the peripheral region of the lung.
• Tumor location not completely obstructed by skeletal structures in the
projection images in the X-ray imaging geometry.
NOTE: The Synchrony Lung Tracking with Respiratory Modeling is not intended to
track lung tumors smaller than 15 mm in any direction or lung tumors located in the
central region of the lung.
Treatment Planning
In the treatment planning phase, identify the location of the tumor to be
treated and generate DRRs. During treatment delivery, the CyberKnife
System refers to rectangular regions that circumscribe the known tumor
contour in the DRRs to detect the tumor location within a region of interest
(ROI) in the live images.
The first step in creating a treatment plan is to load patient data and the
required medical images, including at least one CT series. This step is
described in “Overview” (page 23).
 Tumor and Spine Tracking Volume Segmentation . . . . . . . . . . . . . . . 677
 Tracking Mode Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 680
 Tumor and Spine Tracking Volume Segmentation

The Synchrony Lung Tracking with Respiratory Modeling requires two
special VOIs. The first VOI is the tumor tracking volume. The tracking VOI
is typically based on the gross tumor volume (GTV). The second VOI is a
coarse delineation of the spine. Use the Accuray Precision System
segmentation tools to segment the tumor and spine VOIs.
Segmenting the Tumor Tracking Volume

To segment the tumor VOI, use standard Accuray Precision System
segmentation tools.
1. On the Contour task, select the Manual > Tools step.
2. On the Select VOI drop-down list, select the GTV.
3. Segment the tumor tracking VOI using the standard Accuray Precision
System segmentation tools.
Spine Tracking Volume Segmentation

To segment the spine tracking volume, use the model-based spine tracking
volume segmentation tool in the Contour > Spine-Tracking. Spine tracking
volume segmentation is required for the Synchrony Lung Tracking with
Respiratory Modeling.
WARNING: The Spine Tracking Volume limits the portion of the DRR used for
tracking by the Synchrony Spine Tracking. If the Spine Tracking Volume does not
fully encompass the vertebral column, tracking errors may occur during treatment.
Examine the images to ensure that the vertebral column is fully within the Spine
Tracking Volume.
Spine Tracking Volume Definition
On the Spine-Tracking step, use the Select VOI drop-down list to select a
Spine Tracking VOI. When a different VOI is selected, the previously
selected VOI is reset to a standard VOI, any existing contour set is
removed, and the VOI type is set to be a critical structure.
Spine Tracking Volume

The Spine Tracking Volume defines a structure that includes the vertebral
column and the surrounding area. The surrounding area contains
information that helps generate higher quality DRR images.
NOTE: The Spine Tracking Volume should not contain only the vertebral column,
but should also contain the surrounding area.
NOTE: The Spine Tracking Volume should not include any part of the target VOI.
The treatment plan cannot be saved if any part of the target VOI is included in the
Spine Tracking Volume.
NOTE: The Spine Tracking Volume should only be used to define spine volume for
tracking purposes. It cannot be used to define any other structure.

In either the sagittal view or the coronal view, click on the spine axis line to
define the center position of the new virtual spine disk. A new virtual spine
disk can be added by clicking on the square box in the center of an
interpolated spine disk on any axial slice.
Modifying a Virtual Spine Disk

To move and resize a virtual spine disk, do the following:
To remove a virtual spine disk, do the following:
disk to be removed.
 Tracking Mode Selection

To use the Synchrony Lung Tracking with Respiratory Modeling:
1. On the Setup task, select the Machine > Tools step.
2. Select body-mlc or body_iris-fixed from the Treatment Anatomy drop-down
list depending on your collimator selection.
3. Select Lung with Respiratory from the Synchrony Method drop-down list.
Alignment Center Selection
 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
 DRR Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 682
 Overview
For Synchrony Lung Tracking with Respiratory Modeling, the alignment
center is selected based on the requirements of the Synchrony Spine
Tracking. The alignment center is used to align the patient at the machine
center and allow the image tracking system to track the patient in 6D.
NOTE: For best results, position the alignment center on the same axial slice as the
tumor tracking volume and center the alignment center on the spinal cord.
If the alignment center is on the same axial slice as the tumor tracking
volume, the tumor tracking volume will be visible in the axial view. When
you select the alignment center, you should be able to see the spine
tracking model in all three cardinal views.
The following image shows the tumor in the axial view. The spine tracking
model is visible in all three cardinal views.
 DRR Review
Use the DRR Review step of the Setup task to determine whether the tumor
is visible in the DRR images. This section describes screen controls used
for Synchrony Lung Tracking with Respiratory Modeling in the DRR Review
step.
Default Mode
If only one tumor tracking volume is defined as a target in the Contour task,
that volume is automatically selected as the tumor tracking volume in the
DRR Review step of the Setup task.
The following image shows the DRR Review step. The default DRR type is
Full Content. The name of the tumor tracking volume and the centroid
position point in CT space are displayed on the left of the screen.
If multiple targets are defined in the Contour task, the DRR views will be
blank when you switch to DRR Review step. You must select one tumor
tracking volume as the target before DRR images can be generated.
The DRR images are generated based on the centroid of the tumor tracking
volume. As a result, the tumor tracking volume will always be shown at the
center of the DRR images.
NOTE: To identify the tumor tracking volume in the DRR images, look in the region
at the center of the DRR images.
Tracking Tumor Displays a list of tumor tracking volumes.

drop-down list
Treatment CT Displays the X Y Z coordinates of the selected

Center (IECp) tumor tracking volume.
Display Contour check Displays the contour of the tumor.

box
Invert DRR Images Inverts DRR images black to white and white to
check box black.
Reset to Default W/L Resets to the default contrast of images.

button
DRR Type Full Content option Displays the full content DRR images.
Spine Removed option Displays the DRR images with the spine
removed.
Tumor Region option Displays the DRR images only of the region
around the tumor.
Apply button Confirms that tumor is visible in DRR images.
Confirming a Tumor Is Visible on the DRR Images

1. From the Tracking Tumor drop-down list, select a tumor tracking volume as
the target.
2. (Optional) Select the Display Contour and the Invert DRR Images check
boxes.
You can view the tumor in one of three ways by selecting the DRR type.
3. (Optional) Select the Full Content, Spine Removed, or Tumor Region

options in the DRR Type section.
The selected DRR type images are generated and appear.
4. Select the Full Content option, and then click the Apply button if the tumor
is visible on the DRR images.
NOTE: Only click Apply if you are sure this patient can be treated with Synchrony
Lung Tracking with Respiratory Modeling.
Display Tumor Tracking Volume Contour
1. Select the Display Contour check box to overlay the tumor tracking volume
contour on the DRR images.
2. Clear the Display Contour check box to hide the tumor tracking volume
contour in the DRR images.
The tumor tracking volume contour appears in the same color specified in
the VOI step. Tumor tracking volume contour projections in the DRR
images are generated based on the tumor tracking volume. The tumor
tracking volume centroid is also indicated in the DRR images by a plus sign
(+). The tumor centroid should always be located at the center of the DRR
images.
The following image shows the tumor tracking volume contour overlaid on
Full Content DRR images. The tumor tracking volume centroid is indicated
at the center of the DRR images.
Spine Removed DRR images.
Tumor Region DRR images.
Invert DRR Images
You can invert the DRR images to reverse the contrast to help visually
identify the tumor tracking volume. In some cases the tumor tracking
volume may be more visible in inverted DRR images. The inverted DRR
images are generated by mapping black to white and white to black in the
images.
1. Select the Invert DRR Images check box to invert the DRR images.
2. Clear the Invert DRR Images check box to return to the default contrast in
the DRR images.
The default DRR type is Full Content.
3. Select the Spine Removed or Tumor Region options to view other DRR
image types.
Invert DRR Images and Display Contour

1. Select both the Display Contour check box and the Invert DRR Images
check box.
2. Select Full Content, Spine Removed, or Tumor Region options for different
DRR types.
3. Clear the check boxes to return to the default view.
The following image shows the DRR Review screen with the tumor tracking
volume contour overlaid on inverted DRR Tumor Region images.
Apply
The Apply button is available when the Full Content option is selected. If
you can see the tumor clearly in the DRR images, click the Apply button.
Once the Apply button has been clicked, the Plan task becomes available.
WARNING: If the tracking target is not visible in the DRR images, the Synchrony
Lung Tracking with Respiratory Modeling algorithm might not be able to track the
tracking target. Ensure the target is contoured correctly and is visible in the DRR
images.
Chapter 14

(CyberKnife Option)
Lung Optimized Treatment enables radiation beam delivery to the lung
without the need for implanting fiducials.
Simulation Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
Lung Optimized Treatment . . . . . . . . . . . . . . . . . . . . . . . 699
For more information about the Synchrony Respiratory Tracking System,
refer to the Treatment Delivery Manual.
WARNING: Treatment plans using Lung Optimized Treatment should only be used
for lung cases. Otherwise, patient mistreatment may result.
1072963-ENG B C ha pt e r 1 4: Lu n g O p ti m iz e d Tr e at me n t ( Cy be r Kni f e O p t io n) 689

Simulation Plans
Simulation Plans provide a workflow to determine which tracking method is
optimal for a given patient. This section presents features specific to
Simulation Plans in treatment planning.
 Before You Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
 Creating a New Dual CT Simulation Plan. . . . . . . . . . . . . . . . . . . . . . . 693
 Creating a New Single CT Simulation Plan . . . . . . . . . . . . . . . . . . . . . 696
 Before You Begin

Simulation Plans Dependencies
Simulation Plans have the following dependencies:
Both 1-View and Spine Supine treatments are based on the assumption
that the position and motion range of the target during treatment with
respect to the spine alignment center are well represented by the CT scans
used for treatment planning. For this reason, it is very important that the CT
scans be taken during natural (not forced) inhalation and exhalation, and
that the same immobilization applied to the patient is used for both CT
scanning and treatment delivery. If any compression device is placed on the
patient, it is essential that it be present for both CT scanning and treatment
delivery.
• One CT exam is required to produce a single CT Simulation Plan.
• Two CT exams (inhale and exhale) are required to produce a dual CT
Simulation Plan (recommended workflow).
WARNING: Verify that the Accuray Precision System displays patient

orientation labels as intended by the manufacturer of the scanner. Use of
incorrectly labeled images could result in patient mistreatment.
WARNING: Verify that for each DICOM image series selected, that all slices
are listed and meet the image acquisition guidelines. Refer to the
pretreatment scanning guidelines in the Treatment Delivery Manual for
specific image acquisition guidelines.
Spine Segmentation
Spine Segmentation is required. Use the model-based spine segmentation
tool in the Contour > Spine-Tracking step to segment the spine.
WARNING: The Spine Tracking Volume limits the portion of the DRR used
for tracking by Lung Optimized Treatment. If the Spine Tracking Volume
does not fully encompass the vertebral column, tracking errors may occur
during treatment. Examine the images to ensure that the vertebral column is
fully within the Spine Tracking Volume.
Spine Tracking Volume Definition

On the Spine-Tracking step, the Spine Tracking Volume VOI is
automatically contoured. This VOI is then edited as described in the
sections that follow.
Spine Tracking Volume
The Spine Tracking Volume defines a structure that includes the vertebral
column and the surrounding area. The surrounding area contains
information that helps generate higher quality DRR images.
NOTE: The Spine Tracking Volume should not contain only the vertebral
column, but should also contain the surrounding area.


In any view, click on the spine axis line to define the center position of the
new virtual spine disk.
Moving a Virtual Spine Disk
Resizing a Virtual Spine Disk
1. Browse through the axial view to the image slice that includes the virtual
spine disk.
2. Resize the box that encloses the virtual spine disk.
disk to be removed.
 Creating a New Dual CT Simulation Plan
1. Click the New Plan icon in the Patients and Plans area of the Accuray
2. Select a patient with two image sets from the Patient Name/Patient ID list
on the New Plan screen.
3. Click the Simulation icon in the Select Type area.
4. Click Next >>.
5. On the Select Exams screen, the Modality list displays CT if CT exams are
included.
Exams associated with the selected modality are displayed in the Exam ID
list.
NOTE: If CT exams are not included, another patient exam profile must be
selected.
6. Select an exam (exhale) in the Exam ID list and click Select Exam, or
double-click on the exam to move it to the Selected Exam list. This exam
becomes the primary CT exam.
7. Select a second exam (inhale) in the Exam ID list and click Select Exam, or
double-click on the exam to move it to the Selected Exam list. This exam
will be the secondary CT exam.
Remove.
After removing an exam from the Selected Exam list, click CT in the
(Optional) You can select any RT Structure Set VOI associated with a
primary CT exam.
8. Click Next >>.

Select a treatment machine if there is more than one treatment machine at
your site. If there is only one treatment machine available at your site, it is
selected by default.
9. Click Next >>.

If an RT Structure Set VOI with different VOI names is loaded, VOI name
matching is required.
10. Click Use Template on the Use Plan Template screen.

11. Click OK in the Warning message.
If the time difference between the two CT series (inhale and exhale) is less
than 30 minutes, they are automatically considered to be registered.
Fuse > Setup step is displayed with the Already registered check box
selected unless the CT exams have a time separation of more than 30
minutes.
12. Evaluate the image fusion result. Do one of the following:

• If the CTs are acquired in the same coordinate space, verify that the
Already registered check box is selected and proceed to the next step.
• If the CTs are not acquired in the same coordinate space, verify that the
Already registered check box is not selected and proceed to the
Register step. It is recommended that a spine ROI region be used for
registration. For more information, see “Fuse Task” (page 259).
13. Click Contour. The Contour > Manual step appears.
14. Select TTV(primary) from the Select VOI list.
15. Create primary VOI corresponding to the visible mass of the treatment
target in the axial view using tools selected from the Drawing Tools area.
Use the slider bar to scroll up or down through the slice display in order to
add VOI segments to further define the VOI in 3D.
16. Click the image series label B showing the secondary CT, and select TTV
(secondary) from the Select VOI list.
17. Create secondary VOI corresponding to the visible mass of the treatment
target in the axial view.
18. On the Spine-Tracking step, select the spine VOI from the drop-down list.
Spine Tracking VOI edit mode is activated by clicking anywhere on the
midline column of the VOI in the Sagittal or Coronal view, or anywhere
within the Spine Tracking VOI in the Axial view.
NOTE: If the TTV(primary) VOI overlaps the Spine Tracking VOI, the resulting
Simulation Plan cannot be saved as a deliverable plan. It will be necessary to
refine the boundaries of either or both VOIs to eliminate contact in order to
save as a deliverable plan.
19. Click ITTV Creation, and under Define ITTV Parameters confirm that TTV
(primary) and TTV(secondary) are selected as Source VOI, and that ITTV
is selected as Destination VOI.
NOTE: The Internal Target Tracking Volume (ITTV) is based on the Target
Tracking Volume (TTV) and is generally delineated by the user during
creation of a Simulation plan.
The ITTV represents the expected respiratory excursion of the TTV. The ITTV
is defined from the delineation of the TTV on the two respiratory phases
represented by the CT scans used to create a Simulation plan. The shape
and position of the ITTV is independent of the tracking mode subsequently
selected when creating a treatment plan.
During treatment of a case where 1-View tracking is selected and the
treatment plan was based on a Simulation plan, the projected overlay of the
ITTV is displayed in the untracked Live X-ray image.
20. Click Apply to generate the ITTV VOI.

21. Click Setup. Align > Tools appears.
22. Use the crosshairs in the three 2D views to move the spine alignment center
to the desired position.
23. The blue tracking ROI mesh size may need to be adjusted to cover the
spine.
24. Click Confirm.
25. Click DRR Review.
26. Select TTV(primary) from the Tracking Tumor drop-down list. The DRR
images are processed.
• To view DRRs generated from the secondary CT, select Secondary
from the DRR Image drop-down list.
• To view the projected TTV(secondary) or ITTV on the DRR images,
verify that the Display Contour check box is selected and select TTV
(secondary) or ITTV from the Overlay VOI drop-down list.
27. Click Apply. The DRR Image must be Primary for the Apply button to be
active
28. Click the Save Plan icon.
29. In the Save Plan dialog box, enter an identifying Plan Name, and select the
Make Deliverable option.
30. Click Save.
NOTE: The Simulation Plan cannot be saved without confirming the

Treatment CT Center.

 Creating a New Single CT Simulation Plan
2. Select a patient from the Patient Name/Patient ID list on the New Plan
page.
3. Click the Simulation icon in the Select Type area.
4. Click Next >>.
5. On the Select Exams page, the Modality list will display CT if CT exams are
included.
list.
the exam to move it to the Selected Exam list.
• To remove an exam from the Selected Exam list, select the exam and
click Remove.
• After removing an exam from the Selected Exam list, click CT in the
• (Optional) You can select any RT Structure Set VOI associated with a
primary CT exam.
NOTE: It is recommended that the primary CT be in the exhale phase.
7. Click Next >>.

Select a treatment machine if there is more than one treatment machine
installed at your site. If there is only one treatment machine available at your
site, it is selected by default.
8. Click Next >>.

9. Click Use Template on the Use Plan Template screen. Contour > Manual
step appears.
12. On the Spine-Tracking step, select the spine VOI from the drop-down list.
NOTE: If the TTV(primary) VOI overlaps the Spine Tracking VOI, the
resulting Simulation Plan cannot be saved as a deliverable plan. It will be
necessary to refine the boundaries of either or both VOIs to eliminate contact
in order to save as a deliverable plan.
13. Click ITTV Creation and confirm that TTV(primary) is selected for Define
ITTV Parameters and that ITTV is selected as Destination VOI.
NOTE: The Internal Target Tracking Volume (ITTV) is based on the Target
Tracking Volume (TTV) and is generally delineated by the user during
creation of a Simulation plan.
The ITTV represents the expected respiratory excursion of the TTV. The
ITTV is defined from the delineation of the TTV on the two respiratory phases
represented by the CT scans used to create a Simulation plan. For a single
CT case, the ITTV is defined from the delineation of the TTV on the planning
CT and a range of motion entered by the user. The shape and position of the
ITTV is independent of the tracking mode subsequently selected when
creating a treatment plan.
During treatment of a case where 1-View tracking is selected and the
treatment plan was based on a Simulation plan, the projected overlay of the
ITTV is displayed in the untracked Live X-ray image.
14. Enter values in the 3 (R(-)/L(+), A(-)/P(+), I(-)/S(+)) Range of Motion (mm)
fields. The values should not exceed -50 to +50 to describe the 3 cardinal
components of expected respiratory motion of the target in mm from the
primary position.
NOTE: Range of Motion (mm) values between -50 and +50 must be entered
to activate the Apply button.
15. Click Apply. The ITTV VOI is generated using the TTV(primary) VOI and
Range of Motion (mm) values.
16. Click Setup. Align > Tools appears.
18. Click Confirm.

To view the projected ITTV on the DRR images, verify that the Display
Contour check box is selected and select ITTV from the Overlay VOI
drop-down list.
21. Click Apply.

22. Click the Save Plan icon.
24. Click Save.
This section presents features specific to Lung Optimized Treatment in
treatment planning.
 Accuracy of Spine Supine Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . 699
 Creating a New Lung Optimized Treatment Plan Using 2 CTs . . . . . . 699
 Creating a New Lung Optimized Treatment Plan Using 1 CT . . . . . . . 703
 Synchrony Method Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 706
 Creating an ITV (1-View and Spine Supine Tracking) . . . . . . . . . . . . . 706
 Creating a PTV (1-View and Spine Supine Tracking) . . . . . . . . . . . . . 709
 Align Center Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
 DRR Review (Lung with Respiratory and 1-View Tracking) . . . . . . . . 712
 ITV and PTV Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
 Accuracy of Spine Supine Tracking

The tracking accuracy and stability of Spine Supine Tracking is verified and
validated using phantom experiments as well as clinical patient data.
Synchrony Spine Tracking has an accuracy of ≥ 0.95 mm in end-to-end
phantom experiments. Because of the geometric effect of rotational errors,
the targeting error increases as a function of the distance between tracking
center and treatment center. For example, 0.5 degree of rotational error
translates to 0.1 mm of translational error per 10 mm of distance between
tracking center and treatment center. This accuracy trade-off should be
considered when treating targets with significant distance from the spine.
 Creating a New Lung Optimized Treatment Plan Using

2 CTs
NOTE: When a Lung Optimized Treatment plan is created that is not based
on a Simulation Plan, the projected overlay of the ITTV will not be displayed
in the untracked Live X-ray image for 1-View tracking treatments.
2. Click a patient name from the Patient Name/Patient ID list on the New Plan
screen. The icons for plan type are activated.
3. Click the Lung Optimized icon from the Select Type area to create a new
Lung Optimized Treatment plan.
You may optionally select the Use an existing Simulation Plan check box.
When this check box is selected, select a desired Simulation Plan. Then,

you can add images (such as MR images or additional CT images) to the
images used to create the Simulation Plan.
The Select Exams screen appears with a list of studies associated with the
selected patient. The appropriate plan template for Lung Optimized
Treatment plans is selected automatically.
WARNING: Treatment plans using Lung Optimized Treatment should only

be used for lung cases. Otherwise, patient mistreatment may result.
4. Click CT on the Modality list.

5. Click an exam (exhale) on the Exam ID list and click Select Exam. Then
click a second exam (inhale) on the Exam ID list and click Select Exam.
Choose CT series near full exhale as primary CT, and one CT series near
full inhale as the secondary CT.
(Optional) You can select any RT Structure Set VOI associated with a
primary CT exam.
6. Click Next >>.

Select a treatment machine if there is more than one treatment machine at
your site. If there is only one CyberKnife at your site, it is selected by default.
7. Click Next >>.

matching will be required.
8. Click Use Template on the Use Plan Template screen. A warning appears.
9. Click OK in the Warning message.
If two CTs are selected, Fuse > Setup appears with the Already registered
check box selected, unless the CT exams have a time separation of more
than 30 minutes.
10. Evaluate the image fusion result.

If the CTs are acquired in the same coordinate space, verify that the Already
registered check box is selected and proceed to the next step.
If the CTs are not acquired in the same coordinate space, verify that the
Already registered check box is not checked and proceed to the Register
step. It is recommended that a spine ROI region is used for registration. For
more information, see “Fuse Task” (page 259).
11. Click Contour. Contour > Manual appears.
13. Delineate the TTV in the primary image using tools selected from the
Drawing Tools area.
14. Select CTV(primary) from the Select VOI list.

15. Use Drawing Tools or click icon to create a CTV on the primary CT
image. For more information, see “Contour Task” (page 273).
If Lung with Respiratory is selected as the tracking method, skip to step 20.
16. Click the image series label select B showing the secondary CT, and select
TTV(secondary) from the Select VOI list.
17. Delineate TTV in secondary CT image using tools selected from the
Drawing Tools area.
18. Select CTV(secondary) from the Select VOI list.

19. Use Drawing Tools or click icon to create a CTV on the secondary CT
20. On the Spine-Tracking step, select the spine VOI from the list.
NOTE: If the tracking target VOI overlaps the Spine Tracking VOI, the
resulting plan cannot be saved as a deliverable plan. It will be necessary to
refine the boundaries of either or both VOIs to eliminate contact in order to
save as a deliverable plan.
21. Click the Setup task tab, Machine > Tools step appears.
22. Select a Treatment Machine. If there is only one treatment machine is
available at your site, it is selected by default
23. Enter Number of Fractions.
24. Select a desired collimator type.
25. Only body is available for Treatment Anatomy. Select correct Template
Path Set.
26. The following Synchrony Method are available: Spine Supine, Lung with
Respiratory, Lung 1 View A with Respiratory, and Lung1 View B with
Respiratory.
• Select Spine Supine if tumor is not visible in either X-Ray images or
DRRs.
• Select Lung with Respiratory if tumor is visible in both DRRs.
• Select Lung1 View A with Respiratory or Lung1 View B with Respiratory
if the tumor is visible in only one of the DRR images.
27. If Spine Supine or Lung1 View A with Respiratory/ Lung 1 View B with
Respiratory is selected, the ITV Creation and PTV Creation steps must be
completed before Align step is activated.
28. Click Align. The Align > Tools step appears.
30. Click Confirm.
DRR Review step is not available for Spine Supine tracking.
32. Select TTV(primary) or GTV(primary) from the Tracking Tumor drop-down
list.
The DRR images are processed. To view DRRs generated from the
secondary CT, select Secondary from the DRR Image drop-down list.
To view other target structures on the DRR images, verify that the Display
Contour check box is selected and select the desired VOI from the Overlay
VOI drop-down list.
The Apply button is turned on if a Primary CT and full content DRR are
selected
33. Click Apply.

34. Click Plan to continue the planning procedure. There is no difference
between Lung Optimized Treatment planning and standard treatment
planning for beam optimization and dose calculation.
36. Click Save.
 Creating a New Lung Optimized Treatment Plan Using

1 CT
1. Click the New Plan icon on the Home Page.
2. Select a patient from the Patient Name/Patient ID list on the New Plan
screen.
3. Click the Lung Optimized icon from the Select Type area.
You may optionally select the Use an existing Simulation Plan check box.
When this check box is selected, select a desired Simulation Plan. Then,
you can add images (such as MR images or additional CT images) to the
images used to create the Simulation Plan.
The Select Exams screen appears with a list of studies associated with the
selected patient. The appropriate plan template for Lung Optimized
Treatment plans is selected automatically.
4. Click Next >>.

5. On the Select Exams screen, the Modality list displays CT if CT exams are
included.
list

on the exam to move it to the Selected Exam list.
• To remove an exam from the Selected Exam list, select the exam and
click Remove.
• After removing an exam from the Selected Exam list, click CT in the
• (Optional) You can select any RT Structure Set VOI associated with a
primary CT exam.
NOTE: It is recommended that the primary CT is in the exhale phase.
7. Click Next >>. Select a treatment machine.

8. Click Next >>.
9. Click Use Template on the page. The Contour > Manual step appears.
Use the slider bar to scroll the displayed slice up or down in order to add
VOI segments to further define the VOI in 3D.
12. Select CTV(primary) from the Select VOI list.

13. Use Drawing Tools or click the icon to create a CTV on the primary CT
14. On the Spine-Tracking step, select the spine VOI from the list.
15. Click the Setup task. The Machine > Tools step appears.
16. Select a Treatment Machine.
17. Select a desired fraction number.
18. Select a desired Collimator type.
19. Only body is available for Treatment Anatomy. Select correct Template
Path Set.
20. The following Synchrony Method are available: Spine Supine, Lung with
Respiratory, Lung 1 View A with Respiratory, and Lung 1 View B with
Respiratory.
• Select Spine Supine if tumor is not visible in either X-Ray images or
DRRs.
• Select Lung with Respiratory if tumor is visible in both DRRs.
• Select Lung 1 View A with Respiratory or Lung 1 View B with
Respiratory if the tumor is visible in only one of the DRR images.
21. If Spine Supine or Lung 1 View A with Respiratory/Lung 1 View B with
Respiratory is selected, the ITV Creation and PTV Creation steps must be
completed before Align step is activated.
22. Click Align.
24. Click Confirm.
DRR Review is not available for Spine Supine tracking.
To view the TTV(secondary), ITV, or other VOI projected on the DRR
images, verify that the Display Contour check box is selected and select
TTV(secondary), ITV, or other VOI from the Overlay VOI drop-down list.
27. Click Apply.

28. Click Plan to continue planning activities. There is no difference between
Lung Optimized Treatment planning and regular planning for beam
optimization and dose calculation.
29. In the Save Plan dialog box, enter an identifying plan name, and select the
30. Click Save.
NOTE: If the TTV(primary) VOI overlaps the Spine Tracking VOI, the
resulting Lung Optimized Treatment Plan cannot be saved as a deliverable
plan. It will be necessary to refine the boundaries of either or both VOIs to
eliminate contact in order to save as a deliverable plan.

 Synchrony Method Selection
To enable Lung Optimized Treatment:
1. For both a 1-CT and 2-CT series Lung Optimized Treatment plan with
1-View or Spine Supine as selected tracking method, the TTV(primary) or
GTV (primary) VOIs should be delineated.
2. On the Setup task, select the Machine > Tools step.
In the Treatment Anatomy drop-down list, body is the only available option.
3. In the Synchrony Method drop-down list, select a desired tracking method.
 Creating an ITV (1-View and Spine Supine Tracking)

In this step, a new VOI is created, the Internal Target Volume (ITV). The ITV
for Lung Optimized Treatment is a volume in space that defines the limits of
partially tracked or untracked target motion (minimum to maximum).
Spine Supine ITV

In the situation that no intra-fraction motion tracking is performed (spine
supine tracking), then the Internal Target Volume (ITV) corresponds with
the standard definition of ITV made in ICRU Report 621. That is, the ITV
encompasses the Clinical Target Volume (CTV) and an internal margin (IM)
that accounts for all changes in its position during delivery of the fraction.
1-View ITV
In the situation that intra-fraction motion tracking is performed using one
imaging projection but not both (1-View tracking), the relevant ITV definition
is not the same as the ICRU 62 definition. In this case, the CTV motion
along two orthogonal axes is tracked within the Motion Tracking Plane (see
Figure 1 and Figure 2), and therefore the ITV should only be large enough
to encompass the motion of the CTV along the remaining non-tracked axis.
Figure 1 and Figure 2 illustrate the concept of tracked and untracked motion
for a case where 1-View tracking is selected. The orange circle is the CTV
at the two extremes of respiratory motion. The ITV for 1-View tracking is
different from that for Spine Supine tracking. As shown in Figure 1, the
Spine Supine ITV (shown in blue) encompasses the full range of CTV
motion. In the 1-View scenario, the untracked motion is perpendicular to the
plane of the image being used for tracking, represented in Figure 1 and
Figure 2 as the Motion Tracking Plane. For 1-View tracking, the orange
shapes shown in Figure 2, which include only the untracked component of
motion, represent the ITV at each extreme of the respiratory cycle.
1. ICRU Report 62 (1999) Prescribing, Recording and Reporting Photon Beam Therapy. International
Commission on Radiation Units and Measurements, Bethesda, MD. (Supplement to ICRU Report 50.)
Fig. 1 - Tracked and Untracked Motion for 1-View Tracking
Item Description
This motion is tracked.
This motion is not tracked. ITV should be used to compensate.
Fig. 2 - ITV for 1-View Tracking. Use ITV to allow for all non-compensated tumor positions.

Creating an ITV VOI
1. On the Setup task, select the ITV Creation step.
The Source VOI drop-down list(s) are automatically populated:
• For a 2-CT series Lung Optimized Treatment plan, CTV(primary) and

CTV(secondary) are automatically selected.
• For a 1-CT series Lung Optimized Treatment plan, CTV(primary) is
automatically selected.
The drop-down list(s) are empty if these VOIs have not yet been contoured.
2. Select ITV on the Destination VOI drop-down list.

3. For a 1-CT series Lung Optimized Treatment plan, enter values (in
millimeters) for the Right(-)/Left(+), Anterior(-)/Posterior(+), and
Inferior(-)/Superior(+) expected range of respiratory motion of the primary
CTV, with respect to its position in the primary CT image, in the Range of
Motion (mm) text boxes.
4. Click Apply.
The newly created ITV is displayed automatically and the PTV Creation
step is enabled (see the following images for a 1-CT series or a 2-CT series
example).
5. Evaluate the ITV.
 Creating a PTV (1-View and Spine Supine Tracking)

In this step, the Planning Target Volume (PTV) VOI is created, which is
defined based on the ITV created in the previous step.
It is important to recognize that there are additional geometrical
uncertainties involved in treatment delivery which should be combined into
a setup margin that is applied to the ITV to form a Planning Target Volume
(PTV). These should include an estimate of the Synchrony modeling
uncertainty in the Motion Tracking Plane with 1-View tracking, together with
an estimate of the uncertainty in the position of the ITV relative to the spine
region covered by the Spine Supine Region of Interest (ROI) in the
untracked out-of-plane direction for 1-View tracking or in all directions for
Spine Supine tracking.
Creating a PTV VOI

1. On the Setup task, select the PTV Creation step.
• On the Source VOI drop-down list, ITV is selected automatically.
• On the Destination VOI drop-down list, PTV is selected automatically.

2. If Lung 1 View A with Respiratory or Lung 1 View B with Respiratory is
selected as the tracking method, in the Margins (mm) text boxes, enter
absolute values (in mm) for the In-Plane and Out-Plane ITV to PTV
expansion. The in-plane margin defines the ITV-PTV expansion in the
plane where motion is tracked; the Out-Plane margin defines the ITV to
PTV expansion along the axis normal to this plane, where target motion is
untracked.
3. If Spine Supine is selected as the Synchrony Method, in the Margins (mm)
text boxes, enter absolute values (in mm) for the ITV to PTV expansion in
the Right (R), Left (L), Anterior (A), Posterior (P), Superior (S), and Inferior
(I) directions.
4. Click Apply. The PTV is displayed automatically and encloses the ITV.
The Align step is activated.
5. Evaluate the PTV.
 Align Center Selection

The display panel on the Align step includes five windows. The top windows
are DRRs (left corresponds to Camera B and right to Camera A) of the
patient. The lower images are 2D planar views: axial, coronal, and sagittal.
The intersection of the crosshairs in the 2D images represent the current
position of the align center. The DRRs are based on the current align
center.
NOTE: DRR quality in the treatment planning system differs from that in the
treatment delivery system.
Guidelines for Setting the ROI Height

Set the height of the ROI to achieve optimum coverage of the relevant
skeletal structures. The default ROI height is 60 mm and can be adjusted in
the range of 40 and 100 mm. An aspect ratio of 3:2 is maintained by the
system.
ROI Size Setting

To set the ROI size, adjust the ROI height.
1. Move the Spine Supine ROI Height slider bar. The grid displayed on the
DRR images is updated as the slider bar is adjusted.
The ROI height is displayed in millimeters to the right of the slider bar.
2. Click Confirm to save the position of the align center and the ROI height.

The DRR Review step is available if Lung 1 View A with Respiratory, Lung
1 View B with Respiratory, or Lung with Respiratory is selected as
Synchrony Method. The Plan task becomes active if Spine Supine is
selected as Synchrony Method, and a new plan can be created.
NOTE: The ROI height set in this step is the default size used during
treatment delivery.
For more information about setting the ROI height, refer to “Synchrony®
Spine Tracking (CyberKnife Option)” (page 665).
 DRR Review (Lung with Respiratory and 1-View

Tracking)
The DRR Review step of the Setup task enables you to examine the target
and the projected overlays of target structures in the DRR images. This
section describes screen controls used for 1-View tracking in the DRR
Review step.
Default Mode
To improve tumor tracking accuracy, only TTV(primary) and GTV(primary)
can be selected as the tumor tracking volume for Lung Optimized
Treatment. If only one target VOI is defined, that target VOI is automatically
selected as the tumor tracking volume in the DRR Review step of the Setup
task.
The following image shows the DRR Review step. The default DRR type is
Full Content. The name of the tumor tracking volume and the Treatment CT
Center position in CT space are displayed on the left of the screen.
For Lung 1 View A/B with Respiratory tracking, the DRR image
corresponding to the view to be used for tracking is highlighted in blue, and
centroid position of ITV will automatically selected as Treatment CT Center.
For Lung with Respiratory tracking, the centroid position of the selected
tumor tracking volume will automatically selected as Treatment CT Center.
If multiple targets are defined in the Contour task, the DRR views will be
blank when you switch to the DRR Review step of the Setup task. You must
select one target VOI as the tumor tracking volume before DRR images can
be generated.
The DRR images are generated based on the VOI Treatment CT Center as
center position. As a result, the Treatment CT Center position will always
be shown at the center of the DRR images.
Tracking Tumor drop-down list Displays a list of tumor tracking volume.
Treatment CT Displays the X Y Z coordinates at the centroid

Center of the selected tracking tumor volume for
Lung with Respiratory or the centroid of ITV
for 1-view cases.
Display Contour Displays the contour of the tumor and overlay

check box VOI.
Invert DRR Inverts DRR images black to white and white

Images check to black.
box
Reset to Default Resets to the default contrast of images.

W/L button
DRR Type Full Content Displays the full content DRR images.
option
Spine Removed Displays the DRR images with the spine

option volume removed.
Tumor Region Displays the DRR images only of the region

option around the tumor.

DRR Image drop-down list Selects which CT image is used to create the
displayed DRR for Accuray Precision tumor
motion review.
NOTE: Primary CT image is always used to
create DRRs used for treatment.
Overlay VOI drop-down list Overlays a target VOI (other than the tumor
tracking volume) on the DRR images.
Apply button Confirms that user is satisfied with positions

of VOIs and visibility of tumor tracking volume
in DRR images.
Confirming a Tumor Is Visible on the DRR Images

1. From the Tracking Tumor drop-down list, select a tumor tracking volume as
the target.
2. (Optional) Select the Display Contour and Invert DRR Images check boxes.
You can view the tumor in one of three ways by selecting the DRR type.
3. (Optional) Click the Full Content, Spine Removed, or Tumor Region option
in the DRR Type area. The selected DRR type images is generated and
appears.
4. Click the Full Content option, and then click Apply if the tumor is visible on
the DRR images. Apply button becomes active when Full Content and
Primary are selected.
NOTE: Click Apply only if you are sure that this patient can be treated with
Lung with Respiratory tracking or 1-View tracking.
Display Tumor Tracking Volume Contour

To display the tumor tracking volume contour overlaid on the DRR images:
1. Select the Display Contour check box to overlay the tumor tracking volume
contour on the DRR images.
2. Deselect the Display Contour check box to hide the tumor tracking volume
contour in the DRR images.
The tumor tracking volume contour is displayed in the same color specified
in the VOIs step. Tumor tracking volume contour projections in the DRR
images are generated based on the tumor tracking volume. The Treatment
CT Center is indicated in the DRR images by a plus sign (+).
Full Content DRR images. The Treatment CT Center is indicated at the
center of the DRR images.
Spine Removed DRR images.

Tumor Region DRR images.
Invert DRR Images
You can invert the DRR images to reverse the contrast to help visually
identify the tumor tracking volume. In some cases the tumor tracking
volume may be more visible in inverted DRR images. The inverted DRR
images are generated by mapping black to white and white to black in the
images.
1. Select the Invert DRR Images check box to invert the DRR images.
2. Deselect the Invert DRR Images check box to return to the default contrast
in the DRR images.
The default DRR type is Full Content.
3. Select the Spine Removed or Tumor Region option to view other DRR
image types.
The following image shows the DRR Review screen with Full Content
inverted DRR images.
The following image shows the DRR Review screen with Tumor Region
inverted DRR images.

Invert DRR Images and Display Contour
To simultaneously display the tumor tracking volume contour and invert
image contrast in the DRR images:
1. Select both the Display Contour check box and the Invert DRR Images
check box.
2. Select Full Content, Spine Removed, or Tumor Region option for different
DRR types.
3. Clear the check boxes to return to the default view.
volume contour overlaid on inverted DRR Full Content images.
volume contour overlaid on inverted DRR Tumor Region images.

Apply
The Apply button is turned on when the Full Content option is selected. If
you have confirmed that the VOIs appear with the correct position and
shape in the DRR images and that the tumor tracking volume appears
sufficiently clearly in the DRR images to be used for tracking, click the Apply
button. Once the Apply button is clicked, the Plan task becomes available.
WARNING: If the tracking target is not visible in the DRR images, the Lung
with Respiratory and 1-View tracking algorithms might not be able to track
the tracking target. Ensure the target is contoured correctly and is visible in
both of the DRR images (for Lung with Respiratory), or the DRR image being
used for tracking (for 1-View).
 ITV and PTV Evaluation

Evaluate the ITV and PTV VOIs after generating them for a 0-View or
1-View tracking plan.
ITV for Spine Supine Tracking

After creating the ITV on the Setup > ITV Creation step, review the ITV
using the Measure tool.
PTV for Spine Supine Tracking
After creating the PTV on the Setup > PTV Creation step, review the PTV
using the Measure tool.
ITV for 1-View Tracking

After creating the ITV on the Setup > ITV Creation step, review the ITV.
For a 2-CT series plan, use the DRR Review step to select ITV from the
Overlay VOI drop-down list. Generate DRRs using the primary and
secondary CT. In the view not used for tracking, the CTV should be at
opposite ends of the ITV overlay in the primary and secondary DRRs.
PTV for 1-View Tracking

After creating the PTV on the Setup > PTV Creation step, review the PTV,
which encloses the ITV. Use the Measure tool on the global tool bar to
measure the margin between the ITV and PTV boundaries in the tracking
plane and perpendicular to the tracking plane.
The measured margins should match the In-Plane and Out-Plane margin
values that were entered on the Setup > PTV Creation step.

Chapter 15
PreciseART® and PreciseRTX®

(Option)
PreciseART® and PreciseRTX® are licensed options that offer an
integrated solution with MIM software for automated, offline adaptive
therapy and plan retreatment. PreciseART® is only available for Tomo
plans.
PreciseART® (Tomo® Only) . . . . . . . . . . . . . . . . . . . . . . 724
PreciseRTX® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
1072963-ENG B C h ap te r 15 : Pr e c i s eA RT ® a nd Pr ec i s e R TX ® ( O p t io n) 723
PreciseART® (Tomo® Only)
Use PreciseART® to schedule a treatment plan for dose monitoring and
select from a list of report generation workflows that let you review daily
treatment results and related statistics, monitor treatment status, review
each delivered fraction, and compare the planned dose with the projected
dose. Based on this information, you can choose to modify the plan if
necessary, either by acquiring a new CT image set and using the
PreciseRTX® feature, or, if desired, by reusing the original CT image set in
Compare and Sum Plans.
For more information on PreciseART®, see the MIM For Use With Accuray®
PreciseART® and PreciseRTX® User Guide.
 PreciseART® Replanning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
 Accessing PreciseART®. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
 Enrolling a Plan in PreciseART® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
NOTE: PreciseART® is only available for Tomo plans.
 PreciseART® Replanning
Use PreciseART® monitoring to generate a new plan to adapt to patient's
changing conditions.
For example, if a patient loses significant weight during a current treatment,
you can acquire a new CT image set, then use the accumulated dose,
original CT and original VOIs in the PreciseRTX® workflow and use MIM to
sum the original and new plan. For more information, see “PreciseRTX®
Workflow” (page 728).
For replanning cases that do not require a new CT image, such as
replanning to manage skin, you can use both PreciseRTX® workflow and
Compare and Sum Plans.
You cannot import accumulated dose in Compare and Sum Plans step, but
you can export isodose curves as VOIs from MIM to use as optimization
constraints for a new plan, and then you can scale the original plan's dose
to estimate the delivered dose when summing the original plan and the new
plan.
Use templates for the PreciseRTX® and Compare and Sum Plans
workflows to avoid re-entering plan parameters.
After creating a replan with the same number of fractions and total dose
while the original plan is still under treatment, the replan can be scaled
down to the remaining number of fractions to be delivered. Pause the
optimizer, change the prescription number of fractions and dose
(maintaining the same per-fraction dose), and click Calculate Final Dose.
The optimizer runs 1 iteration to scale the current plan to the new number
of fractions before proceeding with final dose calculation.
 Accessing PreciseART®
From the Home Page, click PreciseART® to open MIM software.
 Enrolling a Plan in PreciseART®

Enroll a patient treatment plan in PreciseART® from Plan Administration or
use the following steps in Evaluate > Review step. For instructions on
enrolling a plan in Plan Administration, see the Data Management Manual.
You cannot enroll the following plans in PreciseART®:
• QA Plans
• Simulation Plans
• Plans with fractions delivered prior to a change in Tomo System density
model unless they were previously enrolled at the time the fractions
were delivered.
NOTE: For plans using Synchrony method, the daily dose calculation performed by
PreciseART® does not take into account changes to the delivery due to the
tracking. The dose represents the original plan recalculated on the daily scan taken
prior to treatment.
1. On the Evaluate > Review step, click Save Plan. The Save Plan dialog box
appears.
2. Select Make Deliverable and Approve for Treatment.

3. Select Enroll plan in PreciseART®and then click Save. The PreciseART®
Enrollment dialog box appears.
4. Select Enroll plan in PreciseART®.
5. Select a workflow option from the Workflow menu.
Workflows define the content of the reports generated for each fraction and
are normally configured at each site to reflect site-specific conventions such
as VOI naming and expected dose limits.
For more information on configuring workflows and reports in MIM, refer to

the MIM For Use With Accuray® PreciseART® and PreciseRTX ® User
Guide.
6. Select a previous plan from the list Group with a previous plan (optional).
Plan groups contain an original plan and one or more PreciseART® plans
to track dose across a set of plans with the same treatment intent.
7. Select the check box to confirm the density model for the treatment
machine is appropriate, and then click OK.
For more information on grouping plans, refer to the MIM For Use With
Accuray® PreciseART® and PreciseRTX ® User Guide.
PreciseRTX®
Use PreciseRTX® to deform plan information (image, dose, VOIs) from a
prior treatment delivery to a new plan and account for the prior treatment
dose in a new plan. You can use a treatment plan or a treatment DICOM
series from a third-party system stored in the iDMS System. PreciseRTX®
is available for both Tomo and CyberKnife plans.
For more information on PreciseRTX®, see the MIM For Use With
Accuray® PreciseART ® and PreciseRTX ® User Guide.
 PreciseRTX® Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728
 Exporting Dose and VOIs to PreciseRTX® Session . . . . . . . . . . . . . . 732
 PreciseRTX® Workflow
1. Click PreciseRTX® from the Home Page. The Previous Treatment Data
window appears.
• If the patient was previously treated with an AccurayTreatment Delivery
System, select the Accuray option.
• If the patient was treated with a third party system, select the Third Party
option.
For Accuray
1. Select a patient from the patient list to display the patient’s available plans.
2. Select one or more plans to display the associated data. For how many
plans are supported, see the MIM For Use With Accuray® PreciseART ®
and PreciseRTX ® User Guide for more details.
For Third Party

1. When you select Third Party, a list of all associated plan DICOM data is
displayed (e.g. CT, RTSTRUCT, RTDOSE, and RTPLAN).
Third-party DICOM data for retreatment can be pushed to iDMS using the
AE Title N1000_REVIEW.
Click the icon to import DICOM data from your local disk.
NOTE: To permanently delete third-party data. use the icon on the Previous
Treatment Data screen.
2. Select one or more plans or third-party DICOM data sets, and then click
Select.
The Select adds images and plans to the Selected Data list. You can select
one or more plans to be summed in MIM.
The Remove button deletes the currently selected item in the Selected Data
list.
Next step for both Accuray and Third Party

3. Click Next. The New Treatment Data: Select Patient window appears.
4. Select a patient for the new plan, and then click Next. The New Treatment
Data window appears.
5. If you select Image, only a new planning image is used as input for
retreatment.
MIM automatically deforms the dose and contours from the previous plan to
the new image. Once this process is complete, the data can be viewed
through MIM. The deformed dose can then be sent back as contours
generated from isodose lines to the Accuray Precision System.
If the deformable registration as reviewed in MIM is not accurate, one cause

may be the initial rigid registration which serves as the starting point for the
deformable registration. To review and manually adjust the rigid
registration, click the Edit Rigid Fusion in the New Treatment Data window
instead of Finish. This will open the images in the Edit Rigid Fusion step.
Review and adjust the fusion as needed.
Edit Rigid Fusion step
6. If you select Plan, a new plan is used as input for retreatment.

MIM automatically produces a summation of the new plan and the previous
plan that can be viewed through MIM. The summation information can then
be sent back to the Accuray Precision System for use as is or additional
adjustment. VOIs exported from MIM can be loaded to a new plan in the
Accuray Precision System from the Select Exams window or from the
Import VOI dialog box accessible from the Contour > Manual step.
7. Click Finish.
 Exporting Dose and VOIs to PreciseRTX® Session

To use the dose export feature, you must first run a PreciseRTX® session
from the Home Page and have both MIM and the Accuray Precision System
open. If MIM is not open, an error is displayed in MIM. If the Accuray
Precision System is not open, the Export Dose and Structures to
PreciseRTX® Session is not available.
Follow the steps below to export the dose and VOIs of a currently loaded
plan to MIM in an existing PreciseRTX® session:
1. Start a New Plan using the same patient currently loaded in the
PreciseRTX® session.
2. When the new plan has dose, click the Export DICOM Data icon from
the Global Tools. The Export DICOM Data dialog box appears.
3. In the Retreatment section, select Export Dose and Structures to

PreciseRTX® Session.
In the Export section, the check boxes for Volume of Interest and/or RT
Dose are automatically selected. Change the description of each if desired.
Fiducial information is exported if the selected plan has fiducial markers.
4. Click Export.
MIM automatically opens and sums the dose between the new plan and the
previous plan. The new summation can be sent back to the Accuray
Precision System, and this process can be repeated if necessary.
Appendix A
Warnings, Errors, and Messages

Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
1072963-ENG B A pp en di x A : W a r ni n g s , E r r or s , a n d M es s a g e s 735
Tables
The tables in this appendix display warning, error, and message text for the
Accuray Precision System. The following indicates a variable in the
message text, such as a number or current plan name: "%s","%.0f", or
"%d".
The tables also includes guidance to help resolve errors.
 Table 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
 Table 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 758
 Table 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
 Table 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
 Table 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800
 Table 1
Code Text Recommended Action
0001 If you close this application, data might be lost. Do you No action required.
want to close this application?
0011 This VOI is not empty. If you change the contour plane, all Proceed to next task or return to
existing contours will be erased. Do you want to continue? previous task.
0012 %d plan(s) have been selected for deletion. All plan data Delete or return to previous
will be lost. Do you want to continue? task.
0013 Deleting the current slice might cause the current series to Delete or return to previous
become unloadable. Do you want to delete the current task.
slice anyway?
0019 Quit this application before logging off or switching to Log off if changing user.
another user.
001B The images have not been registered. 3D images will not Fuse the two loaded medical
be shown correctly. Go back to the Fuse task. images, if desired. Register the
images on the Fuse task.
0022 No VOI contour has been detected after erosion. The Choose to erode less of the VOI
system has canceled the operation and retained the less or delete the VOI.
original VOI. If you want to delete the VOI, use the [Delete
All] command instead.
0023 Do you want to export DICOM data %s? Continue or return to previous
task.
0026 The offset from the centroid of the target dose line to the Try to center the dose
centroid of the target VOI is %s, which is greater than the distribution again. If that fails
tolerance [%s]. Do you want to center the dose again? regenerate either the ball-cube
plan or the ball-cube VOI.
0027 The offset from the centroid of the target dose line to the Accept current offset or try to
centroid of the target VOI is %s, which meets the center the dose distribution
requirement [%s]. again.
Do you want to center the dose again?
002C The plan saved is not deliverable. No action required.
002D The Patient ID (%s) from the central database differs from The primary CT cannot be used
the patient ID (%s) of CT image header. to generate a deliverable plan.
Re-load the CT so that it is
associated with the patient
medical ID.
002E The fiducial tracking plan needs at least one fiducial to be Identify a fiducial.
identified.
002F A deliverable plan must generate at least one treatment Check the plan to be sure that
path with dose. the plan has dose. Regenerate
the beam set if no dose is
present.
0030 The total MU between beam data and path files is Rescale the data so that
inconsistent. rounding errors are minimized.
Verify that all calibration data is
present. Recalculate in high
resolution in Evaluate step and
prescribe.
0034 Do you want to delete the beams generated on this step? Continue or return to previous
task.
0037 Latest change to the Alignment Center has not been Confirm or discard the new
confirmed. Do you want to confirm it? alignment center.
0038 The HU of the following fiducial(s) are below the defined No action required. Verify that
threshold, which may mean that the following fiducial(s) all fiducials are correctly
are not properly identified. Please check the location of the identified.
following fiducial(s) to ensure that they correctly identify
fiducial(s).
%s
0039 Select a fiducial type before defining fiducials. Select the type of fiducial.
003A The input value is out of range. Enter a valid value in [%s]. Change the input value.
003B Maximum fiducial number (eight) has been reached. Stop identifying fiducials or
delete a fiducial before
identifying a new fiducial.
003D Changing VOI set template will override all empty VOIs in If drawn VOI not needed,
the current plan. Do you want to continue? continue. If it is required, select
No.
003E Changing the density model will result in changing the Confirm or return to previous
mapping between the HU values and the densities task.
represented in the current plan.
This will also reset currently defined density overrides %s.
Do you want to continue?
003F Do you want to cancel the current process? Confirm or return to previous
task.
0040 Recovered %s plan in read-only mode. Confirm or return to previous

task.
0042 Do you want to overwrite %s plan? No action required.
0043 Changing the collimator size will delete the current Confirm or return to previous
conformal plan. Do you want to continue? task.
0044 All beams have zero MU. Cannot generate beam data for Generate a plan before creating
report or display. a report for the plan.
0045 There are no beams generated (total beams = 0). Generate plan.
0046 The node coordinates of the beams are inconsistent with Delete all beams and restart
the treatment paths. plan generation process.
0047 The reference dose is inconsistent between the path and Delete all beams and restart
the beam set. plan generation process.
004B Do you want to delete all constraint points? Confirm to delete all constraint
points.
004C The image registration transformation has been changed. Confirm or return to previous
Do you want to save the change? task.
004D Enter a string with at least %s characters. Enter a string of sufficient

length.
004E Enter a string with alphanumeric characters. Enter an alphanumeric string.
004F If you change the density model, the dose volumes will be To apply density model
deleted. Do you want to change the density model? changes, delete dose volumes,
and recalculate, click Yes. To
discard density model changes
and retain existing dose
volumes, click No.
0051 Do you want to delete the plan template? Confirm or return to previous
task.
0053 Do you want to create a new template based on the current Confirm to use current plan
plan settings? settings.
0057 The dose has been successfully centered. Confirm if desired.

The offset from the centroid of the target dose line to the
centroid of the target VOI is %s.
Do you want to refine the center with high resolution dose
volume?
0058 The new position is very close to an existing landmark. The Confirm if desired.
system cannot add the new position as a new landmark.
However, you can choose to replace the existing landmark
with the new position. Do you want to replace the existing
landmark with the new position?
0060 The VOI selected for dose centering is outside the dose Follow prompts on the
box. Do you want to proceed? message.
0061 Template paths from current plan are inconsistent with To create deliverable plan,
template path files on database server. select a new path set and
replan. To review a previously
treated plan, no action required.
0062 The new anatomical region conflicts with the treatment Confirm if desired.
anatomy of this template. The treatment anatomy and
other planning parameters will be reset.
Do you want to apply the new anatomical region?
0063 If you switch to the Home Page, data might be lost. Do you Confirm if desired.
want to switch to the Home Page?
0065 Enter a string with alphanumeric characters. Perform requested action.
0066 The following issues have been detected: Confirm or return to previous
%s task.
Do you want to modify the group?
0067 Select at least one fiducial for fine tuning. Perform requested action.
0068 You are about to change resolution, which will require Make selection as indicated in
recalculation of the dose volumes. message.
Click [OK] to continue.
Click [Cancel] to cancel the change.
0069 Reference beam data is not available or is missing on No action required.

database server.
Overlay data will not be available.
Missing reference file(s) are: %s
0070 The MU entered is greater than %s MU. Do you want to Confirm or return to previous
keep this new MU value? task.
0071 The resulting beam will not intersect any Target VOIs. Do Confirm or return to previous
you want to keep the new target change? task.
0072 This patient cannot be treated using the Lung with Perform requested action or
Respiratory method. Save the current plan and try a return to DRR Review task and,
different Synchrony method if appropriate. if appropriate, confirm patient
for treatment.
0073 No Target boundary was detected after erosion. No action required.

The system has canceled the operation and retained the
previous value.
0074 The difference between the timestamp of the primary CT Confirm that the images are
exam and one or more of the other selected 4D CT exams from the same 4D CT scan.
is greater than %s minutes. Do you want to continue?
[Yes]: Proceed.
[No]: Remain on the current step.
0075 A spine tracking volume must be identified for the Lung Identify missing VOI.
with Respiratory Tracking System.
0076 %s beams would have been re-weighted below the No action required.
minimum deliverable MU.
Those beams have been set to the minimum deliverable
MU (MU = %s).
0077 The Max. Depth allowed for extrapolation is %s. Perform requested action.
Try again.
0078 Accuray Precision terminated unexpectedly. Do you want Confirm if desired.

to recover the previous plan?
Plan Name: %s
Last Auto-save: %s
0083 Beam set does not reflect isocenter changes. Select Apply to accept changes.
You must click Apply to accept changes before leaving
Isocentric planning.
0085 The extrapolation setting in the plan does not match the Make selection as indicated in
extrapolation setting on the server. message.
[Yes]: Use the extrapolation setting on the server.
[No]: Use the extrapolation setting in the plan.
Plan Settings: %s
Server Settings: %s
0088 VOI [%s] is not empty. All contours in this VOI will be Confirm or return to previous
removed. task.
0089 The two VOIs for Lung with Respiratory Tracking, [%s] and Modify these VOIs to ensure
[%s] overlap each other. Modify these VOIs to ensure there there is no intersection.
is no intersection.
The current plan cannot be saved as a deliverable plan.
008A VOI [%s] for Lung with Respiratory Tracking has no Draw VOI before attempting to
contour. save.
The current plan cannot be saved as a deliverable plan.
008B Review of tables has not been completed. Invalid tables Follow prompts on the
are listed below. message.
Do you really want to exit?
[Yes]: Exit
[No]: Continue with review of tables
Invalid tables are :%s
008C All related 4D CT images will be selected automatically. Perform requested action.
This would exceed the total number of images and/or total
number of CT images allowed. Remove excess image(s) in
order to continue.
008D You are about to change the default density model. This Continue or return to previous
change might affect the calculated dose distribution of task.
future plans.
008E You are about to reset the [%s] custom density model. Continue or return to previous
Do you want to continue? task.
008F The tumor tracking VOI is not target VOI. Reset the tumor tracking VOI as
The current plan cannot be saved as deliverable. a target VOI or choose a
different VOI as the tumor
tracking VOI.
0090 The spine tracking VOI is not critical VOI. Change the spine tracking VOI
The current plan cannot be saved as deliverable. to a critical VOI.
0091 The estimated %s MB of memory necessary to complete Review dose calculation box
the requested dose calculation exceeds the %s MB of size in all three dimensions and
RAM available on this computer. reduce size where possible
Dose calculation might take longer than normal to (particularly the number of axial
complete due to disk paging activity. slices).
Continue?
Click [Yes] to continue.
Click [No] to cancel.
0092 The target VOI already has an existing contour defined on Click No to keep the existing
a different image plane. Do you want to copy and replace contour. Click Yes to replace the
the existing contour? existing contour with a copy of
the specified source VOI.
0093 All selected remote host machines will be removed. Click Yes to remove all selected
remote hosts. Click No to
cancel.
0094 Invalid License. The current plan was created with the Follow prompts on the
Monte Carlo Dose Calculation method. This Accuray message.
Precision System does not have a valid license for Monte
Carlo Dose Calculation. This plan can be loaded in
read-only mode on this Accuray Precision System.
[Yes]: Load the plan in read-only mode
[No]: Exit.
0096 Failed to read dose volume and/or uncertainty volume for The RTDOSE and uncertainty
plan %s. volume DICOM files are missing
Do you want to load the plan without this information? for this plan. Perform action as
indicated in message.
[YES]: Load the plan.
[NO]: Exit
009A The current plan does not have a valid Skin structure. Do Click Yes to automatically
you want to select [ %s ] as the Skin structure and detect detect the skin VOI.
the contours automatically?
009B The selected VOI is a Target VOI. Please select a Critical Follow prompts on the
structure. message.
009D In the current plan, conformal weighting was applied to Click No to cancel any changes.
some isocenters but not to all. If you make any changes on Click Yes to apply the current
this step, the Conformal Weights setting will be applied to Conformal Weights setting to all
all isocenters. isocenters.
009F Collimators listed below have calculated TPR and OCR Follow prompts on the
tables. message.
%s
Do you want to redo calculations?
[Yes]: Redo calculations for collimators listed above
[No]: Retain previously calculated TPR and OCR tables.
00A1 %s table(s) have calculated data based on %s uncertainty. Click Yes to discard existing
If you apply uncertainty changes, all previously calculated TPR, OCR, and OF calculated
tables will be replaced. data. Click No to discard
[Yes]: Apply uncertainty changes. changes and retain existing
data.
[No]: Discard uncertainty changes.
00A2 The dose calculation has already been performed for the Click No to cancel the dose
current settings specified. Do you want to perform another calculation. Click Yes to perform
dose calculation? another dose calculation.
00A3 Collimators listed below have calculated TPR and OCR Follow prompts on the
tables. message.
%s
If you apply OCR depth changes, you will lose all
calculated OCR and TPR data.
[Yes]: Apply changes.
[No]: Do NOT apply changes.
00A4 The current beam set was generated on the Sequential No action required.
step. Isocentric conformally weighted beams can be added
to the current beam set. However, if you generate
isocentric non-conformally weighted beams, the current
beam set will be deleted.
00A5 Non-conformal beams generated on the Isocentric step Follow prompts on the
cannot be combined with beams generated on the message.
Sequential step. If you clear the Conformal Weights check
box, the beams generated on the Sequential step will be
deleted. Do you want to make this change?
00A6 This plan contains isocentric non-conformal beams. Follow prompts on the
Isocentric non-conformal beams cannot be optimized on message.
the Sequential step. If you continue, the existing isocentric
non-conformal beams will be deleted.
Click Yes to delete the existing isocentric non-conformal
beams and remain on this step.
Click No to retain the beams and return to the previous
step.
00AA Inconsistent data files. Follow prompts on the

Data files listed below failed data validation and must be message.
reloaded from the database server.
If you reload these files from the server, you must
recalculate.
[Yes]: Reload data files from the server.
[No]: Load plan in read-only mode.
Inconsistent files: %s
00AB Inconsistent data files. Follow prompts on the

Data files listed below failed data validation and must be message.
reloaded from the database server.
If you reload these files from the server, all beams and
dose will be removed and you must replan.
[Yes]: Reload data files from the server.
[No]: Load plan in read-only mode.
00AC MU Cutoff must be greater than 0. Enter value greater than 0.
00AD The current MU Cutoff value would remove all beams from Follow prompts on the
the plan. MU Cutoff value must be lower than Max MU for message.
the plan.
Enter a smaller number for MU Cutoff.
00AE The current MU Cutoff value would not remove any beams Follow prompts on the
from the plan. message.
To remove at least one beam from the plan, enter a larger
number for MU Cutoff.
00AF Select 1 or more collimators. Follow prompts on the

message.
00B0 Select a target. Follow prompts on the

message.
00B1 Select a method. Follow prompts on the

message.
00B2 Select VOI Name for step %s. Follow prompts on the
message.
00B3 Enter Goal value in step %s. Follow prompts on the

message.
00B4 Add at least one step in order to run Sequential Follow prompts on the
Optimization. message.
00B5 Enter a value between %.0f and %.0f for Total MU. Follow prompts on the
message.
00B6 Enter a value between %.0f and %.0f for Max MU per Follow prompts on the
Beam. message.
00B7 Enter a value between %.0f and %.0f for Max MU per Follow prompts on the
Node. message.
00BB A high resolution calculation will be initiated. Follow prompts on the

[OK] to continue or [Cancel] to cancel. message.
00BC Commissioning is in progress. No action required.

Another Precision user is calculating or approving beam
data for treatment machine
Calculation results will not be retained.
00BC Commissioning is in progress. No action required.

Another Accuray Precision user <%s> at IP Address <%s>
is calculating or approving beam data for treatment
machine <%s>.
Commissioning data will be opened in read-only mode.
00BD The plan is based on sample beam data. Delivering this Follow prompts on the
plan to a patient could result in patient injury or death. message.
If this is a phantom plan, click [OK] to continue. If this is a
patient plan, click [Cancel].
00BF The maximum dose in this plan is <%s>.This is below No action required.
minimum allowed. The plan will be saved as
non-deliverable.
00C0 Failed to identify the inconsistent data files from the list of Open in read-only mode, or
files received from server. recalculate dose which may be
The plan will be loaded in read-only mode. different than what was saved.
00C1 PDP/VCP check Failed. Follow prompts on the

Total number of %s failed PDP/VCP check is %s, total message.
number of %s for the plan is %s
All %s and dose will be removed and you must replan.
[Yes]: Remove %s and dose
[No]: Exit to Home Page.
00C3 Recalculating the source model will cause previously Follow prompts on the
calculated data in the OCR, TPR and OF steps to be message.
cleared.
[Yes] to proceed or [No] to cancel.
00C4 The current set of density overrides are not valid. You must Perform requested action.
correct any problems before the density overrides can be
used. The following problems were found:
%s
00C5 The newly selected density model does not contain the Perform requested action.
current density override values. The density model will
revert to the previously selected density model. You must
do one of the following:
(1) select a density model that contains the overridden
densities,
(2) alter the desired density model to contain the
overridden densities and select it again, or
(3) modify or disable the overrides that do not exist in the
desired density model and select it again.
The following problems were found: %s
00C6 Some VOIs with valid density overrides overlap other VOIs. Confirm that the VOI overrides
The following overlaps exist: are correctly used in
%s overlapping region.
00C7 The following problems exist with the current set of density Follow prompts on the
overrides : message.
%s
00CA The following conclusions were drawn during tracker Follow prompts on the
validation: message. Fiducials do not meet
% minimum requirements.
00CB Would you like to create a new session? Follow prompts on the
message.
00CD The plan is based on sample density model data. Follow prompts on the
Delivering this plan to a patient could result in patient injury message.
or death.
If this is a phantom plan, click [OK] to continue. If this is a
patient plan, click [Cancel].
00CF Enter a numeric goal value greater than or equal to %s Follow prompts on the
minutes and less than the current treatment time. message.
00D0 The following problems exist with the current set of density Change the density overrides.
overrides:
%s
00D1 The following problems exist with the density override : Change the density overrides.
%s
00D5 The desired number of nodes must be greater than 0. Follow prompts on the
message.
00D6 The current Desired Number of Nodes would remove all Follow prompts on the
nodes from the plan. The Desired Number of Nodes must message.
be lower than the total number of Non-zero nodes for the
plan.
Enter a smaller number for Desired Number of Nodes.
00D7 The current Desired Number of Node would not remove Follow prompts on the
any nodes from the plan. message.
To remove at least one node from the plan, enter a smaller
number for Desired Number of Nodes.
00D8 No planning nodes exists in the attempt to do the node Regenerate the beam set. If
reduction. problem persists, contact
Accuray Customer Support.
00D9 Accuray Precision could not create a planning robot for the Contact Accuray Customer
node reduction. Support.
00DA This density model does not contain a valid relative No action required.
electron density curve. The density model will revert to the
previously selected density model.
00DB Enabling Detect Padding Pixels will delete all the beams. Follow prompts on the
Do you want to continue? message.
[Yes]: Continue
[No]: Cancel.
00DC The relative electron density model of the current plan is Contact Accuray Customer
empty. Support.
If this is a new plan, the default density model or the
density model contained in the plan template might be
empty.
00DD The relative electron density model used for this plan does Confirm that the density model
not cover the full range of the HU values in the primary CT covers all HU values in the
image. The system uses the last available density value to primary CT dataset.
extend the density curve to the maximum HU value found
in the primary CT image.
00DE The mass density model used to calculate this plan does Confirm that the density model
not cover the full range of HU values in the primary CT covers all HU values in the
image. The system used the last available density value to primary CT dataset.
extend the density curve to the maximum HU value found
in the primary CT image.
00DF Failed to generate DRR. Contact Accuray Customer

Support.
00E0 Confirm that the density model selected for this plan is Perform requested action.
appropriate for the primary CT image set. If the density
model is not appropriate, the calculated dose may not be
accurate. The plot of the density model below shows the
maximum HU value of the image in relation to the points
defined in the density model.
Is the following density model appropriate?
%s
00E1 Reference Plan uses the VOIs, density overrides, beam Perform requested action.
data, density model, dose calculation box, and contour
correction settings from the Active Plan when displaying
and calculating dose for the Reference Plan.
The Reference Plan as displayed may not be the same as
the saved plan. Always review the Reference Plan loaded
as the Active Plan before approving for treatment.
00E3 The density model that will be used for dose calculation Follow prompts on the
may not be valid. The density for water, which has a HU message.
value of 0, should be within the range of [0.85, 1.15]. Would
you like to proceed?
[Yes]: Continue dose calculation with this density model.
[No]: Stop dose calculation.
00E4 The treatment center will be updated based on the No action required.
modified version tracking tumor VOI. All the existing beam
positions will be updated accordingly.
00E5 The system has detected that the current maximum dose Recalculate dose.
value of the plan being loaded is inconsistent with the
value previously saved. This might be due to loading an
older plan with a different calculation method or a
maximum dose outside its dose calculation box. Please
recalculate the plan to update its maximum dose value.
00E7 An ITV already exists. Changes to the ITV contours will

result in deletion of the PTV (If it exists). Continue?
00E6 An ITTV already exists. Continue? Follow prompts on the

message.
00E7 An ITV already exists. Changes to the ITV contours will Follow prompts on the
result in deletion of the PTV. Continue? message.
00E8 A PTV already exists. Continue? Follow prompts on the

message.
00E9 Changes to the selected VOI contours will result in deletion No action required.
of the ITTV.
00EA Changes to the selected VOI contours will result in deletion No action required.
of the ITV and/or PTV.
00EB Changes to the ITV contour will result in deletion of the No action required.
PTV.
00EC The time stamp difference between the primary and Follow prompts on the
secondary series is more than the 30 minute threshold. To message.
proceed, verify that the images are registered based on the
spine. If the registration is not completed based on the
spine, tracking will be compromised.
00ED Selected Synchrony method differs from that prescribed in Follow prompts on the
Simulation Plan. Continue? message.
00EE Changes to the Synchrony method will result in ITV and/or Follow prompts on the
PTV deletion. Continue? message.
00F0 To add a step, there must be at least one target VOI. Follow prompts on the
message.
00F1 The following VOIs are not entirely within the overlapping No action required.
region of the dose extents of the plans being compared.
%s
00F2 Selected VOI cannot be edited. No action required.
00F3 A spine tracking volume must be defined for Lung No action required.
Optimized Treatment.
00F4 The dose extents of the plans being summed do not match. No action required.
The sum of the dose distributions will only be calculated
within the regions where they overlap.
00F5 The following %s have been deleted. These %s are no Follow prompts on the
longer valid positions for the selected treatment path. message.
Review the resulting Makeup Plan to determine if it is
clinically acceptable.
Deleted beams:
%s
00F6 The Makeup Plan cannot be created. Contact Accuray Follow prompts on the
support. message.
00F7 Evaluate the image fusion result. Use spine ROI for fusion Follow prompts on the
if change is needed. message.
00F8 New Treatment Time parameters are being imported. Follow prompts on the
Press OK to confirm? message.
00F9 New Isocurve Template parameters are being imported. Follow prompts on the
Press OK to confirm? message.
00FA Selected Synchrony method differs from what is prescribed Follow prompts on the
in Simulation Plan. Changes to the Synchrony method will message.
result in ITV and/or PTV deletion. Continue?
00FB New AutoSave parameters are being imported. Use the Follow prompts on the
newly imported values? message.
00FC New Rendering parameters are being imported. Use the Follow prompts on the
newly imported values? message.
00FD Moving this VOI Operation will invalidate one or more Follow prompts on the
source VOIs. Move this VOI Operation? message.
00FE Script [%s] already exists. Changes to this script will result Follow prompts on the
in deletion of the original script. Continue? message.
00FF Deleting this VOI Operation will invalidate one or more Follow prompts on the
source VOIs. Delete this VOI Operation? message.
0100 Inconsistent data files in the original plan have been Follow prompts on the
detected. message.
Data files listed below failed data validation and must be
reloaded.
Since a Makeup Plan is in the process of being created, it
will use the latest data files from the server. Hence, the
results of the dose calculation may differ from the original
plan. Compare the original plan to the sum of the delivered
dose and any makeup plans for this plan in order to
evaluate any dosimetric differences.
0101 The following issues were found with the current set of VOI Follow prompts on the
Operations. message.
%s
Continue?
0102 The reference plan being loaded uses a different density A single density model should
model than the active plan. be used for a particular scanner.
Use of the wrong density model
will result in an incorrect dose
calculation.
0103 The reference plan being loaded uses different density Density overrides affect the
overrides than the active plan. dose calculation for both the
VOI and surrounding VOIs.
Confirm that the density
overrides are correct.
0105 An error occurred while saving DICOM RT data including Follow prompts on the
an RT Structure Set and RT Dose. The VOIs will be saved message.
as part of the plan; however, it may not be possible to
export the VOIs for this plan from Plan Administration.
Reloading this plan will require a dose recalculation.
Do you want to continue saving this plan to the database
server without the RT Structure Set and RT Dose?
[Yes]: Save the plan to the database server.
[No]: Cancel the save operation.
Contact Accuray Customer Support for assistance.
0106 The extrapolation setting in the original plan does not No action required.
match the extrapolation setting on the server. The server's
extrapolation setting will be used because a Makeup Plan
is being created. Hence, the results of the dose calculation
may differ from the original plan. Compare the original plan
to the sum of the delivered dose and any makeup plans to
evaluate any dosimetric differences.
Plan Settings: Max. Depth = %d, OCR Method = %s, TPR
method = %s.
Server Settings: Max. Depth = %d, OCR Method = %s,
TPR method = %s.
0107 Current settings result in %d sample points. More than %d Follow prompts on the
sample points may result in long optimization times. message.
Continue?
0108 The density model used in the plan contains density No action required.
definition for HU higher than the maximum allowed value
(4095). The plan will be loaded in read-only mode.
The invalid density pair(s) in the electron density model
are:
%s
The invalid density pair(s) in the mass density model are:
%s.
0109 The plan may not include a dose calculation that covers the Confirm that the dose
entire patient volume. High radiation dose could exist in calculation box includes all
these uncalculated regions which could result in targets, critical anatomy, and
mistreatment of the patient. tissue.
%s
Proceed with saving the plan as deliverable?
[Yes]: Proceed with saving.
[No]: Cancel.
010B The measured OCR data for collimator (at depth in mm) Follow prompts on the
%s contains invalid data for doing radial extrapolation. message.
Check and fix the data in the tail region before continuing.
010C All beams will be repositioned to be delivered from the Follow prompts on the
Cyberknife's nominal position. This operation cannot be message.
undone. Do you want to reposition all of the beams?
010D Not all beams are used in the QA plan. No action required.
010E All the beams have been moved to the CyberKnife's No action required.
nominal position.
010F The MU entered results in beam weights less than %s MU Follow prompts on the
which is the minimum number of MU to be delivered in a message.
single fraction. Plans cannot be saved as deliverable when
they contain beams with weights less than the minimum
number of MU to be delivered.
Do you want to keep this new MU value?
0110 Enter the maximum number of nodes within the range of Follow prompts on the
(%s) using MLC Settings. message.
0111 This density model does not contain a valid mass density No action required.
curve. The density model will revert to the previously
0112 The measured OCR data for one or more of the MLC field Follow prompts on the
sizes contains invalid data for doing radial extrapolation. message.
Check and fix the data in the tail region before continuing.
Issues were detected for the following field size and depth
combinations: %s
0113 The identifier of the image series that was used to create Follow prompts on the
the structure set is not defined in the imported structure message.
set. Please review the imported contours on the image set
to ensure that the contours were segmented for the image
set.
0114 Density overrides for VOI %s will be deleted when Confirm that either the CT area
converted to boundary only. does not require density
overrides or another VOI that
covers the same CT area has
density overrides.
0115 The dose volume may be invalid. There is non-zero dose Contact Accuray Customer
but there are no beams that have MU. Support.
The plan cannot be saved.
0116 With the current lateral / vertical / longitudinal adjustments, Follow prompts on the
the patient may not fit on the couch or in the gantry bore. message.
Ensure that the patient setup position is correct.
Proceed with accepting the new patient position?
[Yes]: Proceed
[No]: Revert to the last accepted patient position.
0118 Unable to save the plan as deliverable. The plan does not Calculate final dose.
have final dose.
011A This plan will be loaded in evaluation mode since it No action required.
contains the following non-licensed feature(s):
%s
011B A computation GPU is required to continue planning. Contact Accuray Customer

Contact Accuray Customer Support. Support.
011C Only one GPU was found in the system, and it is not Contact Accuray Customer
properly configured for compute. Please contact Accuray Support.
Customer Support for assistance.
011D More than two GPUs were found in the system, but none of Contact Accuray Customer
them are suitable for calculation. Treatment planning Support.
cannot continue. Please contact Accuray Customer
Support for assistance.
011E No GPU was found with both TCC and ECC enabled. Contact Accuray Customer
Treatment planning cannot continue. Please contact Support.
Accuray Customer Support for assistance.
011F A GPU was found with TCC enabled, but not ECC. Contact Accuray Customer
013B One or more plans being transferred are enrolled in Follow prompts on the
PreciseART®. message.
Confirm that the density models for all target treatment
machines are defined and appropriate. If the density model
is not appropriate, the calculated dose on treatment
images may not be accurate.
Are the treatment machine density models defined and
appropriate?
%s
0120 A GPU was found with ECC enabled, but not TCC. Contact Accuray Customer
0121 A GPU was found with both ECC and TCC enabled, but it Contact Accuray Customer
does not have sufficient computational capability. Support.
Treatment planning cannot continue. Please contact
0122 The mass density model of the current plan is empty. The Contact Accuray Customer
plan cannot be loaded. Support.
density model contained in the plan template may be
empty.
0123 There is no density model for the current plan. The plan Contact Accuray Customer
cannot be loaded. Support.
density model contained in the plan template may be
unspecified.
0124 This plan requires a density model with a valid electron Choose a density model with a
density curve. valid electron density curve.
0125 The machine setup for this plan requires a density model Choose a density model with a
with a valid mass density curve. valid mass density curve.
0127 The per beam dose is not available. Adding a dose point or Follow prompts on the
modifying an existing dose point requires a new dose message.
calculation. Do you want to continue?
0128 A tumor tracking volume must be identified. Identify a tumor tracking

volume.
0129 Not all the scripts values could be applied to the plan. No action required.
012A The %s file contains one or more invalid DICOM tags. Contact Accuray Customer
Would you like to continue? Support.
Invalid Tags:
%s
012B The Reference Point is not contained within the dose Move the reference point.
calculation box used for the recent dose calculation. The
plan cannot be saved as deliverable.
012C The plan has %s beam angles but treatment machine %s Remove some beam angles
only supports %s beam angles. Excess beam angles will until the maximum is not
need to be removed before the plan can be saved as exceeded.
deliverable.
012D Plan '%s' is currently locked by '%s' using '%s' on the Follow prompts on the
computer with the IP address '%s'. You may continue by message.
loading an unlocked copy of the last saved version of the
plan. Subsequent updates will not be reflected in the
display unless the plan is reloaded.
[OK]: Continue loading an unlocked copy of the plan.
[Cancel]: Cancel the Reference Plan load.
012E Proposed action will decommission the Monte Carlo MLC Follow prompts on the
calculated commissioning data. Recommissioning of the message.
Monte Carlo MLC will be required.
[Yes]: Decommission.
[No]: Cancel.
012F The Monte Carlo algorithm has been revised and will not Follow prompts on the
be available until it is recommissioned. Proceeding will message.
decommission the Monte Carlo algorithm and the
associated calculated commissioning data. Do you want to
continue?
[Yes]: Decommission.
[No]: Cancel.
0132 Changing the plane will delete the VOI's contours. Follow prompts on the
0133 The patient will contact the gantry during treatment. Saving Change the position of isocenter
as deliverable cannot proceed. and regenerate the plan.
0134 The patient may contact the gantry after alignment Double-check the alignment and
adjustments are made for treatment. Do you want to the patient position. Perform
continue saving as deliverable? requested action.
0135 Field size(s) listed below have calculated OCR tables. Follow prompts on the
Do you want to recalculate? message.
[Yes]: Recalculate for Field sizes(s) listed above.

[No]: Retain previously calculated OCR tables.
0136 Field size(s) listed below have calculated TPR tables. Follow prompts on the
Do you want to recalculate? message.
[Yes]: Recalculate for Field sizes(s) listed above.

[No]: Retain previously calculated TPR tables.
0137 One or more isocentric beams refer to a nonexistent Contact Accuray Customer
isocenter. Support.
0138 The following previous treatment items do not match the Follow prompts on the
medical ID or patient name of the new treatment data:%s message.
0139 PreciseART® enrollment failed, but the plan will still be Contact Accuray Customer
saved. Contact Accuray Customer Support. Support.
013A Modality '%s' will be added to the file name. Follow prompts on the
File '%s' already exists. message.
Do you want to replace it?
013B One or more plans being transferred are enrolled in Perform requested action.
PreciseART®.
Confirm that the density models for all target treatment
machines are defined and appropriate. If the density model
is not appropriate, the calculated dose on treatment
images may not be accurate.
Are the treatment machine density models defined and
appropriate?
%s
013C Template [%s] already exists. Changes to this template will Follow prompts on the
result in deletion of the original template. Continue? message.
013D Continuing will remove approvals and require a different Make selection as indicated in
extrapolation method. Taylor Series will be unavailable. message.
Yes to change method. No to keep current extrapolation.
013E Dose must be recalculated because the per beam dose Recalculate the dose.
volumes are not available.
0141 The Reference Point/Dose of the plan being loaded is Fix the problem and try again.
inconsistent with the values previously saved. The dose
must be re-calculated before this plan can be (re-)saved as
deliverable.
0143 This plan contains Isocentric or Sequential beams. If you Follow prompts on the
continue, the existing beams will be deleted. message.
Click Yes to delete the existing beams and remain on this
step.
Click No to retain the beams and return to the previous
step.
0144 This plan contains VOLO Data. If you continue, the existing Follow prompts on the
VOLO data and beams will be deleted. message.
Click Yes to delete the existing VOLO data and remain on
this step.
Click No to retain the VOLO data and return to the previous
step.
0145 The selected script is not compatible with the current plan. Choose a different script.
0146 The selected Template Path Set '%s' is not valid for VOLO Choose a different template
planning. path set.
0147 Remove invalid characters: "\", "^", or any not in the Perform requested action.
ISO/IEC 8859-1 character set.
0148 This plan cannot be enrolled in PreciseART®. There is no Define a valid density model for
valid density model defined for the treatment machine. the treatment machine.
0F9A This workstation is configured to run as a single Accuray Your workstation is incorrectly
Precision instance; however an MD Suite license is configured. Contact Accuray
enabled. Customer Support.
 Table 2
2001 This plan is currently locked by Accuray Precision session Perform requested action.
%s. Do you want to load this plan in read-only mode?
2002 Plan %s is currently locked by %s using %s on the Perform requested action.

computer with the IP address %s. Do you want to load this
plan in read-only mode?
2004 User ID is empty. Enter a valid User ID. Perform requested action.
2005 Password is empty. Enter a valid password. Perform requested action.
2006 Old password is empty. Enter a valid password. Perform requested action.
2007 New password is empty. Enter a valid password. Perform requested action.
2008 Confirm password field is empty. Confirm new password. Perform requested action.
2009 Password has to be changed before you log in. Do you Perform requested action.
want to change it now?
200A New password and Confirm new password do not match. The passwords your enter must
match.
200B Enter a password without spaces. Perform requested action.
200C Enter a password using ASCII characters only Perform requested action.
200D The selected plan was created using a previous version of No action required.
Accuray Precision. The plan will be loaded in read-only
mode.
200E Do you want to delete the manufacture script? Perform requested action.
200F Time reduction cannot proceed since the plan has reached No action required.
the minimum number of beams (%s) or nodes (%s).
2010 Plan '%s' is currently locked by '%s' using '%s' on the No action required.
computer with the IP address '%s'.
2012 Total number of %s that failed the beam entry check from No action required.
the patient plan [%s] is %d out of total %d beams.
2013 The number of beams whose MUs have been raised to the When creating a QA plan and
lowest allowed MU (%s) is scaling dose, QA plan attempts
%s to keep as many beams as
possible. In cases where the
beam’s MU would be scaled
below the minimal deliverable
MU per beam, the system raises
the MU of that beam to the
minimum MU for a beam.
2014 The machine used in the loaded plan is incompatible with No action required.
the current machine.
The plan will be loaded in read-only mode.
2015 Overwriting the plan will delete all QA plans (%d) Perform requested action.
associated with it. Do you want to overwrite the plan and
delete all of its QA plans?
2016 VOIs with duplicate names were found. New unique names VOI names must be unique.
were automatically generated for these VOIs. The changes When importing an RTSS, the
are listed below. system checks to see if there
%s are any duplicate VOI names. If
duplicate names exist, the
system automatically appends a
unique identifier to the VOI
names to make them unique.
2017 This prescription operation will modify the weights of %d Follow prompts on the
beams so that each has a minimum of %.1f MU (%.1f MU / message.
fraction). This will require the dose distribution to be
recalculated. Do you want to continue?
[Yes]: Change the number of fractions and delete the dose
distribution.
[No]: Revert to the original number of fractions.
2018 Changing the number of fractions will cause %d beams to Follow prompts on the
be set to %.1f MU (%.1f MU/fraction). The dose distribution message.
will be deleted and will need to be recalculated in the
Evaluate task. Do you want to continue?
[Yes]: Change the number of fractions and delete the dose
distribution.
[No]: Revert to the original number of fractions.
2019 The requested density override value cannot be achieved Density override values must be
using the current density model. The closest density value achievable values as defined by
is listed below. the currently selected density
Requested relative electron density override value: %s model, such that a CT
number/density value pair must
g/cm3
be in the density model where
Closest electron density value: %s g/cm3 the user desired density
override is within 0.01 of the
density value.
201A The requested density override value cannot be achieved Density override values must be
using the current density model. The closest density value achievable values as defined by
is listed below. the currently selected density
model such that a CT
Requested mass density override value: %s g/cm3
number/density value pair must
Closest mass density value: %s g/cm3 be in the density model where
the user desired density
override is within 0.01 of the
density value.
201B QuickPlan currently in progress has been cancelled. If an error occurs during
The following messages were generated while QuickPlan QuickPlan, QuickPlan will be
was running. aborted allowing the user to
correct the error and you must
%s manually complete planning.
Review the messages displayed
while QuickPlan was running to
ensure that you are aware of the
information that they provide.
201C QuickPlan requires that the VOIs listed below be contoured Perform requested action.
manually.
%s
201E The current template is not satisfactory for use with Perform requested action.
QuickPlan. Resolve the following issues in order to
continue.
%s
2020 QuickPlan has finished. Perform requested action.

The following messages were generated while QuickPlan
was running. QuickPlan responded OK whenever a
response was required. Review the messages to confirm
that each instance was handled properly.
%s
2021 Results that were automatically generated must be Perform requested action.
reviewed prior to saving a plan as deliverable. Review the
results of each item listed in the Save Plan dialog box and
acknowledge that a review has been completed by
checking the box next to each item.
2022 VOIs from the plan template are mapped to VOIs in an Perform requested action.
RTSS that do not have the same type (target/critical). The
VOI type from the plan template will be used when creating
this plan. Review the following list of mismatched types
and confirm that using the VOI type is acceptable.
%s
2023 QuickPlan completed normally. No action required.
2024 The current QuickPlan template must fuse multiple image Perform requested action.
volumes. Some of the image volumes that need to be
fused do not have seed points. Enter seed points for any
volumes that must be fused.
2025 QuickPlan has been cancelled. No action required.
2026 The current plan contains Sequential Optimization Follow prompts on the
parameters that can be saved as a Sequential message.
Optimization script. Plan templates reference scripts so
that multiple plan templates can use the same script.
Do you want to create a new Sequential Optimization script
from the current Sequential Optimization parameters?
[Yes]: Create a new script.
[No]: Use an existing script selected from the Sequential
Parameters tab.
2027 Confirmation of the alignment center is required. Perform requested action.
2028 Placing initialization points for the %s on MR images is not No action required.
supported.
2029 The current template is invalid. Resolve the following Follow prompts on the
issues to continue. message.
%s
202A The current set of operations are invalid. Resolve the Follow prompts on the
following issues to continue. message.
%s
202B Seed points have been defined on one image set but not No action required.
on the other. Seed points will not be used for the
registration process.
202C Plan Templates have already been converted to the latest Follow prompts on the
version. Convert existing Plan Templates again? message.
202D Sequential Optimization scripts have already been Follow prompts on the
converted to the latest version. Convert existing Sequential message.
Optimization scripts again?
202E Creating Makeup Plans is not supported for treatment No action required.
plans created in earlier versions of Accuray Precision.
202F The secondary MR voxel size is larger than recommended Follow prompts on the
(1.25 x 1.5 x 1.25 mm IECp). Evaluate the message.
Autosegmentation results.
2030 The primary CT voxel size is larger than recommended Follow prompts on the
(1.0 x 1.5 x 1.0 mm IECp). Evaluate the Autosegmentation message.
results.
2031 The current Plan Template is not editable. The record is locked by another
%s user. Wait for the user to
release the lock or contact your
System Administrator for
technical support.
2032 The Isocurve Template is not editable. The record is locked by another
technical support.
2033 The current Density Model is not editable. The record is locked by another
technical support.
2034 The current VOI Set template is not editable. The record is locked by another
technical support.
2035 The Treatment Time Parameters are not editable. The record is locked by another
technical support.
2036 AutoSave Parameters are not editable. The record is locked by another
technical support.
2037 The Color and Rendering Parameters are not editable. The record is locked by another
technical support.
2038 The following problems were encountered while resetting No action required.
the factory supplied plan templates.
%s
Not all factory supplied plan templates may have been
reset.
2039 %d beams failed the beam entry check. Follow prompts on the
Do you want to load the original plan? message.
[Yes]: Load the plan with original beams and dose in

read-only mode.
[No]: Turn off beams that failed the check and delete the
dose volume.
The following beams have failed the check:
%s
203A The primary dataset is incompatible with CyberKnife. Select a compatible dataset as
Select a compatible dataset as primary. primary.
203B Window / Level Presets are not editable. %s No action required.
2041 The following destination VOI(s) have not been contoured: Follow prompts on the
%s. Would you like to proceed with the current VOI name message.
matching selection?
[Yes]: Proceed with the current VOI name matching
selection.
[No]: Return to the Match VOI Names dialog.
2042 The following problems were encountered while deleting Retry your request. If the
the script. problem persists, contact
%s Accuray Customer Support.
The script may not have been deleted.
2043 The script can not be changed. The record is locked by another
technical support.
2044 A Makeup Plan cannot be created because the required Commission the required beam
beam data type (%s) has not been commissioned. data type.
2045 Complete all of the Setup steps to proceed. Follow prompts on the
message.
2046 Taylor Series method cannot be used for OCR/TPR. No action required.
2047 At least one beam must be used in the QA plan. No action required.
2048 The MLC beam data has not been approved for patient Review and approve beam data
plans. The current plan cannot be saved as deliverable prior to creating patient
with the MLC selected as the collimator. treatment plans.
2049 The number of nodes available to perform isocentric Use at least the specified
conformal targeting for the following target VOI(s) is less number of nodes.
than the maximum number of nodes (%s):
%s
2050 %s segments would have been re-weighted below the Review the dose distribution.
minimum deliverable MU.
Those segments have been set to the minimum deliverable
MU (MU = %s).
2051 A plan template with this name already exists. Plan Select a different name for the
template names must be unique. plan template. No action
required.
2052 %d of %d %s from the patient plan [%s] do not intersect Realign the QA Plan.
with the CT volume. No %s have been transferred.
2054 The plan %s will be loaded in read-only mode since the No action required.
plan was created for a different MLC.
2055 If the treatment machine selection is changed from "%s" to Follow prompts on the
"%s", planning inputs, including density overrides, and message.
outputs, such as dose and statistics will be discarded. Do
you want to continue?
[Yes]: Switch the treatment machine and discard planning
inputs and outputs.
[No]: Keep the current treatment machine selection for the
plan.
2056 %s%s requires a license. Contact Accuray Customer

Support.
2057 Accept or cancel the couch replacement before leaving this Accept or cancel the couch.
step.
2058 This will cause the new couch image to be discarded. %s Follow prompts on the
Would you like to proceed? message.
[Yes]: Discard the new couch image.
[No]: Keep the new couch image.
2059 Leaving this step will cause the red laser changes to be Follow prompts on the
discarded. Would you like to proceed? message.
[Yes]: Discard the red laser changes and leave this step.
[No]: Keep the red laser changes and remain on this step.
2060 Leaving this step will cause the patient position changes to Follow prompts on the
be discarded. Would you like to proceed? message.
[Yes]: Discard the patient position changes and leave this
step.
[No]: Keep the patient position changes and remain on this
step.
2061 The red laser position has been modified. Click Accept or Follow prompts on the
Revert to leave the Move Red Laser mode. message.
2062 The patient position has been modified. Click Accept or Follow prompts on the
Revert to leave the Move Patient mode. message.
2064 The planned couch travel exceeds %s mm. Verify that the Verify that the planned couch
planned couch travel can be achieved at the desired couch travel can be achieved at the
height to ensure that the plan can be delivered. desired couch height to ensure
Continue with the final dose calculation? that the plan can be delivered.
2065 Red lasers may no longer align with the patient due to the Verify that the red laser
patient position change. Verify that the red laser positions positions are correct.
are correct.
2066 Red laser position has not been confirmed. Accept or move Follow prompts on the
red lasers to exit machine setup. message.
2067 Registration has moved stored red lasers out of range. Red No action required.
lasers have been aligned to machine isocenter.
2068 This plan contains final dose results. Accepting this change Follow prompts on the
will delete the final dose. message.
Click Yes to accept this change and delete the final dose.
Click No to discard this change and retain the final dose.
2069 This plan contains optimization results. Accepting this Follow prompts on the
change will delete the optimization. message.
Click Yes to accept this change and delete the
optimization.
Click No to discard this change and retain the optimization.
2070 This plan contains calculation results. Accepting this Follow prompts on the
change will delete the calculation. message.
Click Yes to accept this change and delete the calculation.
Click No to discard this change and retain the calculation.
2071 This plan has not been optimized. Follow prompts on the
Do you wish to continue with the final dose? message.
2072 Replace the couch before exiting this step. Replace the couch.
2073 The following VOIs were discarded:%s No action required.
2075 The following VOIs are too complex for representation:%s No action required.
Contour stacks with the smallest volume have been
discarded.
2076 Proceeding with this operation will invalidate this plan's Follow prompts on the
final dose results. message.
[Yes]: Continue this operation and delete the final dose.
[No]: Abort this operation and retain the final dose.
optimization results. message.
[Yes]: Continue this operation and delete the optimization.
[No]: Abort this operation and retain the optimization.
calculation results. message.
[Yes]: Continue this operation and delete the calculation.
[No]: Abort this operation and retain the calculation.
2079 The current data is approved. No action required.
2080 Approval failed for the following reason(s): Follow prompts on the
%s message. Detailed instructions
to correct the situation may vary
by case.
2081 If the treatment machine selection is changed from "%s" to Follow prompts on the
"%s", planning outputs, such as dose and statistics will be message.
discarded. Do you want to continue?
[Yes]: Switch the treatment machine and discard planning
outputs.
plan.
2084 The following VOIs had variable spacing between No action required.
slices:%s
The VOIs have been moved or copied to match the slices
of the resampled image with fixed spacing.
2085 Deformable fusion cannot start because of insufficient Reduce the registration ROI box
GPU memory. Reduce the registration ROI box and try and try again.
again.
2086 Deformable fusion failed. Try the following:

• Reduce registration ROI and
try again.
• Save plan, restart the
application, and try again.
• Reboot the system and try
again.
If these attempts fail, contact
2087 Forward Planning information will be lost if this change is Follow prompts on the
made. Do you want to continue? message.
2088 You will lose any planning settings if you make this Follow prompts on the
change. Continue? message.
2089 Free disk space is low. Would you like to switch to the Clear the local patient cache to
Maintenance tab to clear the local patient cache? free disk space.
2090 The current displayed dose is out of date for the current Recalculate or clear dose.
beam configuration. Recalculate or clear dose.
2091 The selected exam was resampled during import. The No action required.
resampled data will be used rather than the original data.
2092 Creating delivered dose plans is not supported for No action can enable creating
treatment plans created in earlier versions of MultiPlan. delivered dose plans for earlier
versions of MultiPlan data.
2093 Deformable registration failed because all voxels in the Check that registration ROI box
secondary image are zero. Check that registration ROI box overlaps with the secondary
overlaps with the secondary image. image.
2095 The current plan contains optimization parameters that can Follow prompts on the
be saved as a script. Plan templates reference scripts so message.
Do you want to create a new Script from the current
parameters?
[No]: Use an existing script.
2096 Angles with zero weight must be deleted to make Delete angles with zero weight.
deliverable.
2097 Dose Point %s is used by Dose Group %s and cannot be Remove the dose point from the
deleted. dose group.
2098 There are auto-shells associated with this VOI. Accepting Follow prompts on the
this change will delete the auto shells. message.
[Yes]: Delete the auto-shells.
[No]: Cancel.
2099 Validation of the current template produced warnings: Review the warnings and follow
%s prompts on the message.
209A Accepting this change will delete one or more dose groups. Follow prompts on the
[Yes]: Delete the dose groups.
[No]: Discard this change and retain the dose groups.
209B Proceeding with this operation will invalidate one or more Follow prompts on the
of this plan's dose groups. message.
[Yes]: Continue this operation and delete the dose groups.
[No]: Abort this operation and retain the dose groups.
209C A VOI change resulted in optimization results being No action required.

deleted.
209D A VOI change resulted in calculation results being deleted. No action required.
209E A VOI change resulted in final dose results being deleted. No action required.
209F A VOI change resulted in one or more dose groups being No action required.
deleted.
20A0 The following VOI were unchanged by their specified Perform requested action.
density overrides and should be changed: %s
20A1 Plan '%s' is currently locked. The plan will be recovered as No action required.
a new unnamed plan.
20A2 Plan '%s' has been modified on the server since the last No action required.
local auto-save. The plan will be recovered as a new
unnamed plan.
20A3 Found and fixed %s VOI(s) with unsupported characters in No action required.
their names.
20A4 Approval process is incomplete. Follow the instructions to

%s complete the approval process.
20A5 The template cannot be changed. No action required.

%s
20A6 The dose calculation box cannot be set to cover the skin Define a skin VOI in the "Skin"
VOI because the skin VOI has not been defined. step if you would like to use it to
specify a dose calculation box.
20A7 The dose calculation box cannot be set to cover all VOIs Draw some VOIs in the
because no VOIs have been defined. "Contour" task if you would like
to use it to specify a dose
calculation box.
20A8 VOI [%s] is used in sequential optimization. All constraints Follow prompts on the
and steps involving this VOI will be removed. message.
20A9 Dose calculation completed without error but did not The beams generated likely do
produce any nonzero dose values. The resulting dose not intersect the patient. Correct
volume will be ignored. the problem, or contact Accuray
Customer Support.
20AA Angles with zero weight must be deleted, or modified to Delete the angles with non-zero
have nonzero weight, before computing final dose. weights.
20AB New password is too long. (0 - 100) Fix the problem and try again.
20AC The selected alignment change will remove %d of %d %s Proceed with planning.
from the patient plan [%s] due to treatment robot
workspace violations.
Would you like to continue? Once the %s are removed,
you will need to return to the register step to restore the
original set.
20AE Do you want to overwrite plan “%s”? The existing plan is in Follow prompts on the
the Approved state and may have been sent to the OIS. message.
When this plan is Approved, it may also be sent to the OIS.
If a prior version of this plan is already in the OIS, it may
need to be manually removed. To continue and overwrite
anyway, press Yes; else press No to cancel.
20AF The current plan contains optimization parameters that can Follow prompts on the
be saved as a script. Plan templates reference scripts so message.
Do you want to create a new Script from the current
parameters?
[No]: Use an existing script.
20B0 The maximum number of secondary datasets has already No action required.
been imported for this plan.
20B1 The MultiPlan plan '%s' was saved with auto-shells No action required.
surrounding the following non-Target VOIs:
%s
These auto-shells are being removed from the plan as they
are incompatible with Precision.
 Table 3
4002 The dose has been successfully centered. No action required.

The offset from the centroid of the target dose line to the
centroid of the target VOI is %s, which is below the
tolerance [%s].
4003 Do you want to delete the current conformal beam set? Follow prompts on the
message.
4004 Print job is completed. No action required.
4006 Selected patient(s) removed from local database. No action required.
4008 The registration has been copied successfully. No action required.
4009 This plan contains isocentric conformal beams. They will No action required.
be included in the optimization. If you select additional
collimators on this step, new beams will be generated in
addition to the isocentric beams previously created.
400A Creating a plan with neither Max MU per Beam nor Max Follow prompts on the
MU per Node constraint can increase the likelihood of hot message.
spots outside the dose calculation region. Do you want to
optimize without these constraints?
Click Yes to proceed with optimization.
Click No to cancel optimization.
400B Perform a dose calculation prior to setting the number of Follow prompts on the
fractions to %s. message.
400C Password has been changed successfully. No action required.
400D RT Plan failed to be created: Contact Accuray Customer

%s Support.
400E The Spine Tracking VOI must be Axial. Redefine the Spine Tracking
VOI in Axial view.
 Table 4
8000 Unknown system error. If the Accuray Precision

System fails, contact Accuray
Customer Support.
8001 The memory address space is fragmented. The Close all non-Accuray
application could not allocate a contiguous memory block. Precision System related
Restart the application. applications. Close and restart
the application.
If this fails, reboot the system.
8002 The current operating system does not support this Contact Accuray Customer
application. Run this application on Windows XP Pro or a Support to arrange a Windows
higher version of the Windows Operating System. operating system upgrade.
8003 Set your display resolution to 1920 x 1200 and 32 color Select the Control Panel from
bits. the Start Menu. Select
Appearance and Themes.
Select Display. Open the
Settings task.
Set the screen resolution to
1920 x 1200 and the color
quality to Highest (32 bit).
8004 Failed to capture image. Recapture image.
8005 Failed to save file [%s]. Ensure disk has enough space If saving data to a floppy disk,
and is not write protected. verify that the disk is writable.
8006 Graphics system failed. Error found in OpenGL [%s]. Reboot the computer.
800B The seed points you have defined are collinear. Redefine Redefine one or more seed
one or more seed points. points so that all three are not
collinear.
800C The seed points you have defined are too close to each Redefine one or more seed
other. Redefine one or more seed points. points and separate them
further.
800D Filter file cannot be loaded. Attempt to load a different filter

file.
800E This version of Accuray Precision cannot support Lung No action required.
with Respiratory method.
800F CyberKnife datafile contains unsupported XST algorithm If the Iris collimator is licensed
version. Please exit Accuray Precision, and reconfigure on your Accuray Precision
the CyberKnife datafile. Treatment Planning System,
commission Iris beam data.
MultiPlan System 3.0 and
above support the Iris
collimator. To use the Iris
collimator, upgrade your
CyberKnife System.
8010 Iris collimator is not supported because: Commission the Iris beam
1. Iris beam data is not commissioned. data. If you are unable to
commission the data, contact
2. Iris collimator feature is not enabled. Accuray Customer Support to
check your license.
8011 The MergeCom-3 DICOM license is invalid. Contact Contact Accuray Customer
Accuray Customer Support. Support.
8012 An internal error has occurred. Please see the log file for Based on information from the
details. datafiles, correct the datafile
format. Contact Accuray
Customer Support.
8013 Set your system locale to one that supports the display of Follow prompts on the
numbers in the North American English format. The message.
decimal symbol must be '.' the digit grouping symbol must
be ',' and the negative sign symbol must be '-'.
8100 Invalid database connection. Restart MSSQL server. Check

network configuration and try
again. If the problem persists,
contact Accuray Customer
Support.
8101 No connection to TPS_DICOM Database via ODBC Ensure MSSQL server is

[DNS:DICOMServer]. running and ODBC connection
is good for
“DNS:DICOMServer”.
8102 No NFS connection to database server [%s] via NFS Ensure database server is up
Client [Windows Services for UNIX 3.5]. and running. Exit application
and restart Accuray Precision
System. If the problem
persists, restart the server and
try again.
8105 Data files are missing on database server. If the space and protection are
%s okay, check the network
connection. Reboot the
8106 Failed to initialize local datafiles for planning. Check network connection and
reboot the system.
8107 Failed to create local data folder. Check permissions in the

c:\accuray folder.
810D Failed to acquire lock for [%s] CT image for %s from Open a different patient or wait
database server. until that particular patient is
unlocked.
8110 Failed to reset the system application. No action required.
8112 Failed to initialize robot data. Check the network connection

and reboot the system.
8113 Invalid TPR table found in data file. Read log file for Based on information from the
details. datafiles, correct datafile
Customer Support for
assistance.
8114 Invalid OF table found on database server. Read log file Based on information from the
for details. datafiles, correct datafile
assistance.
8115 Invalid OCR table found on database server. Read log file Based on information from the
for details. datafiles, correct datafile
assistance.
8117 Failed to remove patient <%s> from local database. Check system permissions to
see if you are allowed to delete
data from the local database.
Contact Accuray Customer
Support.
8123 Failed to copy beam data files to Accuray Precision local Permission error. Contact
drive. Accuray Customer Support.
You will not be able to review beam tables.
See log file in <c:/accuray/log> for detail.
8124 Failed to read extrapolation data from the server. Revalidate and approve the
You must go through commissioning process and approve OCR and TPR data tables. Go
OCR and TPR tables. to Commissioning Tools >
Review Tables > MC TPR &
OCR.
8125 None of the selected % will be modified due to the No action required.
following reason(s):
%s
8126 Invalid data or format in Dose profile data file. Refer to the Physics Essentials
Review content of this file. Guide. Ensure file format
meets requirements.
Refer to user manual for expected format and data for this
file.
8127 Invalid data or file format in Central PDD data file. Refer to the Physics Essentials
Review content of this file. Guide. Ensure file format
meets requirements.
file.
8128 Invalid data or file format in In Air OF (MC output factor) Refer to the Physics Essentials
data file Guide. Ensure file format
Review content of this file. meets requirements.
file.
8129 Failed to update mc_seccollim_geo.xml with changes Send the log file and contact
made to upper and lower limits. Accuray Customer Support.
Read log file for details.
Contact Accuray Customer Support.
8133 Invalid data or file format in data file(s) listed below: Refer to the Physics Essentials
%s Guide for information on data
file requirements for Monte
Review content of this file. Carlo dose calculation
Refer to user manual for expected format and data for this commissioning.
file.
8134 Invalid radial positions. Follow prompts on the

-80.0 (mm) < radial position < + 80.0 (mm) message.
Verify all measured radial positions in mc_doseprofile.dat

file.
8135 Saving a discontinued plan with the same name is not Follow prompts on the
allowed. Use a different name and try again. message.
8136 Invalid Iris OF table found on database server. Read log Follow prompts on the
file for details. message.
8137 Invalid Iris TPR table found in data file. Read log file for Follow prompts on the
details. message.
8138 Invalid Iris OCR table found on database server. Read log Follow prompts on the
file for details. message.
8139 The plan cannot be saved as a deliverable plan because it No action required.
was based on sample beam data.
8140 Failed to update the commissioning status in the database Contact Accuray Customer
server. Support.
Exit all Accuray Precision applications on other
workstations before proceeding.
8141 Failed data integrity check. Read the log file for detail. Contact Accuray Customer
Support.
8142 The plan cannot be saved as a Deliverable plan because it No action required.
was based on sample density model data.
8143 The plan cannot be saved as Deliverable because the Approve the beam data for
beam data has not been approved for phantom plans. phantom plans prior to saving
the plan as deliverable.
8144 The plan cannot be saved as Deliverable because the Approve the beam data for
beam data has not been approved for patient plans. patient plans prior to saving the
plan as deliverable.
8145 All of the MLC FSPB beam data (OCR, TPR, OF, Open Review and approve beam
Beam Profile, PB Modeling) must be reviewed and data.
approved before final approval is given.
8146 Beam data for the MLC is not valid. Check the log file for Contact Accuray Customer
details. Support.
8147 All of the MLC Monte Carlo beam data (MC Source, MC Review the data.
OCR, MC TPR, and MC OF) must be reviewed and
approved before final approval is given.
8203 The image does not contain valid slice spacing. Delete slices that create
erroneous slice spacing.
8206 The pixel format of the image is not supported by this Rescan image or contact
application. Accuray Customer Support.
820C Failed to read image data. The image data might be Rescan or resend image. If that
incomplete or invalid. fails, contact Accuray
Customer Support.
8212 Failed to load image. Image is blank. Try to load a different image.
8216 There are corrupted images. Contact Accuray Customer Contact Accuray Customer
Support. The images sets are: Support.
%s
8217 Patient Medical ID <%s> is out of range. Contact Accuray Customer

Patient Medical ID should be in 'a-z', 'A-Z', '0-9', '-' and '_'. Support.
Contact Accuray Customer Support.
8280 Failed while loading plan. Try to load a different plan. If

loading another plan fails,
reboot the computer and
Support.
8281 Failed to read plan data. The plan might include invalid or Try to load a different plan.
incomplete data.
8288 Failed to initialize plan object. Contact Accuray Customer

Support.
828C Failed to download %s plan data to local drive.[%s] Check network connection. Try
to download a different plan.
Reboot the system.
828D The 4D plan will not be loaded because you do not have Load the plan on a different
the license for this feature. MultiPlan 2.0 or later
workstation that has a 4D
Planning license.
8300 Failed to load RTDose dose distribution. Recalculate after loading and
save the plan.
8301 Failed to load RTSS volumes of interest. Resend RTSS Volumes to the
data server.
8302 Invalid RTSS data or RTSS structure does not contain any Resend RTSS Volumes to the
VOI. data server.
8304 Failed to export the fused image file. Check the following:
• IP address
• AE title
• port of the target machine
• connection of the data
server
Then resend the fused image.
8305 Failed to export the mixed image file. Check the following:
• IP address
• AE title
server
Then resend the mixed image.
8308 Failed to save the volumes of interest. Check the following:

• IP address
• AE title
server
Then resend the volumes of
interest.
8309 Failed to export the original image [%s]. Read log file for Follow prompts on the
details. message.
830B Failed to export the fused moving image. Read log file for Follow prompts on the
details. message.
830C Failed to export the mixed image. Check the following:

• IP address
• AE title
server
Then resend the mixed image.
830F Failed to add the remote machine. Contact Accuray Customer

Support.
8310 The fused volume data is invalid for export. Verify the moving image is
properly registered. Go to Plan
> Fuse.
8312 Failed to export the dose volume. Read log file for details. Follow prompts on the
message.
8313 Failed to export the original image [%s] in N1k Format. Follow prompts on the
Read log file for details. message.
8314 Failed to establish connection to Data Management Check network configuration

System at IP address = %s. and try again.
8317 Failed to load inconsistent data files Follow prompts on the

The plan <%s> Will be loaded in read-only mode. message.
Read log file for detail.
8318 Failed to acquire CyberKnife read lock for CK ID <%s>. Selected record is in use by
Please see log file for detail. another user. If the lock is not
released by the application,
contact your system
administrator. Follow prompts
on the message.
8319 Error loading images, Failed to acquire %s lock on <%s>. Retry loading images after the
other Quick Review session
has finished loading.
8320 Error deleting <%s> patient as the patient is open in No action required.
session <%s>.
8321 Failed to load non-HFS RTSS volumes of interest. These Contour VOI on a non-HFS
volumes of interest are not DICOM Reference Coordinate images.
System compliant data.
8322 The connection to the server has been lost. Check network connections
and retry.
8323 Failed to push the new couch image to computer %s. Contact Accuray Customer
Support.
8324 Failed to export the new couch image file. Contact Accuray Customer
Support.
8325 Failed to load treatment machine <%s>: Contact Accuray Customer

%s Support.
8326 The treatment machine <%s> cannot be opened for Import the correct beam data.
commissioning because beam data for the fixed collimator
set has not been imported.
8380 Failed to connect to DICOM server. The server could be Verify that the recipient DICOM
dead or there might not be a network connection to %s. server is running. Resend
DICOM data. If that fails,
Support.
8381 Interrupted DICOM network connection to %s. Verify that the recipient DICOM
server is running. Resend
Support.
8382 DICOM server aborted this Association request to %s. Verify that the recipient DICOM
server is running. Resend
Support.
8383 Request for this Association rejected by the DICOM Modify the calling AE title for
Server because the calling AE title for %s is incorrect. the remote machine. Resend
Support.
8384 Timeout (%s secs) for pushing DICOM files: SCU Verify that the recipient DICOM
application is hanging because of an AEs error or the server is running. Resend
network might be too slow to %s. DICOM data. If that fails,
Support.
8385 Failed to run C_STORE application as SCU. The Contact Accuray Customer
send_image.exe might be missing. %s Support.
8386 Failed to either verify AEs or write to DICOM database %s. Verify AE title and that the
recipient DICOM server is
running. Resend DICOM data.
If that fails, contact Accuray
Customer Support.
8387 Request for this Association rejected by the DICOM Correct the AE title for the
Server because of an illegal calling AE title for %s. The DICOM Server.
maximum string length of AE title is 16 characters.
8400 Failed to save the plan. Check the connection, data

server, and the permissions of
the current user.
8401 Failed to delete the plan. %s. Check the connection, data
server, and the permissions of
the current user.
8406 Failed to write the treatment path for a deliverable plan. Verify that the node data is
non-zero. Check the network
connection.
8407 Failed to write the check file for a deliverable plan. Check the network connection
and permissions on the data
server. Contact Accuray
Customer Support.
8409 Failed to write the fiducial file for a deliverable plan. Check the network connection
and permissions on the data
server. Contact Accuray
Customer Support.
8410 The plan was saved. However, the dose per beam Contact Accuray Customer
information used by third-party OIS for tracking dose Support.
points were not written out. Contact Accuray Customer
Support.
840C Failed to save the plan due to the following reason: Follow prompts on the
%s message and resolve the
issue.
840D An error occurred while saving DICOM RT data and the Contact Accuray Customer
delivered dose cannot be saved. Contact Accuray Support.
Customer Support.
840E Failed to save the plan due to the following invalid Fix the invalid segments and
segment(s): save.
%s
840F The current leaf configuration is invalid. Correct the leaf configuration.
%s
This must be corrected in order to continue.
8500 The plan is invalid because it has no dose volume or the Generate a plan.
dose volume is empty. Go to the Plan task and create a
valid plan.
8501 The plan is invalid because it has zero beams. Go to the Generate a plan.
Plan task and create a plan with beams.
8600 Failed to create a new contour set. The VOI already has Reformat contour set.
the maximum number [%s] of contour sets.
8707 Failed to load template path sets for treatment planning. Contact Accuray Customer
Support.
8775 Plan reports cannot be generated for an unsaved plan. Save the plan prior to creating
a report.
8776 Treatment Machine was changed. Please save plan again Follow prompts on the
before generating report. message.
8870 Invalid template name. Check printer connection.

The name is same as another existing template name, or Check permissions in
the name is empty. c:\accuray folder. Contact
8900 MU cannot be modified because the beam is shut down. Return to previous task.
8901 The value to the left of the MU operator must be less than Return to previous task.
the value to the right of the MU operator.
8902 Target change was not accepted because a potential Return to previous task.
manipulator error or VCP error was detected.
8903 Target change was not accepted because the beam Return to previous task.
appears to enter the patient outside the bounds of the CT
series.
8904 The Modify Selected Beams input value(s) are invalid. Enter valid values.
Details:
%s
8905 No modification will be performed because all of the Enter valid values.
Modify Selected Beams fields are empty.
8906 No modification will be performed because there are no No action required.

selected beams.
8A00 The current pagefile size (%s MB) is insufficient for The Microsoft Windows XP
Accuray Precision to run effectively. pagefile has been configured at
System reconfiguration is needed before this operation too small a size. The size
can be performed. should have been set correctly
at system configuration /
Contact Accuray Customer Support. software installation time, and
the problem should be referred
to Service.
8A01 The estimated %s MB of memory necessary to complete Review dose calculation box
the requested dose calculation exceeds the total VM size in all 3 dimensions and
space (RAM + pagefile) of %s MB available on this reduce size where possible
computer. (particularly the number of axial
The operation has been canceled. slices).
8A02 Calculation was canceled because there are no beams No action required.
with dose defined.
8A03 Enter an uncertainty value within the range of %s to %s. No action required.
8B00 Failed to read protocol data of MC Commissioning. Read the log file in the
Read log file for details. c:\accuray\log folder. Contact
8B01 Failed to transfer protocol data of MC Commissioning. Restart the application. If that
Read log file for details. fails, check the network
connection and the required
datafiles on the data server.
Contact Accuray Customer
Support.
8B02 Failed to load protocol data of MC Commissioning due to Read the log file in the
unknown error. c:\accuray\log folder. Contact
Read log file for details. Accuray Customer Support.
8B03 Failed to perform the Monte Carlo dose calculation. Check settings and try again.
8B04 Failed to generate source model data. Check settings and try again.
8B05 Failed to generate Monte Carlo calculated OCR data. Check settings and try again.
8B06 Failed to generate Monte Carlo calculated TPR data. Check settings and try again.
8B07 Failed to generate Monte Carlo calculated OF data and Check settings and try again.
Fnormal.
8B08 Failed to save MC protocol data. Check settings and try again.
8B09 Enter FWHM value within the range of %s to %s. Check settings and try again.
8B0A Commissioning data will be opened in read-only mode No action required.

because it is being accessed by another Accuray
Precision workstation.
8B0B Commissioning data will be opened in read-only mode No action required.

because the current user does not have permission to
approve commissioning data.
8B0C All treatment parameters must be filled in before you can Fill in the treatment parameters
move on to another task. prior to exiting the step.
8B0D Failed to load commissioning data <%s>. Contact Accuray Customer

Reported error: %s. Support,
8C00 All fields must be filled in. Check settings and try again.
8C01 Invalid values: Check settings and try again.

%s
8C02 %s The Number of Fractions cannot be modified at this Check settings and try again.
time.
8C03 %s The Prescription fields cannot be modified at this time. Check settings and try again.
8C04 Failed to retrieve the minimum deliverable MU per fraction Check settings and try again.
from iDMS .
8C06 The plan cannot be saved as deliverable. The total MU for Reduce the MU of 5 mm.
the 5 mm Iris collimator exceeds the maximum tolerance beams in the Finetune menu
allowed. Lower the total MU for the 5 mm Iris collimator. and recalculate dose.
8C07 The 5 mm Iris collimator cannot be used for Sequential Follow prompts on the
Optimization. Sequential Optimization will be canceled. message.
8C08 When using the 5 mm Iris collimator, include at least one Follow prompts on the
other collimator size. Sequential Optimization will be message.
canceled.
8C09 To be deliverable, a %s must have either 0 MU or MU Follow prompts on the

greater than or equal to %s MU. There are %d %s that message.
don't meet this criteria.
To adjust %s MU, do any of the following: %s
8D01 There are fewer target VOIs in the plan than in the script. No action required.
8D02 There are fewer critical VOIs in the plan than in the script. No action required.
8D03 Sequential Optimization has failed due to invalid script Follow prompts on the
data. Ensure that the required data is present and that message.
each step is valid. If steps failed validation, they are shown
in orange.
8D04 Sequential Optimization failed because the initial Follow prompts on the
conformal beam set data was not defined. You must either message.
make collimator selections on the Collimators dialog box
or create an initial conformal beam set on the Isocentric
step.
8D05 Failed to generate beams. Sequential Optimization will be No action required.

canceled.
8D06 Sequential Optimization was canceled due to invalid Check settings and try again.
and/or incomplete VOI limits.
8D07 In the Dose Constraints section, a Max Dose must be set Follow prompts on the
for auto-shell [%s]. message.
8D08 In the Dose Constraints section, set the Max Dose for VOI Follow prompts on the
[%s]. message.
8D0B You must first select OMI, OCO, OHI, or DVL for the first Follow prompts on the
step. message.
8D0C Assign an auto-shell structure for step [%s] on the Steps Follow prompts on the
dialog box. message.
8D0D Assign a VOI for step [%s] under the Dose Objectives Follow prompts on the
section of the Constraints and Steps dialog box. message.
8D0E The VOI [%s] associated with step [%s] has no contour. Follow prompts on the
message.
for VOI [%s]. message.
8D12 In the Dose Constraints section, set a Goal for step [%s]. Follow prompts on the
message.
8D13 The script has no steps. Add at least one step on the Follow prompts on the
Steps dialog box. message.
for auto-shell [%s]. message.
8D15 A manufacturer-provided script with the same name Follow prompts on the
already exists. Please choose a different script name. message
8D16 The Accuray Precision System is in an unexpected state. No action required.

The last plan stored in the Solution History will be
restored.
8D17 The VOI associated with step [%s] is invalid. Select a VOI Follow prompts on the
with one of the following types: %s. message.
8D18 Cannot have a DV objective for the Boundary Only VOI Follow prompts on the
[%s]. Delete the DV constraint or change the VOI to a message.
non-Boundary Only VOI.
8D19 Cannot have a DV objective for VOI [%s] since it is not Follow prompts on the
completely within the dose calculation grid. Delete the DV message.
objective or resize the dose calculation grid.
8D20 Two constraint volumes, goal volumes, or relaxed Follow prompts on the
volumes applied to the same VOI cannot be closer than message.
0.5% of the total VOI volume. This occurs for VOI: %s
8D21 Step [%s] relaxation value must be greater than 0 or less Follow prompts on the
than its total volume value. message.
8D22 Cannot have a DV constraint for the Boundary Only VOI Follow prompts on the
[%s]. Delete the DV constraint or change the VOI to a message.
non-Boundary Only VOI.
8D23 Cannot have a DV constraint for VOI [%s] since it is not Follow prompts on the
completely within the dose calculation grid. Delete the DV message.
constraint or resize the dose calculation grid.
8D24 The Sequential Optimization script must have at least one Follow prompts on the
of the following target objectives present: OHI, OCO, OMI, message.
or DVL.
8D25 Step [%s]'s volume value must be greater than or equal to Follow prompts on the
0.1%% of its total volume value and less than or equal to message.
99.9%% of its total volume value.
8D26 VOI [%s] volume value must be greater than 0 or less than Follow prompts on the
its total volume value. message.
8D27 Step [%s] is an OMU step and should not have a VOI or Follow prompts on the
shell assigned to it. message.
8D28 The following VOI(s) are used in the Sequential Follow prompts on the
Optimization script but are not contoured: %s. Please message.
contour these VOI(s) or remove them from the script
before proceeding.
8D29 Step [%s]'s Relaxation Volume value must be greater than Follow prompts on the
or equal to 1% of its total volume value. message.
NOTE: DVL Relaxation Volume value = Volume -
Relaxation Value
8D30 Step [%s]'s Relaxation Volume value must be less than or Follow prompts on the
equal to 99% of its total volume value. message.
NOTE: DVU Relaxation Volume value = Volume +
Relaxation Value
8D31 Enter a Leaf Margin value within the range of %s to %s Follow prompts on the
mm. message.
8D32 There are currently no Target VOIs being targeted. Update Follow prompts on the
the targeting settings using MLC Settings. message.
8D33 DV constraints and sampling on VOI[%s] has removed all Follow prompts on the
maximum dose constraints. Redo optimization at a higher message.
resolution, reduce skip factor, or reduce number of DV
constraints for this VOI before proceeding.
8E00 An unknown Sequential Optimization error has occurred. No action required.

Sequential Optimization will be canceled.
8E01 Sequential Optimization cannot proceed due to a CPLEX Contact Accuray Customer
license issue. Support.
8E02 A CPLEX internal error has occurred. Sequential No action required.

Optimization will be canceled.
8E03 An unknown programming error has occurred. Sequential No action required.

8E04 CPLEX could not allocate enough memory to set up the Follow prompts on the
problem. Sequential Optimization will be canceled. Make message.
the dose box smaller, go to Ray-Tracing Low resolution, or
use fewer collimators before retrying the script.
8E05 The optimization problem has numerical convergence Follow prompts on the
conflicts. Sequential Optimization will be canceled. To message.
minimize conflicts, relax constraints on the VOI Limits
dialog box, remove redundant structures on the
Auto-shells dialog box, and increase relaxation values
and/or change the order of the steps on the Steps dialog
box.
8E06 The problem is infeasible as specified. Sequential Follow prompts on the

Optimization will be canceled. Relax conflicting constraints message.
and ensure sufficient beams are available.
8E07 Skip sampling failed. Sequential Optimization will be Follow prompts on the
canceled. Try entering a lower skip factor. message.
8E08 %s Reduction left no usable %s. Sequential Optimization Follow prompts on the
will be canceled. Run the script from the beginning and message.
ensure that the number of %s is not zero after the first
optimization.
8E09 A VOI being used by Sequential Optimization is entirely Follow prompts on the
outside the dose calculation box. Either resize the box to message.
include some portion of the VOI or remove any constraints
and objectives associated with the VOI.
8E0A Importance sampling cannot be performed because a Follow prompts on the

used VOI has no dose. Sequential Optimization will be message.
canceled. Deselect the VOI or change the constraints so
the VOI receives dose.
8E0B There is a VOI that occupies no voxels. Sequential Fix the problem and try again.
8E0C The server's file system is full. This application will exit and Archive some patients.
run Patient Record Archive and Restore. Consider
archiving some patients.
8EFF Incompatible server version. Contact Accuray Customer

Support.
8F00 Cannot load 4D or phantom overlay plans. Load the 4D or phantom

overlay plan using the primary
MP session.
8F01 User ID or Password does not match. Enter valid User ID Fix the problem and try again.
and Password.
8F02 Login failed. Accuray Precision will exit. Contact your system
administrator.
8F03 The number of failed logins exceeded the maximum Contact your system
number allowed. Contact system administrator to administrator.
reactivate your account.
8F04 User account is inactive. Contact your system

administrator.
8F05 Invalid user ID or password. Fix the problem and try again.
8F06 User ID or password does not match. Fix the problem and try again.
8F07 Login unknown error Contact your system

administrator.
8F08 The new password must be different than the old Fix the problem and try again.
password.
8F09 Old password is incorrect. Fix the problem and try again.
8F0A No password change is allowed for system users. Contact your system
administrator.
8F0C You have reached the maximum number of allowed Only four sessions of the
sessions [%s]. Accuray Precision System or
one session of MD Suite is
allowed.
8F0D Secondary sessions are not allowed when commissioned Contact your system
treatment machines are unavailable. administrator.
8F0E You do not have privilege to run Accuray Precision. Contact your system
Accuray Precision will exit. administrator.
8F0F Cannot launch secondary session without logging in to Log in to the primary session.
Accuray Precision. Please log in through the primary
session.
8F11 Autosegmentation failed. See the log file for details. Contact Accuray Customer
Support.
8F12 Autosegmentation cannot proceed because of the Fix the problem and try again.
following problems:
%s
Correct the initialization points prior to attempting
Autosegmentation again.
following issues:
%s
Create the correct number of initialization points prior to
attempting Autosegmentation again.
following issues:
%s
Create the correct number of initialization points prior to
attempting Autosegmentation again.
8F15 Autosegmentation requires that certain structures be Fix the problem and try again.
segmented prior to others. The following structures must
be selected since the structures that are being segmented
require their presence.
%s
8F16 Head and Neck Autosegmentation only supports Head Contour the VOIs manually.
First Supine (HFS) images. This feature is unavailable for
the current plan.
8F18 The %s cannot be modified with the Autosegmentation Fix the problem and try again.
editing tools because it has not been automatically
segmented yet.
8F19 The %s cannot be modified with the Autosegmentation No action required.

editing tools since it has been manually contoured.
8F1A Autosegmentation cannot proceed because of the Fix the problem and try again.
following problems:
%s
Correct the initialization points prior to attempting to
8F1B Autosegmentation cannot proceed because of the Fix the problem and try again.
following problems:
%s
Correct the initialization points prior to attempting to
8F1C Autosegmentation cannot proceed. The following VOIs Fix the problem and try again.
have a plane other than axial selected for contouring:
%s
8F1D One of the contour modifications for the %s extended Fix the problem and try again.
beyond the allowed range of slices.
8F1E Autosegmentation failed due to invalid input for the %s. Fix the problem and try again.
8F1F Autosegmentation cannot proceed due to invalid Fix the problem and try again.
initialization points for the %s.
8F21 Either select a VOI from patient plan and template plan or Perform requested action.
select another initialization method.
8F22 Enter a valid scaling factor. Fix the problem and try again.
It can either be a positive fractional number less than 1 or
an integer between 1 and 100.
8F23 The Synchrony method of the patient plan (%s) differs Fix the problem and try again.
from the template plan (%s).
Therefore the QA plan cannot be created.
Either the Synchrony methods must be the same or the
Synchrony method of the template plan must be Fiducial.
8F24 The VOI name %s is already in use or is restricted. Enter a Fix the problem and try again.
unique name.
8F25 Failed to compute SUV for the PET image series (index = No action required.
%d).
8F26 Select an SUV method. Perform requested action.
8F27 Enter a valid weight in kilograms. Perform requested action.
8F28 Enter a valid height in centimeter. Perform requested action.
8F29 Select Female or Male. Perform requested action.
8F2A Select either Series Date and Time or Acquisition Date Perform requested action.
and Time.
8F2B Enter a valid value for Half Life. Perform requested action.
8F2C Enter a valid value for Total Dose. Perform requested action.
8F2D Enter a valid value for Radiopharmaceutical Start Perform requested action.
Date/Time.
8F2E QuickPlan has attempted to proceed to a task or step that Contact Accuray Customer
is not ready. Support.
Task = %s
Step = %s
8F2F One of the input parameters for dose calculation is invalid. Contact Accuray Customer
The Accuray Precision System will terminate. Support.
See the log file for details.
8F30 The contours of the VOI [%s] extend beyond the boundary Perform requested action.
of the primary CT image. The density override of this VOI
will not be applied to the dose calculation correctly. Refine
the contours of the VOI and make sure all contours are
within the boundary of the primary CT image.
8F31 Exit the following applications prior to exiting Accuray Follow prompts on the
Precision. message.
%s
8F32 This VOI Operation cannot be performed because there Some VOI Operations require
are not enough empty VOIs to use as temporary temporary VOIs. If all VOIs are
placeholders. being used, VOI operations
Delete unwanted VOIs and try the VOI Operation again. cannot be performed.
8F33 Enter Volume in step %s. Follow prompts on the

message.
8F35 A Makeup Plan cannot be created because a machine file Contact Accuray Customer
has changed since the original plan was created that Support.
requires replanning.
8F36 Enter the dose constraint for %s in Dose Constraints table. Follow prompts on the
message.
8F37 Enter the volume constraint for the VOI %s in Dose Follow prompts on the
Constraints table. message.
8F38 %s has more than one maximum dose constraints. A VOI Follow prompts on the
or shell can have at most one maximum dose constraint. message.
8F3E Select at least one structure before starting Follow prompts on the
Autosegmentation. message.
8F3F CT orientation must be head first supine. Follow prompts on the

message.
8F40 Secondary image must be a T1-weighted MR. Follow prompts on the

message.
8F41 Register the primary and secondary images to proceed. Follow prompts on the
message.
8F42 The following VOIs may not be mapped when creating a Follow prompts on the
Lung Optimized Treatment plan: message.
%s
%s
8F43 Autosegmentation initialization failed, contact Accuray Contact Accuray Customer

Customer Support. Support.
8F44 Failed to acquire lock. The record is locked by another

user. Wait for the user to
technical support.

technical support.

technical support.
8F49 Invalid Path Specified. The directory supplied in the

DICOM Export dialog box does
not exist. Create the directory.
8F4C The OHI dose goal value for step %d must be less than or Follow prompts on the
equal to the maximum dose constraint value of its message.
corresponding VOI.
8F4D For VOI [%s], make sure that as the dose value increases Follow prompts on the
the volume value decreases. message.
8F4E A density model with this name already exists. Density Follow prompts on the
model names must be unique. message.
8F4F To log in to the Accuray Precision, the user profile must Follow prompts on the
include either Plan Administration privileges or at least message.
one treatment planning privilege.
8F50 The defined skin VOI (%s) is not valid because %s. Follow prompts on the
message.
8F52 A different Accuray Precision workstation has this shared The record is locked by another
data file locked. user. Wait for the user to
%s release the lock or contact your
technical support.
8F53 Accuray Precision was unable to acquire a lock on a The record is locked by another
shared data file. user. Wait for the user to
%s release the lock or contact your
technical support.
8F55 Accuray Precision was unable to update a shared data file Retry your request. If the
on the server. problem persists, contact your
%s System Administrator for
technical support.
8F56 The server reported an unexpected error. Contact Accuray Customer

%s Support.
8F57 An error occurred while Accuray Precision was releasing Confirm that changes were
the lock on a shared data file. saved.
8F58 Accuray Precision was unable to delete a shared file. The record is locked by another
technical support.
8F59 Accuray Precision was unable to get the current list of Contact Accuray Customer
shared files. Support.
%s
8F5A The DCE map data is not for prostate anatomy. The data No action required.
will not be loaded into the system.
8F5B The plan cannot be used to create a Lung Optimized Follow prompts on the
Treatment Plan at this time. Click OK to return to the message.
Home Page. Detailed error %s
8F5D Prostate Autosegmentation failed to generate contours Modify the initialization points
using the current set of initialization points. as necessary and retry your
request.
8F5E Select at least one uncalculated field size before starting Follow prompts on the
MC TPR and OCR calculation. message.
8F5F The isodoses, DVH, and dose statistics are currently Follow prompts on the
based on the raw Monte Carlo dose distribution. Switch to message.
Smoothed distribution to enable Save and Print
operations.
8F60 The position is invalid because it would cause the modified Follow prompts on the
leaf to overlap the opposing leaf. message.
8F61 Autosegmentation could not proceed because of the Follow prompts on the
following issues: message.
%s
8F62 Isocentric Conformal targeting cannot be used for the Use conformal avoidance
following target VOI(s) since there are no available nodes targeting.
which can be shaped around the target:
%s
8F63 The following VOIs were not created during brain Manually segment VOIs if
autosegmentation: desired.
%s
8F64 Failed to apply the plan template since the assigned Fix the problem and try again.
sequential script does not match the template's collimator
type. Use Planning Settings to assign an appropriate
sequential script to the plan template.
8F65 Autosegmentation cannot be started because a GPU Follow prompts on the

resource is not available. Try again later. message.
8F66 Accuray Precision has gotten into a state where VOI [%s] Follow prompts on the
has DV constraints defined. To make sure all DV message.
constraints are removed, delete all constraints defined for
this VOI and redefine them again.
8F68 An error occurred during optimization. Contact Accuray Customer

%s Support.
8F69 An error occurred during calculation of final dose. Contact Accuray Customer
%s Support.
8F70 An unspecified error has occurred. Contact Accuray Customer

%s Support.
8F71 The following structure(s) failed to be automatically No action required.

segmented:
%s
8F72 Male Pelvis Autosegmentation only supports Head First Use supported images.
Supine (HFS) and Feet First Supine (FFS) images. This
feature is unavailable for the current plan.
8F73 Angle %s can only be defined once. Perform requested action.

Remove or update angles that are not unique and then
apply.
8F74 There must be at least two beam angles. Add beam angles until you
have two or more.
8F75 An error occurred while calculating field dose. Contact Accuray Customer
%s Support.
8F76 An error occurred while calculating beam dose. Contact Accuray Customer
%s Support.
8F77 A secondary T1-weighted MR image is required. Create a new plan with one MR
image.
8F79 The following VOI are targeted by too few angles: %s Target each VOI with at least
two beam angles.
8F80 The following beam angles have no VOI targeted: %s Target each VOI with at least
two beam angles.
8F81 Too few beam angles requested for some VOI Target each VOI with at least
two beam angles.
8F82 No beam angle has a target VOI Target each VOI with at least
two beam angles.
8F83 Too many beam angles are blocked for a VOI Target each VOI with at least
two beam angles.
8F84 Initial delivery plan validation failed Contact Accuray Customer

Support.
8F85 No leaf open in initial delivery plan. Contact Accuray Customer

Support.
8F86 Treatment Machine "%s" is not compatible with the current Follow prompts on the
plan settings. If this treatment machine is applied, message.
planning inputs such as the machine setup, and outputs,
such as dose and statistics will be discarded. Do you want
to continue?
[Yes]: Apply treatment machine and discard planning
outputs
plan.
8F87 The plan cannot be saved since the selected treatment No action can enable saving
machine has been retired. the plan on a retired treatment
machine.
8F88 The plan cannot be saved since the density model Choose a new density model.
contains a HU higher than the maximum allowed value
(4095).
are:
%s
%s
8F91 An error occurred during calculation. Contact Accuray Customer

%s Support.
8F92 The resulting VOI has no contours. Adjust autosegmentation

parameters and try again.
8F93 Dose curve too complex for VOI representation. Contact Accuray Customer
Support.
8F95 Failed to initialize iDMS license. See log file for details. Contact Accuray Customer
Support.
8F96 Failed to retrieve data associated with this workstation on Contact Accuray Customer
server: %s. Contact Accuray Customer Support to ensure Support.
this workstation is registered to the server. The application
will exit.
8F97 This license entry is missing. Ensure the license is Contact Accuray Customer
regenerated after this workstation was registered, updated Support.
in the license editor, and that the resulting license file is
reimported using the Server Administration.
8F98 This workstation requires a license. Contact Accuray Contact Accuray Customer
Customer Support to enable the license for this Support.
workstation. The application will exit.
8F99 This workstation is not configured properly. Contact Contact Accuray Customer
8F9B This workstation is configured to run as a single Accuray Contact Accuray Customer
Precision instance; however, a multiple session license is Support.
enabled.
8F9C This workstation is configured to run as MD Suite; Contact Accuray Customer

however, the license is disabled. Support.
8F9D This workstation is configured to run Accuray Precision Contact Accuray Customer
with multiple sessions; however, the MD Suite license is Support.
enabled.
8F9E This workstation is configured to run Accuray Precision Contact Accuray Customer
with multiple sessions; however, the Multi-Session license Support.
is disabled.
8F9F Failed to open main log file for writing: %s Contact Accuray Customer
Contact Accuray Customer Support for assistance. The Support.
application will exit.
8FA0 Dose calculation failed. Contact Accuray Customer

Support.
8FA1 Image capture failed. Contact Accuray Customer

Support.
8FA2 There were errors uploading sinogram and/or DRR Contact Accuray Customer
images for the report. Some sinograms and/or DRRs may Support.
be missing from the report. Do you wish to continue
printing the report?
8FA3 The VOI name must have between 1 and 64 characters. Fix the VOI name.
The specified name has %s characters.
8FA4 Updating the plan failed because treatment machine %s is Contact Accuray Customer
not properly configured. Contact Accuray Customer Support.
Support. The plan will be loaded as is.
8FA5 Treatment machine %s is not properly configured. Contact Contact Accuray Customer
8FA6 Unable to save the plan as deliverable. The plan has %s Change the number of beam
beam angles but treatment machine %s only supports %s angles to comply.
beam angles.
8FA7 The selected exam was resampled during import and No action required.
cannot be used for CyberKnife plans.
8FA8 The density-corrected images are not valid for dose Perform requested action.
calculation. Review the density model and density
overrides, then try again.
8FA9 Define a consistent prescription VOI before saving. Perform requested action.
8FAA The following VOI were unchanged by their specified Perform requested action.
density overrides and must be changed: %s
8FAB Group %s invalid Check the settings on the dose

group.
8FAC Invalid contour edits on complex structure. Edits would No action required.
lead to disconnected structure.
8FAE At least one group must be used for normalization. Choose a dose group for
normalization.
8FAF ICD selection application (TreatmentSiteHelperTool) is not Contact Accuray Customer

installed. Support.
8FB0 Unable to approve the plan because it is no longer Recalculate final dose and try
consistent with the current treatment machine data. again.
8FB2 Authentication failed: invalid user ID/password Supply the correct credentials.
8FB3 Authentication failed: insufficient privileges Supply the correct credentials.
8FB4 Failed to approve plan '%s' for treatment machine %s. Contact Accuray Customer
Support.
8FB5 PreciseART® enrollment failed for plan '%s'. PreciseART® Contact Accuray Customer
enrollment can be changed later in Plan Administration. Support.
8FB6 Plan Transfer Canceled: %s No action required.
8FB7 Plan Transfer Summary: %s No action required.
8FB8 Approve Transferred Plans Summary: %s No action required.
8FB9 Suspend Transferred Plans Summary: %s No action required.
8FC1 Failed to import script [%s] : %s Contact Accuray Customer

Support.
8FC2 Failed to export script [%s] : %s Contact Accuray Customer

Support.
8FC3 Cannot compute dose because the Rx Dose Group dose Adjust the prescription dose
objective cannot be reached. group and recompute dose.
8FC4 The following previous treatment items do not match the Perform requested action.
patient position of the new treatment data:%s
Select retreatment data with matching patient positions to
continue.
8FC5 Cannot include the same CT series in both the previous No action required.
and new treatment data or multiple times in previous
treatment data.
8FC6 Failed to import template [%s] Contact Accuray Customer

Support.
8FC7 Failed to export template [%s] Contact Accuray Customer

Support.
8FC8 The RTSS and/or RTDose files selected are not valid for Perform requested action.
use in PreciseRTX® planning. Select different RTSS and
RTDose files to proceed.
8FC9 Cannot sum plans because there is no overlap between Make sure the plans being
dose calculation boxes. summed have some overlap
between the dose calculation
boxes.
8FCA iDMS administration workstation is not properly installed, Contact Accuray Customer
contact Accuray Customer Support for assistance. Support.
8FCB A computation GPU is required to continue. Contact Contact Accuray Customer

8FCC Treatment machine [%s] is an invalid CK Record. Needs Recommission the CyberKnife
to be recommissioned. machine.
8FCD Autosegmentation failed due to empty secondary image. Make sure the secondary
image contains valid image
data.
8FCE Cannot generate Tracking Tumor contour projections: The Contact Accuray Customer
selected Tracking Tumor structure is not visible in both A Support.
& B Xsight cameras.
8FCF Cannot generate ITTV contour projections: The ITTV Contact Accuray Customer
structure is not visible in both A & B Xsight cameras. Support.
8FD0 The Synchrony method of the template plan (%s) is not Choose a different tracking
supported for QA plans. method.
The QA plan cannot be created.
8FD1 The plan cannot be saved as deliverable. A 1 View plan Contact Accuray Customer
based on a Simulation plan must have an ITTV contour. Support.
8FD2 An error occurred while loading the script. Would you like Contact Accuray Customer
to delete the script? Support.
8FD3 An unexpected VOLO optimizer error has occurred. Contact Accuray Customer
Please re-try the operation, or contact customer support Support.
for assistance.
8FD4 There is not enough GPU memory to perform the VOLO Lower the sampling resolution
optimization. especially on large VOIs, or
reduce the number of nodes in
order to decrease the amount
of memory.
8FD5 An exception occurred while performing VOLO Contact Accuray Customer

optimization. Support.
8FD6 An error was detected in the plan setup. Details are as Change the plan settings
follows: based on the details provided,
%s and try again.
8FD9 Installation integrity has been compromised. Please Contact Accuray Customer
contact Accuray for support. Support.
 Table 5
A001 The following VOIs have valid density overrides. Confirm or return to previous
%s task.
Any modification will cause the existing dose volumes to be

deleted.
A002 There have been changes made to the density overrides. Confirm or return to previous
This will require that the dose volumes be deleted. Do you task.
want to keep these density overrides and delete the current
dose volumes?
A003 The plan was generated based on a sample sequential Confirm or return to previous
optimization script. Do you want to save this plan as task.
deliverable?
A006 Inconsistent files in the plan '%s' for a patient '%s'. Please No action required.
go back to a patient plan to resolve it before this QA plan
creation.
A007 No Computed SUV is loaded for the PET image series (ID No action required.
= %s).
A008 The following VOI(s) have contours. Autosegmentation will Follow prompts on the
replace the existing contours with automatically generated message.
contours. Do you want to continue?
%s
A00A Do you want to overwrite the SUV parameters? Follow prompts on the
message.
A00B The loaded PET series(B=%d) is a derived or reformatted No action required.

image which could result in an incorrect SUV calculation.
A00C ‘Outside All VOIs’ has a valid density override. Modifying Follow prompts on the
any VOI will cause existing does volumes to be deleted. message.
A00D The selected density model does not contain the currently The system requires that the
defined density override values. The current set of density user defined density value is
overrides are being reset. included in the current density
model. When changing density
models, this relationship is
confirmed and if it is not valid,
the density overrides will be
removed, and will have to be
manually added again.
A00E VOI [%s] does not allow beams to pass through it. Follow prompts on the
Modifying this VOI will remove the current dose calculation message.
and turn off beams that pass through it.
A00F There are pending edits to the %s that will be discarded. Follow prompts on the
A010 This RT Structure Set was not created from this CT image. Follow prompts on the
An RT Structure Set for the primary CT has not been message.
loaded.
A013 Brain Autosegmentation requires a T1-weighted MR to Follow prompts on the

correctly delineate selected intracranial structures. Confirm message.
that the MR is T1-weighted before proceeding.
A014 The selected MRI image has associated DCE map data. Follow prompts on the
Load the associated DCE map data? message.
A015 The selected VOI (%s) has been identified as the Skin VOI. Follow prompts on the
If changes to the Skin VOI are made, existing dose message.
volumes will be deleted and may cause beams to be turned
off.
A017 The PERM Cap value was not found in the DCE map data. Follow prompts on the
Is this DCE map data for prostate anatomy? message.
[Yes]: Load the DCE map data.
[No]: The data is for a different anatomy and will not be
loaded.
A018 Changing the dose calculation algorithm from Monte Carlo Follow prompts on the
to Ray-Tracing will result in deleting the Monte Carlo dose message.
volume and displaying the Ray-Tracing dose grid. Would
you like to proceed?
[Yes]: Delete the dose volume and display the dose grid.
[No]: Keep the current dose volume and change the
algorithm selection back to Monte Carlo.
A019 Changing the registration will undo the nominal position Follow prompts on the
operation previously performed. Do you want to continue? message.
A01C Do you want to restore the isocentric conformal beams that Follow prompts on the
were deleted during beam reduction? message.
A01D Do you want to delete the beams generated on this step Follow prompts on the
and restore the previous isocentric conformal beam set? message.
A01E Changing the dose calculation algorithm from Monte Carlo Follow prompts on the
to FSPB will result in deleting the Monte Carlo dose volume message.
and displaying the FSPB dose grid. Would you like to
proceed?
[Yes]: Delete the dose volume and display the dose grid.
[No]: Keep the current dose volume and change the
algorithm selection back to Monte Carlo.
A01F The selected script will change one of the following fields: Follow prompts on the
%s message.
A020 The following template settings were not applied because No action required.
they are not compatible with the selected treatment
machine <%s>:
%s
A021 The inconsistent plan being loaded uses an out-of-date No action required.
treatment machine revision.
[%s]: The plan will not be deliverable for treatment unless it
is later updated and recalculated.
[%s]: The plan will be updated to use the latest treatment
machine revision. All dose information will be discarded
and must be recalculated.
Alternatively, if the plan is Approved or Under Treatment,
you can cancel this operation and Self Transfer the plan
instead.
A022 Deleting the plan will delete all QA plans (%s) associated Perform requested action.
with it. Do you want to delete the plan and all of its QA
plans?
A023 Deleting this plan will delete all transferred plans (%s) Perform requested action.
associated with it. Do you want to delete this plan?
A024 Cannot delete treated plan with status: %s No action required.
A025 %s Perform requested action.

This operation is estimated to need %s of GPU memory.
The current amount of free GPU memory is %s out of %s
total.
%s Do you want to continue?
A026 The VOIs listed below are partially or completely outside of Perform requested action.
the CT volume. Dose to the VOI volume outside of the CT
is not included within the VOI's DVH.
%s
Do you want to save this plan as deliverable?
A027 Inspect the secondary image when performing Brain Perform requested action.
Autosegmentation on a deformed secondary image.
A028 The script named '%s' referenced by this template has No action required.
been deleted and cannot be applied.
A029 VOI '%s' is not a valid Skin VOI because %s. This VOI is No action required.
now classified as an ordinary critical structure.
A02A Setting a skin VOI will delete dose volumes and cause Perform requested action.
beams to be turned off. Do you want to continue?
A02B Changing the skin VOI designation may delete dose Follow prompts on the
volumes and cause beams to be turned off. Do you want to message.
continue?
A02C The selected secondary dataset appears to use a Create a new plan with the
T2-weighted MR sequence. Brain Autosegmentation only appropriate MR image.
supports T1-weighted MR sequences.
A02D A new auto-shell cannot be created as no empty critical Delete a critical VOI.
VOI is available.
A02E The inconsistent QA Plan being loaded uses an out-of-date Follow prompts on the
treatment machine revision. Consider re-creating the QA message.
Plan.
[OK]: Load the plan as-is in read-only mode.
[Cancel]: Cancel the load.
A02F Changing the dose calculation box will delete all current Perform requested action.
calculated dose volumes. Do you want to continue?
A030 A Helical Delivery Mode cannot be used for Forward Perform requested action.
Planning. Consider changing the Delivery Mode to Direct
first.
A031 A Helical Delivery Mode cannot be used for Forward Perform requested action.
Planning. Consider changing the Plan Mode first.
A032 The dose extents of the Active and Reference plans do not No action required.
match. The dose difference will only be calculated within
the regions where they overlap.
A033 Deleting this plan will delete the associated transferred Follow prompts on the
plans (%s) and their associated QA plans (%s). Do you message.
want to delete this plan?
A034 Approximate Dose is out of date or unavailable. Perform requested action.

Re-Calculate Approximate Dose first.
A035 At least 95% of potential beams are targeted at a VOI that Follow prompts on the
is a significant distance from the Align Center causing message.
some beams to be unavailable for optimization. If it is
possible to change the Align Center to reduce this
separation, more potential beams will be available.
Do you want to proceed with the calculation?
A036 Changing the dose algorithm will cause the existing dose to Follow prompts on the
be deleted. Do you want to continue? message.
A037 The current density model contains density override No action required.
values, and if you change the density model now they will
be discarded.
Do you wish to continue?
A038 The following VOIs have valid density overrides. Follow prompts on the
%s message.
Any modification will cause the density overrides to be

deleted along with the existing dose volumes. Do you wish
to continue?
A039 Edit could not be performed because of VOI complexity. Use the “Prune Contours”
Consider using the Prune Contours option and then trying option to simplify the VOI. Then
your edit again. try your edit again.
A03A Any changes to the MVCT density model will not take effect No action required.
until the Treatment Delivery Console is restarted.
A03B There have been changes made to the density overrides. Follow prompts on the
This will delete the dose volumes and require the plan to be message.
reoptimized. Do you wish to continue?
A03C This changes %s from a Target to a Critical structure. No action required.
A03D The structure %s will no longer be the designated Skin. No action required.
A03E The VOI '%s' contains cavities and is designated as Skin. Make selection as indicated in
Cavities are undesirable in Skin because they may message.
suppress the display of isodose lines when clipping to skin
is set.
[Yes] Change to Critical (recommended)
[No] Leave as Skin (isodoses may clipped in some
slices/regions).
A03F The structure %s is designated as Spine Tracking and No action required.

cannot be a Target or the designated Skin.
A040 The structure %s is designated as Ball-cube and cannot No action required.

also be designated as Skin.
BFD7 Optimization cannot proceed. No valid beams or segments Check the settings that may
were found. Please verify the inputs and try again. affect targeting, such as
blocking settings on VOIs.
C000 Enter a patient setup time in minutes that is greater than 0. Fix the problem and try again.
C001 Enter an image time interval in seconds that is greater than Fix the problem and try again.
0.
C002 The estimated time [%s] of the current plan is less than the No action required.
minimum allowed time [%s] for a treatment plan.
C006 Changes to the leaf position will result in beams Follow prompts on the
intersecting VOIs which disallow intersection. Select OK to message.
reset the leaf to the previous position.
C007 Collimators listed below have calculated TPR and OCR Follow prompts on the
tables. message.
%s
Do you want to undo calculations?
[Yes]: Delete previously calculated TPR and OCR tables
for collimators listed above
[No]: Retain previously calculated TPR and OCR tables.
C008 The leaf transmission value has changed. Existing TPR, Perform requested action.
OCR and OF calculations will be invalidated. Would you
like to proceed?
C011 Password complexity insufficient. Fix the problem and try again.
%s
C016 Password has been recently used. No action required.
C018 A QA plan cannot be created for the selected patient plan Choose a different template
because the patient plan and treatment machine are not plan with a compatible
compatible. treatment machine.
C019 The highlighted solution is already the current node and No action required.
beam set for the plan.
C020 VOI name is invalid. Choose a valid VOI name.
C021 VOI with contours will be deleted. No action required. This action
will delete the VOIs.
C022 Failed to create Add Fraction Plan. Contact Accuray Customer

Support.
C023 Failed to approve Add Fraction Plan. Contact Accuray Customer

Support.
C024 Plan Name in use - must be unique. Choose another plan name.
C025 Add Fraction Plan Failed. See Summary for results. Contact Accuray Customer
Support.
C026 The selected VOI is required for planning and cannot be No action required.
deleted.
C027 One or more plans being transferred is an add fraction Take note that the transferred
plan. When an add fraction plan is transferred to a machine plans may have different
not initially included with the add fraction plan, the machine delivery instructions.
transferred plan for this particular machine will not have the
same per fraction delivery instructions as the add fraction's
original plan. The transferred plan for this particular
machine may require QA testing. Proceed to transfer
plan(s)?%s
C030 Confirm that the motion compensation image angles Carefully review the selected
selected for final dose calculation for this plan are imaging angles, and follow
appropriate. If the image angles selected are not prompts on the message.
appropriate, motion compensation may not be
accurate.Are the selected imaging angles appropriate?
C031 A GPU hardware failure (Uncorrected ECC error) has been Reboot the workstations and try
detected. Please reboot the workstations and try again. If again. If this error persists
this error persists contact Accuray Support. The contact Accuray Customer
application will exit. Support.
C032 The system's automatically selected imaging angles do not Manually select imaging angles
pass validation. The following errors were found: for treatment.
%s
C033 The system was unable to automatically select the Try the following:
specified number of valid angles.Try moving the isocenter, • Move the isocenter.
using fewer imaging angles, and ensuring that
• Use Fewer imaging angles.
fiducials/VOI are visible on the DRR.
• Make sure that
fiducials/VOIs are visible on
each DRR.
If the automatic selection of
imaging angles continues to
fail, manually select imaging
angles.
C035 The 4D Planning feature is no longer supported. No action required.

A Makeup Plan cannot be created for a plan with 4D
planning data.
C036 The 4D Planning feature is no longer supported. No action required.

The plan will be loaded in evaluation mode.
C037 The plan contains an invalid PET image and will be loaded No action required.
read only.
C038 Must select at least two imaging angles. Select at least two imaging
angles.
C039 Each pair of imaging angles must be at least %s apart from Follow prompts on the
its neighbor. The rule is violated by angles %s and %s. message.
C042 The designated primary series may not produce reliable Follow prompts on the
density values for dose calculation. message.
Click "OK" to continue with the currently-selected primary
series, or "Cancel" to designate another primary series for
the plan.
C00A The VOI capture operation resulted in no new shapes. This No action required.
could be because the selected VOI is completed occluded
by VOIs with higher display priorities.
C00B Enter summation notes using only ASCII characters. Perform requested action.
C00C An error occurred during validation. Perform requested action.

%s
Would you like to continue?
C00D The following template(s) are referencing the following Perform requested action.
script:
%s
Do you want to delete the script?
C00E The PreciseART® client software is not configured Contact Accuray Customer
correctly. Please contact Accuray Customer Support. Support.
C00F This action will cause the dose volumes to be deleted. Do Follow prompts on the
you want to proceed? message.
C01A A Simulation Plan cannot be created since the default Correct the density model.
density model contains a HU higher than the maximum
allowed value (4095).
are:
%s
%s
C01B A Simulation Plan cannot be created since the default Correct the density model.
density model has no relative electron densities defined.
C02A The following errors occurred when validating tracking Review the list of errors
parameters.%s reported, and correct them to
continue.
C02D Current machine is not licensed for Synchrony method %s Obtain a license from Accuray
used in the script. Incorporated for that tracking
method or modify this script to
exclude that tracking method.
C02E Not all the scripts values could be applied to the plan:%s Review the list of script values
and decide if the plan is
acceptable.
C03A The plan contained invalid auto-shell VOIs, which have Follow prompts on the
been deleted. Please reevaluate auto-shells and message.
associated optimization parameters.
C03B None of the selected previous treatment data contains a Follow prompts on the
dose. Do you want to continue? message.
C03D The selected script cannot be loaded because it has no Select a script with Synchrony
Synchrony Method. The current plan is a Tomo Simulation Method or go back to Setup >
Plan and requires a Synchrony Method. Machine step and uncheck the
Simulation Plan check box.
C03E %s Version %s is currently installed. Please install the Contact Accuray Customer
correct driver version before running Precision. Support.
C03F CT image cannot be used for optimization. Image extends Choose an alignment point
beyond SAD. where the image does not
extend beyond SAD.
Appendix B
Glossary
Acronyms and Definitions . . . . . . . . . . . . . . . . . . . . . . . . 812
1072963-ENG B A pp en di x B : G l o s s ar y 811
Acronyms and Definitions
This section provides definitions of acronyms and terms used throughout the
manual.
 Table
Term Definitions
3DCRT 3D Conformal Radiotherapy
3DRA 3D Rotational Angiography
AE Title Application Entity Title
AQA Automated Quality Assurance
ASCII American Standard Code for Information Interchange
BDI Beam Data Import, also Beam Delivery Instruction
BEV Beams Eye View
CCCS Collapsed Cone Convolution Superposition
CCF Collimator Correction Factor
CF Correction Factor
cGy Centigray
nCI New Conformality Index
CI Conformality Index
COLLIM Collimator
CT Computed Tomography
CTV Clinical Target Volume
DCE Dynamic Contrast Enhanced
DCE-MRI Dynamic Contrast Enhanced - Magnetic Resonance

Imaging
deg Degree
Term Definitions
DICOM Digital Imaging and Communications in Medicine
DRR Digitally Reconstructed Radiograph
DTA Distance to Agreement
DVF Deformable Vector Field
DVH Dose Volume Histogram
DVL Dose Volume Lower Limit
DVU Dose Volume Upper Limit
Dx Minimum dose received by the hottest sub volume x
ECF Energy Correction Factor
FFP Feet First Prone
FFS Feet First Supine
FMO Fluence Map Optimization
FOV Field of View
FSPB Finite Size Pencil Beam
FWHM Full Width at Half Maximum
FWQM Full Width at Quarter Maximum
GPU Graphics Processing Unit
GTV Gross Tumor Volume
Gy Gray
HFP Head First Prone
HFS Head First Supine
HIS Hospital Information System
HU Hounsfield unit
ICD International Classification of Disease
ICD-10-CM International Classification of Diseases, Tenth Revision,

Clinical Modification
Term Definitions
ICD9 International Classification of Diseases, Ninth Revision
iDMS Integrated Data Management System
IEC International Electrotechnical Commission
IMRT Intensity Modulated Radiotherapy
ISO International Organization for Standardization
ITTV Internal Target Tracking Volume
ITV Internal Target Volume
kV Kilovolt
kVCT Kilovoltage Computed Tomography
LINAC Linear Accelerator
LOT Lung Optimized Treatment or Leaf Open Time
LVL Level
MC Monte Carlo
MeV Megaelectron Volts
MIM MIM software
MITA Medicaid Imaging & Technology Alliance or Medicaid

Information Technology Architecture
MLC Multileaf Collimator
MRI Magnetic Resonance Imaging
MU Monitor Unit
MV Megavoltage
MVCT Magavoltage Computed Tomography
NTO Normal Tissue Objective
OAR 1. Off-axis ratio

2. Organ At-Risk
OCI Optimize Conformality Index
Term Definitions
OCO Optimize Coverage
OCR Off Center Ratio
OF Output Factor
OHI Optimize Homogeneity Index
OIS Oncology Information System
OMA Optimize Maximum
OME Optimize Mean
OMI Optimize Minimum Dose
OMU Optimize Monitor Units
P. Probability
PDD Percent Depth Dose
PDP Proximity Detection Program or Planned Dose

Perturbation
PDU Power Distribution Unit
PET image Positron Emission Tomography image
PHM Phantom
POS/ANT Posterior/Anterior
PTV Planning Target Volume
QA Quality Assurance
Radixact® Radixact® Treatment Delivery System
RGT/LFT Right/Left
ROI Region Of Interest
RT Radiation Therapy
RT Dose Radiation Therapy Dose
RTDOSE Radiation Therapy Dose
RTSS Radiation Therapy Structure Set
Term Definitions
RTSSET Radiation Therapy Structure Set
SAD Source to Axis Distance
SBRT Stereotactic Body Radiation Therapy
SDD Source to Detector Distance
SFOV Scan Field Of View
SID Source to Isocenter Distance
SSD Source to Surface Distance
SUP/INF Superior/Inferior
SUV Standardized Uptake Value
TPR Tissue Phantom Ratio
UPS Uninterruptible Power Supply
VOI Volume Of Interest
VOLO Accuray Optimizer
Vx Volume of sub volume receiving ≥ dose x
XA X-ray Angiography
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Treatment Planning

Accuray Precision® Treatment Planning System

Treatment Planning Manual

1072963-ENG B Ac cur a y Pr ec isio n® T r ea tm en t P l an nin g S yste m i

1072963-ENG B Ac cur a y Pr ec isio n® T r ea tm en t P l an nin g S yste m i ii

Hardware and Software Maintenance

Use of Third-Party Software

Instructions for Use of the Accuray System

Prescription Device Statement

1072963-ENG B Ac cur a y Pr ec isio n® T r ea tm en t P l an nin g S yste m v

Chapter 2 Treatment Planning

Chapter 3 Commissioning Tools (CyberKnife Only)

Section 3-1 Commissioning Requirements and Reports

Section 3-2 Fixed and Iris Collimator Commissioning

Section 3-3 Multileaf Collimator Commissioning

Section 4-1 QA Plans for Tomo®

Section 4-2 QA Plans for CyberKnife

Chapter 5 Fuse Task

Chapter 7 Setup Task

Section 7-1 Setup Task for Tomo®

Section 7-2 Setup Task for CyberKnife

Chapter 8 Plan Task

Section 8-1 Plan Task for Tomo®

Section 8-2 Plan Task for CyberKnife

Chapter 9 Evaluate Task

Section 9-1 Evaluate Task for Tomo®

Section 9-2 Evaluate Task for CyberKnife

Chapter 10 Utilities Task

Chapter 11 Settings Task

Chapter 13 Synchrony® Lung Tracking™ with Respiratory

Chapter 14 Lung Optimized Treatment (CyberKnife Option)

Chapter 15 PreciseART® and PreciseRTX® (Option)

Appendix A Warnings, Errors, and Messages

WARNING: Treatment plans must be created, approved, and performed by trained

WARNING: Do not attempt to modify a treatment file manually. Improperly changed

CAUTION: Do not modify the Accuray Precision® Treatment Planning System

 Indications for Use

 Requisite Hardware and Software

iDMS Data Management System is an essential component of Accuray

 Undesirable Side Effects

 Accuray Precision System Workstation Specification

NOTE: Accuray Precision System continues to support M5000/M4000 or

CPU Intel Xeon E5-2620v3 (x 2)

Graphic Card RTX4000

Storage 240 GB SATA RAIDI SSD (x 2)

Operating Microsoft Windows 10

 Workstation Storage and Handling

Model Reference Number

Related Power Input

European Authorized Representative

Follow Instructions For Use

Data Matrix Barcode

IEC 62083:2009 Medical electrical equipment requirements for the

IEC 62304:2006/A1:2015 Medical device software – Software life cycle

IEC Part 1: application of usability engineering to

ISO/IEC 25051:2014 Systems and software Quality Requirements and

YY 0832.1-2011 Stereotactic and planning system for radiotherapy

YY0832.2-2015 Stereotactic and planning system for radiotherapy

 Use of Unapproved Equipment

Information related to ongoing threats/vulnerability assessment and

Accuray is committed to providing you with innovative technology that

 Virus Protection Software, Network, and Firewall

For more information about the CyberKnife System network environment

IMPORTANT: No other anti-virus software is supported.