Monaco TPS

Advanced Workshop

Istanbul, November 2019

Dr. Dirk Wolff
Dr. Dirk Wolff – A little about me
2000 – 2004: Studies of Clinical Engineering

2003 - 2009: Universital Hospital Mannheim

• Diploma Thesis (Dipl.-Ing)
• Master of science in medical physics (M.Sc.)
• Dissertation (Dr. sc. hum.)

2009 -2014: University Hospital Gießen

Since 2014: Application Specialist at Elekta (Monaco, ABAS, Oncentra, AQUA)

2 | Focus where it matters

Agenda
Monaco Advanced Workshop

1. Introduction to Monaco 3. Hands-on learning from

treatment planning template-based planning
strategies and advanced use of
Multicriterial Optimization
2. Monaco concepts & tips and
tricks

3 | Focus where it matters

Monaco TPS
Intro and Concepts for Treatment Planning

Dr. Dirk Wolff

Application Specialist, Team DACH
Monaco evolution

Monaco 5.4/5.5
Monaco 1.0 Monaco 3.0–3.3 Monaco 5.10 PlanScorecards,
IMRT SSO for DCAT Advanced 3D MRI Frozen Dose DeformableI image
Monte Carlo 4D Specialty Template Registration, Registration
First TPS with FFF Support Object
Monte Carlo Recalculation Images Sharing
Locate 2 with Angio

Present
day

2007 2010 2011 2013 2015 2016 2017 2019

Monaco 5.3: Automation Toolkit,

Monaco 2.03–2.04 Monaco 5.0 Monaco 5.11
Carbon Ion Automated
VMAT Basic 3D 4D Tools Planning Speed Improvements Planning, Adaptive
Supports Elekta SRS Cones SSO for dMLC Up to 4x faster Workflow
VMAT Delivery New GUI Siemens mARC

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matters
Monaco 5.11

Accuracy Speed Flexibility

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matters
 Z840 28C workstation
Monaco 5.11 vs. 5.10.02 speed comparisons on Z840 28 core workstation

0:50:24

0:43:12

0:36:00

Monaco 5.10.02 0:28:48

on Z840 (hh:mm:ss)
0:21:36

0:14:24

Monaco 5.11
0:07:12
on Z840 28c (hh:mm:ss)
0:00:00
S&S S&S S&S S&S
dMLC IMRT VMAT dMLC IMRT VMAT dMLC IMRT VMAT dMLC IMRT VMAT
LPTMON171212

Head & Neck Prostate 1 Prostate 2 Lung / Esophagus

0:18:53 0:14:53 0:27:38 0:17:47 0:10:19 0:28:21 0:12:40 0:14:25 0:19:53 0:46:10 0:31:39 0:26:22

0:05:55 0:04:33 0:08:24 0:04:47 0:03:35 0:10:19 0:04:36 0:04:51 0:05:07 0:10:48 0:07:30 0:09:03

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matters
 Dynamic SRS/SBRT: the Elekta solution

Monaco Software Features

Monte Carlo Algorithm

Smart Sequencing

Virtual Leaf Width

LPTMON171212

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matters
Monaco’s unique features for dynamic delivery

Dynamically position jaws inside the MLC

leaves during delivery to effectively reduce
Smart sequencer provides high modulation when
leaf width. (Virtual Leaf Width)
needed and fast delivery when less modulation is
required, Versa HD is built to deliver these plans
in high dose rate mode (FFF).

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matters
 Virtual leaf width
Take a closer look: Jaw tracking

Versa HD can move the dynamic jaws

from segment to segment

The MLCs and the jaws can be

placed in 1 mm increments

For small fields this mimics the

effects of smaller MLC leaves
LPTMON171212

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Monaco Monte Carlo algorithm

Source of truth
Continuous arc calculation
vs.
Discrete gantry positions Arc calculation from Continuous Monte Carlo
static gantry positions arc calculation

Ideal for…
Small fields, high doses and anatomy with
varying densities (SRS/SBRT)

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Multicriterial Optimization (MCO)
Achieve the best plan with MCO

• Automatically achieve
better normal tissue
sparing without
sacrificing target
coverage

• Select OAR’s for MCO

• Choose the best plan

possible!
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Automation with templates

1 3
2
SBRT Lung
5 Mouse clicks
2m 42s

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Monaco Concepts
Tips & Tricks
Monaco Concepts
Constrained Optimization

OAR PTV

Compromise

OAR

PTV

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Monaco Concepts
Constrained Optimization

OAR PTV

OAR

PTV

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Monaco Concepts
Constrained Optimization
• Constrained Optimization is logical way to plan.
• Monaco shows where conflicts are and
highlight which cost functions are affecting the
dose to targets.
• There is no guess work in what to change to
achieve the target objective.
• This is a more structured approach to planning
and leads to less iterations.

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Monaco Concepts
Constrained Optimization
1st Order Constraints
• Goal will always be met.
• Serial, Parallel, Quadratic Overdose, Max Dose
2nd Order Constraints
• Goal will be met UNLESS there is a 1st Order constraint.
• Quadratic Under Dose, Under Dose DVH

1st Order Objective

• Goal will be met unless a 1st or 2nd Order Constraints prevents this.
• Target EUD, Target Penalty
2nd Order Objective
• Goal will be met or succeeded unless Constraints prevent and UNLESS 1st order
objectives are not met.
• Cost functions that have “Multi Criterial” option

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 DS: Voxel based tools
Monaco tells you which voxels are impacted

CF Occupancy Variation Relax Response CF Sensitivity

Voxels used by the Voxels most impacted by Voxels impacted when Target’s Voxels impacted
constraint the constraint relaxing the constraint by the constraint

Monaco Unique Feature, not only DVH and dose based assessment, but also Spatial information
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Biological Optimization
The Power Law Exponent - The K Value

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Biological Optimization
The Serial K values range from 1 to 20

A K value of 1 will apply

itself evenly across the
whole curve giving you a
mean dose effect

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Biological Optimization
Serial K A K value of 10 will apply itself more
towards the hotter end of the curve
giving more of a max dose effect

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Biological Optimization – Serial K
Serial K
A K value of 20 will apply itself more heavily towards the hotter
end of the curve nearing similar behaviour to a max dose CF

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Monaco Concepts
Cost Functions – Serial

The ‘Variation’ tool

shows where the
cost function is
applied and the
effect upon the DVH.

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Biological Optimization
The Parallel K values range from 1 to 4

In this Example we have asked for 30Gy to 50%

with a K value of 1. The low K value applies
broader penalty across the entire structure

50%

30Gy
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Biological Optimization
Parallel K

A med K, will apply more toward the

value you have selected but still have
some control over doses above and
below the selected value

50%

30Gy
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Biological Optimization
Parallel K

A high K, will apply more directly

on the value you have selected
and wont have as much control
over doses above and below the
selected value
50%
It then becomes more like
an Overdose DVH CF

30Gy
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Biological Optimization
Parallel K
As the low K value penalizes the dose above and below
the set value it can be too harsh and take dose from the
Target

50%

28 | Focus where it matters 30Gy

Biological Optimization – Parallel K 4
A high K parallel cost function would look something like this, for a
OAR Ref Dose of 35Gy, mean Organ damage of 40%, and K = 4

Note that the

intersection is
what we asked
for when K=4

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Biological Optimization – Parallel K 1
A lower K Value for the same parameters might look like this. Notice how the
whole curve has been pulled down and the target dose has been affected.

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Monaco Concepts
Cost Functions – Parallel

The ‘Variation’ tool

shows where the
cost function is
applied and the
effect upon the DVH.

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What is EUD?
EUD = Equivalent Uniform Dose

• For Targets: EUD represents a homogeneous dose that when

applied to a target, has the same clinical effect as any given
inhomogeneous dose distribution within that target.

• For OARs: EUD represents a uniform dose in an OAR which

leads to the same probability of injury as a corresponding
inhomogeneous dose distribution in an OAR.

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Target EUD Cost Function
Target EUD
25

Increasing Penalty for Cold Spots

20

15
Cell Sen.
10 =0.1
Cell Sen.
=0.25
5
Cell Sen.
=0.5
0
65 67 69 71 73 75 77 79
Dose (cGy)

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Monaco Concepts
Cost Functions – Target Penalty

• Target Penalty is a physical cost function.

• It is an objective version of the Quadratic Underdose.
• It is a quadratic penalty constraint which starts at the
threshold dose.
• The iso effect is a DVH-
based physical
parameter.
• Results in a steeper
Target DVH than an
EUD based cost
function.

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Target Penalty Cost Function

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Monaco Concepts
Cost Functions – Quadratic Overdose

• The Quadratic Overdose allows a Max dose and an RMS excess

to be set.
• The RMS is really just a dose tolerance.
• It is much more flexible than a hard max and gives the system
room to breath.

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Quadratic Overdose
Control of the DVH tail of the structure (Target or OAR)

Reduce the
RMS will reduce
the tail

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 Maximum Dose Cost Function
Maxim um Dose = 70 Gy
Hard Constraint- Use Wisely!
400
350
300
250
Penalty

200
150
100
50
0
-50 50 55 60 65 70 75 80
Maxim um Dose

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Monaco Concepts
Cost Functions – Controlling Hot Spots

• To use the maximum dose to control the global max dose, apply it
to the external contour.
• Use the ‘Optimize over all voxels in volume’ option to apply it to
all voxels in the study set.
• This applies a global ceiling to the optimization.

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Monaco Concepts
Cost Functions – The Shrink Margin

• The Shrink Margin removes voxels in a structure away from

adjacent targets. These voxels will not be used by the cost
function for optimization.
• Extremely useful when multiple targets are being optimized to
transition between a high dose and a low dose.
• Can be used in place of Optimization rings.
• Allows a transition zone between a high dose target and an
overlapping or adjacent OAR.

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Monaco Concepts
Cost Functions – The Shrink Margin – Multiple Targets

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Monaco Concepts
Cost Functions – The Shrink Margin – Multiple Targets

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Transitioning Dose between Targets
Head & Neck Planning Recipe

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3 Targets case
PTV66
Example of 3 levels H&N
PTV60
• PTV66
BODY
- TargetPenalty(66Gy)
- QOD68Gy (RMS=0.5,Margin=0) PTV54
• PTV60
- TargetPenalty(60Gy)
- QOD66 (RMS=0.5,Margin=0)
- QOD62Gy (RMS=0.5,Margin=0.3)
• BODY
- QOD54(RMS=1.5,Margin=0)
• PTV54 - QOD40(RMS=1.5,Margin=1)
- TargetPenalty(54Gy) - QOD35(RMS=1.5,Margin=2) or
- QOD60 (RMS=0.5,Margin=0) maybe consider using Conformality
- QOD55.6 (RMS=0.5,Margin=0.3) - MAXDOSE(72.6, Opt Over All Vox)
44 | Focus where it matters
3 Targets case
Nested Targets
• PTV66
- TargetPenalty(66Gy)
- QOD68Gy (RMS=0.5,Margin=0)
• PTV60
- TargetPenalty(60Gy)
- QOD62 (RMS=1.0,Margin=0) • BODY
• PTV54
- TargetPenalty(54Gy)
- QOD55.6 (RMS=1.0,Margin=0)
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PTV66
PTV60
PTV54
BODY
- QOD54(RMS=0,Margin=0)
- QOD45(RMS=1.5,Margin=1)
- QOD35(RMS=1.5,Margin=2) or
maybe consider using Conformality
- MAXDOSE(72.6, Opt Over All Vox)
Other Tips & Tricks for Monaco
High Fluence Smoothing
Smooths the fluence in stage one
Reducing the complexity of segments
It puts segments together more
thereby reducing the number of MU’s
and increasing the speed of delivery
Fluence smoothing enables an easier
stage two calculation and more
consistent result
600MU’s vs 900MU’s

Modulation degree …
Beamlet Width with High Smoothing

1mm Beamlet Width 2mm Beamlet Width 3mm Beamlet Width

Monitor Units: 348 MU’s: 360.8 MU’s: 387.7
Segments: 128 Segments: 121 Segments: 129
Calc Time: 3.31 Calc Time: 2.35 Calc Time: 2.30

48 | Focus where it matters

Beamlet Width

1mm Beamlet Width 2mm Beamlet Width 3mm Beamlet Width

Monitor Units: 348 MU’s: 360.8 MU’s: 387.7
Segments: 128 Segments: 121 Segments: 129
Calc Time: 3.31 Calc Time: 2.35 Calc Time: 2.30

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Beamlet Width

1mm Beamlet Width 2mm Beamlet Width 3mm Beamlet Width

Monitor Units: 348 MU’s: 360.8 MU’s: 387.7
Segments: 128 Segments: 121 Segments: 129
Calc Time: 3.31 Calc Time: 2.35 Calc Time: 2.30

50 | Focus where it matters

Monaco Concepts
Using Conformality Cost Function

• The cost function can optimize over a 4cm radius or an 8cm.

- This is adjusted by selecting the ‘Optimize over all voxels’ option.

• Values can be set from 0.1 – 1.0, with a lower value giving a
more conformal distribution. Start at about 0.8 - 0.9.

• The value can then be lowered until the desired conformity is

achieved
- Great to apply when all other constraints have been met
- Great to use with MCO
51 | Focus where it matters
Monaco Concepts
Cost Functions – Conformality

• Conformality works well for single target volumes and stereo

volumes.
• It can be less effective with concave targets and complex cases.
- This is due to multiple dose volumes as well as additional structures and
large changes in the patient geometry (remember if conformality is applied
to the patient, higher structures will own the voxels).

52 | Focus where it matters

Monaco Concepts
Cost Functions – Controlling conformity with Quadratic Overdose

• You can control the dose to the patient by using the quadratic
overdose cost functions and a series of stepped shrink margins.
• The shrink margins are used instead of optimization contours.
• Start with a value close to or just lower than the PTV target dose
with a small RMS value.

53 | Focus where it matters

Monaco Concepts
Cost Functions – Controlling conformity with Quadratic Overdose

• The first quadratic overdose is set to the same value as the outer
target dose with no shrink margin.
• The cost function is applying directly against the PTV keeping the
target dose inside the target.

54 | Focus where it matters

Monaco Concepts
Cost Functions – Controlling conformity with Quadratic Overdose

• The second quadratic overdose is set to a smaller dose value

and has a shrink margin of 0.9cm applied.
• This is not applying in the voxels 0.9cm to the target. It only
applies its penalty in the colored voxels.

55 | Focus where it matters

Monaco Concepts
Cost Functions – Controlling conformity with Quadratic Overdose

• The third quadratic overdose is set to an even smaller dose value

and has a shrink margin of 2.4cm applied.
• This is not applying in the voxels 2.4cm to the target. Again, it
only applies its penalty in the colored voxels.

56 | Focus where it matters

Monaco Planning
Sequencing & IMRT Parameters

• Sequencing parameters and IMRT Parameters will affect the

quality AND deliverability of your plan just as much as the
constraints will.
• The following slides will help to explain and review the
parameters as well as give some tips.
• Should not be one size fits all

57 | Focus where it matters

Monaco Planning
Cost Functions – The Surface Margin

• The Surface Margin →Target cost functions.

• Clipping contours at the patient surface.
• Ignores low doses in the build up region.
• Do not try to force dose into the build up region.

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Monaco Planning
Cost Functions – The Surface Margin

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Monaco Planning
Cost Functions – The Surface Margin

• Targets are drawn out to the patient surface

• Decrease in MU
• Decrease in the global max dose.
• The Physician should try to avoid drawing targets to the skin
surface.

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Monaco Planning
Cost Functions – The Surface Margin

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Surface Margin
Understand its application and use it wisely or avoid it!

• Clipping vs Surface Margin of 5mm – CF Occupancy View

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Impact to Fluence Map

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Impact to Fluence Map

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Impact to Fluence Map

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Delivery Comparison
Impact to MU and # of Segments

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Monaco Planning
Sequencing Parameters – Target Margin

• More or less of the

surrounding voxels to the
target in optimization.
• This is comparable
optimization margin in XiO

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Monaco Planning
Sequencing Parameters – Target Margin

• For ‘normal’ planning, try not to restrict the margin too tight, this
can affect the sequencing result if Stage 1 Fluence is poor.

Normal Tight Very Tight

68 | Focus where it matters
68
Reduce Modulation Potential
Keep it smooth for efficient results

• Consider Increasing Smoothing for simple plans

• Increase Beamlet Width (step increment in XiO) –
large reduction in calc time – SSO does a great Job
in delivering quality
• This also reduces segment # and presence of small
undesirable segments (Modulation Degree i)

Low Smoothing & 0.3mm BW High Smoothing & 0.5mm BW

69 | Focus where it matters
Monaco Planning
Sequencing and Parameters – Segment Shape Optimization

• Filter “shapes changed” in the

Optimization Console.
• Do not make Stage 2 changes
until 2-3 loops have occurred.
• This will give it a chance to
converge prior to altering its
optimization pathway.
• Skipping Forward will bypass
SSO loops continuing, which is
ok if the plan quality is met.
70 | Focus where it matters
Monaco planning large volumes
Sequencing parameters—number of rotations

When you add one beam with two rotations, Monaco

enhances the segmentation process. It essentially
splits the fluence through the BEV central X axis.

On one rotation, Monaco will optimize one half of the

volume. With the second rotation, Monaco will
optimize the other half.

Let’s look at an example.

71 | Focus where it matters

Monaco planning large volumes
Sequencing parameters—number of rotations

Example: prostate with nodes and a unilateral nodal volume

Monaco optimizes
and segments this
half during the first
rotation.

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matters
Monaco planning large volumes
Sequencing parameters—number of rotations

Example: prostate with nodes and a unilateral nodal volume

Monaco optimizes
and segments this
half during the
second rotation.

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matters
Monaco planning large volumes
Sequencing parameters—number of rotations

If we look at the
segment for the first The same gantry angle
rotation we can see on the return rotation is
the segments segmenting the other
optimizing the right side of the volume.
side of the volume.

74 | Focus where it matters.

matters
Monaco planning large volumes
Sequencing parameters—number of rotations

Example: prostate with nodes and a unilateral nodal volume

2 beams each 1 beam

with 1 rotation 2 rotations

Note how the dose between the unilateral volumes is better.

75 | Focus where it matters

The benefits of Monaco multi-arc per beam
planning for pelvic disease sites
Background
The Monaco multiple arc-per-beam option allows Kalet, A.M., Richardson, H.L., Nikolaisen, D.A. et al.
radiation dose delivery to be optimized across multiple (2017) Dosimetric comparison of single-beam multi-
arcs, using a single collimator angle, without stopping arc and 2-beam multi-arc VMAT optimization in the
radiation delivery. Monaco treatment planning system. Medical
Aim Dosimetry, 42(2):122-125.
To compare the use of 2 arc-per-beam (2APB)
optimized plans with 1 arc-per-beam (1APB) plans for
pelvic cancer patients.
Method
• Retrospective analysis of 17 previously treated pelvic Figure shows comparison of dose distributions in 2 patients with complex PTV shapes
cancer patients: using 2APB (bottom) and 1APB (top) VMAT optimization
o 9 prostate, 1 bladder, 3 uterus, 3 rectum, and 1
cervix (with and without involved lymph nodes)
• 2 plans generated for each patient:
o one containing 2 beams using an arc-per-beam
setting of “1” (1APB)
o another with a single beam using an arc-per-beam
setting of “2” (2APB)
• Elekta Infinity linac with Agility
• Plans were evaluated for PTV conformity,
homogeneity, total MU, number of control points
(CP), planning time and beam delivery time.
Kalet, A.M. et al. (2017) Medical Dosimetry 42(2): 122-125
Monaco 5.11 Template Based
MultiCriterial Optimization
Automated Planning
What Are Templates?
Monaco is a template-based planning system

What does this mean?

• Templates store beam geometries, calculation parameters, calculation
settings, physician’s intent, IMRT constraints, …..
• Few clicks → ready for calculation.
• Monaco Biological cost functions → robust approach when used with
anatomical volumes
What are the benefits of template-based planning?
• Provides efficient ways to standardize the planning approach.
• With consistent templates, planning VMAT / IMRT is much easier.
• Decreases time to build plans.

78 | Focus where it matters.

What is this all based on? ENZARAD Protocol (78 Gy /39#)
OAR’s, AAPM, Quantec, TROG ENZARAD PTV 78Gy ICRU 50/62/83
Rectum V50Gy < 50%
• Target dose → meet protocols V60Gy < 35%
V65Gy < 25%
• OAR doses based on Quantec, V70Gy < 20%
ENZRAD or department V75Gy < 15%

• MCO will ensure in most cases Bladder V65Gy < 50%

the plan result is customized V70Gy < 35%
V75Gy < 25%
over the patient-specific V80Gy < 15%
anatomy
Femoral Heads V50Gy < 5%

Penile Bulb Mean dose < 52.5 Gy

79 | Focus where it matters. https://www.eviq.org.au/radiation-oncology/urogenital/prostate

The Template

• Template contains the Target/s, Rectum and external contour

- Prostate/GTV is optional
• OARs are controlled and achieved by the Body cost functions

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The Rectum
This can be visualized on the DVH
Parallel Serial CF Serial CF
controlling low controlling controlling
doses high doses overlap region

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The Process
Step 1: MCO over the fluence map

• Ensure Multicriterial is selected for all cost functions and the

system is in Constrained mode
• At the end of stage 1 notice how the Isoeffect (What the system
has achieved) is below the Isoconstraint (what is asked for)

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The Process
Step 2: PARETO optimization with SSO in Stage 2

• When stage one is complete, uncheck ‘Multicriterial’ and switch to

Pareto mode
• Enable Quadratic Underdose Cost Functions on Target/s
• Select Batch Optimise
• As everything has already been achieved it will re converge
quickly and commence Stage 2
• Once stage two is complete review the plan

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In Summary
Template Based MultiCriterial Optimization Automated Planning

• Stage 1 optimisation:
- Constrained Optimisation Mode
- Utilising a robust template
- Utilising Multicriterial Optimisation (MCO)
- Ensuring High Smoothing to control overmodulation

• Stage 2 optimisation
- Pareto Optimisation Mode
- Disable Multicriterial
- Apply Quadratic Underdose Cost Functions to Targets
84 | Focus where it matters.
Thank you