Lattice Planning Guidelines:

(IGRT SRS ARC therapy with Eclipse Treatment Planning)

Updated to include Ethos Information – October, 2020

Contouring
• Insert the Grid study structure template to add the following contours:
GTV_2000, PTV_2000, PTV_6670, PTV_Avoid, and PTV_Control

• Contour normal structures, insert High Density contour if Acuros is going to be used, and insert
machine couch when appropriate.
• Copy and paste MD targets GTV and PTV to GTV_2000 and PTV_2000, this will be the low dose
volume.
• Turn on grid in contouring workspace and set to user defined 3.0cm.

• Starting in the center of the PTV_2000; set the viewing plane indicators to match the Grid
intersection in all three planes.

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• Set a 1.5cm 3D brush and begin contouring PTV_6670 and PTV_Avoid structures.

• The spheres should reside in and around the PTV_2000 in the following pattern. We will remove
undesirable spheres later in the process:

• Contour both target and avoid spheres on each grid plane in the standard manner; we can
switch target and avoid spheres later if needed.
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• Moving superior to the next grid box alternate the placement of the target and avoid spheres.

• Continue this alternating pattern until the most superior region of the PTV_2000 is reached.

• Now continue sphere placement in the inferior direction.

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• Review spheres and decide which are to be target and avoid spheres; translate spheres if
needed for more optimal configuration. (Contact physics to review sphere placement)

• Crop PTV_6670 target spheres to the be within (GTV_2000 – 5mm) for small targets (<600cc)
and within (GTV – 10mm) for large targets. PTV_Avoid spheres can be cropped to the PTV_2000.
Remove all partial spheres.

• Ensure target spheres are not overlapping any critical structures plus some margin. This is
relatively subjective, based on dosimetric objective for each OAR, with the goal to minimize
proximity to OARs and assist in making the planning process easier.

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 • Once complete create PTV_Control by cropping (PTV_6670 + 8mm) from PTV_2000

Planning
• Insert a new course and new plan: Rx 6670cGy in 5 Fractions

• PTV_6670 is the planning target and reference point.

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• Plans should be on the Edge, a Truebeam, or the Ethos using SRS ARC technique.
• Ensure isocenter is in the center of PTV volume.
• 6MV, 6FFF, 10 MV, or 10FFF site dependent.
• Utilize full coplanar arcs and partial arcs with up to 10° couch kicks. There should be atleast 720
degrees of arc angle between all fields.
• Jaw tracking used with initial jaws set to PTV_2000, and collimator rotation of 15°-90°.

• Four ARC fields are usually sufficient for most volumes.

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Optimization
• Ensure jaw tracking is selected

• An MU Objective can be established to aid in proper modulation per beam

• A manual Normal Tissue Objective is set for rapid dose fall-off.

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• Load the “Grid Study” objective template or use the following baseline objectives:

• Add OAR objectives with high priority as needed after start of optimization.

• Pause at each MR level accordingly to ensure optimal plan solution if found.

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Evaluation
• Clinical OAR goals are top priority with high dose sphere coverage a secondary goal. The entire
PTV_2000 should be covered by 95%, and if a PTV_6670 sphere is causing an organ at risk to
exceed clinical objectives that sphere can be retracted or removed entirely.

• There is an active clinical protocol that should be attached to the plan once optimized.

• After objective OAR goals are met, subjective plan analysis is performed.
• Overall lattice dose distribution should be achieved, and the global hot spot around 115%.

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• The PTV_Avoid structures should present with a mean dose between 2000-2400cGy.

• PTV_2000 and PTV_6670 should both receive RX doses to greater than 95% volume respectively.
(Plans can be normalized as long as OARs don’t exceed limits)

• Isodose holes starting at 2400 cGy and below should be present between target spheres.

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• An MU Ratio between 2.0 and 3.0 is desirable.

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 • Once approved, plan write up follows that of SBRT. Particular isodose lines may be requested to
ensure OARs don’t intersect at the time of delivery.

Trouble Shooting
• Evaluate target and avoid spheres and beam arrangement with physics before optimization

• Don’t directly optimize on Mean dose to PTV_Avoid as this will likely cause poor PTV_2000
target coverage

• Be sure to check beam clearance with therapists and/or physics

• Ensure correct table is inserted if required

• Beam selection will be highly site specific

Ethos Lattice Planning in Eclipse

• If you insert plan and select Ethos_Tr2, the Halcyon couch should be automatically placed into
the dataset.
• It is okay to enlarge the image to fit the couch structure when Eclipse gives that warning.
• Verify and adjust the “Halcyon couch” to match the way that the patient will be treated on the
Ethos machine using the overlay board.

For example:

Ethos-Specific Planning Concerns

• General VMAT considerations are maintained when planning for Ethos. The following will touch
on planning concerns that may be different than other linacs.
• No couch rotations are allowed for Ethos plans.
• Beware any anatomy that may be cut-off in your planning scan as this may be indicative of a
possible collision with the bore on Ethos. The Ethos TPS has some detection capability and may
catch a possible collision when your plan is imported there. However, it will only alert users

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 when it determines that the couch structure or the Body will collide. Portions of the patient not
contained within Body are not considered.
• The field size used in Ethos is 28cm x 28cm.
• Ethos plans can be generated with 2 separate isocenters, 8 cm apart (longitudinal shift only)
when needed. Using two isocenters allows Ethos to treat longer targets and may allow for the
MLCs to design sharper fluence in the areas where they overlap.
• Perhaps the biggest thing to watch for when designing lattice plans in Eclipse for treatment on
Ethos is the MU limitation that Ethos currently has.
o This MU limitation will change after Ethos is upgraded to a newer release (MR1) in mid-
November, 2020.
o The current MU limitation requires < 2000 MU per IMRT field for Ethos deliveries.
o The current MU limitation requires < 1500 MU per VMAT field for Ethos deliveries.

Ethos Lattice Plan Preparation for Treatment

• The current workflow for lattice patients that will be treated on Ethos is for the SBRT/SRS team
to complete the planning in Eclipse.
• The SBRT/SRS planner will prepare the plan documents for the approved plan and make the
necessary Aria preparations.
• Once those items are complete, the SBRT/SRS planner will provide a hand-off to a member of
the Ethos planning team so that the Ethos preparations and any incomplete Aria preparations
can be completed. Ideally, this would happen with > 1 day before the patient would start on
Ethos to allow for the necessary time to complete those tasks.

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