Planning Parameters and QA Troubleshooting

Monaco Physics
Planning Parameters & QA Troubleshooting
2 | Focus where it matters.

© 2020 Elekta all rights reserved. Confidential and proprietary information.
E017188/1.0
Planning Parameters & QA Troubleshooting
1- During-Plan Considerations
2- QA Plan Generation
3- Delivery Issues
4- Result Analysis Issues

Topic 1:
During-Plan Considerations

1- During-Planning Considerations
Tasks in the
QA Plan QA Plan Result
Clinical Plan Creation QA Plan Generation
Workflow: Delivery Analysis
Module 4: Planning Parameters & QA Troubleshooting

1- During-Plan 2- QA Plan 4- Result Analysis -
3- Delivery Issues
Considerations Generation Troubleshooting
• Sequencing Parameters • Virtual vs Scanned Phantom • Less than 1 MU per segment • Monaco Related Issues
• RED definition • PRF Pauses • QA Device Related Issues
• Dose Calibration • Effective Dose Rate • Linac Related Issues
• 2D and 3D arrays

1.1- Sequencing Parameters
Conformal RT
When are sequencing parameter used
• Sequencing Parameters are used when using Inverse Planned Treatment
Delivery Methods.
• Each delivery will have common & different parameters. Let’s have a look at
each one of them…
IMRT dMLC VMAT
Dynamic Conformal

Conformal RT
Segment Shape Optimization (SSO)
Step & Shoot IMRT dMLC VMAT
Dynamic Conformal

Segment Shape Optimization (SSO)
 Optimization of beam weights and shapes + what pilot beamlets are:
1- Shape Increment Definition 2- Derivative Computation 3- Derivative Filter 4- Pilot Beamlets 5- Execute Movement
A shape increment is a small • In movement that improves A change is kept only if it has the For the increments being kept, . If the pilot beamlet also
positional change that the CF: ( + ) same sign in both directions: pilot beamlets are created in the improves the CF, then the full
increases (out) or shrinks (in) (negative if worsens it) • Yellow top right: improves the same direction and the parent shape change is made.
the aperture CF if out and worsens CF if in derivative is calculated. Else, the movement is
• Out movement that (this change is kept!) • 3rd leaf bottom right: the pilot proportional to the derivative.
improves the CF: ( - ) • Opposite to it on the left: beamlet also improves the CF.
(positive if worsens it) improves CF if in or out • 4th bottom right: the pilot
(this change is not kept!) beamlet worsens the CF (by a
8 | Focus where it matters. certain amount).
Note: SSO should always be left on
1.1- Sequencing Parameters unless you have issues with your
hardware (as explained in the notes
Segment Shape Optimization (SSO) of the previous slide).
Plan results vs Plan QA results:
Effect on Check Uncheck Comments
Improve Plan Degrade Plan • SSO loops improve plan results.

Plan Results Results • If unchecked the time saved will be minimum if compared with the plan quality results
• Because the segments can increase or decrease it could (in theory) improve or degrade your QA results. In
Plan QA - - practise it shouldn’t make much difference.
Plan = Patient plan created in Monaco. Also, ‘plan results’ refers to dose criteria being met, not necessarily robustness or clinical
acceptability of the plan.
Plan QA = Patient specific QA plan based on the same patient plan
Note: the ‘improve/degrade plan and QA plan results’ (for this parameter and the following ones) is merely a theoretical discussion and
is meant to stimulate thinking and debate about possible impacts of the changes of those values.
Conformal RT
Speed / Plan Quality
Dynamic Conformal

Sequencing Parameters: Speed / Plan Quality
• Use the slider to change the number of shape changing loops.
• The range is from 1 to 20.
• The default is 5.
• As the number the loops increase, the plan quality increases, and Stage 2 time
increases.
• If you increase this number and the plan doesn’t need the extra loops, Monaco
will converge (the plan doesn’t improve much) and will stop earlier and will not run
the remaining loops.

Speed / Plan Quality
Plan Results vs Plan QA Results:
Increase Decrease
Effect on Comments
value value
Plan May Improve May Degrade • Extra loops may produce better plan results. This will of course depend on how well the Cost Functions are setup
Plan Results Plan Results • Too few loops will stop the optimizer from finding better solutions
Plan QA - - • The optimizer may or may not override sequencer parameters

Conformal RT
Minimum Segment Area
Dynamic Conformal

• Type the smallest area of the segment fields you want in the plan.
• Suggested value: 2.0 – 4.0 cm2
• Note:
If you have ‘multiple islands’ in a segment, this restriction applies

to the total area, rather than each individual area.
+ ≥ ‘X’cm2
Where X here is the Minimum
Segment Area chosen

Increase Decrease
Effect on Comments
value value
• Plan will degrade if minimum segment area is increased as this gives less flexibility for the optimizer.
Plan Degrade Plan Improve Plan • Would especially affect plans in need of high modulation
• The more you lower this parameter, the higher the chance your QA may fail, since the smaller the
May Improve May Degrade
Plan QA segments you allow, the higher the uncertainty they will have. For highly modulated plans with many of these
QA results QA Results small segments, disagreements may be seen between calculated and measured doses.

Conformal RT
Minimum Segment Width
Dynamic Conformal

• Minimum gap between adjacent MLC leaves.
• Applied during segmentation and may be violated with SSO.
• Recommend 0.5 cm
• VMAT: If reduced MU is needed use 0.7 – 1.0
• Minimum physical leaf gap (at central axis for Agility):

• At MLC level: 1 mm
• At isocenter: 2.8 mm
• It can be narrower for off axis fields

Type the minimum width for each segment. The suggested value is 0.5 cm
Larger Min Segment Size Small segments will

allow you to achieve
better dose distribution,
especially for small
targets and highly
conformal plans, but
what’s the impact on
Small Min Segment Size your QA??
....
Note: One way to reduce MU in your plan would be to increase this parameter. 1.0 cm may give you fewer MU with similar plan quality.

Increase Decrease
Effect on Comments
value value
May Degrade May Improve • Plan will degrade if minimum segment width is increased as gives less flexibility for the optimizer.
Plan Plan Plan • Would especially affect plans in need of high modulation
*May improve *May Degrade • may theoretically affect your QA results, but likely not the biggest impact; it depends on the number of
Plan QA QA results QA Results segments and how many small segments are created
* It will depend on how small and how many segments the plan has.

Conformal RT
Fluence Smoothing
Dynamic Conformal

Fluence Smoothing
Minimizes steep dose gradients between beamlets
Applied at Stage 1 fluence.
Fluence Smoothing: Fluence Smoothing: Fluence Smoothing: Fluence Smoothing:

Off Low Medium High
Fluence Smoothing Off / Low Smoothing
Select the degree of smoothing you want applied to the

beam fluence. Valid entries are:
Off, Low, Medium and High
 Off or Low: allow for a sharper and more fine degree

amount of details. Used for complex plans. High Smoothing
 Medium or High: A smoothed fluence needs less
segments to be created to fill the fluence profile –
ultimately leading to less modulation or movement
strain on the machine.

↑ Smoothing
↓ Plan Modulation (MU)
Fluence Smoothing
↓ Control Points
↑ Delivery Efficiency
↑ QA pass rates
Effect on High / Medium Off / Low Comments
• The more smoothed the fluence is, the lower are the chances for Monaco to achieve the optimum dose
*May Degrade *May Improve
Plan Plan
distribution.
Plan • Would especially affect plans in need of high modulation and small segments.
*May improve *May Degrade • A smoothed fluence needs fewer segments to be created to fill the fluence profile, leading to less
Plan QA QA results modulation and fewer small segments.
QA Results
* It will depend on how small and how many segments the plan has.

Conformal RT
Min. MU / Segment
Dynamic Conformal

Min. MU / Segment
• This is the minimum monitor units for the optimizer to use when it makes static segments.
• If a potential segment falls below the minimum MU, Monaco does not create the segment.
• The value must be greater than 1 and less than or equal 25.0 (default 4MU).

Min. MU / Segment
Low Min. MU/Segment
Here we have 2 exact same Optimized Fluence profiles (blue line):
• Top: the profile is “filled” with small segment because the ‘Min.
MU/Segment’ is low.
• Bottom: the same profile is “filled” with bigger segments as the
‘Min. MU/Segment’ is higher than before.
You could make an analogy with 2 artists painting the same photo:
• The first painter has a pallet with 10 different colors
• The second painter has a pallet with 100 different colors High Min. MU/Segment
The first artist will be able to achieve a paint that is more similar to
the photo, whilst the second one will have to merge different shades
of the same color into one single shade.

Min. MU / Segment
Min Mu/Seg = 1 • Higher conformality Min Mu/Seg = 2
• Higher MU
1 MU 2 MU 4 MU 5 MU 6 MU 2 MU 4 MU 6 MU
• Less conformality
• Fewer segments
Note: Min MU/Segment has the most impact on number of segments compared to the 2 previous parameters (min seg area and min segment width).

Min. MU / Segment
Increase Decrease
Effect on Comments
Value Value
Degrade Plan Improve Plan
Plan Results
• The smaller the MU/segment it’s allowed, the closer the optimizer will get to the optimized fluence.
Results
*May improve *May Degrade • Very small values for the ‘Min. MU / Segment’ requires more security on the dose delivered per MU.
Plan QA QA results QA Results • You only need to increase it until the zone of stability on the linac’s MU/Dose linearity curve.
* It will depend on how many low MU segments the plan has/requires.

Discussion time!!
Min. MU / Segment
• If using the lowest value of Min. MU/Segment gives more flexibility when it comes to plan quality,
why don’t we all use the lowest setting?
 It’s a compromise between plan quality and QA results

 It’s also a matter of: what’s the lowest point in your MU Linearity curve
that you have confidence on the reproducibility/stability of your beam?

Discussion time!!
Min. MU / Segment
• What’s the difference between the Min. MU per Segment discussed here and the one from the MLC Dynamic parameters?
Sequencing Parameters MLC Dynamics

• This parameter is only for • Here you can control
Step & Shoot both, Static and
Dynamic deliveries.
• Dynamic plans need

• Will Monaco go with the more flexibility
most restrained value? In compared to Static
the sense, if sequencing ones.
parameters is 4 MU and
MLC dynamics is 1MU, will
it use 4 as the minimum as
it’s the most restrictive?
Test results in the next slide…

Discussion time!!
Min. MU / Segment: MLC Dynamics vs Sequencing Parameters
MLC Dynamics: 1.0 MLC Dynamics: 6.0

Sequencing Parameters: 4.0 Sequencing Parameters: 4.0
No segment No segment
smaller than 4.0 smaller than 6.0

Conformal RT
Max # of Segments per Plan
Dynamic Conformal

Max # of Segments per Plan
• This is the maximum number of segments you allow for the plan.
• It doesn’t mean Monaco will use this many segments. If they are not needed, Monaco won’t use them.
• Recommendation/Suggestions:
 Complex plans: keep it high (~200) and let Monaco decide how many it needs. SSO minimizes the number of
segments as much as it can.
 Non-complex plans: depends on case by case and clinic to clinic (~100-150)
Increase Decrease
Effect on Comments
Value Value
May Improve May Degrade
Plan Plan
• More segments allowed = more flexibility for the optimizer
Plan
Plan QA - - • Will be dependent on the other segmentation parameters

Conformal RT
Max # of Control Points per Beam
Dynamic Conformal

Max # of Control Points per Beam
• This is the maximum number of CP per beam allowed for the plan.
• It doesn’t mean Monaco will use this many CP. If they are not needed, Monaco won’t use them.
• Usually this is left unchanged at 30 for all plans
Increase Decrease
Effect on Comments
Value Value
Plan May Improve May Degrade • If the optimizer needs more CPs, it will use them and the plan may improve. If the limit is too low, it
Plan Plan may limit the solutions.
Plan QA - - • -

Conformal RT
Max # of Control Points per Arc
Dynamic Conformal

1.1- Sequencing Parameters MLC Dynamics
Max # of Control Points per Arc

• Similar to the previous parameter (Max # of Control Points per Beam) but
applied to an arc.
• For Elekta linacs, the maximum permitted is 1024 CPs but the maximum
created will be 240 CPs because of the Min. Gantry Degree per Control Point.
(360 deg / 1.5 = 240 CPs)
Increase Decrease
Effect on Comments
Value Value
Plan May Improve May Degrade • If the optimizer needs more CP, it will use them and the plan may improve. If the limit is too low,
Plan Plan it may limit the solutions.
Plan QA - - • -

Conformal RT
Max # of Arcs
Dynamic Conformal

Max # of Arcs
• This is the maximum number of arcs you allow per beam.
• Recommendation/Suggestions:
 Non-complex plans: 1
 Complex plans: 2
 Partial arcs: probably 2 or more
Note:
• When you add one beam with two rotations, Monaco

will split the BEV in the middle.
• The fluence is split in the leaf direction so in some
cases you may need to rotate the collimator to achieve
this benefit.
• Calculation time: 2 beams with 1 arc each takes
longer to calculate compared to 1 beam with 2 arcs.

Max # of Arcs

Max # of Arcs
Increase Decrease
Effect on Comments
Value Value
Plan May Improve May Degrade • More arcs allowed = more flexibility for the optimizer
Plan Plan
Plan QA - - • -

Conformal RT
Park Leaf Gap Under Jaw
Dynamic Conformal

Park Leaf Gap Under Jaw
• For machines that allow leaf interdigitation:

• Option checked:
It parks the closed leaves outside of the treatment field
• Option unchecked:
Monaco optimizes dose leakage through the gaps and adds it
to the total dose delivered by the plan.
Notes:
• Agility doesn’t have backup jaws, so this option is greyed out.
• For non-interdigitating machines, this option is overridden.

Conformal RT
Max Sweep Efficiency
Dynamic Conformal

Mark this field to pre-optimize the starting point of each MLC as it moves from one beam to the
next. This option can reduce the overall monitor units by 20%. Default setting is on.
Starting point
unchecked
Starting point
checked

Plan *Improve Plan *Degrades Plan *Fewer MU with the same plan quality
Results Results
Plan QA - - • -
- -

Conformal RT
Allow Move Only Segments
Dynamic Conformal

Allow Move Only Segments
This parameter toggles between two behaviours of the sequencer that will occur when you have zero
weight patches inside the fluence weight profile, i.e. fluence holes.
 Behaviour 1 (parameter unchecked):

The leaves crossing these patches have:
• maximum leaf speed
• minimum leaf gap (closed leaf pairs)
• no beam interrupt
 Behaviour 2 (parameter checked):

i. The leaves move to the edge of the hole
ii. The beam is then interrupted
iii. The leaves move to the other edge of the hole while the beam is interrupted
iv. Once there, the beam resumes

Conformal RT
Target Dose Rate (MU/min)
Dynamic Conformal

Target Dose Rate (MU/min)
• Target Dose Rate is greyed out when SSO is checked, so is typically irrelevant.
• Even if selected, the optimum dose rate will be decided by the linac.
Increase Decrease
Effect on Comments
Value Value
• Small value = improves plan quality
Plan *Degrades Plan *Improves Plan • Larger value = decreases treatment time (higher D/R = quicker delivery time)
Plan QA - - -

Conformal RT
Constant Dose Rate
Dynamic Conformal

Constant Dose Rate
• A normal VMAT plan requires that the linac can deliver variable dose rate beam output along with variable
gantry speeds. If your clinic has an older linac that does not have this capability, you can use constant dose
rate VMAT.
Degrades Improves
Plan Plan
• It gives less flexibility for the optimizer
Plan
Plan QA - -

Summary time!!
Important topics covered in this section:
• SSO should always be left on unless you have issues with your hardware
• Min MU/Segment has the most impact on number of segments compared to ‘Min Seg Area’ and ‘Min
Segment Width’.
• 1 beam/2 arcs gives Monaco more flexibility to find better solutions and takes less to calculate
compared to 2 beams with 1 arc each.

Topic 2:
QA Plan Generation

Tasks in the

3- Delivery Issues

RED definition
• Has the RED been characterized?
• Must be implemented correctly and consistently
Note: in the next slides we’ll point out some considerations and maybe some recommendations but ultimately you
should follow the setup instructions provided by your QA device vendor.

RED definition
RED=1.14 RED=1.16
Electron density to mass density conversion:
In this example the RED provided by the vendor for the

virtual phantom proved to not be the most consistent one.
This can be explained by the ED to mass density
conversion in Monaco: the equation applies to human
tissue-like materials. Because the material of this phantom
is not a human-like tissue, an adjustment has to be made
to the phantom RED.
A small change was made, and better results were seen.

RED definition
Considerations regarding scanned phantoms:
 The contour is highly user dependent. The surface-

detector distance will vary from user to user. Virtual
phantoms are always the same.
 The edges of the scanned phantom are not sharply
defined. Virtual phantom always have a sharp edge.
 Scanned phantoms can have artefacts that will have to 4.2cm
be contoured and have their RED forced.
 Scanned phantoms have the detectors filled with air.
The RED here has to be overwritten by the
characterized RED.
Note: You can use the scanned phantom as a guide for the detector depth and location but the actual calculation (Which are already
indicated in device manuals), calibration, RED optimization is recommended to be done (if possible) using the virtual phantom. The
reason for this recommendation is due to many support cases on this subject where the issue was caused by an improper use of the
scanned phantom.

RED definition
RED optimization in a 3D Phantom:

•
 In relative mode, adjust the RED of the phantom until the entrance and exit dose produce good agreement
between calculated and measured.

Discussion time!!
RED definition
• Question: If one is using a scanned phantom, can you simply use it as is (Use your CTtoED table and no forcing ED)?
 The absolute calibration of the phantom is done with an ion chamber. The reading is converted into dose applying
correction factors, including one that converts the dose in air (IC cavity air) to dose in water. This way, without forcing
the RED of the volume, the dose deposited at the detector point (that contains air) will not be in agreement with the
measured.

Quiz time!!
RED Optimization
Select the correct statement(s):
When optimizing RED in a phantom we tend to recommend you use a virtual phantom because:
a) The surface-to-detector distance can vary when the scanned phantom is contoured.
b) The contour on a scanned phantom is always sharp and doesn’t vary from user to user.
c) Scanned phantoms can have artefacts.
d) The RED optimization will have no impact on the absolute dose calculation.

Dose calibration
Overview
Detector Array calibration Absolute Dose

Factory or User Factory or User
Using Ion Chamber Using Monaco

Dose calibration
Absolute Dose calibration (using Ion Chamber):
• Flat devices:
i. Setup QA device/additional build-up and deliver beam.

ii. Find what is the water equivalent thickness of the inherent build-
up to reproduce the same measurement with an IC (this
information is provided by the vendor).

Dose calibration
Absolute Dose calibration (using Ion Chamber):
• 3D array devices:
i. Setup QA device and deliver the beam.
ii. Find out the water equivalent thickness from the surface
to the reference detector (this information is provided by
the vendor).
iii. Setup the a flat phantom where the ion chamber is
placed at the same equivalent depth maintaining the
same source to detector distance
Note: Among other reasons, some differences are expected

due to the 1% error dragged from the flat geometry dose
associated to the cylindrical geometry.

Dose calibration
Absolute Dose calibration (using Monaco):
i. Load the phantom in Monaco.

It is required to adjust correctly the RED in
Monaco to emulate the real setup.
ii. Make sure the RED has been optimized for that
phantom before the absolute dose calibration
iii. Run the calculation
iv. Sample the dose point at the reference detector’s

depth
(Remember the Interest points and dose sampling
methods)

Dose calibration
Absolute Dose calibration, Dw/Dm and consistency with QA
• QA calibrated with Monaco: stay consistent with the way chosen to calibrate your QA:
 if Dm was used during the calibration, use Dm when calculating the QA plans.
 if Dw was used during the calibration, use Dw when calculating the QA plans.
• QA calibrated with Ion Chamber: decide if you’re going to use Dw or Dm. After that, use the chosen method for all
your future QA plans so you stay consistent.
 For both, RED optimization and detector absolute dose calibration, follow the instructions provided by your QA device
vendor.
 Considerations:
• Prefer virtual phantom for the calibration and QA generation process.
• Calibrating the QA with Monaco is the simplest way to do it.

Discussion time!!
Dose Calibration
In very short words, explain you answer for the following questions:
 Which one would you do first: QA dose calibration or RED optimization?

RED optimization
 Regarding the discussion Dm or Dw, what is the most important point to keep in mind when it comes to QA?
Stay consistent with the method used for the QA device calibration

2- QA Plan Generation Non-collapsed plan Collapsed plan
Generating the QA Plan
Collapse Gantry/Collimator/Couch to 0°
Here you can change the calculation parameters for your QA
Here you can select which prescriptions you would like to QA

Collapsing Gantry angles
• Collapsed beams:
This approach has some disadvantages:
 Beam changes that may occur with

the rotation of the gantry (flatness,
symmetry, etc.) are not capture here.
 Interactions of the beam with the

couch are not captured either.

Exporting a QA Plan as 2D Dose Planes
Exporting 2D plan slices: Dose Plane
• Used when 2D dose distributions need to be

analysed
• 1 mm fixed interpolated resolution
• The slice to be exported (T/S/C) is the one seen
in the monitor. So if you want to export the slice
at isocenter, scroll to that slice first then select
‘Dose Plane’.
• ‘Individual Beams’ can be useful when
troubleshooting as you can analyse each beam
individually.
• Dose planes are exported to the ‘Dose Planes’
folder in the Focal Data
Tip: Use the ‘Jump to Point’ tool to go to the desired slice to be exported.
Exporting a QA Plan as 3D Dose Cube
Exporting 3D plans: DICOM Export
• Used when 3D dose distributions need to be

analysed.
• Calculated grid size resolution.
• What you select to be exported will depend on
your QA device.
• ‘Individual Beams’ can be useful when
troubleshooting as you can analyse each beam
individually.
• Dicom Exported files can be found in the folder
set by user. (See Folder Structure section)

Summary time!!
• RED needs to be defined properly or it will impact on your QA results.
• Pay attention to the RED for non-human equivalent QA device materials – an adjustment to its RED
may need to be made for Monaco to calculate the correct dose.
• The RED definition needs to be done before the QA device absolute dose calibration.
• The dose calibration can be done using an IC or using Monaco.
• Stay consistent with the calibration method chosen (Dm or Dw) and how you calculate your QA plans.
• Pay attention to the slice selected when your exporting dose planes. Use the tool ‘Jump to Point’.

Topic 3:
Delivery Issues
3- Delivery Issues
Tasks in the

3- Delivery Issues

3- Delivery Issues - Troubleshooting
Possible Monaco causes
Downscaling a Plan:
• Minimum MU will be “bypassed” when you downscale a plan. If you have a segment with less
than 1MU that plan will not be deliverable
• Always check the segment summary – look for the segments with really small MU/Fx
• If you have segments with near 1MU, when the plan is downscaled, that segment may go
below 1MU which will make the plan undeliverable

Other possible causes
Not all issues with your QA results

are Monaco related – you may have
issues with your linac too.
In the next slides we’ll discuss few

points you could investigate if you
are having issues with you plan
delivery.

CP1 CP2
3- Delivery Issues - Troubleshooting 10MU
Possible Linac Causes – PRF Pause
10 MU
Something else to check if issues with the plan
CP2
delivery are coming up are PRF Pauses:
|
PRF Pause
• PRF Pauses can happen when 2 or more

parameters are not in sync by a certain
MU Delivered
tolerance margin. PRF Pause
• After a certain number of PRF pauses, the
beam will be terminated.
PRF Pause
As an example, the diagram on the right has a
single MLC position and MU delivered as an
example. Beam (MU) stops for the MLC
position to catch up
To verify if a PRF Pause is being caused by

your linac or by Monaco you could deliver a 0 MU
| | |
plan that passed before. CP1 0 cm Y1 Leaf 5 Position 10 cm

Possible Linac Causes – Dose Rate
Another suggestion of a parameter to check
in your linac is the Effective Dose Rate
against the Nominal Dose Rate:
a) Go to Integrity in service mode and

run the machine at maximum PRF
(to do this, simply leave the ‘Dose
Rate’ parameter empty, like shown Actual
D/R
Nominal
D/R
in the image).
b) Check that the D/R indicator
(yellow bar that changes as the
D/R changes) is at the centre of the
range.
The example on the right shows a non-

optimized machine.

Summary time!!
• Pay attention to segments with small MUs when you’re downscaling your plan
• Make sure the parameter in your machine are reflective of their nominal value (like D/R, for example) to
avoid issues with PRF pauses.

Topic 4:
Result Analysis Issues

4- Result Analysis Issues - Troubleshooting
Tasks in the

3- Delivery Issues

4- Result Analysis Issues - Troubleshooting
If your QA plan was delivered and you have low pass rates, here’s a non-exhaustive list of suggested
items you can check:
Monaco QA Device Linac

Related Issues Related Issues Related Issues
• Phantom RED • MLC calibration
• Detector type
• Couch (RED / attenuation) • Steering and lookup table
• Detector size
• Number of small segments • Radiation iso x laser/crosshair
• Detectors spacing/resolution
with low MUs • Flatness/Symmetry
• Detector absolute and relative
(static and varying with gantry angle)
calibration • Output
• Type of plan and type of QA
• Beam start-up
device
• Positioning method:
laser/crosshair
Note: The last part (linac related issues) is not discussed in details here but the Linac Physics and EOEP (Elekta Oncology
Engineering for Physicists) are good courses to attend to give you a better understanding on the linac side.
Thank you
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Monaco Physics

Planning Parameters & QA Troubleshooting

2 | Focus where it matters.

4- Result Analysis Issues

3 | Focus where it matters.

© 2020 Elekta all rights reserved. Confidential and proprietary information.

Module 4: Planning Parameters & QA Troubleshooting

5 | Focus where it matters.

IMRT dMLC VMAT

6 | Focus where it matters.

Step & Shoot IMRT dMLC VMAT

7 | Focus where it matters.

Plan results vs Plan QA results:

Effect on Check Uncheck Comments

Improve Plan Degrade Plan • SSO loops improve plan results.

Plan QA = Patient specific QA plan based on the same patient plan

Step & Shoot IMRT dMLC VMAT

10 | Focus where it matters.

• Use the slider to change the number of shape changing loops.

• The range is from 1 to 20.

11 | Focus where it matters.

Plan Results vs Plan QA Results:

Plan QA - - • The optimizer may or may not override sequencer parameters

12 | Focus where it matters.

Step & Shoot IMRT dMLC VMAT

13 | Focus where it matters.

If you have ‘multiple islands’ in a segment, this restriction applies

14 | Focus where it matters.

Plan Results vs Plan QA Results:

15 | Focus where it matters.

Step & Shoot IMRT dMLC VMAT

16 | Focus where it matters.

• Minimum gap between adjacent MLC leaves.

• Applied during segmentation and may be violated with SSO.

• VMAT: If reduced MU is needed use 0.7 – 1.0

• Minimum physical leaf gap (at central axis for Agility):

17 | Focus where it matters.

Larger Min Segment Size Small segments will

18 | Focus where it matters.

Plan Results vs Plan QA Results:

19 | Focus where it matters.

Step & Shoot IMRT dMLC VMAT

20 | Focus where it matters.

Fluence Smoothing: Fluence Smoothing: Fluence Smoothing: Fluence Smoothing:

Select the degree of smoothing you want applied to the

 Off or Low: allow for a sharper and more fine degree

22 | Focus where it matters.

Effect on High / Medium Off / Low Comments

23 | Focus where it matters.

Step & Shoot IMRT dMLC VMAT

24 | Focus where it matters.

25 | Focus where it matters.

26 | Focus where it matters.

27 | Focus where it matters.

Plan Results vs Plan QA Results:

* It will depend on how many low MU segments the plan has/requires.

28 | Focus where it matters.

 It’s a compromise between plan quality and QA results

29 | Focus where it matters.

Sequencing Parameters MLC Dynamics