All patients were immobilized using a thermoplastic mask and a small vacuum bag for head and neck. The CT images were acquired with the head first and supine on position under a Philips Brilliance CT Big Bore (Philips Medical System, 96 Highland Heights). The slice thickness of the reconstructed CT image is 0.3 cm. All CT images were transmitted to Monaco treatment planning system (TPS; Monaco V5.0.2, Elekta AB) to delineate the clinical target volumes (CTVs) and OARs.
Monaco v5
Manufactured by Elekta
Sourced in Sweden
Monaco v5.11 is a radiation therapy treatment planning and delivery system. It provides tools for medical professionals to create and optimize radiation therapy plans for patients. The core function of Monaco v5.11 is to assist in the planning and delivery of radiation treatments.
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16 protocols using monaco v5
1
CT-Guided Head and Neck Immobilization
2
Dosimetric Evaluation of Treatment Plans
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All plans were produced with Monaco treatment planning system (Monaco V5.0.2, Elekta AB, Stockholm, Sweden) and this allowed for all dose volume histograms (DVHs) to be obtained with the same sampling algorithm and evaluation of plans based on the standard DVH. For the PTVs, the parameters analyzed were D 2%, D 98%, V 100%, V 95%, and homogeneity index (HI) and conformal index (CI). The algorithm for CI (19) and HI (18) were described as following.
PTV95% is the planning target volume that received 95% of the prescribed dose, PTV is the planning target volume and V95% is the volume that received 95% of the prescribed dose.
D5% and D98% indicate the doses that covered 5% and 98% of the PTV volume, respectively.
For the OARs, the parameters analyzed included as following: (1) Lung: the volume of Lung receiving dose at least 30, 20 and 10 Gy (V30Gy,V20Gy,V10Gy);(2)Heart: the volume of heart receiving dose at least 40 and 30 Gy( V40Gy,V30Gy), and mean heart dose (Dmean);(3)Spinal cord: the maximum dose covering 1 cc volume of the spinal cord( D1cc).
Peripheral doses around PTVs were analyzed via comparison of volume outside PTV2 covered by 45 Gy, 30 Gy, and 20 Gy (V45Gy, V30Gy,V20Gy).
PTV95% is the planning target volume that received 95% of the prescribed dose, PTV is the planning target volume and V95% is the volume that received 95% of the prescribed dose.
D5% and D98% indicate the doses that covered 5% and 98% of the PTV volume, respectively.
For the OARs, the parameters analyzed included as following: (1) Lung: the volume of Lung receiving dose at least 30, 20 and 10 Gy (V30Gy,V20Gy,V10Gy);(2)Heart: the volume of heart receiving dose at least 40 and 30 Gy( V40Gy,V30Gy), and mean heart dose (Dmean);(3)Spinal cord: the maximum dose covering 1 cc volume of the spinal cord( D1cc).
Peripheral doses around PTVs were analyzed via comparison of volume outside PTV2 covered by 45 Gy, 30 Gy, and 20 Gy (V45Gy, V30Gy,V20Gy).
3
CT-Guided Radiotherapy Treatment Planning
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For each patient, the serious CT scans were performed using a Philips Brilliance CT Big Bore (Phillips Medical System, 96 Highland Heights, OH, USA). Patients were immobilized using a body vacuum pillow and scanned with head first and supine on position. The reconstruction slice thickness is 5mm and region scanned extended from the cricothyroid membrane to the lower edge of liver. All patients CT images were transmitted to Monaco treatment planning system (TPS) (Monaco V5.0.2, Elekta AB, Stockholm, Sweden) to delineate the target volumes and organs at risk (OARs) and design the treatment plan.
4
MR-Linac Radiotherapy Simulation Workflow
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Patients treated on MR-Linac underwent a planning CT scan (Philips, Big Bore CT) and MR simulation scan either on diagnostic MRI (Siemens, Aera 1.5T) or MR-Linac (Elekta Unity, 1.5 T). Bladder filling protocol on MR simulation required patients to empty bladder and drink 700 mls of water 1 h prior to scanning. Scanning was performed in treatment position, ideally with an empty rectum. If rectum ≥5 cm on initial planning scan patients were re-scanned following bowel preparation. Radiotherapy planning was performed on Monaco® v5.40.01 (Elekta AB, Stockholm, Sweden) for Phase 1 and Raystation® v10.0.1.52 (RaySearch Laboratories AB, Stockholm, Sweden) for Phase 2.
5
Prostate Cancer RT with Elekta Unity
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Prior to the first fraction the patients underwent CT and MR simulation scans. Plans were created in the Elekta Monaco v5.40.01 treatment planning system using a 5 beam setup. The minimum number of monitor units per segment was 5 MU with an average of 51.6 segments per plan. A calculation grid spacing of 3 mm was used with a statistical dose uncertainty per segment of 3%. The Elekta Unity has a multi-leaf collimator (MLC) with a leaf width of 7 mm. A total of 160 leafs are present which travel in the cranio-caudal direction and 7 MV flattening filter free beam energy is used.
The clinical target volume (CTV) for these five patients contained the body of the prostate. The PTV structure prescribed at 57 Gy was created using an isotropic margin of 5 mm around the CTV. Moreover, an extended boost volume (EBV) prescribed at 62 Gy was formed by using a margin of 5 mm margin in the caudal, left - right (LR) and anterior directions while excluding the rectum and bladder in an attempt to ensure proper coverage of the CTV while sparing the adjacent OARs. The clinical constraints are presented inTable 1 .
The clinical target volume (CTV) for these five patients contained the body of the prostate. The PTV structure prescribed at 57 Gy was created using an isotropic margin of 5 mm around the CTV. Moreover, an extended boost volume (EBV) prescribed at 62 Gy was formed by using a margin of 5 mm margin in the caudal, left - right (LR) and anterior directions while excluding the rectum and bladder in an attempt to ensure proper coverage of the CTV while sparing the adjacent OARs. The clinical constraints are presented in
Prostate planning constraints, where EBV is the extended boost volume and PTV as the planning target volume.
| VOI | Constraints | ||
|---|---|---|---|
| EBV_62 | V58.9 Gy | 99% | |
| PTV_57 | V54.15 Gy | 99% | |
| Rectum | V62Gy | 1 cm3 | |
| V60Gy | ⩽ | 5% | |
| V40Gy | ⩽ | 50% | |
| Bladder | V62Gy | 1 cm3 | |
| V60Gy | ⩽ | 10% | |
| V40Gy | ⩽ | 50% | |
| Femur heads | V40Gy | ⩽ | 50% |
6
Comparison of HT and VMAT Lung Plans
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The HT and VMAT plans were generated by single dosimetrist using HiArt v.4.1.2 (Accuray, Sunyvalle, CA, USA) and Monaco v 5.11 (Elekta, Stockholm, Sweden) treatment planning systems, respectively. A field width of 2.51 cm, 0.287 pitch, 3–3.5 modulation factors, and 850 MU/min dose rates were used for HT planning. The VMAT plan used a technique involving two partial arcs that was designed to correspond with the tumor location in the lungs in order to avoid delivering a high dose to the OARs. For the structure prioritization, the order for each case varied depending on the types of OARs that were close to the tumor. However, the organ priority was the same for both the HT and VMAT plans. The final dose distribution was calculated by the Collapsed cone convolution algorithm with a grid spacing of 2.5 mm for HT and the XVMC Monte Carlo algorithm with a grid spacing of 3 mm for VMAT.
7
Multicenter VMAT Plan Evaluation
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In this prospective study, 73 subsequent VMAT clinical treatment plans treated between November 2018 and April 2019 were selected for evaluation. The cases were categorized into four clinical sites: Head and Neck (n = 19), Thorax (n = 16), Abdomen (n = 17), and Pelvis (n = 22). All treatment plans were generated using Monaco v5.11 (Elekta AB, Sweden) TPS based on Monte Carlo dose calculation algorithm using a dose grid of 2.5 mm and a nominal acceleration potential of 6 MV was used. All plans were delivered on an Infinity® (Elekta, Stockholm, Sweden) linear accelerator equipped with Agility™ multileaf collimators (MLC).
8
Standardized Breast Immobilization Protocol for CT Simulation
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All patients were simulated in the head first, supine position using the carbon fiber breast bracket (Klarity Inc, Guangzhou, China) for body immobilization. The supporting board inclined at a certain angle (7°/12°/17°/23° for choose) to assure that the sternum was horizontal. The head was positioned straight on a circle sponge head support, with the chin slightly upwards, avoiding skin folds at the lower neck. Both arms rose over the head using a pair of arm-support to expose the breast adequately, and a knee support to prevent the body sliding down. A thermoplastic film (electron density 0.3~0.7, thickness2.4mm) (Klarity Medical Products, Newark OH) was custom molded over the chest and attached to the bracket by a plastic batten (electron density1~1.1). Computed tomography (CT) image with a 3-mm-slice was performed using a large aperture CT Simulation scanner (Brilliance, Philips Medical System, Amsterdam, Netherlands) (Fig. 1). The scan range was from the first cervical vertebra to 2 cm below breast ruffle. The obtained simulation CT images were transferred to the treatment planning system (TPS, Monaco V5.11, Elekta AB, Stockholm, Sweden) for target and OAR delineation and formulate treatment planning.
9
CT-Based Planning for Rectal Cancer
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Simulation CT was performed with 3-mm slices in the prone position on a belly board. All the patients had made dietary preparation at least 1 week prior to the day of the CT scan. And cone beam CT or portal imaging was performed in general for the patients. The CT image was transferred to the workstation (Monaco V5.11, Elekta AB, Stockholm, Sweden), and the target volumes and critical organs were contoured. Clinical target volumes were contoured according to the recommendations of the Radiation Therapy Oncology Group (RTOG). Clinical target volumes were expanded by 5–7 mm (3–5 mm posterior) to produce planning target volumes (PTVs). The location of the anal verge was defined on the basis of the last caudal image of the external sphincter muscle in CT images. The anal canal volume was defined as the volume from the anal verge to 3 cm superior to the anal verge in planning CT images.
10
Dual Arc Radiotherapy Planning Technique
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All patients were laid in a supine position with both arms fully abducted and externally rotated on a vacuum cushion on the all-in-one board. Treatment planning CT scans at 5-mm intervals from the ear to 2 cm below the diaphragm were obtained for each patient with a CT simulator (Discovery CT590, GE, Wisconsin, USA). The target and OARs of this study were delineated following the Radiation Therapy Oncology Group (RTOG) and the International Commission Radiological Units (ICRU) (23 , 24 ). The two groups of patients were treated with continuous semi-arc technology and tangent-arc technology. Both plans were generated using the MonacoV5.11 (Elekta AB, Stockholm, Sweden) three-dimensional treatment planning system by the same senior medical physicist. The “Dual Arc” function provided by the treatment planning system was used to generate clockwise and counterclockwise dual arcs for each plan. The doses were normalized such that the dose to 95% of the planning target volume (PTV) was the same for all plans.
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