Dose optimization and calculation were performed on the Eclipse treatment planning system (version 10.0 or 11.0, Varian Medical System, USA) or the Monaco treatment planning system (version 3.2, Elekta, Sweden), according to the corresponding radiotherapy machines. Both VMAT and IMRT were generated using a 6 MV X-ray system. Based on the tumor volume and the degree of invasion, a single or double arc design was used in VMAT. A 7- or 9-field design was used for IMRT, with similar optimization conditions. The prescribed doses were as follows: 68-72 Gy to the PGTVnx, 64-68 Gy to the PGTVnd, 60 Gy to the PTV1, and 54-56 Gy to the PTV2, in 30-33 fractions. Radiation was delivered once per day, at 5 fractions per week. For all of the plans, the prescribed dose was required to cover at least 95% of the PTV. Besides, the totally volume that received exceed 110% of the prescribed dose was restrained less than 20% inside every PTV but not allowed in any area outside the PTVs. All efforts were made to prevent the dose received by OARs from exceeding the following RTOG0225 and RTOG0615 dose limits: maximum dose (Dmax) <45 Gy for the spinal cord; Dmax <54 Gy for the brain stem, optic nerve and optic chiasm; Dmax <8 Gy for the lens; Dmax <70 Gy for temporomandibular joint; Dmean <46 Gy for inner ear; and the percentage of parotid gland volume receiving 30 Gy (V30) <50%.
Monaco treatment planning system
Manufactured by Elekta
Sourced in United Kingdom, Sweden
The Monaco treatment planning system is a comprehensive radiation therapy planning solution developed by Elekta. It provides advanced tools and algorithms for the optimization and visualization of radiation therapy treatment plans. The core function of the Monaco system is to enable efficient and effective treatment planning for various radiation therapy modalities, including intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT).
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18 protocols using monaco treatment planning system
1
Dose Optimization and VMAT/IMRT Techniques for Nasopharyngeal Carcinoma
2
Radiation Therapy Workflow Protocol
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In this study, we used a Synergy Linear Accelerator, a MOSAIQ system, a MONACO treatment planning system (Elekta AB, Stockholm, Sweden), a computed tomography (CT) simulator (Philips, Amsterdam, the Netherlands), a movable laser light system (LAP, Germany), and a Stratasys F123 3D printer (Stratasys, Rehovot, Israel).
3
Breast Cancer Radiotherapy Treatment Planning
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Over the years, different treatment planning techniques were applied according to protocol in either the XiO or Monaco treatment planning system (Elekta AB, Stockholm, Sweden). All techniques were based on tangential opposing fields and planned on the DIBH planning CT: (1) a conformal planning technique, (2) a forward-planned field-in-field technique, or (3) a hybrid technique in which open beams deliver 70–80% of the dose and segments derived with inverse optimization deliver the remainder [24] (link). For all techniques, treatment plans generally consisted of four beams, with a maximum of eight in case of axilla involvement [11] (link). The number of monitor units per beam was restricted, so that the beam could be delivered within 25 s. In general, the delivery time per beam was between 12 and 18 s. Beams with energies of either 6 or 10 MV were used, or in combination, depending on the patient’s anatomy. Patients were treated either with a conventional fractionated (2 Gy in 25 fractions) or a hypofractionated schedule (2.66 Gy in 16 fractions, or 2.67 Gy in 15 fractions). When indicated, a sequential boost to the tumor bed was applied in 5 – 8 fractions.
4
Pediatric CSI Treatment Protocols
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The treatment data of eight pediatric patients who received CSI treatment are used in this study. The patients were 7 years of age on average, with ages ranging from 3 to 11 years with four female and four male pediatric patients who were presented for this study. CT images are transferred to a Monaco® treatment planning system (Elekta Medical Systems, Stockholm) where the target volumes (brain and spinal cavity) and organs at risk (OARs) were defined as per RTOG (0529 and 0539) guidelines. The clinical target volume (CTV) brain included the whole brain and the meninges. CTV spinal cavity included C1 through S2. The spinal cavity and brain PTVs were created by evenly growing with volumetric margins of 10 mm and 5 mm, respectively, in all directions from the corresponding CTVs. Heart, lungs, liver, mandible, stomach, bowel, external genitalia, kidneys, and optical structures such as eyes, lens, optic nerves, and optic chiasm were the OARs delineated and used for comparison.
5
Cervical Cancer Radiotherapy Protocol
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The clinical target volume (CTV) covers the uterus, cervix, gross tumor parametria, adequate vaginal margin from the gross disease (at least 3 cm), and regional nodes (common, internal, and external iliac nodes, obturator nodes, bilateral groin nodes; in patients with lower 1/3 vaginal involvement). The CTV was extended uniformly by 6 mm in every direction to generate the planning target volume (PTV). The small bowel, rectum, bladder, femoral heads, and bone marrow were delineated as organs at risk. Volumetric‐modulated arc therapy (VMAT) was produced by the Monaco treatment planning system (Elekta AB, Stockholm, Sweden). The PTV received 45 Gy in 25 fractions. Intracavitary, high‐dose rate (HDR) Cobalt‐60 brachytherapy was delivered twice weekly after receiving EBRT. The typical point A prescribed dose was five fractions of 6 Gy per fraction at a HDR. Patients with pelvic lymph nodes received boosts of an additional 10‐20 Gy, lymph nodes boosts was administrated 2 weeks after the end of CRT. The key organ‐at risk dosimetric constraints were the rectum and bladder volume receiving 45 Gy (V45) <45% and the bowel volume receiving <10%, respectively. All VMAT plans were normalized to cover approximately 98% of the PTV with 45Gy.
6
Thyroid Radiation Dosimetry and Hypothyroidism
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Before treatment, a computed tomography (CT) simulation scan, including plain and enhanced CT scans, were taken (slice thickness = 3 mm); the imaging area extended from the top of the head to 2 cm below the sternoclavicular joint. Contouring of the thyroid gland on the CT simulation images was performed with the Monaco treatment planning system (version 5.0, Elekta AB, Stockholm, Sweden). Dose-volume histograms were retrieved from the planning system, including absolute thyroid volume and the percentage of thyroid volume receiving more than 10, 20, 30, 40, 50, and 60 Gy (V10, V20, V30, V40, V50, and V60) of radiation. The percentage of thyroid volume receiving 0–10 Gy (V0,10) was calculated as 100% minus V10; V10,20, as V10 minus V20; V20,30, as V20 minus V30; V30,40, as V30 minus V40; V40,50, as V40 minus V50; V50,60, as V50 minus V60.
After treatment was completed, the patients were followed up at least every 3 months during the first 2 years, every 6 months for at least the next 3 years, and annually thereafter. The thyroid function test was performed during the follow-up visit. HT was diagnosed if the thyrotropin (TSH) level was higher than the upper limit of our institutional reference range (0.27–4.20 μIU/mL) and the free thyroxine (fT4) level was not higher than the upper limit of our institutional reference range (12.00–22.00 pmol/L), regardless of symptoms.
After treatment was completed, the patients were followed up at least every 3 months during the first 2 years, every 6 months for at least the next 3 years, and annually thereafter. The thyroid function test was performed during the follow-up visit. HT was diagnosed if the thyrotropin (TSH) level was higher than the upper limit of our institutional reference range (0.27–4.20 μIU/mL) and the free thyroxine (fT4) level was not higher than the upper limit of our institutional reference range (12.00–22.00 pmol/L), regardless of symptoms.
7
Precise Delineation of NPC Tumor Volumes Using IMRT
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All patients received radical IMRT and were immobilized in the supine position using a thermoplastic head, neck, and shoulder mask. Contrast-enhanced planning computed tomography (CT; 3 mm-slice thickness) images were obtained from the superior border of frontal sinus to 2 cm below sterno-clavicular joint and transferred to the Monaco treatment planning system (version 3.02; Elekta AB, Stockholm, Sweden).
The post-NACT GTVp and GTVnd were delineated on each slice of planning computed tomography (CT) images, according to the post-NACT MRI image by a radiation oncologist (FPC), and then verified by another radiation oncologist (YS) who specialized in NPC treatment. Enlarged retropharyngeal lymph nodes were encompassed in the GTVp, as it is a difficult issue to clearly distinguish the retropharyngeal nodes from primary tumor in NPC [12 (link),13 (link),14 (link)]. For patients whose primary tumor was directly contiguous with the regional nodes, a cut-off level at the mid-C2 vertebra was used to separate the GTVp from the GTVnd, as suggested by Chua et al. [17 (link)]. The volumes were calculated by the treatment planning system using the summation-of-area technique, which multiplies the entire areas by the image reconstruction interval of 3 mm.
The post-NACT GTVp and GTVnd were delineated on each slice of planning computed tomography (CT) images, according to the post-NACT MRI image by a radiation oncologist (FPC), and then verified by another radiation oncologist (YS) who specialized in NPC treatment. Enlarged retropharyngeal lymph nodes were encompassed in the GTVp, as it is a difficult issue to clearly distinguish the retropharyngeal nodes from primary tumor in NPC [12 (link),13 (link),14 (link)]. For patients whose primary tumor was directly contiguous with the regional nodes, a cut-off level at the mid-C2 vertebra was used to separate the GTVp from the GTVnd, as suggested by Chua et al. [17 (link)]. The volumes were calculated by the treatment planning system using the summation-of-area technique, which multiplies the entire areas by the image reconstruction interval of 3 mm.
8
Optimization of SIB IMRT for Head and Neck Cancer
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Optimization was performed by using the Monaco treatment planning system (version 3.1, Elekta Medical Systems, Crawley, UK) and doses were calculated with the Monte Carlo algorithm [14 (link)]. Both plans with pre-correction and post-correction margins were generated for an Elekta Synergy linear accelerator (Elekta, Crawley, UK) using 6-MV photons. A standard constraint set referring to RTOG0615 was used for optimization and evaluation. The aim was to achieve 95% of any PTV at or above the prescription dose, 99% of any PTV at or above 93% of the PTV dose, no more than 20% of the PTV_7000 at or above 77 Gy (that is, 110% of the PTV_7000 dose), and no more than 5% of any PTV_7000 at or above 80.5 Gy (that is, 115% of the PTV_7000 dose). For OARs, the most important objective was to keep maximum doses to the 1% of the PRV of the spinal cord (SpinalCord_PRV) below 50 Gy and to the 1% of the PRV of the brain stem (BrainStem_PRV) below 60 Gy. The second priority was to ensure that 50% of the parotid glands received a dose < 30 Gy (to be achieved in at least one gland). All targets were treated simultaneously by using the simultaneous integrated boost (SIB) technique.
9
Intensity-Modulated Radiotherapy Protocol for Nasopharyngeal Carcinoma
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All patients were treated with IMRT. Delineation of the target volume was in accordance with the treatment protocol of our institution8 and the International Commission on Radiation Units and Measurements reports 50 and 62. All targets were treated simultaneously using the simultaneous integrated boost technique. Intensity‐modulated RT was generated for an Elekta and Varian linear accelerator using 6 MV photons, and delivered in the step‐and‐shoot and sliding window mode. Dose optimization and calculation for IMRT plan were performed on the Monaco treatment planning system (version 3.02; Elekta Medical Systems) using the Monte Carlo algorithm and eclipse treatment planning system (version 11.0; Varian Medical Systems) using the AAA algorithm. The prescribed doses were 66‐72 Gy/28‐33 fractions to the planning target volume (PTV) of the primary gross tumor volume (GTVnx), 64‐70 Gy/28‐33 fractions to the GTV PTV of the involved lymph nodes (GTVnd), 60‐63 Gy/28‐33 fractions to the high‐risk clinical target volume PTV (CTV1), and 54‐56 Gy/28‐33 fractions to the low‐risk clinical target volume PTV (CTV2). Overall, 293 (84.9%) patients received platinum‐based neoadjuvant, concomitant, or adjuvant chemotherapy, whereas 52 (15.1%) patients did not.
10
Thyroid Dose-Volume Histogram Analysis
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Dose‐volume histograms (DVHs) for the thyroid gland were computed from the three‐dimensional (3D) dose distributions and exported from treatment plans of the Monaco treatment planning system (version 3.02; Elekta Medical Systems) and eclipse treatment planning system (version 11.0; Varian Medical Systems). We investigate potential threshold doses in 5 Gy increments, ranged from 5 to 70 Gy, and the percentages of thyroid volume that received more than one of these potential threshold doses of radiation (VDose) were calculated.
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