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XiO

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XiO

®® Manufacturer Japan Manufacturer Japan CMS, Inc. CMS, Inc.

1145 Corporate Lake Drive 1145 Corporate Lake Drive Suite 100 St. Louis, Missouri 63132 Suite 100 St. Louis, Missouri 63132 USA USA http://www.cmsrtp.com http://www.cmsrtp.com Phone: Phone: 1-314-993-001-314-993-000303 Toll Free: Toll Free: 1-800-878-4261-800-878-42677 FAX: FAX: 1-314-993-0071-314-993-00755 Email:

Email: [email protected]@cmsrtp.com Customer Support:

Customer Support: North, Central and South AmNorth, Central and South Americaerica Phone:

Phone: 1-800-878-1-800-878-4CMS (4267)4CMS (4267) Email:

Email: [email protected]@cmsrtp.com

CMS, Japan, K.K. CMS, Japan, K.K. Nagatacho Bldg. 2-4-3, Nagata-cho, Nagatacho Bldg. 2-4-3, Nagata-cho, Chiyoda-ku, Tokyo 100-0014 Chiyoda-ku, Tokyo 100-0014 Japan Japan Phone: Phone: 81-3-3580-71081-3-3580-71000 FAX: FAX: 81-3-3580-7181-3-3580-712020 Email:

Email: [email protected]@cmsrtp.com Customer

Customer Support: Support: JapanJapan Phone: +81-3-3556-5391 Phone: +81-3-3556-5391 Email:

European

European Union Union AsiaAsia CMS GmbH CMS GmbH Heinrich-von-St Heinrich-von-Stephan Str. 5 ephan Str. 5 bb 79100 Freiburg 79100 Freiburg Germany Germany Phone: Phone: +49-761-8818+49-761-88188-08-0 Toll Free:

Toll Free: +800-4000-5+800-4000-5000 (regionally limited)000 (regionally limited) FAX:

FAX: +49-761-88188+49-761-88188-11-11 Free FAX:

Free FAX: +800-4000-500+800-4000-5001 (regionally limited)1 (regionally limited) Email:

Email: [email protected]@cmsrtp.com Customer Support

Customer Support:: Europe, Middle East and AfricaEurope, Middle East and Africa Phone: +49-761-88188-0

Phone: +49-761-88188-0 Email:

European Union Authorized Representative European Union Authorized Representative Paul Shane Bennetts

Paul Shane Bennetts M Devices Group M Devices Group

Marlborough House, Riding Street Marlborough House, Riding Street Southport PR8 1EW UK Southport PR8 1EW UK Phone: (0) 1704 544 944 Phone: (0) 1704 544 944 CMS Worldwide Corp. CMS Worldwide Corp.

25th Floor, Suntime International Mansion 25th Floor, Suntime International Mansion #450 Fushan Road #450 Fushan Road Pudong, Shanghai 200122 Pudong, Shanghai 200122 P.R. China P.R. China Phone: Phone: +86-215058-+86-215058-10411041 FAX: FAX: +86-215058-+86-215058-10451045 Email:

Email: [email protected]@cmsrtp.com Customer Su

Customer Support: pport: ChinaChina Phone:

Phone: +86-215058-1+86-215058-1041041 Email:

Email: [email protected]@cmsrtp.com Customer Suppor

Customer Support: t: Asia, Australia and Asia, Australia and New ZealandNew Zealand CMS Worldwide Corp

CMS Worldwide Corp

Suite 15 International Business Suite 15 International Business CentreCentre Australian Technology Park

Australian Technology Park Eveleigh, Sydney NSW 1430 Eveleigh, Sydney NSW 1430 Australia Australia Phone: Phone: 61-2-9209-45061-2-9209-45077 FAX: FAX: 61-2-9209-4161-2-9209-415454 Email:

Email: [email protected]@cmsrtp.com Revision History

Revision History Revision

Revision Date Date ChangesChanges XiO_URG_430_

XiO_URG_430_ENG_A.pdf ENG_A.pdf 07/18/2005 07/18/2005 New New documentdocument XiO_URG_430_

XiO_URG_430_ENG_B.pdf ENG_B.pdf 06/30/2006 06/30/2006 Update Update screen screen shots shots for for new new logo; logo; contact contact informationinformation XiO_URG_434_EN

XiO_URG_434_ENG_A.pdf G_A.pdf 03/07/2007 03/07/2007 Update Update for for release release 4.344.34 Trademarks

Trademarks

All terms mentioned in this manual that are known trademarks, registered trademarks, or service marks have been All terms mentioned in this manual that are known trademarks, registered trademarks, or service marks have been appropriately labeled as such. Other products, services, or terms that are referred to in this manual may be

appropriately labeled as such. Other products, services, or terms that are referred to in this manual may be trademarks,trademarks, registered trademarks, or service marks of their respective owners. CMS makes no claim to these trademarks. Use of registered trademarks, or service marks of their respective owners. CMS makes no claim to these trademarks. Use of a terma term in this manual should not be regarded as affecting the validity of any trademark, registered trademark, or service mark. in this manual should not be regarded as affecting the validity of any trademark, registered trademark, or service mark. CMS® is a registered trademark of CMS, Inc.

CMS® is a registered trademark of CMS, Inc. XiO® is a registered trademark of CMS, Inc. XiO® is a registered trademark of CMS, Inc. Adobe

Adobe™™_{, Acrobat}_{, Acrobat}™™_{, and the Acrobat logo are trademarks of Adobe Systems Incorporated, which may be registered in}_{, and the Acrobat logo are trademarks of Adobe Systems Incorporated, which may be registered in}

certain

certain jurisdictionjurisdictions.s. Hewlett-Packard

Hewlett-Packard™™_{is a trademark}_{is a trademark of Hewlett-Packard Corporation.}_{of Hewlett-Packard Corporation.}

Netscape

Netscape®®and Netscape Navigatorand Netscape Navigator®®are registered trademarks of Netscape are registered trademarks of Netscape Communications CorporatCommunications Corporation in the Unitedion in the United States and other countries. Netscape's logos and Netscape product and service names are also

States and other countries. Netscape's logos and Netscape product and service names are also trademarks of Netscapetrademarks of Netscape Communications Corporat

Communications Corporation, which may be ion, which may be registered in other countries.registered in other countries. UNIX

UNIX®®is a registered trademark in is a registered trademark in the United States and the United States and other countries, licensed exclusively through X/Open Companyother countries, licensed exclusively through X/Open Company Ltd.

Ltd.

Red Hat and all Red Hat-based trademarks and logos are trademarks or registered trademarks of Red

Red Hat and all Red Hat-based trademarks and logos are trademarks or registered trademarks of Red Hat, Inc. in the UnitedHat, Inc. in the United States and other countries.

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iv _Document_{Document Name:}_{Name: X}_{XiiO_U}_{O_UR}_RG_{G_434_E}_{_434_ENG}_{NG_A.p}_{_A.pdf}_df

Microsoft®, W

Microsoft®, Windows®, and Windows NT® are registered trademarks of Microsoft Corporation in the United indows®, and Windows NT® are registered trademarks of Microsoft Corporation in the United States andStates and other countries.

other countries.

Performance characteristics given in this manual are for reference only and are not intended as guaranteed specifications. Performance characteristics given in this manual are for reference only and are not intended as guaranteed specifications.

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XiO

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Overview

Welcome to XiO! You join thousands of clinicians worldwide who use Welcome to XiO! You join thousands of clinicians worldwide who use XiO to develop treatment plans for cancer patients. As

XiO to develop treatment plans for cancer patients. As you work withyou work with XiO, you will appreciate the remarkable capability you now have XiO, you will appreciate the remarkable capability you now have toto create extremely accurate treatment plans in a

create extremely accurate treatment plans in a minimum amouminimum amount of time.nt of time. In this guide, you will read about the

In this guide, you will read about the underlying concepts that help youunderlying concepts that help you understand the software’s features.

understand the software’s features. XiO is a

XiO is a combination of two-dimensional, three-dimensicombination of two-dimensional, three-dimensional, and IMRTonal, and IMRT radiation treatment planning systems, representing over five

radiation treatment planning systems, representing over five hundredhundred “man years” of cumulative research and development by Computerized “man years” of cumulative research and development by Computerized Medical Systems’ (CMS) scientific staff and academic partners.

Medical Systems’ (CMS) scientific staff and academic partners. While many XiO features are discussed in this guide, some are

While many XiO features are discussed in this guide, some are licensedlicensed individually and it is possible that some topics discussed are not

individually and it is possible that some topics discussed are not available to you. Review your sales contract to

available to you. Review your sales contract to verify the hardware andverify the hardware and software features that were installed at your site

software features that were installed at your site and activated by theand activated by the CMS technician.

CMS technician.

Intended Users of the XiO RTP System

The XiO radiation treatment planning (RTP) system is intended to be The XiO radiation treatment planning (RTP) system is intended to be used by qualified individuals. An intended user should be either a used by qualified individuals. An intended user should be either a

Certified Medical Physicist, a Certified Medical Dosimetrist (CMD), or Certified Medical Physicist, a Certified Medical Dosimetrist (CMD), or aa Registered Radiation Therapy Technologist (RTT), all under the

Registered Radiation Therapy Technologist (RTT), all under the direction of the Radiation Oncologist (MD).

direction of the Radiation Oncologist (MD). They should be knowledgeable in

They should be knowledgeable in radiation treatment planningradiation treatment planning conventions, should be certified by

conventions, should be certified by their respective national accreditingtheir respective national accrediting agency, and should hold all appropriate state and federal

agency, and should hold all appropriate state and federal licenses.licenses.

Intended Use of the XiO RTP System

The XiO RTP System is used

The XiO RTP System is used to create treatment plans for any to create treatment plans for any cancercancer patient for whom external beam radiation therapy or brachytherapy has patient for whom external beam radiation therapy or brachytherapy has been prescribed. The system will calculate and display, both on-screen been prescribed. The system will calculate and display, both on-screen and in hard-copy, either two- or

and in hard-copy, either two- or three-dimensionthree-dimensional radiation doseal radiation dose distribution

distributions within a patient for s within a patient for a given treatment plan set-up.a given treatment plan set-up.

The XiO online documentation contains detailed information on how The XiO online documentation contains detailed information on how thethe system is intended to be used. The

system is intended to be used. The XiO Training Guide XiO Training Guidecontainscontains examples that explain how the system is intended to be used.

examples that explain how the system is intended to be used. You areYou are responsible for ensuring that you use the system in this manner. responsible for ensuring that you use the system in this manner.

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The examples and figures

The examples and figures used throughout the XiO online documentationused throughout the XiO online documentation and

and XiO Training Guide XiO Training Guidedemonstrate specific aspects of the XiO RTPdemonstrate specific aspects of the XiO RTP system. These figures and examples do not necessarily reflect what system. These figures and examples do not necessarily reflect what isis used in a clinical setting and,

used in a clinical setting and, as such, should not be used as as such, should not be used as examples forexamples for treatment planning.

treatment planning.

Training on the XiO RTP System

CMS, Inc.,

CMS, Inc., provides extensive training when the system is installed at theprovides extensive training when the system is installed at the site and has Customer Support Specialists available to answer questions site and has Customer Support Specialists available to answer questions and handle problems encountered during day-to-day

and handle problems encountered during day-to-day operation.operation. The

The XiO Training Guide XiO Training Guidewas designed to supplement CMS training bywas designed to supplement CMS training by explaining how to use the system to set up

explaining how to use the system to set up a treatment plan. The XiOa treatment plan. The XiO online documentation contains detailed explanations on how the

online documentation contains detailed explanations on how the systemsystem works. These manuals are not intended to replace

works. These manuals are not intended to replace CMS training.CMS training. You are responsible for ensuring that all people

You are responsible for ensuring that all people using XiO to generateusing XiO to generate treatment plans have been trained to use

treatment plans have been trained to use the system prior to using athe system prior to using a patient’s treatment plan in a treatment course. If

patient’s treatment plan in a treatment course. If you do not, the plansyou do not, the plans may not be correct, and

may not be correct, and an incorrect dose may be an incorrect dose may be administered to theadministered to the patient.

patient.

Us

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XiO R

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Before using the XiO RTP

Before using the XiO RTP system in clinical applications, you shouldsystem in clinical applications, you should determine the suitability and accuracy of the software for

determine the suitability and accuracy of the software for its intendedits intended use. Only after thoroughly testing and accepting the results from the use. Only after thoroughly testing and accepting the results from the system should you release the software for

system should you release the software for use in your clinic or hospital.use in your clinic or hospital. Remember, treatment plans derived from the use of

Remember, treatment plans derived from the use of this equipment arethis equipment are dependent on data entry made by

dependent on data entry made by those professionals trained to use thethose professionals trained to use the system. As such, treatment plans derived from this equipment should not system. As such, treatment plans derived from this equipment should not be substituted for human judgment. You should verify all treatment plans be substituted for human judgment. You should verify all treatment plans and patient and source data before

and patient and source data before using them in a treatment course.using them in a treatment course.

P

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og

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am Licen

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All terms, provisions, and conditions stated in the Program License All terms, provisions, and conditions stated in the Program License Agreement for XiO apply.

Agreement for XiO apply.

CMS, Inc., must have a signed program license agreement from you on CMS, Inc., must have a signed program license agreement from you on file before you can use the software or contents of the XiO

file before you can use the software or contents of the XiO documentation.

documentation.

A copy of your signed agreement can

A copy of your signed agreement can be obtained by contacting yourbe obtained by contacting your Customer Support Specialist.

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XiO

®®

The B

The Bas

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of a Treat

a Treat ment

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A treatment plan is fundamental when you plan a

A treatment plan is fundamental when you plan a treatment course for atreatment course for a cancer patient. It is a

cancer patient. It is a collection of data files from which the radiationcollection of data files from which the radiation dose data is calculated. A treatment plan

dose data is calculated. A treatment plan specifies how radiation sourcesspecifies how radiation sources are applied to a patient and

are applied to a patient and incorporates these items:incorporates these items: •

• _{Information about the patient}_{Information about the patient} •

• _{Information about the radiation sources used (the teletherapy}_{Information about the radiation sources used (the teletherapy} beams or the brachytherapy source groups)

beams or the brachytherapy source groups) •

• _{Information that describes how the radiation is to be}_{Information that describes how the radiation is to be applied to the}_{applied to the} patient

patient

P

lan

Types

XiO differentiates between plans that have been created

XiO differentiates between plans that have been created and savedand saved (called “permanent plans”) and plans that have not yet

(called “permanent plans”) and plans that have not yet been saved (calledbeen saved (called “temporary plans”). When you start a new

“temporary plans”). When you start a new treatment plan, that plan istreatment plan, that plan is temporary until you actually save it in the XiO

temporary until you actually save it in the XiO database. When you usedatabase. When you use or edit a plan that

or edit a plan that is already permanent, XiO provides a copy is already permanent, XiO provides a copy instead of instead of letting you work directly with the permanent plan; this copy is also a letting you work directly with the permanent plan; this copy is also a temporary plan. If you edit the temporary plan and

temporary plan. If you edit the temporary plan and then save it, XiOthen save it, XiO replaces the original permanent plan with the modified version. replaces the original permanent plan with the modified version.

Patient Data

XiO maintains demographic and anatomical data for each patient for XiO maintains demographic and anatomical data for each patient for whom treatment planning is performed. All patient data is stored under a whom treatment planning is performed. All patient data is stored under a unique, user-defined patient ID.

unique, user-defined patient ID.

D

Demographiemographic Dc Datataa

Patient demographic data about each patient is collected and stored for Patient demographic data about each patient is collected and stored for use in demographic studies and

use in demographic studies and tumor registry. Typical demographic datatumor registry. Typical demographic data includes patient name, address, telephone number, birth date, and gender. includes patient name, address, telephone number, birth date, and gender.

A

Anatnatomy Domy Datataa

Patient anatomical data identifies the disease sites. XiO categorizes Patient anatomical data identifies the disease sites. XiO categorizes information about patient anatom

information about patient anatomy in terms of y in terms of anatomical sites andanatomical sites and anatomical structure names. These are defined on a

anatomical structure names. These are defined on a clinic-by-clinic basisclinic-by-clinic basis and are applied to all

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Patient anatomy data is physical information about a patient. Patient Patient anatomy data is physical information about a patient. Patient anatomy data includes:

anatomy data includes: •

• _{Anatomical structure contours}_{Anatomical structure contours} •

• _{Tissue density of anatomical structures}_{Tissue density of anatomical structures}

Entering Patient Anatomy Data

Patient anatomy data can be entered into

Patient anatomy data can be entered into XiO in two forms: pixel imagesXiO in two forms: pixel images and contours.

and contours.

Pixel Images

Pixel images are images of

Pixel images are images of patient anatomical structures formed usingpatient anatomical structures formed using tissue density information stored in units called pixels. Specifically, a CT tissue density information stored in units called pixels. Specifically, a CT combined with the appropriate electron

combined with the appropriate electron density conversion filedensity conversion file determines the tissue density of a pixel-size area

determines the tissue density of a pixel-size area of patient tissue. MRIof patient tissue. MRI may also be used,

may also be used, but the pixel information does not determine the tissuebut the pixel information does not determine the tissue density. Using unique shades of color to represent each

density. Using unique shades of color to represent each pixel’s numericpixel’s numeric value, XiO constructs a patient anatomy image. Five or

value, XiO constructs a patient anatomy image. Five or more pixelmore pixel images in the

images in the same orientation comprise a three-dimensional patientsame orientation comprise a three-dimensional patient volume.

volume.

Although a pixel image contains the tissue density of many anatomical Although a pixel image contains the tissue density of many anatomical structures, it does not differentiate the structures. You must outline each structures, it does not differentiate the structures. You must outline each structure before XiO can use the

structure before XiO can use the pixel image data.pixel image data.

Figure 1: Pixel image Figure 1: Pixel image

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XiO

®® Figure 2: Contours Figure 2: Contours Contours Contours

In XiO, a single CT image is referred to as a cross section. Contours are In XiO, a single CT image is referred to as a cross section. Contours are connected line segments that outline the

connected line segments that outline the individual anatomical structuresindividual anatomical structures within a cross section. Individual structures include such things as the within a cross section. Individual structures include such things as the patient outline, the tumor, individual target r

patient outline, the tumor, individual target r egions, and individualegions, and individual organs (such as the lungs, the

organs (such as the lungs, the heart, or the spinal cord).heart, or the spinal cord). You create the contours in the

You create the contours in the Patient File Maintenance module of XiOPatient File Maintenance module of XiO using:

using: •

• _{A tablet (digitizer), which is used to}_{A tablet (digitizer), which is used to trace drawings from graph}_{trace drawings from graph} paper, a radiograph, or a hardcopy CT image.

paper, a radiograph, or a hardcopy CT image. •

• _{A mouse, which is used to}_{A mouse, which is used to either trace a structure’s contour}_{either trace a structure’s contour} directly from the screen or to select an area of the image for directly from the screen or to select an area of the image for automatic contouring (that is, the

automatic contouring (that is, the automatic generation of automatic generation of

individual contours in a cross section). XiO provides four methods individual contours in a cross section). XiO provides four methods of automatic contouring:

of automatic contouring: °

° _{Auto-by-Threshold}_{Auto-by-Threshold}−−_{XiO draws a contour around the edge}_{XiO draws a contour around the edge} of a sharply delineated structure by

of a sharply delineated structure by detecting the abruptdetecting the abrupt change in color.

change in color. °

° _{AutoSegmentation}_{AutoSegmentation}−−_{XiO draws a contour after}_{XiO draws a contour after analyzing}_analyzing subtle changes in gray level and

subtle changes in gray level and intensity taken from a user-intensity taken from a user-defined segment of the image.

defined segment of the image. °

° _{Auto Margin}_{Auto Margin}−−_{XiO draws a second contour around a}_{XiO draws a second contour around a} structure. XiO also offers three-dimensional variable auto structure. XiO also offers three-dimensional variable auto margin and the ability to draw one

margin and the ability to draw one contour around acontour around a structure combination.

structure combination. °

° _{Interpolation}_{Interpolation}−− _{XiO generates contours on cross sections that}_{XiO generates contours on cross sections that} lie between the beginning and ending contours that you lie between the beginning and ending contours that you specify.

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Figure 3: Contour with an automatically generated margin. Figure 3: Contour with an automatically generated margin.

Contours can be imported along with digital image data in the

Contours can be imported along with digital image data in the DICOMDICOM 3.0 image format.

3.0 image format.

Although a contour image contains the contours of many anatomical Although a contour image contains the contours of many anatomical structures, it does not contain the tissue density of

structures, it does not contain the tissue density of each structure. Youeach structure. You must enter the tissue density of each

must enter the tissue density of each structure or use a pixel-by-pixelstructure or use a pixel-by-pixel calculation instead of assigning a value to a

calculation instead of assigning a value to a structure before XiO can usestructure before XiO can use the contour data. XiO prompts you for this

the contour data. XiO prompts you for this information.information.

Figure 4: Pixel image with contours traced on Figure 4: Pixel image with contours traced on it.it.

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XiO

®®

Figure 5: Zoom in on the image to see each of the tiny

Figure 5: Zoom in on the image to see each of the tiny squares, or pixels, thatsquares, or pixels, that make up the image.

make up the image.

Five or more cross sections in the

Five or more cross sections in the same orientation comprise a three-same orientation comprise a three-dimensional patient volum

dimensional patient volume. It is e. It is important to remember that at least oneimportant to remember that at least one contour in a cross section outline must be the

contour in a cross section outline must be the patient’s external outlinepatient’s external outline (the skin).

(the skin).

Anatomy Data Classifications

S

Sttudysudysetetss

Studysets are sets of cross sections intended for use

Studysets are sets of cross sections intended for use with a specificwith a specific

treatment plan. Studysets can be broken down into image-based and treatment plan. Studysets can be broken down into image-based and non-image-based studysets. Because isodose treatment plans require at least image-based studysets. Because isodose treatment plans require at least one transverse patient cross section, any studyset to be used

one transverse patient cross section, any studyset to be used in an isodosein an isodose treatment plan must contain one. Each studyset is referenced by

treatment plan must contain one. Each studyset is referenced by aa studyset ID.

studyset ID.

Predefined Anatomy Site

An anatomical site is a description of a

An anatomical site is a description of a particular area of the body particular area of the body (for(for example, “head and neck,” “lung,” or

example, “head and neck,” “lung,” or “prostate”). In general, these sites“prostate”). In general, these sites correspond to the anatomy surrounding a specific region of the

correspond to the anatomy surrounding a specific region of the body.body. These sites are user-definable and vary

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Anatomical information can be obtained from pixel images or contours. Anatomical information can be obtained from pixel images or contours. XiO reconstructs pixel images (such as CT images) from numeric

XiO reconstructs pixel images (such as CT images) from numeric valuesvalues captured by the scanner or

captured by the scanner or other imaging machine.other imaging machine.

Each anatomical site contains corresponding internal structures Each anatomical site contains corresponding internal structures

(contours) identified by anatomical structure names. For example, the (contours) identified by anatomical structure names. For example, the anatomical site “lung” might contain anatomical structures

anatomical site “lung” might contain anatomical structures named “rightnamed “right lung,” “left lung,” “heart,” and

lung,” “left lung,” “heart,” and “spinal cord.” These structure names are“spinal cord.” These structure names are also user-definable. Each anatomical structure name has one of

also user-definable. Each anatomical structure name has one of threethree classification types assigned to it:

classification types assigned to it: •

• _General_General−−_{Includes the structure names}_{Includes the structure names automatically included in}_{automatically included in} each anatomical site. General structures are

each anatomical site. General structures are further divided into thefurther divided into the following categories:

following categories: °

° _Patient_Patient−−_{The patient’s external outline (the skin); this}_{The patient’s external outline (the skin); this} structure is always required. All other structure definitions structure is always required. All other structure definitions are optional.

are optional. °

° _{Tumor (Tum)}_{Tumor (Tum)} −−_{The tumor to be treated.}_{The tumor to be treated.} °

° _{Target Volumes 1 through 5 (TV1, TV2,}_{Target Volumes 1 through 5 (TV1, TV2, TV3, TV4, and}_{TV3, TV4, and} TV5)

TV5)−−_{The area defined as}_{The area defined as the tumor plus a user-defined}_{the tumor plus a user-defined} margin to account for microscopic extensions of the tumor margin to account for microscopic extensions of the tumor that cannot be precisely seen and to allow for a margin of that cannot be precisely seen and to allow for a margin of error in defining the tumor.

error in defining the tumor. •

• _{Specific – Includes structure names inside of the}_{Specific – Includes structure names inside of the patient contour}_{patient contour} other than the tumor and target volumes.

other than the tumor and target volumes. •

• _User-defined_User-defined−− _{Includes all user-defined structure names for}_{Includes all user-defined structure names for} individual sites.

individual sites. If you don’t add a

If you don’t add a predefined site, you only have general and predefined site, you only have general and specificspecific contour names.

contour names.

Patient Anatomy File Identification

An anatomy file is identified by its orientation, location, and anatomy An anatomy file is identified by its orientation, location, and anatomy data mode.

data mode.

Orientation

The orientation of a cross

The orientation of a cross section is determined by its position relative tosection is determined by its position relative to the patient coordinate system axes. A cross

the patient coordinate system axes. A cross section can be orthogonalsection can be orthogonal (perpendicular to one of the three

(perpendicular to one of the three axes) or semi-orthogonal (at someaxes) or semi-orthogonal (at some angle other than 90 to the axes).

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XiO

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Orthogonal planes are classified as being transverse, sagittal, or coronal. Orthogonal planes are classified as being transverse, sagittal, or coronal.

•

• _{Cross sections or image planes that are}_{Cross sections or image planes that are perpendicular to the patient}_{perpendicular to the patient} Y

Yppaxis are calledaxis are calledtransversetransverse..

•

• _{Cross sections or image planes that are}_{Cross sections or image planes that are perpendicular to the patient}_{perpendicular to the patient} X

Xppaxis are calledaxis are calledsagittalsagittal..

•

• _{Cross sections or image planes that are}_{Cross sections or image planes that are perpendicular to the patient}_{perpendicular to the patient} Z

Zppaxis are calledaxis are calledcoronalcoronal..

Figure 6: Patient orientation Figure 6: Patient orientation

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Location

The location of each cross section within a

The location of each cross section within a patient is also determined bypatient is also determined by its reference distance. The reference

its reference distance. The reference distance of a cross section specifiesdistance of a cross section specifies the coordinate where the plane containing the cross section intersects the the coordinate where the plane containing the cross section intersects the patient axis to which it is

patient axis to which it is perpendicular.perpendicular.

Figure 7: Reference distance Figure 7: Reference distance

Ana

Anattomy Daomy Datta Ma Modeode

The anatomy data mode describes whether contours or pixels are

The anatomy data mode describes whether contours or pixels are defineddefined and, for pixel data,

and, for pixel data, what parameter the pixel values denote. The possiblewhat parameter the pixel values denote. The possible anatomy data modes (and their standard abbreviations) are:

anatomy data modes (and their standard abbreviations) are: •

• _{Wireframe contours (WC)}_{Wireframe contours (WC)} •

• _{Computed tomography (CT)}_{Computed tomography (CT)} •

• _{Electron density converted from CT pixels (EP)}_{Electron density converted from CT pixels (EP)} •

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XiO

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P

l

an Modes

A treatment plan can be

A treatment plan can be two-dimensitwo-dimensional or three-dimensional (2-D or 3-onal or three-dimensional (2-D or 3-D), based on the nature of the studyset. The plan mode affects how the D), based on the nature of the studyset. The plan mode affects how the plan appears on the screen, how the plan is set up, and how the dose is plan appears on the screen, how the plan is set up, and how the dose is calculated.

calculated. •

• _{If the plan has a}_{If the plan has a studyset with fewer than five transverse cross}_{studyset with fewer than five transverse cross} sections, the planning mode is set to 2-D.

sections, the planning mode is set to 2-D. In this mode, onlyIn this mode, only individual cross sections are displayed on the screen.

individual cross sections are displayed on the screen.

Representations of beams and treatment aids are displayed in Representations of beams and treatment aids are displayed in twotwo dimensions.

dimensions. •

• _{If the plan uses five to 30 transverse cross sections, you can set up}_{If the plan uses five to 30 transverse cross sections, you can set up} the treatment plan as 2-D or 3-D.

the treatment plan as 2-D or 3-D. •

• _{If you have more}_{If you have more than 30 cross sections, you can}_{than 30 cross sections, you can display individual}_{display individual} cross sections or a patient volume constructed from several cross cross sections or a patient volume constructed from several cross sections in 3-D.

sections in 3-D.

Intensity Modulated Radiation Therapy

When creating a 3-D treatment plan, you

When creating a 3-D treatment plan, you also have the option of also have the option of Intensity Modulated Radiation Therapy (IMRT). In IMRT, rather Intensity Modulated Radiation Therapy (IMRT). In IMRT, rather thanthan manipulating beam parameters to achieve a

manipulating beam parameters to achieve a suitable dose distribution,suitable dose distribution, you “reverse” the process by defining the clinical

you “reverse” the process by defining the clinical goals first and thengoals first and then allowing the optimization algorithm to find the

allowing the optimization algorithm to find the best configuration of best configuration of beam intensities.

beam intensities.

Interest Points and Markers

Optional interest points and markers can be defined on each Optional interest points and markers can be defined on each crosscross section. Interest points are used to obtain dose calculations at specific section. Interest points are used to obtain dose calculations at specific points in a cross section. Markers are

points in a cross section. Markers are used to mark specific points inused to mark specific points in anatomical structures. Dose is not calculated at markers.

anatomical structures. Dose is not calculated at markers. Interest points and markers are defined in two

Interest points and markers are defined in two places within XiO:places within XiO: •

• _{In the actual studyset, while entering cross sections. These points}_{In the actual studyset, while entering cross sections. These points} are available in any treatment plan containing this cross section. are available in any treatment plan containing this cross section. •

• _{While you are setting up the}_{While you are setting up the treatment plan. These points are}_{treatment plan. These points are} available only for this treatment plan.

available only for this treatment plan. •

• _{Interest points and markers are affected by}_{Interest points and markers are affected by the treatment planning}_{the treatment planning} mode:

mode: °

° _{Interest points and markers}_{Interest points and markers in three-dimensional planning}_{in three-dimensional planning} mode can be defined, moved, or added to anywhere in the mode can be defined, moved, or added to anywhere in the patient including between cross sections.

patient including between cross sections. °

° _{Interest points and markers}_{Interest points and markers in two-dimensional planning}_{in two-dimensional planning} mode must be located on individual cross sections in the mode must be located on individual cross sections in the

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orientation in which the point was originally defined. In orientation in which the point was originally defined. In other words, a point originally defined on a

other words, a point originally defined on a transverse crosstransverse cross section can be relocated only to

section can be relocated only to relevant transverse crossrelevant transverse cross sections and cannot be located between cross sections. sections and cannot be located between cross sections. In XiO, interest points and markers are

In XiO, interest points and markers are displayed using the same symboldisplayed using the same symbol (+), but in different colors.

(+), but in different colors.

Calculation Region

The calculation region is that region in the

The calculation region is that region in the patient anatomy for which thepatient anatomy for which the radiation dose will be calculated. Only points inside (including on the radiation dose will be calculated. Only points inside (including on the edge) of this region are

edge) of this region are used during dose calculation.used during dose calculation. The type of calculation region used in

The type of calculation region used in the treatment plan is called thethe treatment plan is called the calculation mode. The calculation area and region are

calculation mode. The calculation area and region are specified by theirspecified by their x, y, and

x, y, and z coordinates. The possible modes include:z coordinates. The possible modes include: •

• _Volume_Volume −−_{Available only for three-dimensional plans, a}_{Available only for three-dimensional plans, a} calculation volume consists of user-definable, equally spaced calculation volume consists of user-definable, equally spaced calculation points along each dimension of the volume. You may calculation points along each dimension of the volume. You may specify the volume’s size, its center position, and the

specify the volume’s size, its center position, and the number of number of points in each dimension or grid spacing to place calculation points in each dimension or grid spacing to place calculation points. The system calculates the radiation dose for each

points. The system calculates the radiation dose for each point inpoint in the matrix, along with any interest points you have specified. the matrix, along with any interest points you have specified. •

• _{Selected Planes}_{Selected Planes}−−_{Available when two- or}_{Available when two- or three-dimensional}_{three-dimensional} treatment plans are used, this method calculates dose for an

treatment plans are used, this method calculates dose for an area onarea on user-selected cross sections. This area is divided into a

user-selected cross sections. This area is divided into a series of series of equally spaced calculation points along the two dimensions of the equally spaced calculation points along the two dimensions of the area. You may specify the

area. You may specify the orientations and reference distances fororientations and reference distances for each cross section, the dimensions along two of the

each cross section, the dimensions along two of the axes that applyaxes that apply to the plane, two center

to the plane, two center coordinates of the calculation area, and thecoordinates of the calculation area, and the number of points in each dimension or grid spacing to

number of points in each dimension or grid spacing to placeplace calculation points. The system calculates the radiation dose for calculation points. The system calculates the radiation dose for each point in the matrix, along with any

each point in the matrix, along with any interest points you haveinterest points you have specified.

specified. •

• _{Interest Points Only}_{Interest Points Only} −−_{This mode is available when interest points}_{This mode is available when interest points} are defined in the

are defined in the treatment plan. Each calculation point is definedtreatment plan. Each calculation point is defined by its coordinates in the patient coordinate system. The system by its coordinates in the patient coordinate system. The system calculates the dose only at the specified interest points.

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XiO

®®

Figure

Figure 8: 8: 3-D 3-D calculation calculation region region Figure Figure 9: 9: 2-D 2-D calculation calculation regionregion

Tis

Tisssue Due Densensitity Hetery Heterogogeneiteneitiesies

Tissue density heterogeneities are tied to the calculation region and may Tissue density heterogeneities are tied to the calculation region and may be either included or excluded in dose

be either included or excluded in dose calculation.calculation. When the heterogeneities are not considered in the dose

When the heterogeneities are not considered in the dose calculation, thecalculation, the entire volume inside the patient surface is calculated as

entire volume inside the patient surface is calculated as homogeneoushomogeneous water. The relative electron densities of the anatomical structures and water. The relative electron densities of the anatomical structures and tumors will be ignored.

tumors will be ignored.

Use heterogeneity corrections to account for innate variability in the Use heterogeneity corrections to account for innate variability in the anatomy, density, and geometry of

anatomy, density, and geometry of individual patients.individual patients.

When the heterogeneities are considered in the dose calculation, two When the heterogeneities are considered in the dose calculation, two different methods of deriving the

different methods of deriving the tissue densities (relative electrontissue densities (relative electron densities) inside the patient exist. These are:

densities) inside the patient exist. These are: •

• _{For non-image-based and image-based cross sections, the method}_{For non-image-based and image-based cross sections, the method} uses user-assigned relative electron densities, which

uses user-assigned relative electron densities, which assume thatassume that the entire region inside each user-defined contour is homogeneous the entire region inside each user-defined contour is homogeneous with one relative electron density.

with one relative electron density. •

• _{For image-based cross sections, the pixel values used to}_{For image-based cross sections, the pixel values used to generate}_generate the image are used to

the image are used to determine density values within a contour.determine density values within a contour. Even when heterogeneity corrections are turned off, XiO converts the Even when heterogeneity corrections are turned off, XiO converts the patient data to an electron density matrix. When

patient data to an electron density matrix. When calculating with acalculating with a homogeneous patient

homogeneous patient, the electron densities of , the electron densities of the pixels inside thethe pixels inside the patient wire contour are set to 1.0 and outside are set to 0.0.

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Before you use XiO

Before you use XiO for the first time, your medical physicist gathers afor the first time, your medical physicist gathers a great deal of information from your equipment and enters

great deal of information from your equipment and enters it into XiO.it into XiO. Most of this information consists of measurements obtained from the Most of this information consists of measurements obtained from the linear accelerator and acceptance tests of

linear accelerator and acceptance tests of the many XiO programs. Thisthe many XiO programs. This process of integrating XiO into your clinic is called

process of integrating XiO into your clinic is called commissioningcommissioning oror

machine commissioning

machine commissioningand is an important responsibility of the medicaland is an important responsibility of the medical physicist. XiO must be commissioned before you can use it

physicist. XiO must be commissioned before you can use it on a dailyon a daily basis for treatment planning. The information in this book does not cover basis for treatment planning. The information in this book does not cover machine commissionin

machine commissioning nor does it explain how g nor does it explain how to create and store theto create and store the files containing data about the radiation sources. But it does

files containing data about the radiation sources. But it does explain whatexplain what this data is and how

this data is and how it is used in preparing your treatment plans.it is used in preparing your treatment plans. A machine ID identifies each teletherapy source. Use

A machine ID identifies each teletherapy source. Use this user-definedthis user-defined ID to recall the entered source data used in the treatment plan.

ID to recall the entered source data used in the treatment plan.

Telet

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Source parameters are all of

Source parameters are all of the treatment beam constraints that specifythe treatment beam constraints that specify how radiation sources are applied to the patient in

how radiation sources are applied to the patient in the treatment plan. Inthe treatment plan. In teletherapy plans, these determine how

teletherapy plans, these determine how individual beams are positionedindividual beams are positioned on the patient.

on the patient.

This data is supplied by the machine manufacturer or

This data is supplied by the machine manufacturer or is determined fromis determined from clinical measurements. The system uses this data to determine the limits clinical measurements. The system uses this data to determine the limits for treatment setups.

for treatment setups.

XiO requires these parameters for each e

XiO requires these parameters for each energy of the machine:nergy of the machine: •

• _{The modality (photon, electron, or proton)}_{The modality (photon, electron, or proton)} •

• _Energy_Energy •

• _{Machine reference distance}_{Machine reference distance (source-to-isocen}_{(source-to-isocenter distance, where}_{ter distance, where} the field size readout on the

the field size readout on the machine is defined)machine is defined) •

• _{Machine setup (source-to-axis distance, source-to-skin distance,}_{Machine setup (source-to-axis distance, source-to-skin distance,} rotational arc, or symmetric or asymmetric beam)

rotational arc, or symmetric or asymmetric beam) •

• _{Collimator settings and angle (including asymmetric jaw}_{Collimator settings and angle (including asymmetric jaw} parameters or multileaf

parameters or multileaf collimators)collimators) •

• _{Gantry settings, angles, and degrees of rotation}_{Gantry settings, angles, and degrees of rotation} •

• _{Couch settings and angle}_{Couch settings and angle} •

• _{Isocenter/beam entry point location}_{Isocenter/beam entry point location} •

• _{Placement of treatment aids (wedges, ports, and compensating}_{Placement of treatment aids (wedges, ports, and compensating} filters)

filters) •

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XiO

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•

• _{Normalization method and settings}_{Normalization method and settings} •

• _{Source-to-skin distance (which varies for each treatment plan)}_{Source-to-skin distance (which varies for each treatment plan)}

S

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Source physics data consists of the following tables or parameters used Source physics data consists of the following tables or parameters used to calculate the radiation dose. From the

to calculate the radiation dose. From the following list of data tables,following list of data tables, photon machines maintain internal tables for BSF, PSCF,

photon machines maintain internal tables for BSF, PSCF, TAR, TPR,TAR, TPR, OCR (aligned and diagonal), PDD, dose outputs, and

OCR (aligned and diagonal), PDD, dose outputs, and irregular field data.irregular field data. Electron machines maintain tables for PDD and cone parameter data. Electron machines maintain tables for PDD and cone parameter data. NotNot all tables listed exist for all machines. The

all tables listed exist for all machines. The data required by radiationdata required by radiation dose calculation varies with the

dose calculation varies with the calculation algorithms. These parameterscalculation algorithms. These parameters determine the range of values, which can

determine the range of values, which can be used when positioningbe used when positioning individual beams in a treatment plan. Source physics data consists of a individual beams in a treatment plan. Source physics data consists of a subset of the following tables or parameters used to calculate dose: subset of the following tables or parameters used to calculate dose:

•

• _{Backscatter factors (BSF)}_{Backscatter factors (BSF)} •

• _{Phantom scatter correction factors (PSCF)}_{Phantom scatter correction factors (PSCF)} •

• _{Tissue-air ratios (TAR)}_{Tissue-air ratios (TAR)} •

• _{Tissue-phantom ratios (TPR)}_{Tissue-phantom ratios (TPR)} •

• _{Aligned and diagonal off-center ratios (OCR/OCD)}_{Aligned and diagonal off-center ratios (OCR/OCD)} •

• _{Percent depth doses (PDD)}_{Percent depth doses (PDD)} •

• _{Dose outputs}_{Dose outputs} •

• _{Cone parameters}_{Cone parameters} •

• _{Irregular field parameters}_{Irregular field parameters} •

• _{Penumbra modeling parameters}_{Penumbra modeling parameters} •

• _{Machine energy spectra}_{Machine energy spectra} •

• _{Collimator, MLC transmission parameters}_{Collimator, MLC transmission parameters} •

• _{Machine non-scanned data (geometry and}_{Machine non-scanned data (geometry and other information)}_{other information)}

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Wedge data consists of the wedge type

Wedge data consists of the wedge type and all parameters required forand all parameters required for the wedge correction and attenuation. The wedge types available with the wedge correction and attenuation. The wedge types available with XiO are:

XiO are: •

• _{Physical wedge}_{Physical wedge} •

• _{Motorized wedge}_{Motorized wedge}−−_{A wedge angle synthesized from a wedge that}_{A wedge angle synthesized from a wedge that} is in place for a specified fraction of the treatment and then

is in place for a specified fraction of the treatment and then removed for the

removed for the remaining portion.remaining portion. •

• _{Enhanced dynamic wedge}_{Enhanced dynamic wedge}−− _{A software simulated wedge for}_{A software simulated wedge for} Varian linear accelerators.

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•

• _{Virtual wedge}_{Virtual wedge}−−_{A software simulated wedge for Siemens linear}_{A software simulated wedge for Siemens linear} accelerators.

accelerators.

Compensating filter (or compensator) data consists of

Compensating filter (or compensator) data consists of the compensatingthe compensating filter type and all parameters required for

filter type and all parameters required for the addition of a compensatingthe addition of a compensating filter to a treatment plan. A

filter to a treatment plan. A compensating filter attenuates the radiationcompensating filter attenuates the radiation beam before the radiation reaches the patient.

beam before the radiation reaches the patient. The purpose is to provideThe purpose is to provide an even dose distribution to the patient at

an even dose distribution to the patient at the required depth in thethe required depth in the

presence of patient irregularities (surface shape or internal densities). The presence of patient irregularities (surface shape or internal densities). The compensating filters available with XiO are:

compensating filters available with XiO are: •

• _1D_1D−−_{1D compensators}_{1D compensators provide one-dimensional compensation.}_{provide one-dimensional compensation.} One-dimension

One-dimensional filters are al filters are constructed by stacking thin sheets constructed by stacking thin sheets of of attenuating material of different lengths in stepwise fashion, only attenuating material of different lengths in stepwise fashion, only over the area requiring compensation. You can send

over the area requiring compensation. You can send 1D1D compensating filter data to a plotter.

compensating filter data to a plotter. •

• _Ellis_Ellis−−_{Ellis compensators provide}_{Ellis compensators provide two-dimensional compensation.}_{two-dimensional compensation.} Ellis filters are attached to a

Ellis filters are attached to a mounting tray and constructed withmounting tray and constructed with aluminum or brass blocks that correspond to the irregular surface aluminum or brass blocks that correspond to the irregular surface or internal inhomogeneities. You can

or internal inhomogeneities. You can send Ellis compensatingsend Ellis compensating filter data to a

filter data to a plotter.plotter. •

• _{Milling machines}_{Milling machines}−−_{XiO supports Huestis and Par Scientific}_{XiO supports Huestis and Par Scientific} milling machines. Milling machines are linked to

milling machines. Milling machines are linked to the planningthe planning system in order to

system in order to automate the construction of compensators,automate the construction of compensators, which can be constructed with a

which can be constructed with a variety of materials of differentvariety of materials of different mass densities. These include wax, plastic, aluminum, brass, and a mass densities. These include wax, plastic, aluminum, brass, and a gypsum/steel mixt

gypsum/steel mixture. You can send ure. You can send the data for Huestis and Pthe data for Huestis and Parar Scientific filters to the

Scientific filters to the milling machines.milling machines. •

• _.decimal_.decimal−−_{These compensating filters are built using data files you}_{These compensating filters are built using data files you} send to .decimal via email. The

send to .decimal via email. The .decimal compensating filter is.decimal compensating filter is made using special CADCAM software on a

made using special CADCAM software on a computer networkedcomputer networked to a computerized milling machine. The standard .decimal

to a computerized milling machine. The standard .decimal

compensator is machined from aluminum, however brass may also compensator is machined from aluminum, however brass may also be used. The .decimal compensator is shipped with a

be used. The .decimal compensator is shipped with a qualityquality assurance report.

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Three types of brachytherapy source information are stored in source Three types of brachytherapy source information are stored in source files:

files: •

• _{Source types}_{Source types}−−_{A source type is a set of data that defines certain}_{A source type is a set of data that defines certain} parameters about a source, such as the geometry of a source and parameters about a source, such as the geometry of a source and which method is used to create a dose rate table for the source. which method is used to create a dose rate table for the source. •

• _{Source templates}_{Source templates} −−_{A source template is based on}_{A source template is based on the data found in}_{the data found in} a source type, but

a source type, but adds information about the calibration date,adds information about the calibration date, calibrated strength, and other specifics to make the template calibrated strength, and other specifics to make the template clinically useful.

clinically useful. •

• _{Catheter templates}_{Catheter templates}−−_{A catheter template is a set of data about one}_{A catheter template is a set of data about one} or more physical catheters. Information like the geometric

or more physical catheters. Information like the geometric properties of the catheter and its source

properties of the catheter and its source loading are maintainedloading are maintained here.

here.

Dose Calculation Algorithms

A dose calculation algorithm is a set of

A dose calculation algorithm is a set of principles, models, and formulasprinciples, models, and formulas used to calculate the dose throughout the calculation area, volume, or used to calculate the dose throughout the calculation area, volume, or setset of interest points.

of interest points.

Algorithms available are: Algorithms available are:

•

• _Clarkson_Clarkson •

• _{Fast Fourier Transform (FFT) Convolution}_{Fast Fourier Transform (FFT) Convolution} •

• _{Superposition}_{Superposition} •

• _{Fast Superposition}_{Fast Superposition} •

• _{Electron 3-D Pencil Beam}_{Electron 3-D Pencil Beam} •

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