XiO IMRT Training Guide Release 5.10

XiO® 5.
10
XiO IMRT
Training Guide
Document ID: LTGXIO0510 / 1.0

Language: English
Publication Date: 2015-05
Table of Contents
XiO IMRT Training Guide
Revision History
Revision Version Date Task Number Changes

LTGXIOIMRT0500 1.0 August 2013 26997 Interest Point Calculation versus
Interpolation
DRR Overlay
DICOM Improvements Project
LTGXIOIMRT0500 2.0 May 2014 26997 REV1: Corrected part number on
cover page.
LTGXIOIMRT0510 1.0 May 2015 27834 Update the document identifier and
version identifier.
Copyright statement
© 2015 IMPAC Medical Systems, Inc. All rights reserved. Do not make printed or electronic copies of this guide, or parts of it,
without written permission from IMPAC Medical Systems, Inc.
The information in this guide is for the sole use of IMPAC Medical Systems, Inc. personnel, authorized users and licensees of
IMPAC Medical Systems, Inc. products, and no other purpose.
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Referenced documents
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Document ID: LTGXIOIMRT0510
Part Number: C#98914-EN
ii
Table of Contents
Table of Contents
Section 1. Introduction to IMRT (Presentation)
Section 2. IMRT Planning and Workflow

IMRT Overview ............................................................................................................................................................ 2-1
Task 1. Contour all Targets and Organs at Risk ............................................................................................ 2-1
3D Auto-margin Generation ................................................................................................................. 2-2
Transition Volumes .................................................................................................................................. 2-4
Task 2. Beam Placement ......................................................................................................................................... 2-5
Beam Requirements ................................................................................................................................ 2-5
Isocenter Placement ................................................................................................................................ 2-5
Fractionation .............................................................................................................................................. 2-6
Automatically Set Collimator Jaws or Create Ports for all Beams ........................................ 2-6
Task 3. Using the XiO IMRT Module.................................................................................................................. 2-7
Sub-task 1. IMRT Parameters ............................................................................................................. 2-7
Selecting Beams to Be Optimized ......................................................................................... 2-9
Sub-task 2. IMRT Prescription............................................................................................................ 2-11
Structure ......................................................................................................................................... 2-12
Type .................................................................................................................................................. 2-12
Rank .................................................................................................................................................. 2-12
Objective, Dose (cGy/Gy), and Volume (%)..................................................................... 2-15
Weight.............................................................................................................................................. 2-19
Power ............................................................................................................................................... 2-19
Status ................................................................................................................................................ 2-21
Prescription DVH Graph Options.......................................................................................... 2-22
Sub-task 2. IMRT Prescription............................................................................................................ 2-23
Sub-task 3. Start Optimization............................................................................................................ 2-24
Set Your Step Increment/Resolution .................................................................................. 2-24
Select a Minimum Transmission Multiplier (MLC plan only)................................... 2-25
Set the Iterations between DVH Update ............................................................................ 2-27
Initial Optimization .................................................................................................................... 2-27
Sub-task 3. Start Optimization............................................................................................................ 2-29
Smoothing Parameters ..................................................................................... 2-30
Fluence Optimization ....................................................................................... 2-32
Beam Weight Optimization ..................................................................................................... 2-34
Generate MLC Segments or Design Compensators ....................................................... 2-37
Evaluate the DVH and Isodoses of the Optimized Plan ............................................... 2-38
Display the DVH Statistics ....................................................................................................... 2-38
Re-display a Histogram ............................................................................................................ 2-42
XiO iii
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Section 2. IMRT Planning and Workflow (cont.)

Create a Structure from Isodose ........................................................................................... 2-42
Review Ideal Intensity Maps (optional) ............................................................................ 2-46
Sub-task 4A. Generate Treatment Aids - MLC .............................................................................. 2-47
IMRT Segmented MLC Parameters ...................................................................................... 2-48
IMRT Segmented MLC Parameters ...................................................................................... 2-57
Minimum Monitor Unit per Segment .................................................................................. 2-59
Minimum Segment Area ........................................................................................................... 2-59
Segment Suppression Factor .................................................................................................. 2-60
Segment Suppression Factor .................................................................................................. 2-61
IMRT Optimization Summary ................................................................................................ 2-62
Minimum Monitor Unit per Segment .................................................................................. 2-62
Start the Segmentation ..................................................................................... 2-62
IMRT Delivery Summary.......................................................................................................... 2-62
Review MLC Segments .............................................................................................................. 2-63
Sub-task 4B. Generate Treatment Aids – CF ................................................................................. 2-65
Intensity Map Smoothing Distance ...................................................................................... 2-66
Generate Compensators ........................................................................................................... 2-66
Review Compensating Filter or Relative Fluence Intensity Maps (optional) .... 2-67
Sub-task 5. Segment Weight Optimization (optional).............................................................. 2-69
SWO Grid Spacing ....................................................................................................................... 2-70
Convergence Criterion .............................................................................................................. 2-70
Maximum Iterations................................................................................................................... 2-71
Revise Iterations.......................................................................................................................... 2-71
Minimum Segment MU ............................................................................................................. 2-71
Use Fast Superposition ............................................................................................................. 2-71
Task 4. Calculate Dose ........................................................................................................................................... 2-72
Task 5: Review Segmented MLC or Relative Fluence Intensity Maps (optional) ......................... 2-72
Task 6: Print MLC Segments................................................................................................................................ 2-73
Task 7: Print the MLC Segment MU Report.................................................................................................... 2-73
Print the MLC Leaf Positions ................................................................................................................ 2-73
Task 8. Review and Make Changes to Finish the IMRT Plan ................................................................. 2-74
Task 9. Save the IMRT Plan ................................................................................................................................. 2-74
Task 10. Quality Assurance of IMRT Plans ...................................................................................................... 2-75
Create a Single Beam QA Plan .............................................................................................................. 2-75
Create a Composite IMRT QA Plan..................................................................................................... 2-76
Create a Maximum Extent DRR ........................................................................................................... 2-77
Utilize Intensity Maps ............................................................................................................................. 2-77
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Table of Contents
Section 2. IMRT Planning and Workflow (cont.)

Task 11. Customization and Preferences......................................................................................................... 2-78
Optimization ............................................................................................................................................... 2-78
IMRT Graphs ................................................................................................................................. 2-79
Initial Optimization .................................................................................................................... 2-80
Beam Weight Optimization ..................................................................................................... 2-81
Delivery ......................................................................................................................................................... 2-82
SmartSequencing.............................................................................................. 2-83
Ideal Map Extension................................................................................................................... 2-84
Discrete Intensity Levels .......................................................................................................... 2-84
Split Field Parameters ............................................................................................................... 2-84
Sliding Window ............................................................................................................................ 2-86
Smart Sequencing ....................................................................................................................... 2-86
Compensating Filter................................................................................................................... 2-86
Segment Weight Optimization ............................................................................................... 2-86
Intensity Map .............................................................................................................................................. 2-88
Display Print.................................................................................................................................. 2-88
Output Map To.............................................................................................................................. 2-89
ASCII Output .................................................................................................................................. 2-90
Define Default Filename Format ........................................................................................... 2-90
Default Filename Formats ....................................................................................................... 2-91
Smoothing ...................................................................................................................................... 2-92
Other Settings and Preferences ............................................................................................. 2-93
Section 3. Planning Suggestions

Workflow Suggestions .............................................................................................................................................. 3-1
Composite and Synchronous Planning Suggestions..................................................................................... 3-5
Contouring Suggestions ........................................................................................................................................... 3-6
Beam Arrangement Suggestions .......................................................................................................................... 3-14
Prescription Suggestions ......................................................................................................................................... 3-15
Smoothing Suggestions ............................................................................................................................................ 3-17
Intensity Map Editing Suggestions ...................................................................................................................... 3-17
Edit MLC Leaf Positions Suggestions .................................................................................................................. 3-18
Segment Weight Optimization (SWO) Suggestions...................................................................................... 3-18
Suggestions for When the Final Plan Does Not Match the Optimized Plan ........................................ 3-19
Site Specific Suggestions .......................................................................................................................................... 3-21
Prostate ......................................................................................................................................................... 3-21
XiO v
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Section 3. Planning Suggestions (cont.)

Brain ............................................................................................................................................................... 3-23
Head and Neck ........................................................................................................................................... 3-24
Section 4. IMRT Prostate Plan

IMRT Prostate Plan Part 1
Practice Exercise ......................................................................................................................................................... 4-1
Task 1. Open Patient for IMRT ........................................................................................................... 4-2
Task 2. Dose Calculation Settings..................................................................................................... 4-3
Task 3 Place Beams and Conform Jaws or Ports........................................................................ 4-4
Task 4. Create a Template .................................................................................................................... 4-7
Task 5. IMRT Parameters and Prescription Table ..................................................................... 4-8
Treatment Goal ............................................................................................................................ 4-9
Task 6. Start IMRT Optimization Page ............................................................................................ 4-11
Task 7. Optimized DVH and Isodoses .............................................................................................. 4-13
Task 8. Review/Edit Ideal intensity Maps (optional) ............................................................... 4-15
Task 9. Prescription Adjustment ....................................................................................................... 4-16
Task 10 Generation and Review of MLC Segments or Compensating Filters .................. 4-18
Sub-task 1A.Generate and Review MLC Segments ........................................................ 4-18
Sub-task 1B. Generate and Review Compensating Filters ........................................ 4-21
Sub-task 1C. Generate and Review Dynamic MLC Segments.................................. 4-23
Task 11.Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans ...................... 4-25
Task 12. Save the IMRT Plan ................................................................................................................ 4-27
Task 13. Quality Assurance of the IMRT Plan ............................................................................... 4-28
Sub-task 1. Visualize, Sample and Output Intensity Maps for QA .......................... 4-28
Sub-task 2. Largest Leaf Extent Verification ................................................................... 4-30
Sub-task 3. Create a QA Plan on a Phantom and Export Doses to a File.............. 4-31
Sub-task 4. Create a Single Beam QA File on a Phantom ........................................... 4-35
Example Prescription ...................................................................................................... 4-36
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Section 4. IMRT Prostate Plan (cont.)

IMRT Prostate Plan Part 2 (Composite Synchronous)
Task 1. Open Patient for IMRT ............................................................................................................ 4-37
Task 2. Import Template....................................................................................................................... 4-38
Task 3. Composite Plan Setup ............................................................................................................. 4-39
Task 4. Composite Plan Prescription ............................................................................................... 4-40
Treatment Goal ............................................................................................................................ 4-40
Task 5. Optimize and Assess Results ............................................................................................... 4-42
Task 6. Combine Plans and Assess Results ................................................................................... 4-43
Example Prescription ................................................................................................................ 4-43
Task 7. Synchronized Plan (Revert to Initial Plan and Add Template) ............................. 4-44
Task 8. Synchronous Plan Setup ........................................................................................................ 4-45
Task 9. Optimize the Plan and Assess Results ............................................................................. 4-47
Task 10.Assess Individual Plans ......................................................................................................... 4-48
Task 11. Compare Plans using Plan Review .................................................................................. 4-49
IMRT Prostate Plan Part 3 (Planning with SWO)

Task 1. Create a SWO plan..................................................................................................................... 4-51
Task 2. Compare the SWO plan to an existing plan .................................................................... 4-52
IMRT Prostate Plan Part 4 (Planning and Smoothing)

Task 1. Optimize with Smoothing Turned on................................................................................ 4-53
Task 2. Compare the Prostate1SMTH plan to an existing plan .............................................. 4-54
Section 5. Adjusting Objectives

Task 1. Open Saved Permanent Plan ............................................................................................... 5-1
Task 2. Edit Prescription and Parameters ..................................................................................... 5-2
Task 3. Adjusting Dose........................................................................................................................... 5-4
Task 4. Adjusting Weight ...................................................................................................................... 5-4
Task 5. Adjusting Power ....................................................................................................................... 5-4
Task 6. Plan Review ................................................................................................................................ 5-5
XiO vii
Table of Contents
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Section 6. Head and Neck

Task 1. Open Patient for IMRT ........................................................................................................... 6-2
Task 2. Prepare Contours for IMRT.................................................................................................. 6-3
Task 3. Dose Calculation Settings...................................................................................................... 6-6
Task 4. Place Beams and Conform Jaws or Ports ........................................................................ 6-7
Task 5. IMRT Parameters and Prescription Table ..................................................................... 6-10
Treatment Goal ............................................................................................................................ 6-11
Task 6. Start IMRT Optimization Page ........................................................................................... 6-13
Task 7. Optimized DVH and Isodoses ............................................................................................. 6-15
Task 8. Prescription Adjustment ...................................................................................................... 6-17
Task 9. Review/Edit Ideal Intensity Maps (optional) ............................................................. 6-19
Task 10. Generation and Review of MLC Segments................................................................... 6-20
Task 11. Segment Weight Optimization (Optional) .................................................................. 6-23
Task 12. Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans.................... 6-24
Task 13. Save the IMRT Plan ............................................................................................................... 6-26
Task 14. Compare Plans with Different Minimum Transmission Multipliers ............... 6-27
Task 15. Quality Assurance of the IMRT Plan .............................................................................. 6-28
Sub-task 1. Visualize, Sample, and Output Intensity Maps for QA....................... 6-28
Sub-task 2. Largest Leaf Extent Verification ................................................................. 6-30
Sub-task 3. Create a QA Plan on a Phantom and Export Doses to a File ........... 6-31
Example Prescription .............................................................................................................. 6-35
Section 7. Breast IMRT

Task 1. Open Patient for IMRT ............................................................................................................................ 7-2
Task 2. Prepare Contours for IMRT .................................................................................................................. 7-3
Task 3. Dose Calculation Settings ...................................................................................................................... 7-8
Task 4. Place Lateral IMRT Beam....................................................................................................................... 7-9
Task 5. IMRT Parameters and Prescription Table ...................................................................................... 7-10
Treatment Goal ......................................................................................................................................... 7-11
Task 6. Start IMRT Optimization Page ............................................................................................................. 7-12
Task 7. Optimized DVH and Isodoses............................................................................................................... 7-13
Task 8. Review/Edit Ideal intensity Maps (optional) ............................................................................... 7-14
Task 9. Prescription Adjustment........................................................................................................................ 7-15
Task 10. Extend Ideal Map ...................................................................................................................................... 7-16
Task 11. Generation and Review of MLC Segments ..................................................................................... 7-17
Task 12. Editing MLC Segment .............................................................................................................................. 7-18
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Section 7. Breast IMRT

Task 13. Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans ..................................... 7-18
Task 14. Save the IMRT Plan ................................................................................................................................. 7-20
Task 15. Creating a Flash Margin When Planning with Compensating Filters ................................ 7-21
Create an Expanded Target Volume.................................................................................................. 7-21
Forward Planning Breast Technique.................................................................................................................. 7-27

Overview ...................................................................................................................................................... 7-27
Forward Planning For Breast .............................................................................................................. 7-27
Task 1: Open the Patient .......................................................................................................... 7-27
Task 2: Put the Beams on the Plan ....................................................................................... 7-29
Task 5: Creating the First MLC Segment (Control Point) ........................................... 7-35
Task 6: Additional Optional Functionality
Subtask 1: Locking a Segment’s Weight................................................................... 7-44
Subtask 2: Deleting Segments ...................................................................................... 7-44
Subtask 3: Adding Segments ........................................................................................ 7-45
Subtask 4: Reweighting a Beam .................................................................................. 7-45
Subtask 5: Renumbering Segments ........................................................................... 7-45
Task 7: Editing a MLC Segments Using the Port Menu ................................................ 7-46
Subtask 1: Mouse Functionality ............................................................................................ 7-46
Subtask 2: Dialog Box Functionality.................................................................................... 7-47
Section 8. Additional Practice Plans

Head and Neck including Lower Neck Nodes ................................................................................................. 8-1
Prescription................................................................................................................................................. 8-1
Example ........................................................................................................................................................ 8-2
Brain .............................................................................................................................................................. 8-3
Prescription................................................................................................................................................. 8-3
Example ........................................................................................................................................................ 8-4
Prostate with Iliac Nodes......................................................................................................................................... 8-5
Prescription: Option 1............................................................................................................................. 8-5
Prescription: Option 2 (escalated dose).......................................................................................... 8-5
Plan Comparison and Evaluation ......................................................................................................................... 8-6
Section 9. Are You Ready for IMRT? (Presentation)
Section 10. Data Requirements and Beam Modeling (Presentation)
XiO ix
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Section 11. XiO IMRT Optimization and Calculation Physics

(Presentation)
Section 12. QA Tools and Methods (Presentation)
Section 13. QA Phantoms

Overview .............................................................................................................................................................. 13-1
Task 1. Create a CT-to-ED file ............................................................................................................. 13-1
Task 2. Creating a Non-Image Based Phantom............................................................................ 13-5
Subtask 1 Naming the Patient ................................................................................................ 13-5
Subtask 2 Slice Definition ........................................................................................................ 13-7
Subtask 3 Generating the Patient Contour ....................................................................... 13-8
Task 3. Creating an Image Based Phantom ................................................................................... 13-10
Subtask 1. Naming the Phantom .......................................................................................... 13-10
Subtask 2. Importing the Images ......................................................................................... 13-12
Subtask 3. Finish Image Transfer ........................................................................................ 13-15
Subtask 4. Create the Patient Contour Using Auto-by-Threshold
(Multiple Slices)........................................................................................................................... 13-18
Subtask 5. Verifying the CT-to-ED file ............................................................................... 13-23
Task 4. Using the Phantom in Teletherapy ................................................................................... 13-28
Subtask 1. Creating a QA Plan ............................................................................................... 13-28
Subtask 2. Setting the Dose Calculation Parameters ................................................... 13-31
Subtask 3. Drawing Dose Profiles ....................................................................................... 13-33
Subtask 4. Exporting Dose Planes ....................................................................................... 13-36
Subtask 5. (Optional) Exporting Dose Planes for Other Beams.............................. 13-37
Section 14. ADS in XiO — Adaptive Diffusion Smoothing

(Presentation)
x
Introduction to XiO IMRT
IMRT Overview
• Define clinical goals in the Rx. Then, let the optimization

algorithm find the best configuration of beam intensities.
• Beams are divided into beamlets, each representing a

potential MLC opening or Compensator milling location.
• These beamlets can have varying intensities as defined by

the optimization algorithm.
• Segments/Compensators are generated from the intensity

maps that satisfy the Rx. An additional option is to optimize
the segments. Finally, dose is recalculated to show the
actual treatment plan.
Defining Clinical Goals
Prescription:
DPTV1 : Min 7000 cGy

Max 7200 cGy
DRECTUM: <15% of the

Volume to receive
4000cGy
Beamlet Creation
Beamlet Leaf width
Intensity Maps
This could be a clever

way to place the
intensities. White is low
intensity. Black is high
intensity.
But, computers are not

clever, so they need to
do an iterative method.
XiO Intensity Map
This is the intensity

map we would like the
system to generate.
Intensity Map Creation
Start with an open field.
The intensity is uniform

over the entire field.
Iteration 1
Based on the prescription,

the optimizer changes
beamlet intensities
PTV1= high intensity
Rectum = lower intensity

Iteration 5
Intensity levels are

continuous.
Iteration 50
• This is the ideal
intensity map.
• It is editable.
• It is a mathematical
concept.
• No real physics
calculations.
Now the system has to recreate it using treatment aids: MLC

or Compensators.
Generate Treatment Aids
New Choice of Sequencing Options:

1. Sliding Window (Sweep or Progression Based Segmentation).
2. Smart Sequencing (Cluster Based Segmentation)
If using MLCs and Sliding Window:

1. Input Discreet Intensity Levels
2. Set Minimum Segment Size (Area)
3. Sequencer does not generate Segments
that fall below the minimum segment
area
If using MLCs and Sliding Window:

• Ideal intensity map is first discretized
• You define the number of discrete intensity levels
• You define the Minimum Segment Size (area)
• More intensity levels yield better resolution
4 intensity levels
Two Intensity Levels
Two (2) levels are

not enough to
mimic the ideal
map.
Three Intensity Levels
Three (3) levels are

better, but resolution
is still not very good.
10 intensity Levels
Better resolution with

10 levels
Segment Creation
• Below is an example using two intensity levels for simplicity.
• The goal is to create segments so that the sum of all their
intensities equals the intensities in the discretized intensity map
(shown below).
• The weights of each segment will be multiples of each other.
Intensity = x
Intensity = 2x
Segment Creation
+ +
=
If using MLCs and Smart Sequencing:
1) Set your Minimum MU/Segment
2) Set Minimum Segment Area
3) To help minimize the total number of
Segments, Input Segment Suppression
Factor.
Note: The resulting segment monitor

units depend on the Total Number
of Monitor Units in the plan. So, it
is important to set up the
fractionation scheme before
Generating Treatment Aids.
What is the difference between Sliding Window and Smart Sequencing?
• Sliding Window produces segments are typically long and vertical in shape.
In general, the segments progress in a smooth, logical fashion from one
side of the field to another. The purpose of the design is minimize the
change in segment movement.
• Smart Sequencing is a Hyperion-based segmenter that produces segments
based on Clusters or groups of similar intensities. In general, the segments
take the shape of squares and rectangles and do not necessarily follow a
logical sequence. The purpose of the design is to produce fewer segments
which may help to reduce treatment time.
• You can use all current options including Smoothing, Field Extensions, and
Segment Weight Optimization (SWO) with both the Sliding Window and
Smart Sequencer sequencers.
• The following slide contains visual examples of each.
Segment Progression from Sliding Window is independent of site
Location (breast, head and neck, prostate, etc).
Note: The collimator is rotated 90° for this example.

Segment Progression from Sliding Window
Segment Progression from Smart Sequencing is independent of site
location (breast, head and neck, prostate, etc).
Note: The collimator is rotated 90° for this example.

Segment Progression from Smart Sequencing
Optimize Segment Weights (optional)
• Use Segment Weight Optimization to re-weight

segments and improve plan quality.
- Potentially improves the agreement
between the optimized and final dose
distribution
- Potentially reduces the number of

segments in a plan
- May be run multiple times, changes to the

IMRT Rx may be made before using
segment weight optimization
- Not useful for all types of IMRT plans

(It is mainly used for more complex plans.)
IMRT Planning and Workflow
IMRT Overview
The Intensity Modulated Radiation Therapy (IMRT) lecture is a preliminary

discussion to the XiO IMRT training exercises. Patients used in the IMRT
training exercises are included in the installation packet, and if loaded on
your XiO workstation, they will reside in a clinic labeled XiO Training Data.
It is assumed that you are familiar with the XiO 3D Radiation Therapy
Treatment Planning (RTP) system as well as the principles of IMRT. This
lecture enables you to complete any IMRT plan step-by-step.
In the traditional approach to treatment planning, you create a plan based

on manual trial and error efforts to arrive at a suitable arrangement of
beams that generate an acceptable final plan. In IMRT, rather than
manipulating beam parameters to achieve a suitable dose distribution, you
"reverse" the process by defining the clinical goals first then allow the
optimization algorithm to find the best configuration of beam intensities.
During optimization, beam fields are subdivided into "beamlets." A beamlet
is the area representing a potential MLC opening or compensator milling
location. The term "intensity modulated" comes from the fact that the beam
is divided into beamlets of varying intensities. The IMRT prescription is a
group of interrelated instructions that define the limits, priorities, and goals
for the optimization algorithm. These include several different kinds of
dose-objectives, desired goals, and their relationships for both targets and
organs at risk (OARs).
Task 1. Contour all Targets and Organs at Risk
Contouring is a very important part of the IMRT process. Field sizes are
smaller and more conformal in IMRT plans than in traditional 3D plans, so
creating contours that actually represent the volume of the structure is
imperative. You should note that any structure for which you intend to
deliver dose or restrict dose in the IMRT prescription must be contoured. A
text book that may be useful when beginning contouring for IMRT is, Clinical
Target Volumes in Conformal and Intensity Modulated Radiation Therapy, V.
Gregorie, P. Scalliet, K.K. Ang.
XiO® 2-1
Task 1. Contour all Targets and Organs at Risk (cont.)
The following example demonstrates how creating bad contours can

influence the outcome of the plan. The image labeled Good Contours has the
actual nodal region contoured. This should allow for better cord sparing.
The image labeled Bad Contours has the nodal region and more surrounding
tissue contoured which is typical of the fields treated using posterior neck
electron boost fields. Using these contours when planning an IMRT
treatment will limit the sparing effect to the cord that more conformal
contours allow.
Good Contours Bad Contours
3D Auto-margin Generation
Use 3D Auto-margin to create non-variable or variable margins around

structures, such as creating a CTV or PTV around a GTV. You may also want
to use a 3D auto-margin to expand an organ at risk (OAR) and use the
expanded structure in the prescription to prevent prohibitive doses near the
original structure. The margin from CTV/GTV to PTV is a clinical decision to
take into account internal motion and set up variations. Refer to ICRU
reports 50, 62, and 83 for more details.
2-2
Task 1. Contour all Targets and Organs at Risk
3D Auto-margin Generation (cont.)
You can create 3D auto-margins by clicking the 3D Auto-margin button

located on the Patient File Maintenance sub-mode toolbar. When expanding
CTV/GTVs to create PTVs, be sure to clip inside the patient surface by at
least 0.5 cm to avoid having a target structure in the buildup region. If the
target needs to include the buildup region due to skin involvement, consider
using bolus.
The following example demonstrates the effect of clipping inside the patient
surface. The yellow line represents the original contour of breast tissue. To
improve the optimization by removing tissue that is in the buildup region,
use the Clip at Patient Surface option to produce a contour that is shown
here in light blue. Only the contour at the surface is affected using this tool.
If you have more than one target, you should create a 3D auto-margin that
encompasses all targets. The structure margin is not used in the IMRT
prescription, but rather, used for isocenter placement as well as conforming
the collimator jaws.
XiO® 2-3
Task 1. Contour all Targets and Organs at Risk (cont.)
Transition Volumes
In cases where you have abutting target structures, target structures within
target structures, or abutting target structures and organs at risk that have
different dose prescriptions, it is often necessary to create a structure called
a "transition volume." A transition volume is a structure that you can create
using 3D auto-margin to help transition the dose in a high gradient region
between two structures with different prescriptions. Refer to the Planning
Suggestions discussed in Section 3 of this guide for information on creating
and prescribing to a transition volume.
2-4
Task 2. Beam Placement
The next step in the IMRT planning process is determining an adequate

number of beams and arranging them in a logical and useful manner.
Some common IMRT beam arrangements are five-field, seven-field, and

nine- field, equally spaced, non-opposing beams. Most of the examples in
this guide use a five-beam technique with gantry angles evenly spaced 72
degrees apart. This is a recommendation only. You may find that other
beam arrangements work well and do not restrict you to the use of coplanar
beams. Likewise, even when using one of the equally spaced beam
arrangements described above, you may find that starting at an angle other
than the nominal angle (0 degrees in these examples) is beneficial. It can
also be advantageous to optimize the beam angles as such so that you
minimize beams passing through critical structures.
Appropriate energy selection will also influence the quality of the IMRT plan.
For deep-seated tumors, such as the prostate, consider using 15X or 18X if
available. Be aware of issues concerning scatter radiation from these higher
energies if using MLC-based IMRT.
As you may often be placing beams in the same arrangement from one IMRT
plan to the next, we suggest you familiarize yourself with the use of the
Template function in XiO. (See Planning Suggestions in the next section of
this guide.) This serves as a plan library and can help automate some of the
IMRT planning process.
Beam Requirements
You must model machines for IMRT. You should use asymmetric jaws, and
remove wedges from IMRT-specific machines. XiO does not support the
Clarkson algorithm for IMRT planning.
Isocenter Placement
You should place the isocenter as such so that you cover all targets as
symmetrically as possible. If you have only one target volume, you should
place the isocenter in the center of that target. If you have two or more
targets, you should place the isocenter in the center of the structure
combination that encompasses all targets. You could create this structure
combination using the 3D Auto-margin function.
XiO® 2-5
Task 2. Beam Placement
Isocenter Placement (cont.)

Be aware that there is a weight-point dependence. Avoid placing the weight
point behind an OAR or in an air cavity or tissue/bone/air interface.
Discrepancies between the optimized dose distribution and the final dose
distribution could be due to weight points ending up in an area where the
dose is mostly due to scatter.
Fractionation
If the delivery method is dynamic, the resulting segments are influenced by

the dose rate and maximum leaf speed, which is a function of the number of
fractions.
Automatically Set Collimator Jaws or Create Ports for all Beams
Before you begin planning, you should automatically set your collimator
jaws to create field sizes that encompass all beams symmetrically or
asymmetrically around the target(s). For compensator-based IMRT, you
should create a conformal MLC or conformal block/aperture for each beam,
as the compensating filter cannot attenuate enough of the beam outside of
the target area for adequate shielding. Ensure there is an adequate margin,
0.5 cm is a good starting point for compensator-based IMRT. For all other
forms of IMRT, a margin of 1.0 cm is a good starting point. There is no need
to create static MLC ports for the segmented MLC delivery, but conforming
the collimator jaws to the target(s) with a margin greater than the
optimization margin is recommended.
The optimizer will not move the jaws during the optimization process.
Therefore, if you do not want your beams to split, you should manually set
the jaws up to be smaller than the split limit. Portions of a target that are
not included in the reduced field should be treated by another field.
Click the Port drop-down menu and select the Auto, Active Beam, and
Multiple Beams options to create the jaw setting or ports for multiple beams
at once.
2-6
Task 3. Using the XiO IMRT Module
There are five major IMRT buttons (shown in the above toolbar) that walk
you through the IMRT process.
• IMRT Parameters
• IMRT Prescription
• Start Optimization
• Generate Treatment Aids
• (Optional) Segment Weight Optimization
Reviewing each of these buttons will assist you in creating an IMRT plan in
XiO.
Sub-task 1. IMRT Parameters
IMRT Parameters is where you select your modulator type and the
beams to be optimized.
XiO® 2-7
Sub-task 1. IMRT Parameters (cont.)

In XiO, there are two options for modulator type:
• MLC
• Compensating Filter
If you choose compensating filter as the modulator type, XiO allows you to
select a filter type of .decimal, Huestis, or Par Scientific and edit the filter
material, the tray distance, and the filter effective attenuation coefficient for
each beam. Setup in Source File Maintenance (SFM) is required for each
compensating filter type before being it can used for planning. The
compensating filter tray factor can be edited for non .decimal compensators.
2-8
Selecting Beams to Be Optimized
Under the heading Opt Yes/No, set the beams you want to optimize to Yes;
set all others (if any) to No. Use the following scenarios to guide you when
determining which beams to optimize.
If you are creating a single IMRT plan, XiO lists all the IMRT beams on the
IMRT Parameters page.
If you are creating a boost IMRT plan, XiO lists beams from the original plan
on the IMRT Parameters page as long as they meet the beam requirements
for IMRT planning (Photon beam, not Clarkson algorithm and contain no
blocks). If the original beams are turned to the On position on the Weights
page when you create the boost plan, the dose from the original plan will be
taken into consideration when planning the boost (synchronous IMRT).
Therefore, you will need to enter total doses in the prescription, or turn the
original plan’s beams off on the Weights page and plan the boost alone.
If you are creating a boost IMRT plan and the original plan was an IMRT
plan, XiO lists beams for all the plans on the IMRT Parameters page. When
you plan the boost, do not optimize the original plan’s beams. Set them to
No, or you will lose the integrity of the first plan. The dose from the original
plan is taken into consideration when planning the boost (synchronous
IMRT), that is, unless you turn the original plan’s beams off on the Weights
page and plan the boost alone. In the latter case, only the boost IMRT plan
beams is listed on the IMRT Parameters window.
XiO® 2-9
Selecting Beams to Be Optimized
Refer to the Planning Suggestions section of this guide for more information
on composite planning and synchronous IMRT.
2-10
Task 3. Using the XiO IMRT Module (cont.)
Sub-task 2. IMRT Prescription
The IMRT Prescription window (accessed by clicking the Prescription button

located on the IMRT secondary toolbar) is where the bulk of the IMRT
planning takes place.
The Prescription window is where you determine the following:
• Which structures will be optimized
• The priority of the voxels within the structures
• Whether the structure is a Target or an Organ at Risk (OAR)
• What doses will be prescribed
• What objective functions will be used for each structure
XiO activates the scrollbar at the right side of the prescription window if the
number of structures contoured exceeds the available space on the page.
There is also an interactive DVH where you can manipulate the DVH curves.
When filling out the prescription panel for the first time, the only system-
populated fields are the Structure, Type, and Rank fields.
XiO® 2-11
Sub-task 2. IMRT Prescription (cont.)
Structure
XiO lists all structures that have been contoured for this patient. Before
filling out the IMRT prescription panel, you should determine which
structures you want to optimize. In Task 1, it was suggested to create 3D
auto-margins around some targets and OARs. You may want to prescribe to
these structures. However, when you review your DVH after optimization,
analyze the coverage of the original targets and OARs.
Type
Each structure to be optimized must be assigned a type. The structure will

either be assigned as a Target or an OAR. After you assign the type, only the
objective functions for that type are available for that structure. For
example, if you selected Target, you have to select at least a minimum and
maximum dose objective. For an OAR, select at least a maximum dose
objective, or a dose volume objective.
If you would like to sort your structures by type, click the Type heading. XiO
lists all targets at the top of the list or all targets at the bottom of the list.
Rank
Each structure to be optimized needs to be assigned a rank. Rank

determines how the IMRT optimizer will treat the voxels in the volume
where structures overlap. It does not imply that one structure’s objectives
are more or less important.
NOTE: A voxel is a volume element of a structure.
The structure assigned the higher priority "owns" the voxels in the overlap
region. Therefore, the objective function for the higher priority structure
includes the contribution of these voxels, but the objective function for the
lower priority structure does not include these voxels. One (1) is considered
the highest priority; higher numbers have lower priorities.
2-12
Rank (cont.)
Each structure to be optimized is typically assigned a rank even if it does not

appear to overlap another. To sort your structures by rank, click the Rank
heading. XiO lists them in order from highest to lowest, or lowest to highest
rank.
The image below illustrates an example of rank as applied to a simplified

prostate and rectum contour.
PTV
In this example, the PTV
"owns" the voxels in the
overlap region. The
PTV rank = 1
optimizer applies the
Rectum rank = 2
objectives associated
with the PTV to this
portion of the rectum
that is in the overlap
Rectum region.
PTV
In this example, the

Rectum "owns" the PTV rank = 2
voxels in the overlap Rectum rank = 1
region. The optimizer
applies the objectives
associated with the
rectum to this portion of Rectum
the PTV that is in the
overlap region.
XiO® 2-13
Rank (cont.)
PTV
In this example, the
voxels in the overlap
region are shared. The
PTV rank = 1 optimizer decides the
Rectum rank = 1 dose to put in this region
based on the Prescription
taking weight and power
assigned to each
Rectum structure into account.
In this example, assign

PTV2 needs to be
PTV2 assigned a rank of one or
PTV1 it will be ignored in the
PTV2 rank = 1
PTV1 rank = 2 Prescription, since PTV1
totally encompasses
PTV2.
2-14
Objective, Dose (cGy/Gy), and Volume (%)
Once you determine the structures to be optimized and assign a type and
rank, the dose objectives can be set. To set the objectives, right-click on the
line where you want to add your first objective. XiO shows a drop-down
menu with the options available for that structure type.
TARGET OAR
For a Target, your first option is to Add Minimum/Maximum dose objectives.

Once you select this option, you can enter the Dose (cGy/Gy) values for those
objectives. These are the minimum and maximum doses you would like to
achieve within that structure. If you would like to toggle the objective
(maximum or minimum) that is to show first on the prescription table, click
the Dose (cGy/Gy) heading.
XiO® 2-15
Objective, Dose (cGy/Gy), and Volume (%) [cont.]
A good starting point for an IMRT plan is to enter the actual required dose as
the minimum and enter a maximum 3-5% above the minimum.
After you add these doses, you then have the opportunity to select the Add
Goal dose. This is an optional parameter. By default, the goal is set half way
between the minimum and maximum. The goal is the point between the
minimum and maximum where there is no penalty applied. In some cases,
you would want to move the goal toward the minimum dose objective. This
is because you most likely want to avoid large cold spots in the target, but
are willing to accept larger hot spots.
With the prescribed dose set as the minimum objective, setting the goal dose
the same or close to the minimum can be very useful when the
minimum/maximum spread is very large. By changing the goal dose, you
shift the linear portion of the objective function curve from the center
toward the minimum or the maximum dose. Consider an example where the
minimum dose is 6600 and the maximum dose is 7000. If you do not add a
goal, the objective function assumes the goal is 6800. If you change the goal
to 6700, the objective function curve shifts as shown on the following page.
Any dose above 6700 will be penalized by the maximum dose function, and
any doses below 6700 will be penalized by the minimum dose function.
NOTE: If you are creating a synchronous IMRT plan, you need to

enter doses representing a composite plan. For example, if
you have already given 4000 cGy from the original plan and
now you are creating a boost plan to deliver 2500 cGy using
synchronous IMRT, you would enter a total dose of 6500 cGy
for the prescribed dose to the target. This works the same for
OARs.
2-16
For an OAR, your first option is to add a Maximum objective. Once you select
the objective, you can enter the dose value for that objective. This objective
sets the maximum dose you would like to achieve within that structure. The
minimum dose will be zero. You are not required to enter a maximum dose
(i.e., zero is an acceptable maximum).
The second option is to add a Dose Volume objective. Placing dose volumes
can help shape the DVH curve. Once you select this option, you can edit the
Volume (%) value. For example, a dose volume would be placed if you want
no more than 50% of a structure to receive a dose in excess of 3000. You
can place up to five dose volume objectives per OAR.
In cases where an OAR overlaps or is immediately adjacent to a target, dose

volume objectives can be used without a maximum. This permits a portion
of the OAR to receive a high dose, which allows the OAR voxels immediately
adjacent to the target to receive the target dose without incurring any
penalty. Examples of this are given in the practice exercises that follow this
lecture.
After you select either one or both of these options for objective dose for the
OAR, you can set a Threshold dose. This is an optional parameter similar to
a goal dose for a target. By default, the threshold is set to zero, since ideally
you would like all doses to the OAR to be zero. But, if you would like to allow
no cost to be applied up to a certain delivered dose to the OAR, you can set
that dose as your threshold. The penalty will be applied only after that dose
has been reached.
XiO® 2-17

The following example depicts the change in the objective function curve
when a threshold objective has been added at a dose of 1500. The maximum
dose is still 4500.
The spinal cord is an organ that may benefit from having a threshold dose as
it is acceptable to give a dose up to the tolerance dose but not above it. A
threshold dose of 4000 cGy with a max of 4500 cGy means that the cord does
not incur penalties for doses received up to 4000 cGy only those once the
4000 cGy has been met.
There are several other options available on the drop-down menu for any
structure type:
Delete All Objectives deletes all the objectives for the structure selected.
All Objectives On and All Objectives Off turns the selected structure on or off
for the optimization.
Show/Hide Unused toggles the structure list from showing all the structures
contoured, to showing only the structures where you have entered
objectives.
Print Table prints the IMRT Prescription table.
2-18
Weight
Weight is an option you can use to increase the relative importance of an

objective and is particularly useful for improving the minimum target
coverage. When you change the importance weighting, you change the
shape of the linear and non-linear portions of the objective function
proportionately. Weights range from 1 to 1000. You can use weight to
increase the importance of a target’s minimum or maximum dose to help
achieve the objective. You may also apply weight to an OAR exceeding its
objectives, especially when dose volumes are used. The following example
depicts how the objective function curve changes if the cord is set to be 10
times more important, and the minimum objective for the target is set to be
five times more important.
Power
Power is an option you can use to increase the penalty to those voxels with
doses in violation of a structure’s objective. It should be used instead of
weight and only used when increasing the weight does not achieve the
desired objectives. Power is particularly useful when applied to a max dose
constraint that is not being achieved with the default values. The numerical
value of this field determines the exponent for the non-linear portion of the
objective function curve. The values range from 2.0 to 5.0 in increments of
0.1. A value of 2.0 indicates a standard "quadratic" penalty.
XiO® 2-19

Changing the power changes the shape of the non-linear portion of the
objective function. A small increase in power can make a large change in the
objective function curve. The higher the power, the more the curve becomes
a dose boundary. For example, if the dose prescribed to the cord is
exceeding its prescription due to the optimizer trying to achieve the
prescribed dose to the target, you could increase the value of the power for
the cord objective so that voxels in the cord get penalized much more for the
same dose violation of the objective. The optimizer, in seeking to minimize
the overall numerical penalty, will try harder to achieve the cord dose
objective. An increase in power from 2.0 to 2.8 would be similar to
increasing the weight from 100 to 500. Recommended power values are in
the range of 2.0 to 3.0. Higher values can cause the optimizer to concentrate
too much on a particular objective at the expense of other objectives. The
example on the following page depicts what happens to the shape of the
objective function curve when you increase the power.
NOTE: For best results when using a higher power value, we

recommend that you enter a smaller convergence criterion
and/or a higher number for maximum iterations to force
more optimization iterations. This is because the penalties
incurred when higher powers are used are very large and will
cause the optimizer to completely bias the first few iterations
toward decreasing this penalty.
2-20
Status
This option allows you to toggle a prescribed structure On or Off. All

structures to be optimized should be turned on; all others can be turned off
and will not be optimized. You can also toggle the status using the All
Objectives On and All Objectives Off available when you right-click.
XiO® 2-21
Prescription DVH Graph Options
You can move any minimum, maximum, goal, or threshold dose point on the
DVH graph by left-clicking on the DVH point and dragging it to a new
location.
Expand the graph by dragging the small box located at the lower left corner
of the graph to the left.
Zoom in on any portion of the graph by holding down the Ctrl key and
dragging a selection box around the part of the graph that you want to zoom.
When you right-click in the DVH window, XiO offers you the following
options:
• Toggle the legend on and off.
• Toggle the DVH grid on and off.
• Plot the DVH graph.
• Reset the zoom.
2-22
Prescription DVH Graph Options (cont.)
When you right-click on a particular objective on the Prescription DVH, you

get a menu of options similar to those available from right-clicking on the
Prescription panel.
XiO® 2-23
Sub-task 3. Start Optimization
After completing the IMRT prescription page, set up optimization

parameters and click the Start Optimization button. It is here that XiO
allows you to set the step increment/resolution, initial optimization criteria,
beam weight optimization criteria, and to start and stop the optimization.
Set Your Step Increment/Resolution
The step increment value sets the size of your beamlets in the direction of
leaf travel at isocenter for MLC-based optimization. In the case of MLC-
based IMRT, you can only set this value in the X direction. (The Y direction
is a function of the MLC width.) If using compensating filters, you can set the
resolution in both the X and Y directions. The step increment you choose
must be the same as or larger than the calculation volume grid spacing.
2-24
Set Your Step Increment/Resolution (cont.)
The following intensity maps demonstrate the effect of decreasing the step
increment from a 1 cm increment to a 0.5 cm increment using MLC leaves.
Since the leaves are 0.5 cm in width, this dimension stays the same on both
intensity maps. Note however, that the length of the intensity bixels on the
first intensity map is 1 cm and the length on the second is 0.5 cm.
1.0 x 0.5 cm
0.5 x 0.5 cm
1 cm step with 0.5 cm MLC 0.5 cm step with 0.5 cm MLC
Select a Minimum Transmission Multiplier (MLC plan only)
The Minimum Transmission Multiplier is a tool you can use to account for
transmission dose in areas mainly covered by closed leaves during the
delivery of a segmented MLC beam. The product of the user-definable
Minimum Transmission Multiplier, the MLC transmission (defined in Source
File Maintenance) and the maximum beamlet intensity (calculated for each
intensity map) are used to establish the minimum value for beamlet
intensities. In cases where there is significant modulation, increasing this
value should improve the agreement between the optimized dose
distribution and the final dose distribution of your final plan due to
underestimation of transmission. For example, consider an ideal map
composed of two peaks that are delivered one at a time.
XiO® 2-25
Select a Minimum Transmission Multiplier (MLC plan only) [cont.]
XiO’s current method of determining the minimum beamlet intensity

underestimates the actual minimum transmission, resulting in discrepancies
between the optimized and deliverable doses. Increasing the value of the
Minimum Transmission Multiplier mitigates this effect.
Solid DP - Min. Transmission Multiplier 1 The yellow line across the transverse image
Dashed DP - Min. Transmission Multiplier 6 represents the location of the dose profiles.
Until you become more comfortable with this tool, we suggest that you
optimize using the default value of 1.0. If you find that the doses to critical
structures in the final plan are excessively degraded, try re-optimizing with
a higher Minimum Transmission Multiplier. The range is 1 to 10.
2-26
Sub-task 3. Start Optimization (cont.)
Set the Iterations between DVH Update
Enter a value that represents how often you would like the scored DVH to
update during the optimization. The range is from 0 to 300. If you never
want it to update, enter 0. Enter 1 if you want the DVH to update with each
iteration. If you have a slower computer or just do not want it to update
with each optimization, enter a higher number.
Initial Optimization
These settings affect the initial fluence optimization, which results in the
generation of ideal intensity maps. In this step, individual beamlet weights
are optimized.
Convergence Criterion
The Convergence Criterion sets the termination point for the IMRT
optimization iterations. When the difference in the Score Function from one
iteration to the next goes below the Convergence Criterion, the iterations
will stop. The lower you set this value, the more iterations it performs. To
ensure the optimizer does not stop short, set a value of 0.001.
XiO® 2-27
Initial Optimization (cont.)
Maximum Iterations
This function allows you the freedom to set the maximum number of
iterations very high or very low depending on your objective for the
optimization. The optimization will stop when the convergence criterion or
the maximum number of iterations have been met, whichever comes first.
The bulk of the optimization occurs in the first 30 iterations. After these
small improvements are made to a point where there is no significant
change in the plan, 60 iterations is a reasonable value to set for the
maximum number of iterations.
Scatter Extent
When XiO applies the beamlet dose model, scatter is taken into account
during the optimization. Scatter extent is the distance any beamlet
contributes dose beyond its geometric edges. XiO measures scatter extent
from the edge (not the center) of the beamlet. If the scatter extent is zero,
the optimization algorithm ignores scatter altogether. The larger you set the
scatter extent, the better the optimized plan will represent the final plan
once treatment aids are generated. Increasing the scatter extent also
increases the optimization time. A minimum of 1.5 cm should be used, but
higher values should be used for more complex sites. The scatter extent
should be set large enough to fully span narrow critical organs such as the
spinal cord or optic nerves. If your treatment-planning computer has a
limited amount of memory that causes problems, you may need to limit the
scatter extent to a value of 1 cm.
2-28
Optimization Margin
During optimization, it is desirable to restrict the optimization to an area

around the target(s), while including some margin for penumbra. The
optimization margin allows you to limit the optimization to the beamlets
that intersect the target(s), plus a small 3D margin. If the optimization
margin is zero, the algorithm optimizes only the beamlets that intersect the
target(s). An optimization margin of 0.5 cm is suggested. Setting the margin
too large may cause more dose than desired outside of the target(s) volume
unless dose constraints are placed on surrounding structures. Setting the
margin too small may decrease the dose to the edge of the target volume.
The following intensity maps demonstrate the effect of creating an

optimization margin larger than zero. The target structure is outlined in
light blue. Only the intensity bixels that are shown will be used in the
optimization.
0.5 cm optimization margin 0.0 cm optimization margin
XiO® 2-29
Smoothing Parameters
You can choose to apply a diffusion-based smoothing parameter during

fluence optimization to remove potential spikes in the fluence that could
result in segments that are too small. Using a smoothing parameter should
have the added benefit of reducing the number of generated segments.
NOTE: If fluence maps are relatively smooth to begin with, adding a

smoothing parameter does not have much effect.
A set of predefined smoothing parameters is available. However, you can

edit these and create your own smoothing parameters in Edit| Preferences|
IMRT| Smoothing.
Until you become more familiar with the smoothing options, you should use
the predefined ones as outlined here. The GeneralHighSmoothing option is a
good general smoothing option that could be used in many cases. In general,
Simple, Intermediate, and Complex smoothing options refer to the
complexity of the case and the level of smoothing is scaled accordingly.
2-30
Smoothing Parameters (cont.)
See the physics section on Adaptive Diffusion Smoothing for more detailed
information regarding the smoothing algorithm.
No Smoothing Intermediate Low Smoothing General High Smoothing
XiO® 2-31
Fluence Optimization
XiO IMRT uses a "conjugate gradient" optimization algorithm, which is a

special type of "gradient descent" optimization algorithm. The fluence
optimization process consists of a series of iterations in which the optimizer
updates beamlet doses until the current dose distribution is not significantly
closer to the defined dose objectives than the previous iteration, or when
you manually terminate the optimizer. To convey these iterations on the
screen, XiO initializes a "score function" that is normalized to 100, and with
each iteration, converges towards 0. The total score function is composed of
the sum of the prescribed objective functions for all targets and organs at
risk.
Objective = a (Dcurrent − D prescribed )

n
where
Dcurrent is the current dose to a voxel
D prescribed is the prescribed dose to a voxel
a is the weight
n is the power
Example, for a prescription in which a minimum and maximum dose to the

target was defined, as well as a maximum dose to an organ at risk, the total
score function would be:
Score Function = Target max doseobjective + Target min doseobjective + OAR max doseobjective
2-32
Fluence Optimization (cont.)
The score function is a measure of how close the dose distribution is to the
user- defined dose objectives. You control the maximum number of
iterations and the convergence criterion.
Illustrated below is an example of an objective function curve. In this

particular example, the minimum prescribed dose is 6600, the maximum is
7000, and the goal dose (where zero penalty is applied) is 6800. An
objective function curve can be further divided into a linear and a quadratic
portion. In the example below, the linear penalty is applied to keep the
delivered dose close to the goal dose. The larger the difference between the
objective dose and the actual dose to a voxel, the larger the penalty. The
quadratic portion of the curve depicts this rapidly increasing penalty.
XiO® 2-33
Beam Weight Optimization
Once the initial optimization and segmentation takes place, XiO calculates
the final plan and optimizes the beam weights. Beam Weight Optimization
uses the same prescription as the initial optimization to determine the final,
optimum beam weights. Individual segment weights are not optimized in
this step; only the weights of the entire beams are adjusted. Beam Weight
Optimization optimizes the loss between the optimized plan and the
segmented or compensated plan.
The convergence criterion sets the termination point for the IMRT
optimization iterations. When the difference in the Score Function from one
iteration to the next goes below the convergence criterion, the iterations will
stop. The lower you set this value, the more iterations it performs. To
enable the optimizer to reach a good solution, the value here should be
0.001.
Maximum Iterations
This function allows you the freedom to set the maximum number of
iterations.
Setting the Convergence Criteria and Maximum Iterations too low could
cause premature optimization convergence and therefore result in a set of
beam weights that are truly not optimized. Allow the optimizer to reach a
good solution. Set at least 30 iterations. Given the improvements made to
XiO IMRT in version 4.2 (i.e., the pencil beam model), you may find this final
round of optimization unnecessary and sometimes elect not to perform
beam weight optimization altogether (that is, set maximum iterations to
zero). It is better to perform no beam weight optimization than to run an
insufficient number of iterations, and therefore converge at a non-optimum
set of beam weights. If powers were used in the dose prescription, the beam
weight optimization could be skewed to favor those select criteria, resulting
in a sub-optimal final dose distribution. In this case, either set the number of
iterations to 0 (to skip the optimization), or set it to a high number such as
50 to allow the optimizer to work on all entered dose constraints.
2-34
Beam Weight Optimization (cont.)
Once you set up the optimization criteria, you can begin the optimization.
To do this, click the Start button. Before the optimization process begins, all
beams are divided into beamlets whose dimensions depend on the user-
defined values for step increment if using MLCs, or resolution, if using
compensators. This calculation is done using a pencil beam algorithm
calibrated against Convolution or Superposition, depending on the algorithm
you chose in the beginning. The optimization engine is then initialized and
an iterative process using a ‘conjugate gradient’ method is used to vary
individual beamlet intensities until a solution is reached. The variation in
beamlet intensities from one iteration to the next depends on the total
penalty calculated with each iteration. As the optimizer runs through its
iterations, the DVH updates based on the value set for Iterations between
DVH Update. When the difference from the previous iteration to the current
iteration meets the convergence criterion or when the maximum number of
iterations is reached, the optimization terminates and the Status is listed as
Optimization Complete. If necessary, you can stop the iterations manually by
clicking the Stop button.
If you need to adjust the objectives, return to the prescription page, make
adjustments, and start the optimizer again.
The same options as the prescription graph apply to the optimization graph,
such as toggling the legend, grid, etc. For more information, review the
Prescription DVH Options.
NOTE: The optimization graph is not necessarily a true

representation of the dose received by the entire organ, but
only the part of the organ that is being considered by the
optimizer as determined by the rank set in the prescription.
XiO® 2-35
Beam Weight Optimization (cont.)
2-36
Generate MLC Segments or Design Compensators
Once the optimization is complete, you can move on to generating treatment

aids by selecting the shortcut button Generate MLC Segments. If you are
planning with compensating filters, it will read Design Compensators.
However, it is customary when beginning an IMRT plan to evaluate the

optimized DVHs and isodoses before continuing to the final dose calculation.
So, we recommend that you do not generate treatment aids until you are
certain that the plan meets all prescription requirements, and this can only
accurately be assessed with the true DVH. If this is your intention, continue
on with this process. If you would like to skip the optimization evaluation,
proceed to Generate Treatment Aids.
XiO® 2-37
Evaluate the DVH and Isodoses of the Optimized Plan
To quickly evaluate the DVH of the optimized plan, click the Histogram
button on the IMRT supporting toolbar and select the structures you want to
show. At this point, the doses are based on the ideal intensity map doses
only. Use the DVH as a tool to evaluate the prescription you have given, and
to verify that it results in structure doses are reasonable.
NOTE: If you have overlapping structures, the voxels that are in the
overlap region will always be included in the DVH for every
structure. Structure priorities only affect the optimization and
optimization graph, not the DVH calculation.
To quickly evaluate the isodose for the optimized plan, click the Isodose
Lines button on the IMRT supporting toolbar and enter the isodose lines
you want to view. To view the isodoses in 3D, click the Dose in MPV
button on the IMRT supporting toolbar. Remember, these isodoses are
based on the ideal intensity map doses only and will change when this ideal
intensity map is converted to deliverable segments. The isodoses help you
evaluate hot and cold volumes on your optimized plan
Display the DVH Statistics
You can quickly evaluate the plan’s statistics on the DVH Statistics tab of the
Histogram dialog box.
1. Click the Histogram button.
OR
2-38
Display the DVH Statistics (cont.)
Select Dose | Histogram | Statistics.
OR
Select DVH Statistics from the mouse menu in the DVH window.
XiO shows the DVH Statistics tab of the Histogram spreadsheet. It

shows all contoured structures as well as all structure combinations
you defined as part of the Full DVH.
XiO automatically reports the Volume (cc), Min Dose(cGy), Max

Dose(cGy) and Mean Dose(cGy) for all displayed structures. You can
see more statistics for the structures. Select the Statistic you wish to
see in the Goal Type column.
2. You can see multiple goals for a structure. Click on the structure name
and select Add Goal from the mouse menu to add a new for a structure.
3. You can remove goals from a structure. Click on the structure name
and select Remove Goal from the mouse menu to remove the row.
XiO® 2-39
4. You can print a DVH Statistics Report. Click in the table and select Print
DVH Stats. XiO prints the report.
5. The Goal Types you can select are:
Min Dose (cGy or Gy): Type the minimum dose the structure should
receive. You can see the minimum dose to the structure in the Actual
column. If the Actual minimum dose is greater than or equal to the
minimum dose you entered, XiO highlights the Actual cell in green.
Max Dose (cGy or Gy): Type the maximum dose the structure should
receive. You can see the maximum dose to the structure in the Actual
column. If the Actual maximum dose is less than or equal to the
minimum dose you entered, XiO highlights the Actual cell in green.
Target Mean (cGy or Gy): Type the mean dose the structure should
receive. You can see the mean dose to the structure in the Actual
column. If the Actual Mean dose is greater than or equal to the mean
dose you entered, XiO highlights the Actual cell in green.
OAR Mean (cGy or Gy): Type the mean dose the structure should
receive. You can see the mean dose to the structure in the Actual
column. If the Actual Mean dose is less than or equal to the mean dose
you entered, XiO highlights the Actual cell in green.
Min DVH Volume (% or cc): Type the volume (either % or cc) and the
minimum dose that volume should receive. You can see the volume
receiving that dose in the Actual column. If the Actual Volume is
greater than or equal to the volume you entered, XiO highlights the
Actual cell in green.
2-40
Max DVH Volume (% or cc): Type the volume (either % or cc) and the
maximum dose that volume should receive. You can see the volume
receiving that dose in the Actual column. If the Actual Volume is less
than or equal to the volume you entered, XiO highlights the Actual cell
in green.
Min DVH Dose (cGy or Gy): Type the minimum dose and the volume
that should receive this dose. In the Actual column, you see the Dose
to the Volume you entered. If the Actual Dose is greater than or equal
to the Dose you entered, XiO highlights the Actual cell in green.
Max DVH Dose (cGy or Gy): Type the maximum dose and the volume
that should receive this dose. In the Actual column, you see the Dose
to the Volume you entered. If the Actual Dose is less than or equal to
the Dose you entered, XiO highlights the Actual cell in green.
The % Inclusion column shows the % of the structure inside the

calculation volume. Structures with a contour on either the first or last
cross-section of the structure set appear with an * before the value.
You can load and save templates which include the structures and
Goals you use frequently.
6. Click the Save as Template button to save your current setup.
7. Type the DVH Template ID and Description (the description is

optional).
8. Click OK to save the Template.
9. Click in the Load DVH Statistics Template field to view a list of

templates you saved.
XiO® 2-41
10. Select the template from the list of choices in the drop-down box. XiO
replaces the structures currently shown in the histogram with the
structures from the template. XiO loads the values for the Structure
Name, Goal Type, Goal Volume (%) and Goal Dose. After loading the
template, XiO recalculates the Volume, Min Dose, Max Dose, Mean Dose,
and Goal Volume (cc), Actual values and % Inclusion.
Re-display a Histogram
If you create a histogram, then change something about the plan that forces
a re-calculation, such as generating treatment aids, XiO removes the DVH
structures from the graph. Once the calculation is complete, XiO re-displays
the structures on the DVH graph.
Create a Structure from Isodose
The Create Structure from Isodose feature lets you move or remove a hot
spot if you change the isodose curve to an optimization structure, and then
set objectives in the IMRT Prescription page. You can also use this tool to
find the volume inside a specific isodose level.
This example shows how to create an optimization structure from an

isodose level. You can refer to XiO Volume I. Training Guide for additional
information.
2-42
Evaluate the DVH and Isodoses of the Optimized Plan (cont.)
NOTE: When you select Create Structure from Isodose, the system
assigns 1.0 as the default density. This density is not “forced”
or overridden for pixel-by-pixel calculations. If you want to
assign a density other than 1.0 to the converted isodose, then
change the assigned electron density of that structure after
you create it
1. In this task, you identify an unwanted hot spot in the larynx.
2. Note the Isodose Value corresponds to the hot spot used to create the
structure.
XiO® 2-43
3. In the Isodose Lines dialog box, select Create Structure. This selection
shows the Create Structure from Isodose dialog box.
2-44
4. In the Create Structure from Isodose dialog box, type a value less than
1.0cc in the Minimum Volume (cc) field to create a structure that more
closely matches the volume inside the isodose level.
5. Proceed to the IMRT Prescription page and set objectives for the new
structure.
After you evaluate your optimized plan, you can make changes to the IMRT
prescription. If this is your intention, go back to the IMRT Prescription page.
To do this, click the IMRT Prescription button, make changes, and then re-
optimize. To do this, click the Start button on the Start IMRT Optimization
dialog box.
NOTE: While you review the DVH and isodoses of the optimized
plan, note that IMRT Dose appears in the bottom right corner
of the window. In its place, Dose Valid and OPT DOSE show on
the DVH. You can also look at the Source Data. But, no
monitor units show until XiO calculates the final dose.
XiO® 2-45
Review Ideal Intensity Maps (optional)
After the optimization is complete, you have the ability to turn on the ideal
intensity map in a BEV or ABV window. The Ideal Intensity map is a
graphical representation of the IMRT beam used to show the optimized
intensity (the ideal fluence) of the beamlets projected to isocenter in the
absence of the patient. The ideal intensity map is essentially a mathematical
concept. It shows the configuration of beamlet intensities that the optimizer
has determined would be needed into order to satisfy the prescription goals.
It does not take into account limitations due to treatment aids (MLCs or
compensators). You can quickly turn on the intensity map using the Display
Intensity Maps/BEV button , or click the Tools drop-down menu and
select Display Intensity Maps to view more options. From the Display
Intensity Maps dialog box, you have the additional options of changing the
highest intensity to black or white and viewing the anatomy in outlines or
full structures. You can print ideal intensity maps from the File drop-down
menu by selecting the Print and Intensity Maps options, or send to an ASCII
file from the Tools drop-down menu and selecting the Output Intensity Maps
in ASCII option.
You can also edit the ideal intensity map. If you would like to change the
intensity of individual pixels, right-click in the BEV or ABV window and
select the Edit Intensity Map option. Use the mouse to point to a pixel where
you want to change the intensity, then hold your left mouse button down
and drag right to increase the intensity or left to decrease the intensity. You
can sample the intensity map without editing by clicking your right mouse
button on the BEV or ABV window and selecting the Sample Intensity Map
option. If you edit an intensity map, XiO updates the isodoses to reflect the
changes due to the new intensity value. The DVHs may be recomputed and
will also reflect the changes due to the new intensity value.
2-46
Sub-task 4A. Generate Treatment Aids - MLC
Continue here if you are using MLCs for modulation. If you are planning with
Compensating Filters, go to Sub-task 4B.
Once you optimize and are satisfied with the DVH and/or isodoses of the
optimized plan, you can continue by generating treatment aids. XiO creates
MLC patterns in the form of segments in an attempt to generate intensities
that mimic the ideal intensity map.
This is a good time to save the optimized IMRT plan as a "pre-segmentation"

plan. You can return to this saved plan at a later time to make adjustments
to the prescription and re-optimize without having to recalculate the open
fields. Saving your plan at this point allows users with the capability of
splitting beams to revert to the parent beams if beam splitting has occurred.
Remember to delete the optimized plans once a final plan has been
approved. The pencil beam doses saved with the optimized plans take up a
large amount of memory on your system.
XiO® 2-47
Sub-task 4A. Generate Treatment Aids – MLC (cont.)
IMRT Segmented MLC Parameters
Depending on the type of treatment machine you plan with, the fields on the
IMRT Segmented MLC Parameters dialog box vary. Depending on the
segmentation method and the treatment machine you use, you may or may
not have all these options.
Step and Shoot/Sliding Window
2-48
Sub-task 4A. Generate Treatment Aids – MLC
IMRT Segmented MLC Parameters (cont.)
XiO® 2-49
Dynamic/Dynamic Sliding Window
2-50
Delivery Method
XiO supports two delivery methods. The Step and Shoot method of IMRT
delivery is such that a set of static MLC segments are treated where the
beam is off while the MLC leaves are positioned for each segment. The
Dynamic method of IMRT delivery is such that the MLC leaves are moving
while the beam is on.
Segmentation Method
If you are planning Step and Shoot IMRT, you have two options for
segmentation method:
Sliding Window creates segments that step across the field from left to right.
SmartSequencing is a segmenter that produces platform segments based on

clusters or groups of similar intensities. If you select this segmentation
method, you should also perform Segment Weight Optimization.
If you have a Siemens accelerator and purchased ImFAST™, XiO offers you
several other segmentation options. If you are licensed for internal ImFAST
and all of your optimized beams use Siemens MLCs, XiO shows the ImFAST
segmentation algorithm options in the Segmentation Method drop-down list.
If you are using External ImFAST and all of your optimized beams use
Siemens MLCs, XiO offers you the option of exporting the intensity maps to
an external copy of the ImFAST program for segmentation. See your ImFAST
literature for more information on the effects of the different selections on
the segmentation. XiO does not support ImFAST for the 82 leaf MLC.
XiO® 2-51
Ideal Map Extension (optional)
This option is available anytime there is a beam that extends beyond the
surface of the patient. Distance to Extend and Averaging Distance deal with
extending intensity maps at the patient’s surface. For example, if you are
planning an IMRT Breast, you may want to extend the intensity map out past
the surface to account for breathing and flash inclusion. The field is
extended towards the surface using the value entered for Distance to Extend.
You also have the capability of using the Averaging Distance value to average
over a specified distance, the intensity along a given row to determine an
average extension value. This provides a smoother intensity map on the
patient’s surface and smoother MLC segments. Clicking Extend Map Edges
applies the Ideal Map Extension values.
Intensity maps are only extended in the direction of MLC leaf travel. The
averaging distance starts (at the edge to be extended) from the first pixel
with intensity greater than leakage. The number of pixels into which this
side of the row is extended is the integer multiple that is greater than, or
equal to, the specified Distance to Extend (cm), but is extended into any
pixels fully under the jaw. The initial field size must be wide enough in the
flash direction to include the extension. All of the pixels in the extension and
averaging regions are set to the new pixel value.
2-52
The following example illustrates intensity maps on a breast patient that

have, and have not been, extended to include flash.
Intensity Map not extended for Flash Intensity Map extended for Flash
XiO® 2-53
Discrete Intensity Levels

This option is only available when using the Sliding Window Segmentation
Method. This value directly affects the number of segments generated for a
plan. More intensity levels translate to more segments being generated for
the final dose calculation. Fewer intensity levels translate to fewer
segments being generated for the final dose calculation. The following
example demonstrates the effect of increasing or decreasing the number of
intensity levels. Note that using a high number of intensity levels can result
in many small segments being created. These small segments will increase
delivery time and leakage dose.
7 Intensity Levels 15 Intensity levels

Results in 24 segments for this beam Results in 51 segments for this beam
NOTES: At this point, you can interactively enter a number of discrete

intensity levels and the isodoses. The DVH updates using the
discretized intensity map, which can be viewed on the ABV.
You can also make edits to your discretized intensity map

before you segment to shrink or eliminate hot spots.
See Planning Suggestions for more specific information on these topics.
2-54
Minimum Segment Size

This value also affects the number of segments being generated for the final
dose calculation. Any apertures in a segment with a 4A/P value that is less
than the value entered are deleted. A segment is deleted if all apertures in
the segment are less than the user defined Minimum Segment Size. The
weights from the deleted segments are redistributed equally among the
remaining segments. A value of 1.0 to 1.5 will eliminate small, possibly
insignificant segments.
Beam Splitting Notification

XiO IMRT detects fields that violate the maximum allowable distance
between the most retracted leaf, and the most extended leaf for treatment
machines that are capable of beam splitting, and automatically splits them
into two or more fields (child beams) which can be delivered. Typically, field
widths greater than 14 or 14.5, depending on the MLC leaf type, are split
automatically. The gantry, collimator angles, and isocenter remain
unchanged. XiO updates the field size and weight point for each child beam.
The optimizer typically seeks to find the best place to position the weight
point. However, due to the search routine it uses, the weight point may be
placed incorrectly. This weight point positioning issue can also arise if the
default values given to the user when the beam is about to be split are not
suitable for their given plan.
There are three options to try if your weight points are not acceptably
placed.
1. Change the split field parameters when the system warns you it’s about
to split the beam.
2. Move the weight point manually after the dose calculation is finished.
This changes the isodose distribution slightly.
3. Re-optimize the plan. Keep only the beams that have not been split and
the created child beams from the original plan. Delete the parent
beams.
There are four parameters to verify or change, if desired.
XiO® 2-55
Minimum Field Width: This is the minimum field width you want XiO to
create when it creates the child beams. XiO uses an algorithm incorporating
the value for minimum field width and the value of overlap extent to
determine the location of the parent beam split. This algorithm is dependent
on the left side of the field, so often the overlap extent will be created to the
right of the center of the field. If you would like to move the split towards
the left, enter a larger minimum field width value. Depending on the
location of the collimator field edge, the minimum field width could end up
slightly smaller that the value entered.
Overlap Extent is the extent in the width direction where the fields of the
child beams overlap. An algorithm determines the location of the overlap
extent and the value you enter determines the width. The overlap extent
spans across the same set of bixels from row to row on an intensity map.
Split Extent is the distance along an intensity row over which the dose
delivered from the first child beam goes from 100% to 0% and the dose
delivered from the second child beam goes from 0% to 100%. This allows
for dose feathering in the beam abutment region. The split cannot be larger
than the overlap extent, but can have the same value. The split extent will be
the same width but may be in a different location from row-to-row on the
intensity map. XiO searches each row within the overlap extent to find the
lowest contiguous average intensity over the width defined for split extent.
This is where the dose feathering between child beams occurs for that row.
2-56
Beam Splitting Notification (cont.)
Delete Parent Beam: If you answer yes, XiO automatically deletes the parent
beam from the plan and only the child beams remain. If you choose to make
further edits to the prescription, XiO uses the child beams with the overlap
extent as already defined. There will be no "split extent," so no "feathering"
will occur. Optimization takes longer when using child beams, as there are
more beamlets to be considered due to the overlaps. If you answer no, the
parent beams remain, but are turned off on the Beam Weight and Beam
Spreadsheet dialog, and turned off for optimization. To re-optimize with
parent beams only, delete the child beams and turn the parent beams back
on, or alternatively revert to the saved pre-segmentation plan.
The graphs on the following page demonstrate the concepts of overlap

extent and split extent. Two rows of intensities from a single intensity map
are represented on the two graphs. There are four lines on each graph. The
dark blue line represents the optimized intensities along that row. The
magenta line represents the discrete intensities received when 10 intensity
levels were chosen. The cyan and yellow lines represent the intensities
along the same row of each child beam created for the treatment. In this
example, a 4 cm overlap extent and 2 cm split extent were used. The overlap
extent range is shown in blue and the split extent for each row is shown in
red. The intensity map itself shows that the overlap extent does not change
from row to row, but the split extent can if the defined value is smaller than
the overlap extent.
XiO® 2-57
Beam Splitting Notification (cont.)
2-58
Minimum Monitor Unit per Segment
This option is only available if you select the Smart Sequencing

Segmentation Method. This is the minimum Monitor Unit value you will
accept for any segment the system creates.
NOTE: It is possible that when using the SmartSequencer

segmentation algorithm, the Minimum MU/Segment you
enter may be violated. The Minimum MU/Segment entered is
passed to the SmartSequencer along with the ideal intensity
map converted to MU using the open field dose calculation.
When the segments are returned, XiO converts the segment
MU to relative weight, computes the final dose, computes
segment MU correction factors and then computes final MU.
As a result, the final segment MU may be slightly different
from those returned from the SmartSequencer.
Segment Weight Optimization (SWO) uses the Minimum

MU/Segment value during optimization; therefore, the
Minimum MU/Segment should never be violated when using
SWO.
Minimum Segment Area

Segmentation Method. This value represents the smallest segment field area
(cm2) you are willing to accept in your plan. The area is the sum of the area
of all apertures in a segment.
XiO® 2-59
Segment Suppression Factor

Segmentation Method. This factor is used during the sequencing of segments
and is a means to control the number of segments generated. The higher the
value, the fewer segments will be generated. When segments are similar, XiO
evaluates the contribution from both weight and area. The total flux
(fluence x area) of two segments must differ by less than the product of
Minimum MU x Minimum Segment Area x Segment Suppression Factor in
order to remain individual segments. Otherwise, the segments will be fused.
In this example, let:
• Min MU/Segment = 3
• Min Segment Area = 2
• Segment Suppression Factor = 4
2-60
Segment Suppression Factor
If Segment 1 has MU1 MU, and Segment 2 has MU2 MU, then:
(1) The Combined Segment has (MU1 + MU2) MU.
(2) Net alteration to segment 1 : 0.
(3.). Net effect of segment 2 alteration: MU2 x (2 x (1.5 x 2) (fill in

corners) + MU2 x (2 x 2) (add sore thumb)
The Min MU/Segment*Min Segment Area * Segment Suppression

Factor = 3*2*4=24.
Therefore, if MU2 <= 2.4, the operation would be performed.

Otherwise, the two segments would not be fused.
XiO® 2-61
IMRT Optimization Summary
If you would like to review or print a summary of the optimization

parameters used for this plan, click the IMRT Optimization Summary button.
Minimum Monitor Unit per Segment
Start the Segmentation
Once you enter all the required values on the IMRT Segmented MLC
Parameters page, click the Start Segmentation button to begin the generation
of the MLC segments.
IMRT Delivery Summary
If you would like to quickly review or print the number of segments

produced per beam, based on the intensity level chosen, click the IMRT
Delivery Summary button.
2-62
Review MLC Segments
If you would like to review the created MLC segments, complete the
following steps.
1. Click the Review MLC Segments button. XiO shows the IMRT Leaf
Segment Review dialog box.
2. Scroll through each beam and its associated segments by clicking on

the Prev and Next tabs. You can manually delete segments as desired
by clicking the Delete Segment button (step and shoot method only).
When you delete segments, XiO automatically redistributes the relative
MUs among the remaining segments.
NOTE: XiO automatically produces the most efficient leaf

sequence for your treatment machine.
XiO® 2-63
Review MLC Segments (cont.)
3. If you are reviewing dMLC segments, XiO automatically movies through

the segments when you click the Start Movie button. Click the Stop
Movie button to stop the movie.
NOTE: When you stop the movie, understand the shown dose
fraction or MU value may not match the values on the
MLC Segments index because the movie may have
stopped between segments. If you want to see the actual
segment dose fraction or MU value shown, use the
previous and next buttons to movie through the
segments.
4. After you review the segments, click OK.
5. At this point, if you are not satisfied with the number of segments per
beam, change the number of intensity levels and regenerate segments.
OR
Proceed to Segment Weight Optimization
OR
Proceed to Calculate Dose.
2-64
Sub-task 4B. Generate Treatment Aids – CF
Compensating Filter IMRT delivery is such that a physical intensity-

modulated compensator is milled and used for each beam instead of MLC
leaves. When using compensators for modulation, the relative intensities
from the intensity map determine the thickness of each milling location.
Areas that require low doses correspond to larger compensator thickness
and vice versa. Since the IMRT Segmented MLC /dMLC Parameters and
IMRT Compensating Filter Parameters have different properties, the options
are explained separately.
If you are planning IMRT using compensating filters, XiO shows the
following dialog box.
XiO® 2-65
Sub-task 4B. Generate Treatment Aids – CF (cont.)
Intensity Map Smoothing Distance
When XiO creates the IMRT compensating filter, smoothing of the intensity
map is performed to smooth peaks between pixels so that the compensating
filter is easily mill-able. The smoothing algorithm uses the average of the
intensity values over the number of pixels selected. The default value for
Intensity Map Smoothing Distance is three pixels. However, the value is
editable if you would prefer an even smoother compensating filter. Be
aware that applying more smoothing may cause deterioration of the
optimized solution since this process occurs after optimization.
Generate Compensators
1. Once you enter all required values on the IMRT Compensating Filter
Parameters window, click the Generate Compensators button to begin
the generation of the compensating filters.
2. Click Cancel to close the IMRT Compensating Filter Parameters window

and launch the final dose calculation.
OR
Click the Dose button to launch the final dose calculation.
Be aware that once XiO launches the final dose calculation, it generates
the compensators and deletes the initial intensity maps. Now, it is not
possible to edit the intensity maps. To do this, you must re-optimize or
alternatively return to the previously saved pre-segmentation plan.
2-66
Sub-task 4B. Generate Treatment Aids – CF (cont.)
Review Compensating Filter or Relative Fluence Intensity Maps (optional)
Once the dose calculation is complete, you can review the compensating
filter or relative fluence intensity maps.
1. Click the Tools drop-down menu and select the Display Intensity Maps
option. XiO shows a window that allows you to select the map type you
want to review. You also have the options of changing the highest
intensity to black or white and viewing the anatomy in outlines or full
structures.
XiO® 2-67
Sub-task 4B. Generate Treatment Aids – CF
Review Compensating Filter or Relative Fluence Intensity Maps (optional)

[cont.]
2. To print the compensating filter or relative fluence intensity maps,

click the File drop-down menu and select the Print and Intensity Maps
options.
OR
To send an ASCII file, click the Tools drop-down menu and select the
Output Intensity Maps in ASCII option.
2-68
Sub-task 5. Segment Weight Optimization (optional)
Segment weight optimization is an optional process that may accomplish the

following, when used appropriately.
• Improve the agreement between the optimized and final dose

distribution
• Compensate for loss of dose coverage to target volumes
• Improve OAR sparing
• Reduce the number of segments in a plan
When XiO applies the segment weight optimization, it optimizes the segment
weights and calculates the dose contribution from each segment using the
same optimizer, IMRT Prescription and algorithm as was used for the IMRT
fluence optimization and full dose calculation.
Segment weight optimization is compatible with all currently supported step

and shoot segmenters, including ImFast. Dynamically segmented beams are
not supported for use with SWO.
It may not be appropriate to use SWO for every IMRT plan. Note that the
global max dose for a plan using SWO is usually higher than a plan that does
not use SWO. See the Planning Suggestions section of this training guide for
more information.
XiO® 2-69
Sub-task 5. Segment Weight Optimization (optional) [cont.]

To perform segment weight optimization, you can click the Segment Weight
Optimization button on the IMRT Segmented MLC Parameters dialog box,
click the Segment Weight Optimization button or press F9 on the

keyboard to show the Segment Weight Optimization dialog box.
SWO Grid Spacing
This is the grid spacing that XiO uses to calculate each segment. Setting a
grid spacing that is too small, could cause your systems to run out of
memory depending on your hardware.
The Convergence Criterion sets the termination point for the segment
weight optimization iterations. When the difference in the Score Function
from one iteration to the next drops below the Convergence Criterion, the
iterations stop. The lower you set this value, the more iterations it performs.
2-70
Sub-task 5. Segment Weight Optimization (optional) [cont.]
Maximum Iterations
This function gives you the freedom to set the maximum number of
iterations very high or very low depending on your objective for the
optimization. The optimization stops when the convergence criterion or the
maximum number of iterations has been met, whichever comes first. The
bulk of the optimization occurs in the first 30 iterations. After these, small
improvements are made to a point where there is no significant change in
the plan.
Revise Iterations
XiO removes segments that fall below the Minimum MU per segment and the
remaining segments are re-optimized. The optimizer re-runs until this
specified number of iterations is met.
Minimum Segment MU
This value is the minimum MU value you are willing to accept per segment.
XiO removes segment MUs that fall below this value and re-optimizes the
remaining segments.
NOTE: Segments for which dose cannot be calculated, as in air

cavities and in flash, are ignored. Original MUs are retained.
Use Fast Superposition
You only see this option if you have chosen Superposition as the algorithm
for the full dose calculation. This gives you the opportunity to choose Fast
Superposition instead of Superposition for Segment Weight Optimization,
thus reducing the time it will take to calculate segment doses.
Click the Start button to start segment weight optimization. Messages

regarding segments that were removed or not calculated are shown at the
bottom of the dialog box during optimization. Once XiO completes the
segment weight optimization, click OK on the SWO dialog box to start the
final dose calculation.
XiO® 2-71
Task 4. Calculate Dose
To start the dose calculation, click Cancel to close the IMRT Segmented MLC
Parameters dialog box.
OR
Click the Dose button to launch the final dose calculation.
Be aware that once XiO launches the final dose calculation, it finalizes the
segments and deletes the optimized intensity maps. At this point, it is not
possible to edit the intensity maps. To do this, XiO requires that you re-
optimize, or alternatively return to a previously saved "pre-segmentation"
plan.
Task 5: Review Segmented MLC or Relative Fluence Intensity Maps (optional)
Once XiO completes the dose calculation, you can review the Segmented MLC
or Relative Fluence intensity maps. The segmented MLC intensity map is a
graphical representation of the beamlet’s relative intensity (that is, the
fraction of MUs "seen" by each bixel) derived from the segmented MLC’s leaf
segment shapes and weights. The relative fluence map is a graphical
representation of the beam fluence in the absence of the patient and is
computed on a fanline-by- fanline basis from the beam photon spectrum.
The term "relative fluence" refers to the fact that these fluences are
expressed relative to the open field fluence on the CAX of the reference field
size.
1. Click Tools | Display Intensity Maps. XiO lets you select the map type
you want to review. You also have the options of showing the highest
intensity to black or white, and viewing the anatomy as outlines or full
structures.
2. To print segmented MLC or relative fluence intensity maps, click

File | Print | Intensity Maps.
OR
Click Tools | Output Intensity Maps in ASCII. XiO sends to an ASCII file.
2-72
Task 6: Print MLC Segments
Follow these steps if you would like to print MLC Segments for verification.
1. Click File | Print | MLC Segments. This shows the Print MLC Segments
dialog.
2. Middle-click in the Beam Number field and select a beam number.
3. Type a range of segments that you want to print for that beam in the
Segments to Print field.
4. Select a number of segments to print per page from the drop-down

menu. The number of pages that to print shows by default just below
this field.
5. Type an optional comment that shows on the printout.
6. Click OK to print the segments.
Task 7: Print the MLC Segment MU Report
You can print the MLC Segment MU report from the Reports drop-down
menu by selecting MLC Segment MU.
Print the MLC Leaf Positions
You can print the MLC leaf positions from the Reports drop-down menu by
selecting MLC Leaf Positions. In order to select this option, you must have a
BEV or ABV shown that contains the active beam. The active beam must
contain either a conformed MLC or MLC segments.
XiO® 2-73
Task 8. Review and Make Changes to Finish the IMRT Plan
At this point, complete the following tasks:
• Review the final DVHs.
• Review the dose distribution.
• Make changes to the IMRT plan as necessary.
- If you need to make changes to the prescription or intensity

maps, use the saved pre-segmentation plan.
Task 9. Save the IMRT Plan
Once you have completed you plan, from the File drop-down menu, select
Save Plan, XiO shows the save permanent plan dialog window.
You can save your segment dose files along with the plan. However, the files
take up a large amount of disk space. We suggest that you save segment dose
files when you are in the middle of planning and need to close the patient,
but will re-open and continue planning at a later date. This prevents you
from having to re-calculate dose for the segments. Segment dose files will be
removed any time a full dose calculation is performed.
You can also delete the segment dose files. From the File drop down menu,
select Delete then Segment Dose Files. You can delete all segment dose files,
those that are older than a certain date, or the files for the current plan.
2-74
Task 10. Quality Assurance of IMRT Plans
Once you complete and save your IMRT plan, you should verify the plan
using any or all of the following Quality Assurance tools. XiO offers four
separate tools you can use to ensure that treatments are verified and
delivered properly. These tools consist of modeling the delivery of a single
beam to a flat phantom, creating a single beam QA plan, creating a
Composite QA plan, creating a Max Extent DRR, and visualizing and
exporting Intensity Maps.
Create a Single Beam QA Plan
XiO lets you to recreate the dose for individual beams perpendicular to a flat
phantom without creating a separate QA plan. After the IMRT plan is
complete, click the Tools drop-down menu and select the Modulation QA
option. Here, you are able to enter values for the SSD, depth, material, and
density to create a homogeneous phantom on which to calculate the dose for
the individual beams. You can also edit filenames and monitor units for each
beam.
Consider the following aspects when using this method for IMRT QA:
• The phantom is a flat homogeneous phantom.
• The grid spacing used is the smaller of 0.25 cm or the grid spacing of
the original beam calculation.
• You cannot add any points of interest in which to calculate dose.
• You cannot produce a composite dose plane.
• Filenames for individual beams are user-definable.
• Monitor units for individual beams are user-definable.
• At the export distance (SSD + Measurement Depth), the dose plane

extends past the field edge to a distance equal to the TERMA extent
for the FFT Convolution, superposition, and Fast Superposition
algorithms.
• If a beam contains any bolused fractions, XiO shows the bolused

MUs.
• The patient ID shows in the exported file.
• These files are saved in /FOCUS/tmp/network/MLC/QA or

compf/QA.
XiO® 2-75
Task 10. Quality Assurance of IMRT Plans
Create a Single Beam QA Plan (cont.)
• The dose that shows is absolute dose.
• Dose along the weight point fan line is normalized to 100%.
To delete these QA files, click File | Delete | QA Files. You can delete All QA
files, QA files that are older than a number of days, or individual QA files.
Create a Composite IMRT QA Plan
XiO lets you recreate the composite IMRT plan on any QA phantom. After
you complete and save the IMRT plan, close the plan and open a New QA
Plan. Here, you are able to select the phantom you want to use and select the
IMRT plan you want to recreate on that phantom. XiO calculates dose using
the monitor units from one fraction of the original patient plan. If bolus is
present on the original patient plan, XiO uses the bolused MU. XiO does not
add a bolus to the QA plan. Once the QA plan is calculated, you can select to
export the doses from any transverse, sagittal, or coronal view. Click the
Dose Profile button, select a sub-window that contains the plane you want to
QA, and then click the Dose Plane Output button. Enter a user-definable
filename. The files are written in ASCII text format to
/FOCUS/tmp/network/QA.
It is possible to output an individual beam dose plane by turning on only one

beam at a time on the Beam Weight or Beam Spreadsheet dialog. If you plan
to QA each individual beam using this method, consider selecting Set all
Beams to Nominal when loading the plan on the QA phantom.
2-76
Task 10. Quality Assurance of IMRT Plans (cont.)
 Consider the following aspects when using this method for IMRT QA.
 You can scan any phantom for use in IMRT QA.
 You can define the isocenter by an existing interest point, beam

isocenter, or by entering coordinates.
 You can use any grid spacing to calculate the dose.
 You can specify interest points in the QA phantom. XiO reports the
dose to those points. XiO will either calculate the dose or interpolate
the dose to the interest points, depending on how you have the
preference set. Select Edit | Preferences | General to set this
preference.
 You can use any number of beams to create the dose plane.
 You can define filenames for the dose plane output.
 Phantom ID shows as the patient ID in the exported file.
Create a Maximum Extent DRR
XiO allows projection of the largest leaf extent onto a Digitally Reconstructed
Radiograph. You can use these as field verification films.
Utilize Intensity Maps
XiO allows you to visualize, sample, print, and/or export intensity maps
created in the IMRT plan or the QA IMRT phantom plan. You can find
exported intensity maps in /FOCUS/tmp/network/QA/IMAP. You can also
use intensity maps for qualitative QA purposes. You can use fluence maps
for quantitative purposes if you have the appropriate dosimetry equipment.
For more information on IMRT QA, see the document QA of IMRT Beams-
Technical Considerations under the Technical References heading in the
Online Help.
XiO® 2-77
Task 11. Customization and Preferences
To make IMRT planning easier and more consistent, you should consider
reviewing and setting the available IMRT preferences found under Edit |
Preferences | IMRT. The following IMRT specific preferences are available.
In Edit| Preferences | IMRT, there are four preference options from which
you can make a selection.
• Optimization
• Delivery
• Intensity Map
• Smoothing.
Optimization
These are the preferences you can set for the optimization parameters.
1. Select Optimization from the drop-down list to show the IMRT

Optimization Preferences dialog window.
2-78
Optimization (cont.)
IMRT Graphs
2. Click the drop-down arrow in the Grid field and select On or Off as the
default value for showing the grid.
3. Click the drop-down arrow in the Legend field and select On or Off as
the default for showing the legend.
4. Select the default number of Iterations between DVH Updates during

IMRT optimization.
5. Click the drop-down arrow in the Modulator field and select the
preferred preference for your IMRT modulator. Your choices are MLC
or Compensating Filter.
6. Click the drop-down arrow in the Compensating Filter Type: field and
select the compensating filter type. Your choices are Huestis, Par
Scientific or decimal.
NOTE: You must define Filters in Source File Maintenance (SFM)

before you can use them in Teletherapy.
7. Enter a value in the MLC Step Increment X(cm): field. Acceptable

values range between 0.3 and 2.0 in steps of 0.1 cm. The step
increment is the width of the ideal fluence elements used during
optimization. The leaf step increment and the leaf width (defined by
XiO MLC configuration file) determine the resolution of the MLC
intensity map.
8. Enter a default value for the Minimum Transmission Multiplier. Range

is 1.0 to 10.0 in steps of 0.1.
9. Enter a value for the compensating filter resolution in the Resolution

X(cm): and Y(cm): field. Acceptable values range from 0.3 cm to 2.0
cm, in steps of 0.1 cm. These represent the width and length of the
ideal fluence elements used during optimization.
XiO® 2-79
The optimization stops when either the difference between successive score
functions is less than the convergence criteria, or the maximum number of
iterations has been reached.
10. Type a value in the Convergence Criterion (%): field. Acceptable values
range from 0.0001 to 100, in steps of 0.0001. Tip: Use a starting
convergence criterion of 0.001.
11. Type a value in the Maximum Iterations: field. Acceptable values range
between 0 and 300, in steps of 1.
12. Type a value in the Scatter Extent (cm): field representing the distance
that is measured from the edge (not from the center) of the beamlet.
Acceptable values range from 0.0 cm and 3.0 cm, in steps of 0.1 cm.
13. Type a value in the Optimization Margin (cm): field representing the
area to which the optimization is restricted around the target (which
includes some margin for penumbra). Acceptable values range from
0.0 cm and the value of Scatter Extent, in steps of 0.1 cm.
14. Select a default Smoothing Parameter from the drop-down options.

None is a valid option.
2-80
Beam Weight Optimization
The optimization stops when either the difference between successive score
functions is less than the convergence criteria, or the maximum number of
iterations has been reached.
15. Type a value in the Convergence Criterion (%): field. Acceptable values
range from 0.0001 to 100, in steps of 0.0001. Tip: Use a start
convergence criterion of 0.01.
16. Type a value in the Maximum Iterations: field. Acceptable values range
between 0 and 300, in steps of 1.1.0
17. Click OK to update the IMRT Optimization Preferences.
XiO® 2-81
Task 11. Customization and Preferences (cont.)
Delivery
These are the preferences available for IMRT delivery.
1. Select Delivery from the drop down list to show the IMRT Delivery
Preferences dialog window.
2. Click the drop down arrow in the Delivery Method field and select a
preferred default delivery method. Options are Step and Shoot and
Dynamic.
2-82
Delivery (cont)
3. Click the drop-down arrow in the Segmentation Method field and select a
segmentation algorithm. For MLC-based IMRT, the options are:
• Sliding Wnd (Sliding Window)
• DynSlidingWnd (Dynamic Sliding Window)
SmartSequencing
If your clinic uses ImFast, you also have these segmentation algorithm
options:
• ExpIntMap (Export Intensity Maps)
• Platform (Platform Optimal ImFAST - only for the internal version of

Siemens’ ImFAST™ )
• PltFluence (Platform Optimal ImFAST with Fluence Correction - only

for the internal version of Siemens’ ImFAST™ )
• Standard (Standard Optimal ImFAST- only for the internal version of

Siemens’ ImFAST™ )
• StdFluence (Standard Optimal ImFAST with Fluence Correction -

only for the internal version of Siemens’ ImFAST™ )
XiO® 2-83
Delivery (cont.)
Ideal Map Extension
Use the ideal map extension in IMRT when you need to extend the MLC field
beyond the patient’s surface for flash or movement. This is most frequently
used for IMRT breast tangents.
4. Type a value in the Distance to Extend (cm): field to extend the edge of
the ideal intensity map. Acceptable values range from 0.0 cm to 3.0 cm,
in steps of 0.1 cm.
XiO extends the edge of the intensity map along the direction of the leaf
travel and outward from the patient.
5. Type a value in the Average Distance (cm): field as the preferred

distance from the edge of the skin back into the patient, to use for the
intensity in the extended region. Acceptable values range from 0.0 cm
to 2.0 cm, in multiples of the step increment used for the optimization.
XiO averages these intensities and assigns the average to the extended
portion of the intensity map.
Discrete Intensity Levels
6. Type a value in the Discrete Intensity Levels: field. Acceptable values

range from 2 to 20, in steps of 1.
Split Field Parameters
Type the preferred preferences to use on beams that need to be split after
optimization. Some users can have IMRT fields that need to be split due to
the field width limitation of their Linac’s MLCs.
7. Type a value in the Minimum Field Width (cm) field representing the
smallest allowable width for the beams resulting from the beam
splitting (also called child beams). Acceptable values range from 0.5
cm to 10.0 cm, in steps of 0.5 cm.
2-84
Delivery
Split Field Parameters (cont.)
8. Type a value in the Overlap Extent (cm) representing the preferred

preference for the extent, in the MLC leaf travel direction, that the child
beams will overlap. Acceptable values range from 0.0 cm to two-thirds
of the value defined for Minimum Field Width, in steps of 0.5 cm.
9. Type a value in the Split Extent (cm) field representing the width
direction, over which the intensity of the original (parent) beam will be
distributed to the child beam intensity maps. Valid entries lie in the
range of 0.0 cm to the value defined for Overlap Extent in steps of 0.5
cm.
NOTES: If the Split Extent is set equal to the Overlap Extent, XiO
distributes the intensities in the entire overlap region
between the resulting child beams.
If the Split Extent is less than the Overlap Extent, XiO

determines (for each leaf pair) where the lowest dose
region of contiguous width equal to the Split Extent lies,
and distributes the intensities of this region among the
child beams.
10. Click the drop-down arrow in the Delete Parent Beams field and select
the action you would like XiO to take after the beam splitting has been
accomplished. Yes means XiO deletes the parent beams when the final
dose calculation is launched after segmentation.
OR
No means XiO turns the parent beams off and does not delete the parent
beams when the final dose calculation is launched.
XiO® 2-85
Delivery (cont.)
Sliding Window
11. Type a value in the Minimum Segment Size (cm): field. Acceptable
values range from 0.0 cm and 3.0 cm, in steps of 0.1 cm.
Smart Sequencing
12. Type a value in the Minimum MU/Segment field. Acceptable values

range from 1.0 to 10.0 in steps of 0.1.
13. Type a value in the Minimum Segment Area (cm^2) field. Acceptable
values range from 0.1 to 100.0 in steps of 0.1.
14. Type a value in the Segment Suppression Factor field. Acceptable

values range from 1.0 to 10.0 in steps of 0.1.
Compensating Filter
15. Click the drop-down arrow in the Compensating Filter Intensity Map
Smoothing Distance (pixels): field and select a value for the preferred
number of pixels. Acceptable values are 3, 5, 7, or 9 pixels. The default
value is 3.
Segment Weight Optimization
16. Type a default value in the Convergence Criterion (%): field.

Acceptable values range from 0.0001 to 100, in steps of 0.0001.
17. Type a default value in the Maximum Iterations: field. Acceptable

values range between 0 and 300, in steps of 1.
18. Type a default value in the Minimum MU/Segment field. Range is 0.0 to
10.0 in steps of .1.
19. Select the default of yes or no for using Fast Superposition for the
segment dose calculations.
2-86
Delivery
Segment Weight Optimization (cont.)
20. Click OK to update the IMRT Delivery Preferences.
Export Segments as Beams
You can export segments as individual beams.
1. Click Edit | Preferences | DICOM. XiO shows the DICOM Preferences

dialog box.
2. If you would like to send MLC segments as individual beams, click the
drop-down arrow next to the field Export Segments as Beams and
select Yes. If you answer yes, each MLC segment is exported as an
individual beam. This preference only applies to step and shoot
segmented beams. Exported beams are numbered according to BBSSS,
where BB is the two digit beam number, and SSS is the three-digit
segment number for that beam.
3. You can change this option at the time you export the plan from the
Export DICOM dialog box.
XiO® 2-87
Task 11. Customization and Preferences (cont.)
Intensity Map
Intensity maps are two-dimensional planes of data perpendicular to the

central axis and projected to isocenter. Set the intensity map preferences
here.
1. Select Intensity Map from the drop down list to show the IMRT
Intensity Map Preferences dialog box window.
Display Print
2. Click the drop-down arrow in the Highest Intensity field and select the
preferred color for showing intensity maps.
Black means the highest intensity is shown in black. Intensities less

than the highest are shown in decreasing shades of gray. This is the
default.
White means the highest intensity is shown in white. Intensities less

than the highest are shown in increasing shades of gray.
2-88
Intensity Map
Display Print (cont.)
3. Click the drop-down arrow in the Anatomy Outlines field and select On
(meaning the preferred preference for the anatomy outlines is on and
they are included in the output).
OR
Select Off (meaning the preferred preference for anatomy outlines is

off and they are not included in the output).
Output Map To
4. Click the drop-down arrow in the Output Map To: field and select the
preferred output device.
NOTE: If you only have one device set up. XiO shows it as the
default.
5. Click the drop-down arrow in the Paper Size: field and make a
selection.
The choices available depend on your output device.
A/A4 (ANSI, size A: 8.5 x 11 inches)

B/A3 (ANSI, size B: 11 x 17 inches)
8x10 in (for film printers)
14x17 in (for film printers)
Large A (user-defined size)
Large B (user-defined size)
The default is A/A4.
6. (This field only appears for PostScript Output.) Click the drop-down
arrow in the Spooler: field and select an output device (Laser Printer or
Plotter) on which the intensity maps are to be printed. Plotter is the
default.
XiO® 2-89
Intensity Map (cont.)
ASCII Output
7. Enter a value in the Resolution (cm): field representing the preferred

resolution for the 2-D intensity map scale, in the X and Y directions.
The resolution is the same in both directions. Acceptable values range
from 0-1. cm to 1.0 cm, in steps of 0.1 cm. The default value is 0.1 cm.
Define Default Filename Format
Use the following fields to define the format for the file names used when
XiO outputs intensity maps in ASCII. This format becomes the default
filename; you can change it, if necessary, when you output the intensity map.
8. Enter the first part (prefix) of the filename in the Prefix: field (up to
three alphanumeric characters). The default is blank.
9. Enter the Maximum Patient ID Characters (alphanumeric). Acceptable

values range from none (blank) to up to 14 alphanumeric characters.
The default maximum is no characters (blank).
10. Click the drop-down arrow in the Include Beam Number field and
select
Yes to include the beam number in the filename.
OR
Select No to not include in the file name. The default is No.
11. Enter the Maximum Beam Description Characters. The acceptable

values range from none to 24-characters. The default maximum is no
characters (blank).
12. Enter a suffix in the Ideal Map Suffix: field for ideal map filenames. You
can enter up to three-alphanumeric characters. The default is blank.
2-90
Intensity Map
Define Default Filename Format (cont.)
13. Enter a suffix in the Segmented MLC Map Suffix: field for the MLC
intensity map filenames. You can enter up to three alphanumeric
characters. The default is blank.
14. Enter a suffix in the Compensating Filter Map Suffix: field for
compensating filter map filenames. You can enter up to three
alphanumeric characters. The default is blank.
15. Enter a suffix in the Relative Fluence Map Suffix: field for relative
fluence map filenames. You can enter up to three alphanumeric
characters. The default is blank.
16. Click the drop-down arrow in the Generate Unique Filename: field and
select Yes to add a unique number to the filename.
OR
Select No.
Default Filename Formats
XiO shows sample filenames based on your entries.
• Ideal Map
• Segmented MLC Map
• Compensating Filter Map
• Relative Fluence Map
17. Click OK to update the Intensity Map Preferences.
XiO® 2-91
Intensity Map (cont.)
Smoothing
1. Select Smoothing from the drop-down list to show the IMRT Intensity
Map Preferences dialog box window.
2. Select a smoothing preference Label from the drop down list of

options if you want to edit an existing preference.
OR
Type a new Label if you want to create a new preference.
OR
Select a smoothing preference and click the Delete button to delete an

existing preference.
3. Type or edit the preference Description in the optional description

field.
4. Type or edit the value for w = time step.
5. Type or edit the value for a = multiplier.
6. Type or edit the value for n = power.
2-92
Intensity Map
Smoothing (cont.)
7. Type or edit the value for Weight, a weighting factor applied to the
smoothing component.
NOTE: For more detailed information regarding these smoothing

components, see the physics presentation in this guide
regarding Adaptive Diffusion Smoothing.
Other Settings and Preferences
Under Edit/Preferences/General, set the option Automatically Start Dose

Calculation to Yes.
You cannot use the Clarkson algorithm for IMRT planning. To avoid having
Clarkson as an option, either create a machine in Source File Maintenance
specifically for IMRT where Clarkson is not validated, or in Site
Customization/Calculation Defaults/Teletherapy, select any algorithm
except for Clarkson as the default algorithm for photons.
Refer to the XiO Training Guide Site Customization and Preferences sections
for more information on general system and planning customization.
XiO® 2-93
Planning Suggestions
Below are a few planning suggestions you may want to consider using when
creating an IMRT plan in XiO.
Workflow Suggestions
All variables are recommendations only.
1. Contour all required structures.
(1) If you have more than one target, combine them to create a combo
target.
(2) Contour transition structures when going from a high dose region
to a low dose region.
(3) Use the clip inside the patient skin feature to keep targets at least 3
mm inside the skin.
2. Create IMRT beams (use a template).
(1) Use appropriate machine and energy.
(2) Set isocenter to center of target or combined targets or as

appropriate to technique.
(3) Set jaws to asymmetric.
(4) Set appropriate algorithm, Convolution/Superposition.
(5) Set grid spacing to 0.3/0.4 (to increase optimization speed).
(6) Check location of weight point in BEV for each beam, move if
behind the OAR, in an air cavity, or tissue/air or tissue/bone
interface.
3. Conform beams to largest target or combined target structure.
(1) Conform jaws only for MLC-based IMRT.
(2) Conform MLC/Aperture for compensator-based IMRT.
(3) Set an adequate margin (approx 1 cm) around the target or

combined targets.
XiO® 3-1
Workflow Suggestions (cont.)
4. Enter Min/Max and (Optional) Goal dose for target(s).
(1) Min = prescribed dose, Max = prescribed dose + approx 5%,

(Optional) Goal dose = min dose + approx 1%.
(2) Leave weight and power at default settings for the initial
optimization.
(3) Remember that the quadratic portion of the penalty function does
not apply until the dose is outside the prescribed range. Therefore,
in the prescription, it may be necessary to enter in a minimum
dose, which is higher than is clinically required, and a maximum,
which is lower than is clinically acceptable.
(4) The closer the minimum and maximum dose are to each other, the
more homogeneous the dose distribution will be. Setting the
maximum dose too low may impact on the minimum coverage.
You should use a realistic acceptable maximum. Consider using a
higher maximum for more complicated volumes such as head and
neck plans.
(5) If there is more than one target, use the appropriate rank (see
Section 1. Task 3, Sub-task 2 of this guide for more information on
rank).
(6) Use transition structures (see Contouring Suggestions below).
5. Run Optimization.
Use default settings (see Task 3, Sub-task 3 of this guide for more
information).
6. Check the target coverage.
(1) Use DVH and isodose distribution to check for adequate target
coverage. If target is not covered, adjust the following until target
coverage is achieved: number of beams, gantry positions, energy,
prescription, and minimum dose.
(2) Weight and/or Power can be increased. Keep power low (2.1-2.3)
to achieve minimum target coverage.
7. Check dose to OARs.
(1) Use DVH and isodose distribution to assess dose received by OARs.
(2) Structures that receive dose below the tolerance dose may not
need to be included in prescription.
3-2
8. Add OARs to prescription as required.
(1) Only include structures that are violating the tolerance doses in the
prescription.
(2) Add one structure at a time. Use default weight and power
settings.
(3) Use dose volume points instead of maximum doses for OARs that
are adjacent to or overlapping the target.
(4) Use appropriate rank for OARs that overlap the target(s).
9. Run optimization.
Use default settings again.
10. Check target coverage and OAR dose.
Use DVH and isodose distribution to check the OAR dose and the target
coverage.
XiO® 3-3
11. Adjust the prescription to achieve goals if required.
(1) Check the structures that are not meeting the requirements and
increase weight or power to better meet requirements. Identify
the exact prescription variable that is in violation and only
adjust that variable.
(2) Re-run the optimization.
12. Generate segments/create compensators.
(1) Check the resultant dose distribution and choose the

appropriate number of intensity levels/minimum segment size
or smart sequencing parameters.
(2) Generate segments and review.
13. (Optional) Edit MLC Segment Leaf Positions
See the planning suggestions section Edit MLC Leaf Position

Suggestions for useful tips.
14. (Optional) Optimize segment weights.
See the planning suggestions section on Segment Weight Optimization

for useful tips.
15. Launch the final dose calc.
(1) Set the grid spacing to 0.2 as soon as the final dose calc is
launched.
(2) Assess plan, approve, plot, and perform QA.
NOTE: When beginning with IMRT planning, it is best to make one

change at a time to the prescription and run the
optimization to assess the impact of the change. This will
help you to understand how the optimization process
works and identify any conflicts being created in the
prescription.
3-4
Composite and Synchronous Planning Suggestions

If you are adding IMRT boosts to conventional or original IMRT plans, here
are some suggestions:
Since XiO has the capability of showing composite plans, even conventional
plus IMRT composite plans, it is most common and highly beneficial to add
boost beams to an existing plan so you can view a composite when you are
finished.
There are two options for creating IMRT composite plans.
1. The first option is creating an original plan (conventional or IMRT),

adding boost plan beams, and planning the IMRT boost with the
original plans beams turned off, then adding them together in the end.
When you plan this way, enter IMRT prescriptions that represent the
dose contribution from only the boost plan.
2. The second option is planning synchronous IMRT where you create the
original plan, add the boost beams, leave the original plans beams
turned on, but do not optimize them. The IMRT optimizer recognizes
that dose was delivered from the original plan and how that dose was
distributed. Then, it uses that information when producing the IMRT
boost. The original plan remains unaffected. When you plan this way,
enter composite doses for the IMRT prescription. Be aware that if the
initial plan did not adequately cover the target and/or had hot spots
within the target, the boost plan will take this into account and correct
for the dose variation. This will result in a composite plan that looks
good, but make sure that you review the boost plan alone to verify that
you do not have any undesirable radiobiological results when treating
the boost plan alone.
3. The first time you complete the prescription table set up, optimize.
Then, save the optimized plan so that you can start again from that
point, if necessary. For example, if you are a Varian user and you have
completed an IMRT plan where the beams split, but you are not
satisfied with the prescription, you may want to close the plan, open
the saved optimized plan, and adjust the prescription and continue —
rather than deleting the child beams that were created, turning on the
parent beams that were turned off, and then returning to the
prescription to re-optimize.
XiO® 3-5
Composite and Synchronous Planning Suggestions (cont.)
4. There is one caveat to this practice. Plans saved just after optimization,
include the pencil beam calculation that make the optimized plan file
very large (1 to 1 ½ GB). After you have completely finished planning
this patient and saved the final dose calculation, delete all optimized
plans to free up space on the disk.
5. You can create templates by saving any completed plan using the File
drop-down menu and selecting the Save as Template option. XiO saves
the following items in a template (as long as these values have all been
entered when the template is saved).
• Number of beams
• Beam parameters (gantry angle, collimator angle, width, length,
weight, etc.)
• Heterogeneity correction setting
• Pixel by pixel calculation settings
• Distance between calculation points along width, height, and depth
• Window layout
• Wedge (s) defined for each beam
• IMRT optimization parameters and prescriptions
For more information on templates, refer to the XiO Help topic "What are
treatment plan templates?"
Contouring Suggestions
Make use of default anatomical site names and templates for recurring IMRT
treatment setups and prescriptions. When using templates for IMRT, it is
necessary for contour names to be consistent from patient to patient. Create
default anatomical site names in Site Customization and use in planning to
maintain a consistent naming scheme when planning.
3-6
Contouring Suggestions (cont.)
Create transition volumes when necessary. You can create a transition

volume using 3D auto-margin to help transition the dose in a high gradient
region between two structures with different prescriptions. This method is
particularly useful for targets within targets, targets with
abutting/overlapping OARs, and any situation where dose is not conforming
to the target as required.
(Example a) Target within a target.
You can use the transition volume to transition the dose from 4500 cGy in
PTV1 up to 5800 cGy for PTV2 and helps prevent hotspots within PTV1. The
transition volume is created around PTV2 using the 3D auto margin feature.
TRANSVOL = PTV2 + 0.5 CM.
TRANSVOL is set in the prescription as an OAR and has a max dose of 5800
cGy assigned. The rank is 2, PTV2 is ranked 1, and PTV1 is ranked 3. This
means that the pixels within the transition volume but outside PTV2 cannot
receive a dose higher than the prescribed dose to PTV2. Effectively, this
means that the dose farther outside the transition volume will also not
exceed the prescribed dose. See the following diagram.
PTV1
Rank=3
TRANSVOL
Rank=2
PTV2
Rank=1
XiO® 3-7
Illustrated below is the prescription for this plan.
NOTE: The maximum for PTV1 is much lower than the dose being
prescribed to PTV2. Without the transition volume, this max
has to be at least as high as the minimum of PTV2 that allows
hot spots within PTV1.
3-8
(Example b) Target with an adjacent or overlapping OAR.
In this case, the target dose is 6000 cGy, and the max dose to the OAR (right
parotid) is 1500 cGy. In this situation, there has to be some compromise as
it is not possible to achieve such a large dose variation. By creating a
transition volume around the PTV (PTV + 0.5 cm margin) and making it an
OAR with a maximum dose equal to the minimum prescribed dose to the
PTV, there is effectively no penalty for voxels within the transition volume.
This transition volume also helps restrict hot spots outside the target. Again,
the rank is important. The PTV must be ranked 1, the transition volume
ranked 2, and the right parotid ranked 3.
Right
Parotid TRANSVOL
Rank=3 Rank=2
PTV4
Rank=1
XiO® 3-9
(Example c) Transition volume to reduce hotspots and increase conformity.
You can also use a transition volume used to allow the dose to transition
from high dose within a target to low dose area outside of the target. It also
prevents hot spots outside the target by limiting the immediately
surrounding tissue to the same dose as the target or less. A second
transition volume can increase this effect even further resulting in an
extremely conformal plan where many OARs may not need to be included in
the prescription.
The examples below show the dose distribution for a simple prostate plan.
Diagram 1 shows the expanded PTV (green), TRANSVOL1 (yellow) is a 0.5

cm auto margin on the PTV, and TRANSVOL2 (cyan) is a further 0.5 cm
expansion on TRANSVOL1.
Diagram 1
3-10
Diagram 2 shows the prostate and seminal vesicles as PTV1, the required
dose is 7000 cGy, and the rectum is the only other organ being considered in
the prescription. The dose is not conforming to the target very well and the
local max is outside the target and within the bladder.
Diagram 2
XiO® 3-11
Diagram 3 shows the same plan with the only addition being that
TRANSVOL1 is now included in the prescription, it is set as an OAR with
rank=2, and max dose = to the min PTV dose (7000 cGy). There is a definite
increase in the conformity of the plan. The local max has moved within the
target. The 5000 cGy isodose lines outside the target are now smaller.
Diagram 3
3-12
Diagram 4 shows the same plan again this time, with the addition of the
second transition volume to the prescription. TRANSVOL2 is also defined as
an OAR with the maximum dose being equal to approximately half the dose
of TRANSVOL1 (3500 cGy). The isodose distribution is now highly
conformal. The 5000 cGy isodose line is almost gone from outside the target.
The plan may need rescaling, as it is so conformal that it may not cover the
entire target completely, but the shape of the distribution will not change in
this process.
Diagram 4
XiO® 3-13
Beam Arrangement Suggestions

1. For non-concave targets, any standard arrangement that one would
use for regular 3D planning should suffice, since the modulation will
improve on the dose distribution. Five (5) evenly-spaced beams is a
good place to start.
2. For concave targets, you are more likely to require more beams in
order to shape the dose distribution around the target. Seven to nine
(7 to 9) beams will usually work, and there is not much advantage in
going much higher than nine (9) beams as far as dose distribution is
concerned.
3. The more beams you have, the less complicated the intensity maps.
This could result in fewer segments overall.
4. Try to have beams that are independent of each other by avoiding

opposed beams.
5. At least fifteen (15) degrees of separation between beams is a

general rule of thumb for beam independence
6. Use a BEV to find beam angles that yield the best separation between
target and critical structures.
7. Avoid using one “very good” beam as the optimizer will tend to
overuse that beam, resulting in high entrance dose for that particular
beam. A good example of this is a five-field prostate with one of the
beams being a lateral. You tend to get about 70% entrance dose or
higher for that beam.
3-14
Prescription Suggestions
1. When completing the prescription table, only turn on the prescription
for the target(s) for your first iteration.
2. Understand that you may not need to use weights or powers to achieve
your prescription goals. Always start out with the default values and
change them only when necessary.
3. Make sure you turn on all the target structures at once so that the
beamlet dose will not have to be recomputed when targets are turned
on/off. When you review your optimized DVH, XiO enables you to
evaluate the OARs and determine if they need to be included in the
prescription or not.
4. At this point, check that the target coverage is achievable. If the target
coverage cannot be achieved without any OARs turned on, you need to
reassess the beam arrangement until coverage can be achieved.
5. After you have made your evaluation, return to the Prescription

window and turn each structure on one by one, optimize, and evaluate
the optimized DVH. Using this method will help you to understand the
effects the weight and power of each structure has on the complete
prescription.
6. When you have abutting or overlapping targets and OARs, you could
create and use transition volumes as described above, or you could
simply use dose volume penalties on the structures themselves. For
example, if you have a target (TV) that overlaps an organ at risk
(OAR), set the ranks the same for the TV and OAR.
7. Enter the prescription requirements to the TV and then enter dose

volumes for the OAR instead of a maximum dose. This allows the
optimizer to determine the trade-offs in dose between the two
structures, and works much better than just trying to set a maximum
dose for the OAR to receive, thus compromising the dose to the target.
(See the lecture section on Rank for more information.)
XiO® 3-15
Prescription Suggestions (cont.)

8. Avoiding prescriptions that fail. If the optimizer fails to start, or starts
and only runs a few (less than 10) iterations, chances are you may
have entered prescription values that are not valid. For best results,
you will want the optimizer to run at least 30 to 50 iterations before it
converges. If the optimizer only runs a few iterations, it might indicate
that the problem was very simple, or the prescription was easy to
meet. This is not usually the case in IMRT.
9. Always remember to prescribe in total dose. If you are creating a
composite plan, you may need to enter composite doses depending on
the composite option you choose (see Workflow suggestions).
10. Always review the doses to the OARs and verify that the prescribed
doses are feasible.
11. Check for variables with high power and/or weight assigned and
assess the variable to see if it is feasible.
12. Do not be too literal with the prescription. Remember, if structures are
overlapping, the rank determines which part of the structure is being
optimized. Example, if 20% of the rectum is overlapping the PTV and
PTV is ranked 1, and the rectum ranked 2 or higher, you are only
prescribing to the remaining 80% of the rectum. 20% will receive the
full PTV dose.
13. It is okay to "pad" the dose. If your plan looks good, but the target
coverage is slightly less than required, try adding an extra 50–100 cGy
to the minimum target dose and re-optimize. This can be a better
solution than rescaling, as rescaling will increase the max dose and the
dose to all OARs.
14. Use power or weight, not both. Power is often applied to a maximum
objective since it is exponentially more powerful than weight and can
act as a barrier. Weight is often applied to a minimum objective since it
affects the entire shape of the curve and can help to edge the minimum
up to the required value.
15. To show organs that are not included in the prescription at the bottom
of the list, assign a high rank number to the organ and reorder by rank.
Click on the word Rank at the top of the column to do this.
16. Set the goal dose close to, or equal to, the minimum dose. This
minimizes high dose regions within the target.
3-16
Smoothing Suggestions
Another suggested smoothing option is the GeneralLowSmoothing option.
This smoothing option works well on a variety of plan types. Create a
smoothing file using the following parameters:
• w: 0.5
• a: 0.3
• n: 0.3
• Weight: 0.2
Intensity Map Editing Suggestions

(MLC or CF IMRT) If you have unwanted or poorly located hot spots after
optimization, you can try editing individual bixels on each beams intensity
map before selecting the Generate Treatment Aids option.
1. Place a marker on the transverse slice where the hot spot is located.
This marker then shows on each beams eye view.
2. Right-click on the intensity map and select Edit Intensity Map.
3. Locate the marker on the BEV and edit individual bixel values on each
BEV with the mouse. Notice that the isodoses automatically update after
the edits are made.
4. Re-show the DVH after making an edit.
(MLC IMRT only) After optimization and before segmentation, you have the
option to review the effects of intensity levels on the isodose curves. The DVH
will need to be re-shown after making a change.
1. On the IMRT Segmented MLC Parameters window, enter a number of

discrete intensity levels and the isodoses will update using the
discretized intensity map (which can be viewed on the ABV). This
allows you to instantly view the effect of using different numbers of
intensity levels.
XiO® 3-17
Intensity Map Editing Suggestions

2. Change the number as many times as you want to review your options
before you segment the plan. You may find in some cases, using fewer
intensity levels actually produces a better plan than more intensity
levels.
(CF IMRT only) If you are having trouble fabricating a compensating
filter because there is too much fine detail to the generated filter, try using
a different intensity map smoothing distance. When you use a larger
smoothing distance, XiO replaces specific intensities in the X and Y
direction, with average intensities. The number of pixels selected
determines the average intensity. However, as the smoothing distance
increases, more and more fine detail in the compensator is lost. . If
smoothing was turned on during fluence optimization, you may want to
set the smoothing distance to ‘1’ so the compensator is not over-
smoothed.
Edit MLC Leaf Positions Suggestions

1. You can remove hotspots or other undesirable doses from a plan by
editing the MLC leaf positions of the MLC segments.
2. Dose recalculates after each edit. You should review the updated dose
distribution between edits to make sure you don’t degrade your plan.
3. If large changes are needed you may be better off editing the IMRT
Prescription and reoptimizing and regenerating segments.
Segment Weight Optimization (SWO) Suggestions

1. Calculation times can be long for SWO calculations since a full dose
calculation is done for each segment. A recommendation is to use a 3mm
or 4mm grid spacing for SWO.
2. When planning to apply SWO after segmentation, you may want to use
fewer intensity levels when segmenting (6-8 intensity levels). SWO
should help to regain the dose coverage loss due to fewer intensity
levels.
3. Less complex prescriptions often work better when you plan to apply
SWO.
4. Do not expect that segment weight optimization will make every plan
better. If a prescription is difficult to meet, SWO may not help. If your
plan already has a small number of segments per beam, SWO may not
improve your plan.
3-18
Suggestions for When the Final Plan Does Not Match the Optimized Plan
Number of intensity levels and minimum segment size.
1. Adjust the number of intensity levels and refresh the DVH to see the
affects of different numbers of intensity levels. A higher number of
intensity levels does not always result in a better plan. Minimum
segment size is usually less than 2.0.
2. The greater the number of segments, the larger the difference between
the optimized and final plan. This is due to the lack of leaf leakage
modeling.
Beam weight optimization. This is a process that runs when you launch the
final dose calculation. It takes the intensity maps that have been generated
during the optimization process and re-weights the beams to better meet
the prescription. Unfortunately, the default values are not ideal and can
cause some problems with the final plan. There are two ways to fix this.
1. Change the number of iterations to 30 and the convergence criteria to

0.0001 (this is only for beam weight optimization). This allows the
beam weight optimizer to not be dominated by dose prescriptions
with powers.
OR
Set the number of iterations to 0. This prevents the beam weight

optimizer from running at all.
2. The beam weight optimization can also cause problems if high power
values are used in the prescription. Try to avoid high power values as
much as possible. If necessary, consider switching the beam weight
optimization to zero iterations so it does not run at all.
Segment weight optimization. Optimizing the segment weights can help to

improve the correlation between the optimized and final dose calculation
since each segment is calculated individually. Segments with monitor units
below a user specified value are removed, and segment weights do not have
to be multiples of each other allowing for more flexibility of dose per
segment. You can edit the IMRT Rx between iterations of segment weight
optimization. This lets you tailor the dose constraints to the plan’s problem
areas.
XiO® 3-19
Suggestions for When the Final Plan Does Not Match the Optimized Plan (cont.)
Scatter extent. The larger value you have for the scatter extent, the closer
your optimized plan will be to the final plan. A value that is too small will
result in scatter being underestimated by the optimizer. When you show the
final plan and the actual dose is calculated, the scatter is taken into account
resulting in higher dose to OARs. Disclaimer: the larger the scatter extent
the longer the optimization will take. It should be large enough to span
critical organs such as the spinal cord.
Grid spacing. We recommend 0.2 cm for the final dose calculation for
segmented plans, and 0.25 for compensator plans. The step increment
should be equal to or larger than the grid spacing.
Weight points. There is a weight-point dependence. Ideally, the weight

points for each beam should be within a target and not at an interface
between air/bone etc. Also, the weight point should not be behind an OAR
when looking from the beams eye view. You may need individual weight
points for each beam to achieve this.
3-20
Site Specific Suggestions
Prostate
Eliminating peripheral hotspots. A peripheral hotspot may result from a

beam arrangement that includes one particularly "good" beam position.
This can happen with a prostate plan where a lateral beam gives the
optimizer a clear path to the target without a contributing dose to the
rectum or bladder. The optimizer uses this good beam to deliver a large
proportion of the dose that may result in a peripheral hotspot especially if
using a low energy beam like 6X. You can fix this by changing the beam
gantry angle for the beam that is causing the issue.
Having a too-restrictive constraint on the rectum can cause hotspots outside

the PTV laterally and/or within the PTV on the anterior rectal wall. If the
rectum is receiving a dose that is below the specified constraints and you are
seeing these hotspots, try relaxing the rectal constraints so more dose can be
put through the rectum. This can reduce the severity of the hotspots.
In this case (phase 1 prostate and seminal vesicles), the PTV coverage is
good and OARs are also within tolerance. However, the significant
maximum dose within the PTV is in an undesirable position, on the anterior
rectal wall, and within the bladder.
XiO® 3-21
Prostate (cont.)
The plan meets the prescription as it is not specified where within the PTV
the significant maximum (in this case 105%) should be. It has ended up in
an undesirable position. The example below shows how you can manipulate
the 105% to be within the GTV (prostate) using existing structures. The
GTV is now included in the prescription, as this is a more desirable location
for the 105% dose. Note, the rank of the GTV(1) and PTV(2) and also that
the maximum dose for the PTV is lowered and a power is assigned to this
value to keep the PTV from receiving the significant maximum. Note, TRANS
= PTV + 0.5 cm.
3-22
Prostate (cont.)
Brain
1. If the dose to the eyes is too high, try a non-coplanar beam

arrangement to avoid gantry positions that enter or exit through the
eyes.
2. If it is not possible to avoid the eyes on entry and exit, exclude the eyes
from the fields before commencing IMRT optimization. To do this,
conform beams, jaws only, then go to port mode and create an MLC or
aperture that excludes the eyes only.
3. Try moving the isocenter so the eyes are excluded by the central axis.
This is a non-divergent border. So, you can reduce the dose to the eyes,
particularly exit dose.
XiO® 3-23
Site Specific Suggestions (cont.)
Head and Neck
1. To reduce the total number of segments and treatment time, consider

using a non-IMRT lower neck arrangement and asymmetric junction to
the IMRT upper neck fields. To do this, calculate and show the non-
IMRT field dose before optimizing so the optimizer can take the lower
neck dose into account at the junction. (If using an asymmetric match,
you will need to reposition the weight point for each beam.) Turning
on smoothing during the fluence optimization may help reduce
segments as well.
2. Choose a "good" weight point location for each beam. This is a point
that is not in a low dose region (behind an OAR), not in an area of very
high or low density, or on the interface between high or low-density
tissue.
3. Create a PTV that is clipped inside the skin by 0.3-0.5 cm. This takes
the target out of the dose build up region and makes for a more
achievable prescription. If you require dose to the skin, then consider
using bolus.
4. Make use of transition volumes and only add organs to the prescription
that are receiving excessive dose.
5. Use an adequate number of beams. Five to seven equally spaced beams

is a good starting point.
6. Try different beam arrangements. For a "horseshoe-shaped" volume,

make sure you have some post oblique beams.
3-24
IMRT Prostate Plan
IMRT Prostate Plan (Part 1)
Practice Exercise
The following procedures cover the common features of IMRT using XiO.
There are many ways to complete an IMRT plan in XiO. This is just one
suggested method of the IMRT planning procedure. The design of this plan
provides step-by-step procedures to create an IMRT plan using any of the
following methods, MLC, compensating filter, or dMLC.
There are four parts to this exercise. At the end of the first two parts, there is
a completed prescription table with values entered that create an acceptable
plan for the prostate cases.
The goal of Part 1 of this exercise is to create a prostate plan and prescribe
6600 cGy. Then, in Part 2, you will add an additional 1200 cGy IMRT boost.
There are two methods to approach this, composite and synchronous. In
this exercise, you will explore both composite and synchronous planning. A
synchronous plan takes the original plan dose into consideration when
assigning the boost dose. Whereas, a composite plan is a simple addition of
two independent plans. Part 3 is optional, but allows you to take your
previously saved plan and apply SWO so you can compare a SWO plan with a
plan that did not use SWO. Part 4 is optional, but allows you to take a
previously saved plan and re-optimize it with smoothing turned on. You will
then compare the original plan with the smoothed plan.
Part 1 of this exercise discusses the following tasks:
Task 1. Open Patient for IMRT

Task 2. Dose Calculation Settings
Task 3. Placement of Beams
Task 4. Create a Template
Task 5. IMRT Parameters and Prescription Table
Task 6. Start IMRT Optimization Page
Task 7. Optimized DVH and Isodoses
Task 8. Review/Edit Ideal Intensity Maps (optional)
Task 9. Prescription Adjustment
Task 10. Generation and Review of MLC Segments or Compensating
Filters
Task 11. Using DVH, Isodoses, and Intensity Maps to Evaluate IMRT Plans
Task 12. Save the IMRT plan
Task 13. Quality Assurance of the IMRT Plan
XiO® 4-1
IMRT Prostate Plan
1. Log in to the XiO system.
2. Select the XiO Training Data clinic.
3. Select the Teletherapy option on the XiO main window.
4. Click the File drop-down menu and select the New Teletherapy Plan
option.
5. Select the prostate patient for IMRT planning, studyset, and graphics
area setup as shown in the following window.
4-2
IMRT Prostate Plan
6. Click OK.
XiO® 4-3
IMRT Prostate Plan
This task demonstrates where you verify and change calculation settings
when necessary. It is not required that you complete this task for every
IMRT plan. However, it helps to understand the settings on this page and
how they affect IMRT calculations.
1. Click the Dose drop-down menu and select the Calculation and Settings
options. XiO shows the Dose Calculation Settings dialog box.
2. Set the heterogeneity correction to the setting you use in your clinic.
3. Optionally, you may want to decrease the calculation region to speed

up the calculation time. This can be done using the keyboard or the
mouse.
To use the mouse, right-click in a transverse, sagittal, or coronal

window and select Calc Size.
Adjust the calculation region highlighted in red in any or all of these

windows.
Set your grid spacing to 0.3 cm along the width, height, and depth.
NOTE: We recommend a 0.2 cm grid spacing for the final

calculation of all segmented MLC IMRT plans and a 0.25
grid spacing for the final calculation of all compensator
based IMRT plans. You are using 0.3 cm for this exercise
to speed up the calculation time.
4. Click OK to close the Dose Calculation Settings dialog box.
4-4
IMRT Prostate Plan
Task 3. Place Beams and Conform Jaws or Ports
For this training plan, use a 5-beam arrangement. Each beam is spaced 72
degrees apart at gantry angles of 0, 72, 144, 216 and 288 — using any of the
following treatment machines Vari06xIMRT, Siem06xIMRT, or Ekta06xIMRT.
1. Click the New Beam button on the Beam supporting toolbar.
OR
Press the F5 key on your computer keyboard. XiO shows the New
Beam dialog box.
2. Select one of the following Treatment machines: Vari06xIMRT,

Siem06xIMRT, or Ekta06xIMRT.
3. Make sure the collimator jaw is set to Asymmetric and place the beam
in the center of the structure named PTV1. PTV1 encompasses the
prostate and seminal vesicles with a 0.5 cm margin.
XiO® 4-5
IMRT Prostate Plan
Task 3. Place Beams and Conform Jaws or Ports (cont.)
4. Click OK. XiO shows the Photon Beam dialog box.
5. (Optional) Enter a Field ID and beam Description for beam 1.
6. Enter a gantry angle of 0.
7. Type 1320 cGy for the beam weight and 33 fractions. If the delivery
method is dynamic, it is important to set the fractions when setting up
the beams, since the segmentation is affected by the fractionation.
8. It is not necessary to edit the field sizes, isocenters, weight points, or

weights. All have either already been defined, or are automatically
generated during the IMRT process. Verify that either the Convolution
or Superposition algorithm has been selected.
4-6
IMRT Prostate Plan
9. Click OK.
10. Copy the active beam four times by clicking the Copy Beam button
on your toolbar.
OR
Press the F7 key on your computer keyboard four times. This will
quickly create 5 beams.
11. Click the Beam Spreadsheet button on your toolbar to open the
Beam Spreadsheet dialog.
12. From the General tab, type beam Description for each of the beams
(optional).
13. Click the Beam tab. Change the gantry angle of beams 2 through 5 to 72,
144, 216 and 288, respectively.
14. Click the Port drop-down menu and select the Auto and Multiple Beams
options. XiO shows the Photon Conform Beams dialog box.
15. Select all the beams by clicking on the beam numbers. (The buttons
are highlighted in blue when selected.)
16. Middle-click in the Structure field and select the structure PTV1.
17. Enter a margin of 1.0 cm.
18. Middle-click in the Collimator Type field and select Jaws Only.
19. Click OK. XiO conforms the jaws on all the beams to 1.0 cm around the
structure PTV1.
XiO® 4-7
IMRT Prostate Plan
Task 4. Create a Template
Create a template for use in part 2 of this exercise. This saves you from
having to create individual beams for the boost.
1. Click the File drop-down menu and select the Save as Template option.
2. Enter a name for the template, 5Field. The description is optional. You
can use it for further clarification.
3. Click OK. You have now created a template that is available for current
or future use.
4-8
IMRT Prostate Plan
1. Click the IMRT button on the Teletherapy toolbar.
OR
Press the Shift and F6 keys on your computer keyboard.
2. Click the IMRT Parameters button on the IMRT supporting toolbar.
OR
Press the F5 key on your computer keyboard. XiO shows the IMRT
Parameters dialog box.
3. Select MLC or Compensating Filter as the Modulator type. If you select

the Compensating Filter option, you are then able to select the type of
compensator to use and edit the CF Tray Distance, CF Material, and CF
Effective Attenuation Coefficient. These fields default to the values
entered as defaults in Source File Maintenance for the selected
machine. Use the material cfIronGran if you elect to plan using a
Heustis or Par Scientific compensating filter.
XiO® 4-9
IMRT Prostate Plan
Task 5. IMRT Parameters and Prescription Table (cont.)
Treatment Goal
• Deliver 6600 cGy to at least 95% of PTV1 (prostate and seminal
vesicles).
• Limit 17% of the rectum to 5000 cGy and 35% of the rectum to 3100
cGy.
• Limit 25% of the bladder to 5000 cGy and 50% of the bladder to
3100 cGy.
• Limit the femoral heads to less than 10% receiving 4000 cGy.
(A valid prescription example is shown at the end of this exercise.)
4. Click the IMRT Prescription button on the IMRT supporting toolbar.
OR
Prescription dialog box.
4-10
IMRT Prostate Plan
Treatment Goal (cont.)
5. Locate PTV1 in the list and set the type to Target.
6. Set the rank for PTV1 to 1.
7. Right-click in the objective box for the target structure and enter your
prescription. Enter a minimum, maximum, and (optionally) goal for
the target structure. Below is an example you could use. Enter
whatever values you want in order to fulfill the prescription
requirements. There is more than one method for filling out this
prescription table.
8. Leave the weight and power at their default settings.
9. Click OK when you have filled out the prescription table with the target
structure values.
XiO® 4-11
IMRT Prostate Plan
You have intentionally not turned on any critical structures (OARs). Often
after evaluation of the initial plan, you will find that a critical structure does
not need to be turned on at all. More importantly, you must determine if a
good plan is achievable without critical structures being turned on. First,
you must optimize the plan with only the target structures prescribed.
1. Click the Start Optimization button on the IMRT supporting toolbar.
OR
Press the F7 key on your computer keyboard. XiO shows the Start
IMRT Optimization dialog box.
4-12
IMRT Prostate Plan
Task 6. Start IMRT Optimization Page (cont.)
2. If you are using MLC as your modulator, enter the Step Increment
shown in the above dialog. If you are using Compensating Filters, enter
the X and Y resolution as shown in above dialog box.
3. Enter the information above for the Initial and Beam Weight
Optimizations.
Optional: Smoothing is not used in this task. This plan is re-optimized

in Part 4 with smoothing turned on. You may select to use smoothing
at this time if you want. The suggested Smoothing Parameter is General
High Smoothing.
4. Click the Start button to begin. Once again, if you would like to use
different values for any of these items, you may do so. If necessary, go
back to the lecture to understand what each of these values represents
so you can enter values appropriately. The message "Optimization
Complete" appears when it has reached the selected criteria.
NOTE: It may take some time to calculate the pencil beams and
initialize the optimizer after you click the Start button.
The status indicator at the bottom of the Start IMRT
Optimization window shows the processes as they run.
XiO® 4-13
IMRT Prostate Plan
Once the plan is optimized, it is important to review the optimized DVH and
the optimized isodoses to see if the prescription gives a good result or if
some adjustments need to be made.
1. Click the Histogram button on the IMRT supporting toolbar.
2. Select window 5 under Display DVH in the subwindow.
3. Click OK. XiO shows the Histogram dialog box.
4. Turn on the structures that are shown as "on" in the following window.
5. Click OK to keep the DVH in view.
6. Click the DVH Statistics tab. You can type the statistics you wish to
check. XiO outlines goals which are met in green. XiO outlines goals
which are not met in red. See the IMRT Planning and Workflow section
of the XiO IMRT Training Guide for more information on DVH Statistics.
4-14
IMRT Prostate Plan
Task 7. Optimized DVH and Isodoses (cont.)
NOTE: This DVH is based on the intensity map calculation. It

gives you an idea as to how the optimization is doing up
to this point. It also represents an idealized situation. If
the DVH is not acceptable for any structure, you would
probably not want to continue. But rather, go back and
examine the IMRT prescription and, possibly, the beam
arrangement.
7. Click the Isodose Lines button on the IMRT supporting toolbar to

review isodose lines.
8. Enter isodose lines such as 6600, 6270, 5940, 3300, etc. to evaluate the
coverage of the associated volumes.
XiO® 4-15
IMRT Prostate Plan
At this point, you can turn on the ideal intensity maps that have been created
and based on the optimized plan. You also have the capability of sampling
and editing individual pixel intensities.
option and turn on the intensity maps.
OR
Click the Display Intensity Maps/BEV button on the toolbar. XiO

turns on the intensity maps.
2. Movie through each beam to review all intensity maps. Turn off all
contours, if necessary.
3. Sample the intensity map by clicking your right mouse button in the
ABV window and selecting the Sample Intensity option.
4. Move your mouse cursor over the intensity map. A brown box indicates
which pixel is being sampled. The relative value shows in the lower left
corner of the window.
5. Edit the intensity map by clicking your right mouse button in the ABV
window and selecting the Edit Intensity option.
6. Move your mouse cursor over the intensity map. A red box indicates
which pixel is to be edited.
7. Over the selected pixel, hold down the left mouse and move right or left
to increase or decrease the intensity of that pixel. The relative value
shows in the lower left corner of the window.
8. If you would like to restore the originally calculated intensities, right-

click in the ABV window and select the Restore Intensity option.
4-16
IMRT Prostate Plan
After reviewing the optimized DVH, isodoses and intensity maps, you have
two options:
If the target dose needs adjustment:
(1) Return to the prescription table and change the weight and/or power,
then re-optimize.
(2) Make sure the prescription to the target produces an acceptable DVH
before adding OARs.
If the target doses are acceptable:
(1) Begin adding one OAR, if necessary, to the prescription. Then, re-
optimize.
(2) Right-click in the objective window for the OAR structure and add a
maximum or dose volume points and an (optional) threshold value.
(3) Make adjustments to the prescription as needed.
(4) Continue by adding each OAR, if necessary, to the prescription table

until you have an acceptable optimized DVH for the entire plan.
1. In either case, click the Prescription button and make adjustments

to the prescription.
NOTE: For the OARs, consider adding dose volume points to

shape the DVH curve.
2. Once you make changes to the prescription, click the Start Optimization
button to re-optimize.
3. Repeat these steps as many times as necessary until the optimized DVH
is acceptable for all structures.
XiO® 4-17
IMRT Prostate Plan
4. Click the File drop-down menu and select the Save Plan option.
5. Enter the Plan ID optplan. You may want to return to this point after
the final dose calculation if changes to the prescription are necessary.
4-18
IMRT Prostate Plan
Task 10. Generation, Review, and Editing of MLC Segments or Compensating Filters
Once the optimized plan is acceptable, complete the IMRT process by

generating the MLC segments, compensating filters, or dMLC segments.
Sub-task 1A. Generate and Review MLC Segments

Skip to Sub-task 1B if you plan to use compensating filters, or Sub-task 1C if
you plan to use dMLC segments.
1. Click the Generate Treatment Aids button.
OR
Segmented MLC Parameters dialog box.
2. Select the Step and Shoot Delivery Method and select the Sliding
Window Segmentation Method.
3. Enter a value for the number of Discrete Intensity Levels. The number
of intensity levels affects the number of segments generated per beam.
As you change this value, XiO automatically updates the intensity map
and isodose lines before you segment. This can be a valuable tool to
determine just how many intensity levels are necessary. You may also
update the DVHs so you can determine the effects of discretization in
the DVHs.
XiO® 4-19
IMRT Prostate Plan
Task 10. Generation, Review, and Editing of MLC Segments or Compensating

Filters
Sub-task 1A. Generate and Review MLC Segments (cont.)
4. Set the Minimum Segment Size (cm) to 1.0 cm. XiO deletes any
segments with an equivalent field size of less than 1.0 cm. This value is
only a suggestion.
5. Click the Start Segmentation button.
6. Click the IMRT Delivery Summary. For some plans, the total number of
segments may produce treatment times that are too long. If the
number of segments is unacceptable, try a different number of
intensity levels and/or a different minimum segment size.
7. Click the Quit button to close the IMRT Delivery Summary report.
9. Using the Next buttons, you can review all segments for all beams and
delete any as necessary using the Delete Segment button.
10. Click View | Plan Objects | Port Projection | Display to turn on the
display of the port projection. XiO shows the port projection of
individual segments as you movie through the segments.
4-20
IMRT Prostate Plan

Filters
11. Click the OK button. XiO closes the IMRT Leaf Segment Review dialog
box.
12. Click the Cancel button on the IMRT Segmented Parameters dialog box
to launch the final dose calculation.
13. Click View | Plan Objects | Port Projection | Display to turn off the
display of the port projection.
14. Click Beam | Beam Spreadsheet. XiO shows the Beam Spreadsheet box.
15. Click the Segments tab. You can add, delete, renumber, reweight and
edit MLC segments from this tab.
16. Click Dose | Dose in BEV.
17. (Optional) Renumber segments by typing the new numbers in the #

column.
18. Click the Edit Segment button .
19. Click the Prev and Next buttons to movie through the beam’s segments
.
20. Click the Leaf Index button. XiO shows the report with the leaf and
width jaw positions for the active segment.
21. QUIT the index.
22. Select Edit Leaf from the mouse menu in the ABV. Use the mouse to
drag leaves into and out of the field to cover any hot spots you wish to
remove or expose parts of the target you wish to receive a higher dose.
XiO® 4-21
IMRT Prostate Plan

Filters
23. Click the Prev and Next buttons to change the Active Beam.
24. Click OK to close the dialog box.
25. XiO recalculates dose if you’ve made any changes.
26. See the Breast IMRT Exercise for more information on editing MLC
segments.
Sub-task 1B. Generate and Review Compensating Filters
OR
Compensating Filter Parameters dialog box.
4-22
IMRT Prostate Plan

Filters
Sub-task 1B. Generate and Review Compensating Filters (cont.)

2. (Optional) Edit the Intensity Map Smoothing Distance. The default
value of 3 pixels is what XiO has historically used with .decimal as the
compensator. If you are using Heustis or Par Scientific, you may want
to edit the smoothing distance to create well-designed compensators
using Styrofoam milling machines.
3. Click Generate Compensators. XiO creates compensators for all beams.
4. Click Cancel to launch the final dose calculation.
5. After the calculation is complete, you can review the compensators that
were created. From the Tools drop-down menu, select Review
Compensating Filter. XiO shows 2D and 3D views of the selected beams
compensator and shows the Review Compensating Filter dialog box.
6. Change beams or edit the color of the shown compensator from the
Review Compensating Filter dialog box.
7. Right-click in the 3D window to rotate or scale the 3D image of the

compensator.
8. Right-click in either 2D window and select Plane Icon. Hold down your
left mouse on the white line (plane) to move the plane and review the
shape of the compensating filter.
XiO® 4-23
IMRT Prostate Plan
Task 10. Generation and Review of MLC Segments or Compensating Filters

(cont.)
Sub-task 1C. Generate and Review of Dynamic MLC Segments
OR
2. For Delivery Method, select Dynamic. XiO produces 320 segments for
dynamic delivery
3. Click the Start Segmentation button. XiO automatically produces 320

segments for dynamic delivery.
4. Click the IMRT Delivery Summary to review the optimization summary.
5. Click the Quit button to close the IMRT Delivery Summary report.
7. Select the Beam Number you want to review by entering a beam

number or clicking the Prev or Next button next to the Beam Number.
4-24
IMRT Prostate Plan
Task 10. Generation and Review of MLC Segments or Compensating Filters
Sub-task 1C. Generate and Review of Dynamic MLC Segments (cont.)
8. Enter a Segment number, or click the Prev or Next button to manually

movie through the segments.
OR
Click the Start Movie button to view the segments in a movie. This
action automatically takes you through all 320 segments. Click the
Stop Movie button to stop the movie.
9. Click the OK button when you are finished with the review. XiO returns
you to the IMRT Segmented Parameters dialog box.
10. Click the Cancel button to launch the dose calculation.
XiO® 4-25
IMRT Prostate Plan
Once XiO finishes calculating the final plan, you can evaluate the plan using
the DVH, isodose lines, and intensity map tools.
1. Click the Redisplay Histogram button. XiO redisplays the DVH of

the structures that were originally shown.
2. Right-click and select a tool to evaluate the DVH. Use the Histogram
Cursor to show the volume of a structure and the dose it is receiving.
Use Movie to toggle the active structure information. Verify that you
meet or exceed the following criteria.
• At least 95% of PTV1 is receiving 6600 cGy.
• A limit of 17% of the rectum to 5000 cGy and 35% of the

rectum to 3100 cGy has been achieved.
• A limit of 25% of the bladder to 5000 cGy and 50% of the

bladder to 3100 cGy has been achieved.
• A limit of the femoral heads to less than 10% receiving 4000

cGy has been achieved.
3. The isodoses entered earlier should re-display. Verify that the coverage
of the volumes is acceptable.
4. Intensity maps should already be shown. Movie through each beam to

review all intensity maps. Turn off all contours, if necessary.
4-26
IMRT Prostate Plan
Task 11. Using DVH, Isodoses, and Intensity Maps to Evaluate IMRT Plans (cont.)
7. If you are not satisfied with the final plan and need to make edits to the
prescription, proceed using one of the following steps:
Close the patient and open the permanent plan optplan.
Click the IMRT button, then the Prescription button.
OR
Stay in the current plan. Then, click the IMRT and Prescription
buttons.
XiO® 4-27
IMRT Prostate Plan
When you have met the prescription criteria and are satisfied with the plan,
save it.
2. Enter a Plan ID Prostate1 and (optional) description.
3. Click OK.
4-28
IMRT Prostate Plan
Once you save the IMRT plan, there are several methods for verifying the
quality of the plan. This task shows you how to do the following:
• Use and export intensity maps for QA.
• Verify the largest leaf extent on a DRR.
• Create QA plans on a phantom and export dose planes to a file.
• Create single beam QA files and export them.
For more detailed explanations on IMRT QA, refer to the QA of IMRT Beams
—Technical Considerations located in the XiO Online Help.
Sub-task 1. Visualize, Sample and Output Intensity Maps for QA

1. Select beam 1 from the box in the upper right corner of the window to
make it active.
2. Click the View drop-down menu and select the Enhance Contours
option to turn off all the contours.
3. Click the All Structures Off button. The intensity map shows in the ABV
window.
4. Right-click in the ABV window and select the Sample Intensity option.
5. Move the mouse around the intensity map to view the relative intensity
values across the field. The relative values show at the bottom of the
window on the status bar.
6. If you would like to output your intensity maps, click the Tools drop-
down menu and select the Output Intensity Maps in ASCII option. XiO
shows the associated dialog box.
XiO® 4-29
IMRT Prostate Plan
Sub-task 1. Visualize, Sample, and Output Intensity Maps for QA

(cont.)
7. Click the drop-down arrow in the Map Type field and select the map
type Segmented MLC or Relative Fluence.
8. Enter a filename for each beam intensity map you would like to export.
After you enter the filenames, you can toggle on/off the beam intensity
maps you would like to output. When the beam number and name are
highlighted blue, this indicates they are selected to be output.
9. Click the Output ASCII button. XiO shows a message next to the output
button that states "Intensity Map Files Generated." These files are
saved in XiO so that third party software can retrieve them.
10. Click the Cancel button to exit.
You can find files in /FOCUS/tmp/network/QA/IMAP.
4-30
IMRT Prostate Plan
Task 13. Quality Assurance of the IMRT Plan (cont.)
Sub-task 2. Largest Leaf Extent Verification
1. Click the Beam button, then the DRR button. XiO turns on the
DRR and shows the largest extent of the leaves on the DRR in the ABV
window.
2. If you would like to print the DRR, click the File drop-down menu and
select the Print and DRR options. When you print the DRR, you have the
option of overlaying the plan information on the DRR. See the
Miscellaneous Tasks section of the XiO Training Guide for more
information.
XiO® 4-31
IMRT Prostate Plan
Sub-task 3. Create a QA Plan on a Phantom and Export Doses to a File

1. Click the File drop-down menu and select the Close option to close the
plan.
2. Click the File drop-down menu and select the New QA Plan option. XiO
shows the New Teletherapy QA Plan dialog box.
3. Under Phantom ID, select cmsPHANTOM.
4. Under Studyset ID, select Phantom20. This gives you a 20 x 20 cm

square water phantom. In your clinic, you may select the phantom
created by your physics staff.
5. Under Graphics Area Setup, select 6TSCMxA.
4-32
IMRT Prostate Plan
Sub-task 3. Create a QA Plan on a Phantom and Export Doses to a

File (cont.)
6. Click OK. XiO shows the Retrieve Plan for Quality Assurance dialog box.
7. Under Plan ID, select the plan name (Prostate1) that you saved.
8. In this exercise, select No to leave all the beams in their original gantry
orientation. If you would like to set all the beams gantry angles to zero
for QA of each individual beam, select Yes.
9. Click OK. XiO shows the Isocenter Location dialog box.
10. Under Isocenter, select either option. Potentially, you could have
points of interest to set your isocenter to, or you can enter coordinates.
11. Click OK. XiO starts the dose calculation of the IMRT plan on the
phantom.
12. Click the T key on the keyboard. XiO removes the beam lines from the
phantom.
13. Click the Optimize drop-down menu and select the IMRT and Segment
Review options to open the IMRT Leaf Segment Review dialog.
14. Review the segments as necessary.
XiO® 4-33
IMRT Prostate Plan
Sub-task 3. Create a QA Plan on a Phantom and Export Doses

to a File (cont.)
15. Click the Dose button, then the Isodose Lines button. XiO shows
the Isodose Lines dialog box.
16. Enter isodose lines such as 220, 210, 200, 190, 170, 150, and 100.
17. Right mouse click in any SPV window and select the Reference Point
Loc option.
18. Hold down your left mouse button in any SPV to sample the dose to any
point in the plan. The dose and point coordinates show in the upper
right corner of each SPV window. This could be useful in verifying dose
to specific coordinates in the plan with dose to specific coordinates in
an actual phantom.
19. You can export any viewable dose plane (transverse, sagittal or
coronal) using the Dose Plane Output option in the Dose Profile Tool.
Click the Dose Profile button. XiO opens the Dose Profile dialog
box.
4-34
IMRT Prostate Plan
Sub-task 3. Create a QA Plan on a Phantom and Export Doses

to a File (cont.)
20. Enter the SPV subwindow number to select the plane you would like to
export.
21. Click the Dose Plane Output button. XiO shows a dialog box where you
can enter a filename for the dose plane.
22. Enter a filename and click OK. The plane information has now been
created in ASCII format and is located in a file on the XiO planning
system.
23. After you export all the planes you want to verify, click OK on the Dose
Profile dialog box. XiO closes the Dose Profile dialog box.
XiO® 4-35
IMRT Prostate Plan
Sub-task 4. Create a Single Beam QA File on a Phantom

After you complete your plan, you can elect to create individual beam QA
files for your IMRT plan.
1. Click the Tools drop down menu and select the Modulation QA option.
OR
Click the Optimize drop-down menu and select the IMRT and IMQA
options.
XiO shows the Intensity Modulation Quality Assurance dialog box.
2. Enter the SSD, depth, phantom material and phantom relative electron
density to create your flat homogeneous phantom.
3. Select each beam for which you would like to create a QA plan by
selecting Yes for each beam under the QA heading.
4. Enter a user-definable Filename for each beam.
5. Enter/edit the Time or Monitor Units you want to use for this QA plan.
If you leave this field blank, XiO uses the mu/fx from the weight page.
6. Click OK to begin the calculation of the single beam QA plans. Once XiO
calculates the plans, it creates a file that can be used by a third party
vendor’s software for QA purposes.
4-36
IMRT Prostate Plan
Sub-task 4. Create a Single Beam QA File on a Phantom (cont.)
Example Prescription
The following illustration depicts a valid prescription for the prostate plan.
It was not necessary to turn on any other critical structures. All met the
criteria.
XiO® 4-37
IMRT Prostate Plan
IMRT Prostate Plan (Part 2) Composite/Synchronous
Practice Exercise
The goal of this exercise is to utilize the Prostate plan you completed in Part
1 that was prescribed 6600 cGy, and add an additional 1200 cGy IMRT boost.
There are two ways to approach this, composite and synchronous. Initially,
you will explore composite planning. A composite plan is a direct addition of
dose from two independently created plans. In this case, the original plan
and the boost plan. Starting with Task 7, you will explore synchronous
planning.
This exercise discusses the following tasks:

Task 2. Import Template
Task 3. Composite Plan Setup
Task 4. Composite Plan Prescription
Task 5. Optimize and Assess Results
Task 6. Combine Plans and Assess
Task 7. Revert to Initial Plan and Load Template
Task 8. Synchronous Plan Setup
Task 9. Optimize Plan and Assess Results
Task 10. Assess Individual Plans
Task 11. Compare the Plans using Plan Review
4. Click the File drop-down menu and select the Open Permanent Plan
option.
5. Select the patient FusionProstate, and Plan ID Prostate1.
4-38
IMRT Prostate Plan
Task 2. Import Template
To save time creating individual beams for a boost, import the template
saved in part 1.
1. Click the File drop-down menu and select the Import Template option
to show the Import Template dialog.
2. Middle-click in the field and select the 5Field template.
3. Enter No to Retain Segmented MLCs upon Import and Retain Dynamic

Conformal Arcs upon Import.
4. Click OK to show the Isocenter Location dialog.
5. Middle-click in the field and select beam 1 isocenter.
6. Click OK. XiO imports the five beams for the boost and places them at
the plan isocenter.
XiO® 4-39
IMRT Prostate Plan
Task 3. Composite Plan Setup
1. Click the Beam Weight button on the toolbar.
2. Set the correct number of fractions, 33 for the initial course and 6 for
the boost.
3. Turn the first five beams off, as they will not be considered in the
optimization. The dialog box should look like this.
OR
From the Beam drop-down menu, select Beam Spreadsheet and update
the Beam Weights there.
4. Click the IMRT button on the toolbar.
5. Click the IMRT Parameters (F5) button. Only the boost beams are
available for optimization as the first five have been turned off.
6. Click OK. XiO closes the IMRT Parameters dialog box.
7. Conform these beams from the Port, Auto, Multiple Beams option using
a relevant IMRT machine and a 1cm margin to PTV2.
8. Check that the beams have been conformed by turning PTV1 off and
PTV2 on under the View, Enhance Contour option, or use the keyboard
shortcut C.
4-40
IMRT Prostate Plan
Treatment Goal
• Deliver 6600 cGy to at least 95% of PTV1 (prostate and seminal
vesicles).
• Deliver a further 1200 cGy to at least 95% of PTV2 (prostate alone).
For the boost alone:
cGy.
• Limit 25% of the bladder to 1000 cGy and 50% of the bladder to 700
cGy.
For the composite:
cGy.
3800 cGy.
• PTV1 to receive 6600cGy to 95%.
• PTV2 to receive 7800 cGy to 95%.
As this is a composite plan with the first five beams turned off, the
prescription is related to the boost only. Minimum and maximum target
doses will be set to achieve 1200 cGy to PTV2, and all dose constraints will
be related to this dose.
XiO® 4-41
IMRT Prostate Plan
OR
2. The objectives are carried over from the template. You will need to
edit them. Delete all objectives for PTV1. (Right mouse click on PTV1
and select the Delete all objectives option.)
3. Locate PTV2 in the list. Then, set the type to Target.
4. Set the Rank for PTV2 to 1 and enter the minimum/maximum and goal
values.
5. Click and drag the points on the DVH to adjust the doses for the rectum
to reflect the boost prescription.
4-42
IMRT Prostate Plan
Task 5. Optimize and Assess Results
OR
2. The parameters used in the initial optimization are still available.

Therefore, it is not necessary to alter them.
3. Click the Start button and observe the DVH as the boost plan optimizes.
4. To review the plan, alter the isodose lines to be relevant to the 1200
cGy prescribed.
5. Enter the following isodose values 1275, 1200, 1140, 1080, 840, 600.
6. Click the Redisplay Histogram button and verify that the plan meets the
criteria specified. (Be sure to add PTV2 to the histogram.)
7. Revisit the prescription and re-optimize if it is not satisfactory.
8. Once you complete an acceptable optimized plan, generate

segments/compensators and calculate dose.
9. Review the segmented plan.
XiO® 4-43
IMRT Prostate Plan
Task 6. Combine Plans and Assess Results
Now that you have a final boost plan, combine the boost and initial plans and
assess the composite plan. Be aware, there is the possibility for small
hotspots in both plans to overlap and combine to give undesirable results.
1. Click the Beam Weight button.
OR
Click the Beam drop-down menu, open the Beam Spreadsheet, and turn
on the initial five beams.
2. Click the Update display to reflect changes button.
3. Enter relevant isodose line values for the composite plan. The
prescribed dose is 7800 cGy. Use values such as the following 8190,
7800, 7410, 7020, 5460, 3900, etc. Review the isodose coverage.
4. Click the Redisplay Histogram button and assess dose to the targets and
critical structures.
5. If you are satisfied with the final plan, save as CompProstate.

Otherwise, revisit the prescription. You need to again turn off the
initial beams if you are re-optimizing the boost only.
6. (Optional) Print a DVH to compare with the synchronized IMRT plan.
The following illustration depicts a valid prescription for the prostate boost.
4-44
IMRT Prostate Plan
Task 7. Synchronized Plan (Revert to Initial Plan and Add Template)
In this task, the plan is going to be synchronous. This means that the dose
from the initial plan will be taken into account during the optimization of the
boost.
1. Close the patient.
option.
3. Select the FusionProstate patient and Plan ID Prostate1.
4. Import the same template as before using the same isocenter.
XiO® 4-45
IMRT Prostate Plan
Task 8. Synchronous Plan Setup
1. Click the IMRT button. Then, click the IMRT Parameters button.
options to conform these beams option, using a relevant IMRT machine
and a 1cm margin using Jaws Only around PTV2.
3. Select the correct beams for optimization and for conforming. Set Opt
to no for beams 1-5. These beams are from the initial plan. You do not
want to change these. The dialog window should look like this.
4. Click OK.
5. Enter the Synchronous prescription. In this exercise, as the initial

beams are still being shown, the doses must reflect the total dose for
both the initial and the boost.
4-46
IMRT Prostate Plan
Task 8. Synchronous Plan Setup (cont.)
The goals for the synchronous plan are the same as for the composite.
cGy.
3800 cGy.
• PTV1 to receive 6600cGy to 95%.
• PTV2 to receive 7800 cGy to 95%.
PTV1 has already received 6600 cGy. Therefore, you do not need to include
it in the prescription. PTV2 needs to receive 7800 cGy and the rectum and
bladder dose restricted as described in the above examples.
XiO® 4-47
IMRT Prostate Plan
Task 9. Optimize the Plan and Assess Results
1. Optimize using the same previous settings. Assess the final result using
DVH and isodose display.
2. As with the composite plan, alter the isodose lines to reflect the 7800
cGy.
3. Assess the optimized plan results and revisit the prescription, if

necessary, until you achieve a good optimized plan.
4. Generate segments/compensators and assess the final dose.
4-48
IMRT Prostate Plan
Task 10. Assess Individual Plans
With a synchronous plan, it is important to review the individual courses as

well as the combined dose. The optimizer has taken the dose already
planned in the initial course into account. If there were hotspots in the
initial plan, the optimizer will not need to put as much dose in that region for
the boost. This can produce cold spots in the boost. This may be clinically
significant. Therefore, the boost must be reviewed alone.
1. Click the Beam Weight button on the toolbar.
OR
Click the Beam drop-down menu, open the Beam Spreadsheet, and set
the appropriate number of fractions: 33 for initial five beams, 6 for the
boost.
2. Turn off the initial beams (1-5) and click the Update Display to reflect
changes button.
3. Adjust the isodose lines to reflect the 1200 cGy boost and assess the
PTV2 coverage. Notice the boost is not the same as the boost done for
the composite plan.
4. There is no need to re-assess the initial 33-fraction plan as it has

already been assessed and approved earlier.
5. Turn all beams on and name the plan SyncProstate.
6. (Optional) Print the DVH and compare it with the composite plan DVH.
XiO® 4-49
IMRT Prostate Plan
Task 11. Compare Plans using Plan Review
When you have more than one plan and want to compare them, or would
like to subtract plans or add plans for evaluation, you can use the Plan
Review tool.
Click the Tools drop-down menu and select the Plan Review option. XiO
shows the Plan Review Maintenance dialog box.
1. Right-click next to plan 2 and select the Plan ID of the plan you would
like to compare to the one already loaded into XiO.
2. Select Plan 1-Plan 2 for the plan 3 option. This generates a subtraction
plan and shows where the dose differences are between the two plans.
3. Select the Graphics Area Setup 9MultiPlan.
4. Click OK. XiO closes the Plan Review dialog box.
5. Use the Reference Cursor to compare point doses on each plan.
6. Create a DVH to compare plans graphically. All plans show on the same
graph.
7. Edit the isodose values and use the colorwash options for better plan
comparison.
8. Turn on dose in the MPV window.
9. Turn on SPV images in the MPV window.
10. Click the View drop-down option, select Image in MPV.
11. Select a rendering.
4-50
IMRT Prostate Plan
Task 11. Compare Plans using Plan Review (cont.)
The following illustration depicts a valid prescription for the synchronous
prostate plan.
You have just completed both synchronous and composite IMRT planning.
To review the two methods:
The synchronous plan gives homogenous dose coverage when viewed as a

combined plan, but may not do so for the boost.
The composite plan boost dose will be homogenous, but when combined
with the initial dose, there is potential for hotspots to overlap.
XiO® 4-51
IMRT Prostate Plan
IMRT Prostate Plan (Part 3) Planning with SWO
Practice Exercise
Part 3 is optional, but allows you to take your previously saved plan and
apply Segment Weight Optimization so you can compare a SWO plan with a
plan that did not use SWO.
Task 1. Create a SWO plan
1. In Teletherapy, open the Permanent Plan Prostate1 created in Part 1 of

this exercise.
2. Click the IMRT button, then click the Start Optimization button. Use the
same optimization criteria that you used in Part 1, Task 6.
3. Click the Start button on the Start IMRT Optimization dialog to re-
optimize the plan.
4. When optimization is complete, click the Generate MLC Segments

button.
5. Click the Start Segmentation button on the IMRT Segmented MLC

Parameters dialog.
6. Click the Segment Weight Optimization button. This opens the Segment
Weight Optimization dialog.
4-52
IMRT Prostate Plan
IMRT Prostate Plan (Part 3) Planning with SWO
Task 1. Create a SWO plan (cont.)
7. Type the information shown in the above fields for the segment weight
optimization criteria.
8. Click the Start button to begin. If you would like to use different values
for any of these items, you may do so. If necessary, go back to the
lecture and review what each of these values represents so you can
enter values appropriately.
9. After SWO is complete, click the OK button to start the final dose
calculation.
10. Once dose is calculated, save the plan as Prostate1SWO.
Task 2. Compare the SWO plan to an existing plan
1. To compare the SWO plan to the original plan, click Tools | Plan Review.
The SWO plan will default as plan 1.
2. From the drop down menu for plan 2, select Prostate1.
3. For plan 3, select Plan 1-Plan 2.
5. Click OK to open and compare plans.
XiO® 4-53
IMRT Prostate Plan
IMRT Prostate Plan (Part 4) Planning with Smoothing
Practice Exercise
Part 4 is optional. You will take your previously saved plan and apply
smoothing during the optimization. You will then compare a smoothed plan
with a plan that did not use smoothing.
Task 1. Optimize with Smoothing Turned on
1. In Teletherapy, open the Permanent Plan Prostate1 created in Part 1 of

this exercise.
2. Click the IMRT button, then click the Start Optimization button. Use the
same optimization criteria that you used in Part 1, Task 6.
3. Select General High Smoothing from the Smoothing Parameters dialog

box.
4. Click the Start button on the Start IMRT Optimization dialog to re-
optimize the plan.
5. When optimization is complete, click the Generate MLC Segments

button.
6. Click the Start Segmentation button on the IMRT Segmented MLC

Parameters dialog.
7. Click Cancel to close the dialog box and start the final dose calculation.
8. Once dose is calculated, save the plan as Prostate1SMTH.
4-54
IMRT Prostate Plan
IMRT Prostate Plan (Part 4) Planning with Smoothing
Task 2. Compare the Prostate1SMTH plan to an existing plan
1. To compare the smoothed plan to the original plan, click the Tools |
Plan Review. The smoothed plan will default as plan 1.
2. From the drop down menu for plan 2, select Prostate1.
3. For plan 3, select Plan 1-Plan 2.
5. Click OK to open and compare plans.
6. Click Reports |Source Data | 1:## to review the Source Index for the
smoothed plan.
7. Click Reports| Source Data | 2:Prostate1 to review the Source Index for
the original plan.
XiO® 4-55
Adjusting Objectives
Practice Exercise
This exercise illustrates the various methods you can use to customize
inverse planned dose distributions in XiO. While it is possible to get an
acceptable plan using the nominal dose, weight, and power settings, there
will be times when you will need to adjust these parameters in order to
achieve good results. This is particularly true for cases where the targets
either abut or overlap with critical structures/OARs.
For this exercise, you will use the “optplan” that you saved in Section 3.
IMRT Prostate Plan (Part 1). The new treatment goal requires that you
deliver 6600 cGy to the prostate while limiting the rectum to only 5000 cGy.
Task 1. Open Saved Permanent Plan
option. XiO shows the Open Permanent Plan dialog box.
3. Select the FusionProstate patient ID and the optplan plan ID.
4. Click OK. XiO loads the patient in Teletherapy.
XiO® 5-1
Task 2. Edit Prescription and Parameters
OR
prescription dialog box.
2. Right-click and delete all dose objectives except for PTV1.
3. Enter 6600 for the PTV1 minimum objective and 6900 for the
maximum objective.
5-2
Task 2. Edit Prescription and Parameters (cont.)
4. Verify the weight and power parameters are set to their nominal
settings of 100 and 2.0 respectively.
5. Verify the rank is set to 1.
6. Click OK.
7. Start the optimization without changing any other settings.
8. Evaluate your PTV1 coverage using the DVH graph and DVH Statistics.
8. Review the isodose lines and coverage to PTV1.
9. Save this plan as PTV1only.
10. Add the structure rectum to the prescription as an OAR and change its
rank to 2. This ensures that PTV1 will own the voxels in the overlap
region.
11. Enter 5000 as the maximum dose to the rectum and make sure that the
weight and power for the rectum are also set to the nominal settings.
12. Start the optimization.
13. Review idosose lines, particularly the 6600 and 5000.
14. Save this plan as nominalplan.
15. Review the PTV1 coverage using the DVH graph and DVH Statistics.
XiO® 5-3
Task 3. Adjusting Dose
Notice that the coverage to PTV1 for nominalplan is no longer acceptable.
1. On the prescription window, change the minimum dose objective for

PTV1 to 6700.
2. Restart the optimization.
3. Review the isodose lines and DVH.
4. Save this plan as PTVdose6700.
Task 4. Adjusting Weight
1. Change the PTV1 minimum dose objective back to 6600cGy.
2. Change the weight of the rectum maximum dose objective to 500.
3. Restart the optimization.
4. Review idosose lines.
5. Save this plan as RectWt500.
Task 5. Adjusting Power
1. Change the weight on the rectum maximum objective back to 100.
2. Change the power on the rectum maximum objective to 3.
3. Start the optimization.
4. Review the isodose lines.
5. Save this plan as RectPwr3.
5-4
Task 6. Plan Review
Use the XiO plan review tool to evaluate the plans you have saved. You can
review up to three plans simultaneously.
1. Click the Tools drop down menu and select the Plan Review option. XiO
shows the Plan Review Maintenance dialog box.
2. The current plan RectPwr3 will default into the first available space.
3. Middle-click on the second and third spaces and select RectWt500 and
PTVdose6700 respectively.
4. Select 9MultiPlan as the Graphics Area Setup.
5. Click OK.
6. Click the Histogram button. Type 9 in the DVH Window field.
7. Click the structures you want to show.
NOTE: The RectPwr3 plan is different than the other two plans.
It gives better results for the rectal dose, but
compromises coverage to PTV1.
8. Click the DVH Statistics tab. Type all the statistics you wish to check.
XiO shows the statistics for all loaded plans.
XiO® 5-5
IMRT Head and Neck
IMRT Head and Neck
Practice Exercise
The following procedures cover the common features of MLC-based IMRT
using XiO. There are many ways to complete an IMRT plan in XiO. This is
just one suggested method of the IMRT planning procedure. We used step
and shoot segmented MLCs to write this plan. However, you can plan with
compensating filters or dMLC. See the prostate exercise in this training
guide to review the instructions for planning with compensating filters or
dMLC.
At the end of the last task in this exercise is a completed prescription table
that has values entered that are a good starting prescription for this head
and neck plan.
This exercise includes the following tasks:

Task 2. Prepare Contours for IMRT
Task 4. Placement of Beams
Task 10. Generation and Review of MLC Segments
Task 11. Segment Weight Optimization (optional)
Task 14. Compare Plans with Different Minimum Transmission Multipliers
XiO® 6-1
IMRT Head and Neck
IMRT Head and Neck

1. Log in to your XiO system.
option.
5. Select the RTOG protocol head and neck patient, studyset and graphics
area setup as shown in the following example.
6. Click OK.
6-2
IMRT Head and Neck
IMRT Head and Neck

Some structures (targets) that you intend to treat using XiO IMRT may
require a 3D auto-margin. Some OARs may also require a small 3D auto-
margin to provide a larger area around the structure for which the optimizer
is to restrict dose. For isocenter localizations, combine target structures
with a margin.
1. Click the Contour button on the Teletherapy main toolbar.
2. Click the 3D Auto-margin button. XiO shows the 3D Auto-margin

dialog box.
3. Create a structure to encompass all the targets for isocenter placement

by entering Combo in the New Structure Name field.
4. Under Structure, middle click and select ptv2, ptv3, ptv4, and enter a
0.0 cm margin for each (ptv1 is encompassed by ptv2 and does not
need to be included).
5. Select Include for each of these structures.
6. Click the Create 3D Auto-margin button to create the structure on

which you will center your beams.
XiO® 6-3
IMRT Head and Neck
IMRT Head and Neck
Task 2. Prepare Contours for IMRT (cont.)
7. Read and acknowledge the yellow warning message, then click the
Accept 3D Auto-margin button.
8. Create a margin around the ptv1 called ptvtransvol using a 0.5 cm

margin of inclusion. Use ptvtransvol as the prescription structure.
Since ptv1 is a "target inside a target," there will be a steep dose
gradient between ptv1 and ptv2. Expanding ptv1 ensures that the
prescription to that structure is met with no large cold spots.
9. Create a margin around ptv3 and ptv4 called ptv3/4transvol using a

0.5 cm margin of inclusion. Use ptv3/4transvol to limit the dose
outside ptv3 and ptv4. This controls hotspots outside of ptv3 and
ptv4.
10. Create a margin around the cord called cordplus using a 0.5 cm margin
of inclusion. The RTOG protocol requires that the prescription apply a
0.5 cm margin to the cordplus.
11. Once you create and accept these three structures, click the Cancel
button to exit 3D Auto-margin.
12. Click the Beam button on the main toolbar to enter into
Teletherapy. XiO shows a Yes/No dialog box.
13. Click Yes to save the changes made in PFM.
14. Read and acknowledge the yellow message about the data having been
changed.
15. Click the View drop-down menu and select the Enhance Contour
option.
OR
Press the C key on your computer keyboard to show the Enhance

Contour dialog box.
6-4
IMRT Head and Neck
IMRT Head and Neck
16. Click the All Structures Off button. Then, turn on the highlighted
structures as shown in the following window example.
17. Click OK.
XiO® 6-5
IMRT Head and Neck
IMRT Head and Neck

In this task, you will verify and change calculation settings when necessary.
It is not required that you complete this task for every IMRT plan, but it
helps to understand the settings on this page and how they affect the IMRT
calculations.
1. Click the Dose drop-down menu and select the Calculation and Settings

mouse.
Mouse: To use the mouse, right-click in a transverse, sagittal, or

coronal window and select Calc Size. Adjust the
calculation region highlighted in red in any or all of these
windows.
OR
Keyboard: Use the keyboard to enter the calculation region values.
4. Set your grid spacing to 0.3 cm along the width, height, and depth.
NOTE: We recommend a 0.2 cm grid spacing for all final

segmented MLC IMRT plans and 0.25 cm grid spacing for
all final IMRT plans using compensating filters. You are
using 0.3 cm for this exercise to speed up the calculation
time.
6-6
IMRT Head and Neck
IMRT Head and Neck
Task 4. Place Beams and Conform Jaws or Ports

For this training plan, use a 7-beam arrangement. Space each beam 51
degrees apart at gantry angles of 0, 51, 102, 153, 204, 255, and 306 — using
any of the following treatment machines Vari06xIMRT, Siem06xIMRT, or
Ekta06xIMRT.
1. Click the New Beam button on the Beam supporting toolbar.
OR
Press the F5 key on your computer keyboard. XiO shows the New
Beam dialog box.
2. Select one of the following treatment machines: Vari06xIMRT,

Siem06xIMRT, or Ekta06xIMRT.
3. Change the collimator jaw to asymmetric, and place the beam in the
center of the structure named Combo.
XiO® 6-7
IMRT Head and Neck
IMRT Head and Neck
4. Click OK. XiO shows the Photon Beam dialog box.
5. (Optional) Enter a beam description for beam 1.
6. It is not necessary to edit the field sizes, isocenters, or weights. All

have either been defined already or will automatically be generated
during the IMRT process. Validate that you either selected the
Convolution, Fast Superposition, or Superposition algorithm. We
recommend Fast Superposition or Superposition for head and neck
cases.
7. Type the beam weight and number of fractions. If the delivery method
will be dynamic, it is important to set the fractions when setting up the
beams, since the segmentation is effected by the fractionation.
8. The weight point must be in a position of homogenous tissue and away
from potentially steep dose gradients. For the weight point location,
Default To: center of ptv2.
6-8
IMRT Head and Neck
IMRT Head and Neck
Task 4. Placement of Beams (cont.)
9. Copy the active beam six times by clicking the Copy Beam button
on your toolbar.
OR
Press the F7 key on your computer keyboard six times. This quickly
creates seven (7) beams.
10. Click the Beam Spreadsheet button on your toolbar to open the
Beam Spreadsheet dialog.
11. From the General tab, type beam Description for each of the beams
(optional).
12. Click the Beam tab. Change the gantry angle of beams 2 through 7 to
51, 51, 102, 153, 204, 255 and 306, respectively.
options. XiO shows the Photon Conform Beams dialog box.
14. Select all the beams by clicking on the beam numbers. The buttons are
highlighted in blue when selected.
15. Middle-click in the Structure field and select the structure Combo.
16. Enter a margin of 1.0 cm.
17. Middle-click in the Collimator Type field and select Jaws Only.
18. Click OK. XiO conforms the jaws on all the beams to 1.0 cm around the
structure combo.
XiO® 6-9
IMRT Head and Neck
IMRT Head and Neck
1. Click the IMRT button on the main Teletherapy toolbar.
OR
2. Click the IMRT Parameters button on the supporting toolbar.
OR
Parameters dialog box. Use MLC as the Modulator type.
3. Verify that all the beams to be optimized are set to yes.
4. Click OK.
6-10
IMRT Head and Neck
IMRT Head and Neck
Treatment Goal
• Deliver 6600 cGy to at least 93% of ptv1.
• Deliver 6000 cGy to at least 93% of ptv2.
• Deliver 5400 cGy to at least 93% of the nodes (ptv3 and ptv4).
• Limit the dose to 4500 cGy on the cordplus. Less than 1% of the
volume of the cordplus structure should exceed 4500.
• Limit the dose to 3000 cGy over less than 50% of e ach parotid. No
more than 50% of each parotid should receive more than 3000.
5. Click the IMRT Prescription button.
OR
6. Locate the target structures in the list and set the type for all of them
to Target.
7. Rank them in order of overlap priority. Remember, you can rank some
structures the same.
XiO® 6-11
IMRT Head and Neck
IMRT Head and Neck
8. Right-click in the objective box for each structure and enter your
prescription. Enter a minimum, maximum and (optionally) goal for all
target structures. Below is an example you could use. Utilize whatever
values you want in order to fulfill the prescription requirements.
There is more than one way to fill out this prescription table.
9. Leave the weight and power at the default settings.
10. Once you have filled out the prescription table with the target
structure values, click OK.
6-12
IMRT Head and Neck
IMRT Head and Neck

You have intentionally not turned on any critical structures (OARs). Often
after evaluation of the initial plan, you will find that a critical structure does
not need to be turned on at all. More importantly, you must determine if a
good plan is achievable without critical structures being turned on. First,
optimize the plan with only the target structures prescribed.
OR
2. Enter the information shown in the above fields for the initial and
beam weight optimizations.
XiO® 6-13
IMRT Head and Neck
IMRT Head and Neck
Task 6. Start IMRT Optimization Page (cont.)
3. ( Optional) Select one of the default Smoothing Parameters to use

smoothing during the fluence optimization.
4. Click the Start button to begin. Once again, if you would like to use
different values for any of these items, you may do so. If necessary, go
back to the lecture and review what each of these values represents so
you can enter values appropriately. XiO shows the message
"Optimization Complete" when it has reached the selected criteria.
initialize the optimization after you click the Start button.
The Status indicator at the bottom of the Start IMRT
6-14
IMRT Head and Neck
IMRT Head and Neck

Once you optimize the plan, it is important to review the optimized DVH and
For this training exercise, the following requirements must be met:
• The DVH goal is to have at least 93% of the volume of each PTV
structure receive its prescribed dose.
• Less than 1% of the volume of the cordplus structure should exceed

4500 cGy.
• No more than 50% of each parotid should receive more than

3000 cGy.
1. Click the Histogram button on the IMRT supporting toolbar.
2. Type 5 in the DVH Window field.
3. Left-click on each structure to turn it off or on.
4. Click ptv1, ptv2, ptv3, ptv4, rtpar and cordplus to display them in the
DVH.
XiO® 6-15
IMRT Head and Neck
IMRT Head and Neck
Task 7. Optimized DVH and Isodoses (cont.)
5. Click the DVH Statistics tab to review the statistics. You can see the
Volume of a structure and the doses it is receiving.
6. Add goals to evaluate specific criteria for each structure.
7. Right-click in the DVH window and make a selection from the list of
tools to evaluate the DVH.
• Use the Histogram Cursor to show the volume of a structure and

the dose it is receiving.
• Use Movie to toggle the active structure information.
NOTE: This DVH and its statistics are based on the intensity map
calculation. It gives you an idea of how the optimization is
doing up to this point. It also represents an idealized
situation. If the DVH is not acceptable for any structure, you
would probably not want to continue. But rather, you would
go back and examine the IMRT prescription, and possibly the
beam arrangement.
8. Click the Isodose Lines button on the IMRT supporting toolbar to

review isodose lines.
9. Enter isodose lines such as 6600, 6000, 5400, 4500, etc. to evaluate
the coverage of the associated volumes.
6-16
IMRT Head and Neck
IMRT Head and Neck

After reviewing the optimized DVH, isodoses, and intensity maps, you have
two options:
If the target doses need adjustment:
(1) Return to the prescription table and change the weight and/or
power, then re-optimize. Be sure to not just check the
variable(s) that have been changed in the prescription as
increasing the weight or power of one variable will affect how
other variables are handled during optimization. You may have
improved the coverage of one target but reduced the coverage of
another.
(2) Make sure the prescription to the targets produces an acceptable

DVH before adding OARs.
If the target doses are acceptable:

(1) Begin by adding one OAR to the prescription. Right-click in the
objective field for the OAR structure and add a maximum or dose
volume points and an optional Threshold value, then re-
optimize.
(2) Include the structure ptv3/4trans as an OAR max dose =
minimum ptv3 and ptv4 dose. This will help transition the dose
between the target and OARs.
(3) Make adjustments to the prescription as needed. Continue by
adding each OAR to the prescription table until you have an
acceptable Optimized DVH for the entire plan. If a Target or OAR
is not meeting the dose constraints, check the isodose
distribution to see where the structure is in violation.
(4) Adding OARs will impact on target coverage so you may need to
increase power or weight of the minimum target doses or further
increase the minimum doses to maintain coverage.
1. In either case, click the IMRT Prescription button and make

adjustments to the prescription. For the parotids, you may consider
adding dose volume points to shape the DVH curve. For the spinal
cord (cordplus expand), you may want to use a threshold dose with
the maximum dose.
XiO® 6-17
IMRT Head and Neck
IMRT Head and Neck
Task 8. Prescription Adjustment (cont.)
2. Once you have made the changes to the prescription, click the Start
Optimization button to re-optimize.
3. Repeat this process as many times as necessary until the optimized

DVH is acceptable for all structures.
5. Enter the plan ID optplan. You may want to return to this point after
the final dose calculation if changes to the prescription are necessary.
6-18
IMRT Head and Neck
IMRT Head and Neck

At this point, you can turn on the ideal intensity map that is created based on
the optimized plan. You also have the capability of sampling and editing
individual pixel intensities.
option.
OR
Click the Display Intensity Maps/BEV button on the IMRT

supporting toolbar. XiO turns on the intensity maps.
2. Movie through each beam to review all intensity maps. Turn off all
contours, if necessary.
3. Sample the intensity map by right-clicking in the ABV window and

selecting the Sample Intensity option.
4. Move your mouse cursor over the intensity map. A brown box
indicates which pixel is being sampled. The relative value shows in the
lower left corner of the window.
5. Edit the intensity map by right clicking in the ABV window and
selecting the Edit Intensity option.
7. Over the selected pixel, hold down your left mouse and move right or
left to increase or decrease the intensity of that pixel. The relative value
8. Right-click in the ABV window and select the Restore Intensity option
to restore the originally calculated intensities.
9. If you have made changes that you want to keep, be sure to resave as
optplan.
XiO® 6-19
IMRT Head and Neck
IMRT Head and Neck

generating and reviewing the MLC segments.
1. Click the Generate Treatment Aids button on the IMRT supporting

toolbar.
OR
Only Users with

beam splitting
capabilities will
see this
information.
2. Select Step and Shoot Delivery Method and Sliding Window or

SmartSequencing Segmentation Method.
3. It is not necessary to use the Ideal Map Extension for this patient.
However, it is available since beams fall off the patient’s surface from
some or all of the beams.
6-20
IMRT Head and Neck
IMRT Head and Neck
Task 10. Generation and Review of MLC Segments (cont.)
4. (Sliding Window Segmentation) Enter a value for the number of

Discrete Intensity Levels. The number of intensity levels affects the
number of segments generated per beam. As you change this value,
XiO automatically updates the intensity map and isodose lines before
you segment. You will need to re-show the DVH to see the impact of
changing the discrete intensity levels. Also be aware of the global
maximum as this can change with the intensity levels. This can be a
valuable tool for determining just how many intensity levels are
necessary. Try different values and choose the lowest value that
maintains the integrity of the optimized plan. This will result in the
lowest number of segments to deliver the plan.
5. Users with machines capable of beam splitting: The example on the

previous page shows that beams 3 and 4 need to be split. XiO detects
fields that violate the maximum difference between most retracted leaf
and most extended leaf and automatically splits them into two or more
fields (child beams) that can be delivered. The gantry, collimator
angles, and isocenter remain unchanged. The field size and weight
point are updated for each child beam. There are four parameters to
verify or change, if desired. For this plan, the defaults are sufficient.
6. (Sliding Window Segmentation) Set the Minimum Segment Size (cm)

to 1.0 cm. This deletes any segments with an equivalent field size of
less than 1.0 cm. This value is only a suggestion.
7. (Smart Sequencing Segmentation) Set the Minimum MU/Segment to 5.

This is the minimum Monitor Unit value you will accept for any segment
the system creates.
8. (Smart Sequencing Segmentation) Set the Minimum Segment Area to 2.0

cm2. This value represents the smallest segment field area (cm2) you are
willing to accept in your plan.
9. (Smart Sequencing Segmentation) Set the Segment Suppression Factor

to 3.0. This factor helps to control the number of segments generated.
XiO® 6-21
IMRT Head and Neck
IMRT Head and Neck
Task 10. Generation and Review of MLC Segments (cont.)
11. Click the IMRT Delivery Summary. For some plans, the total number of
segments may produce treatment times that are too long. If the
number of segments is unacceptable, you can try a different number of
intensity levels and/or a different minimum segment size.
Split Beam fields only: Notice that the child beams have been assigned
a number of MLC segments.
12. Click Quit to close the IMRT Optimization Summary report.
14. Using the Next buttons, you can review all segments for all beams and
delete any as necessary using the Delete Segment button.
15. Click OK.
16. If you do not want to perform segment weight optimization, click the
Cancel button to begin the final dose calculation. Otherwise, continue
to task 11.
6-22
IMRT Head and Neck
IMRT Head and Neck
Task 11. Segment Weight Optimization (Optional)

Some plans may benefit from optimizing the segment weights. You can
perform segment weight optimization using these optional steps.
1. Click the Segment Weight Optimization button. XiO opens the Segment
Weight Optimization dialog.
NOTE: Dose calculation (pre SWO) starts when you open this dialog
box. If you want to compare your pre-SWO dose to your
post-SWO dose, save the plan after you calculate the dose for
all beams.
2. Type the information shown in the above fields for the segment weight
optimization criteria. Click the Start button to begin. If you would like to
use different values for any of these items, you may do so. If necessary,
go back to the lecture and review what each of these values represents
so you can enter values appropriately.
3. Status updates appear just below the SWO criteria during segment
weight optimization.
4. Click the OK button to start the final dose calculation.
5. After final dose calculation, if you saved your Pre-SWO dose, you can
compare Pre and Post SWO doses using Tools/Plan Review.
XiO® 6-23
IMRT Head and Neck
IMRT Head and Neck
Task 12. Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans
Once the final plan has finished calculating, the plan can be evaluated using
the DVH tool, isodose lines, and intensity maps.
1. Click the Histogram button. XiO redisplays the DVH and DVH
Statistics of the structures that were originally shown.
2. Click the DVH Statistics tab to review the plan statistics.
• Review volume of a structure and the Min, Max, and Mean doses it is
receiving.
• Use Goal Type column to verify that you meet or exceed the following
criteria. The DVH goal must have at least 93% of the volume of each
PTV structure to receive its prescribed dose. Less than 1% of the
volume of the cordplus structure should exceed 4500. No more than
50% of each parotid should receive more than 3000. If you entered
these criteria earlier, XiO updates the results to reflect the new dose
distribution.
3. The isodoses entered earlier should redisplay. Verify that the
coverage of the volumes is acceptable.
4. Intensity maps should already be shown. Movie through each beam to
review all the intensity maps. Turn off all contours if necessary.
5. Sample the intensity map by right-clicking in the ABV window and
selecting the Sample Intensity option.
6. Move your mouse cursor over the intensity map. A brown box
indicates which pixel is being sampled. The relative value shows in the
lower left corner of the window.
prescription, proceed using one of the following processes:
All Users:
(1) Close the patient and open the permanent plan optplan.
(2) Click the IMRT button then the Prescription button.
OR
(3) If you are still working in the same plan, click the IMRT button
then the Prescription button.
6-24
IMRT Head and Neck
IMRT Head and Neck
Task 12. Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans (cont.)
Users with Beam Splitting Capability:
You can re-optimize the plan using the child beams that were created.
If you want to delete the child beams and restore the parent beams
before re-optimization, do either of the following:
Either close the plan and open the saved plan optplan.
OR
(1) Turn on the parent beams by selecting Weight from the Dose
drop-down menu.
(2) Turn the parent beams from off to on.
(3) Click the Beam drop-down menu and select the Delete Beams
option to delete all the child beams.
(4) Click the IMRT button then the Prescription button to show the
dialog box. Edit the prescription and continue to the Start
Optimization dialog box to re-optimize. XiO automatically forces
the recalculation of the open beams before the re-optimization.
XiO® 6-25
IMRT Head and Neck
IMRT Head and Neck

save it.
2. Enter a Plan ID and (optional) description.
3. Click OK.
6-26
IMRT Head and Neck
IMRT Head and Neck
Task 14. Compare Plans with Different Minimum Transmission Multipliers

Some plans may require you to change the minimum transmission multiplier
so the dose distribution is not degraded during final dose calculation due to
under estimation of transmission. Although this particular plan may not
need a higher minimum transmission multiplier to get a good plan, you will
see a change in the final doses particularly to the spinal cord structure.
1. Open your saved Head and Neck plan and change the Minimum
Transmission Multiplier on the Start Optimization page to a value of 6.
NOTE: If you are using a machine where beams were split, you need
to delete all the child beams (Beams drop-down menu,
Delete Beams) and turn on all parent beams on the Weights
page before you optimize.
2. Optimize the plan, create segments using the same setting as the
original plan and calculate dose.
3. Save the plan as MTM6.
4. Click the Tools drop-down menu and select the Plan Review option.
5. Select your original saved plan as plan 2 for comparison.
6. Create a window format that shows transverse, sagittal, and MPV

images of both plans and the DVH.
7. Enter appropriate isodose values and review the DVH and DVH
Statistics. Notice the dose differences between the two plans,
especially to the spinal cord dose.
8. Movie to the transverse slice –74.30.
9. Click the Dose drop-down menu and select the Dose Profile option.
10. In the transverse image window, hold down your left mouse button
and drag across the image from left to right drawing a line through the
level of the spinal cord. Notice the difference between the dose
profiles of the two plans.
XiO® 6-27
IMRT Head and Neck
IMRT Head and Neck

Once you save the IMRT plan, there are several ways to verify its quality.
This task reviews the following processes:
• How to visualize, sample, and output intensity maps for QA

• How to verify the largest leaf extent on a DRR
• How to create QA plans on a phantom and export doses to a file
• How to create single beam QA files and export them
For more detailed explanations on IMRT QA, refer to the QA of IMRT Beams
—Technical Considerations located in the XiO Online Help.
Sub-task 1. Visualize, Sample, and Output Intensity Maps for QA
1. Activate beam 1 by selecting it as the Active Beam in the upper right-

hand corner of the window.
2. Click the View drop-down menu and select the Enhance Contours
option.
3. Click the All Structures Off button.
4. Click OK. The intensity map should be shown in the ABV window.
5. Right-click in the ABV window and select the Sample Intensity option.
6. Move your mouse around the intensity map to view the relative
intensity values across the field. The relative values show at the
bottom of the window.
7. If you want to output your intensity maps, click the Tools drop-down
menu and select the Output Intensity Maps in ASCII option. XiO shows
the associated dialog box.
6-28
IMRT Head and Neck
IMRT Head and Neck
Sub-task 1. Visualize, Sample and Output Intensity Maps for QA

(cont.)
8. Select the Map Type of Segmented MLC or Relative Fluence.
9. Enter a Filename for each beam intensity map you would like to
export. After the filenames have been entered, you can toggle on/off
the beam intensity maps you would like to output. When the beam
number and name are highlighted as blue, this means they are selected
to be output.
10. Select Output ASCII to send the files. XiO shows a message next to the
output ASCII button that states "Intensity Map Files Generated." XiO
saves these files in a network folder so third party software can
retrieve them.
11. Click Cancel to exit.
XiO® 6-29
IMRT Head and Neck
IMRT Head and Neck
Sub-task 2. Largest Leaf Extent Verification
1. Click the Beam button, then the DRR button. XiO turns on the
DRR. The largest extent of the leaves should show on the DRR in the
ABV window.
2. If you would like to print the DRR, click the File drop-down menu and
select the Print and DRR options. (The ABV window must be active to
get the DRR option under the print menu.) When you print the DRR,
you have the option of overlaying the plan information on the DRR. See
the Miscellaneous Tasks section of the XiO Training Guide for more
information.
6-30
IMRT Head and Neck
IMRT Head and Neck

File
1. Click the File drop-down menu and select the Close option to close the
plan.
2. Select File | New QA Plan. XiO shows the New Teletherapy QA Plan
dialog box.
3. Under Phantom ID, select cmsPHANTOM.
4. Under Studyset ID, select Phantom20. This gives you a 20 x 20 cm

square water phantom. In your clinic, you may select the phantom
created by your physics staff.
5. Under Graphics Area Setup, select 6TSCMxA.
XiO® 6-31
IMRT Head and Neck
6-32
IMRT Head and Neck
IMRT Head and Neck

File (cont.)
6. Click OK. XiO shows the Retrieve Plan for Quality Assurance dialog
box.
7. Under Patient ID, enter HNrtogIMRT.
8. Under Plan ID, select the plan name that you saved.
9. In this exercise, select No to leave all the beams in their original gantry
orientation. If you would like to set all the beams gantry angles to
beam down for QA of each individual beam, you could select Yes.
10. Click OK. XiO shows the Isocenter Location dialog box.
11. Under Isocenter, select center of studyset. Potentially, you could have
points of interest to set your isocenter to, or you can enter coordinates.
12. Click OK. XiO starts the dose calculation of the IMRT plan on the
phantom.
13. Click the T key on the keyboard. XiO removes the beam lines from the
phantom.
14. Click the Optimize drop-down menu and select the IMRT and Segment
Review options to open the IMRT Leaf Segment Review dialog box.
Review the segments as necessary.
15. Click the Dose button, then the Isodose Lines button. XiO
shows the Isodose Lines dialog box.
XiO® 6-33
IMRT Head and Neck
IMRT Head and Neck

(cont.)
16. Enter isodose lines that represent dose from one fraction. Review the
isodose lines on the phantom.
17. Right-click in any SPV window and select Reference Point Loc.
18. Hold down the left mouse button in any SPV to sample the dose to any
point in the plan. The dose and point coordinates shows in the upper
right corner or each SPV window. This could be useful in verifying
dose to specific coordinates in the plan with dose to specific
coordinates in an actual phantom.
19. You can export any viewable dose plane (transverse, sagittal or
coronal) using the Dose Plane Output option in the Dose Profile Tool.
Click the Dose Profile button. XiO opens the Dose Profile dialog
box.
6-34
IMRT Head and Neck
IMRT Head and Neck

(cont.)
20. Enter the SPV subwindow number to select the plane you would like to
export.
21. Click the Dose Plane Output button. XiO shows a dialog box where you
can enter a filename for the dose plane.
22. Enter a filename and click OK. The plane information has now been
created in an ASCII format and is located in a file on the XiO planning
system.
23. After you export all the planes you want to verify, click OK on the Dose
Profile dialog box. XiO closes the Dose Profile dialog box.
XiO® 6-35
IMRT Head and Neck
IMRT Head and Neck
Sub-task 4. Create a Single Beam QA File on a Phantom
After you complete your plan, you can elect to create individual beam QA
files for your IMRT plan.
1. Click the Tools drop-down menu and select the Modulation QA option.
OR
Click the Optimize drop-down menu and select the IMRT and IMQA
options.
XiO shows the Intensity Modulation Quality Assurance dialog box.
2. Enter the QA Measurements SSD, depth, phantom material, and

phantom relative electron density to create your flat homogeneous
phantom.
3. Select each beam for which you would like to create a QA plan by
selecting Yes for each beam under the QA heading.
4. Enter a user-definable Filename for each beam.
5. Enter/edit the Time or Monitor Units you want to use for this QA plan.
If you leave this field blank, XiO will use the mu/fx from the weight
page.
6. Click OK. This begins the calculation of the single beam QA plans.
Once the plans are calculated, XiO creates a file that can be used by a
third-party vendor’s software for QA purposes.
6-36
IMRT Head and Neck
IMRT Head and Neck
Sub-task 4. Create a Single Beam QA File on a Phantom (cont.)
The following window illustrates a valid prescription.
XiO® 6-37
Breast IMRT
Breast IMRT
Practice Exercise
The following procedures cover the common features of MLC-based IMRT

using XiO. There are many ways to complete an IMRT plan in XiO. This
section demonstrates two suggested methods of the IMRT planning
procedure. This plan is written using MLCs. However, you can plan with
compensating filters or dMLC. You will find suggestions for creating a flash
margin when planning using comp filters at the end of this exercise.
There are many ways to plan breast treatments. In the case of a simple
tangential arrangement, it is not possible to avoid part of the lung receiving
most of the dose prescribed to the target. IMRT using tangents does
however give very homogenous dose distribution throughout the target.
This is difficult, if not impossible to achieve with standard methods. Less
conventional beam arrangements can be used with XiO IMRT in an attempt
to lower lung and heart dose. You are welcome to explore different field
arrangements.
The first exercise highlights the 3D auto-margin tools and the IMRT map
extension feature that automatically generates "flash" to allow for daily
variations in the size/shape/position of the breast. The second exercise
demonstrates how to manually create beams which contain multiple
segments (control points).
XiO® 7-1
Breast IMRT
Breast IMRT
option.
5. Select the breast patient, studyset, and graphics area setup as shown in
the following window example.
6. Click OK.
7-2
Breast IMRT
Breast IMRT
Some structures (targets) that you intend to treat using XiO IMRT may be
created using the 3D Auto-margin tool. In this case, place one beam to use as
a guide, and then use a combination of tools to create the breast tissue
volume. For IMRT treatments, you must have a target contoured. Since
breast tissue is not typically contoured for conventional planning, a
suggested method has been derived to quickly contour the breast target
tissue. This is only a suggested method. There are many other ways to
create the breast tissue structure. This method allows a beam to be placed
as it would on a simulator to include breast tissue and the required lung
volume.
1. Click the New Beam button on the toolbar. XiO shows the New
Beam dialog box.
2. Type Vari06xIMRT in the Machine ID field.
3. Leave the Setup as SAD.
4. Set the Collimator Jaws to Asymmetric.
5. Select the Beam Isocenter Placement point to the interest point named
Isocenter.
6. Click OK. XiO opens the Photon Beam dialog box.
7. Rotate the Gantry to 65.
8. Rotate the Collimator to 356 and the Couch to 7.
9. Set the field borders as follows: LW= 7.0, RW= 5.5, UL= 11.5, and LL=
11.
10. Set the algorithm to Superposition or Fast Superposition.
11. Enter 2520cGy for the beam weight and 28 fractions. If the delivery
method will be dynamic, it is important to set the fractions when
setting up the beams, since the segmentation is effected by the
fractionation.
12. Click the View drop-down menu and select Window Format.
OR
Press W on the keyboard. XiO opens the Window Format dialog box.
XiO® 7-3
Breast IMRT
Breast IMRT
13. For the transverse image in window number 1, middle-click in the Ref
(cm) field and select –105.00. This is the CAX slice.
14. Click the Update Graphics Display button.
15. Click OK to close the Window Format dialog box.
16. Click the Contour button on the Teletherapy main toolbar. XiO
toggles you into contouring where you will create two structures: (1)
to help create the target volume, and (2) the target volume itself.
17. Create a "box" structure to encompass all the target tissue. Movie to
slice T= -105. This is the CAX slice.
18. Click the drop-down arrow in the Group field and select the User
Defined group.
19. Click the drop-down arrow in the Contour field and select the contour
name BreastBridge.
20. Click the Draw Mode button to draw a box around the breast tissue.
Use the internal beam edge as a guide. Refer to the following image.
21. Click the Edit Mode button.
7-4
Breast IMRT
Breast IMRT
22. Select the structure you just drew so that it has the edit box around it.
23. Use the keyboard shortcut Ctrl+C to copy that structure.
24. Movie to approximately 1 cm inferior to the superior border, T= -

94.81. This insures that the breast tissue is inside the superior border.
25. Use the keyboard shortcut Ctrl+V to paste the contour to that slice.
26. Movie to approximately 1 cm superior to the inferior border, T=-

113.10. This insures that the breast tissue is inside the inferior border.
27. Use the keyboard shortcut Ctrl+V to paste the contour to that slice.
28. Click the Interpolation button to interpolate the contour onto the
remaining slices. You have now created a box that will be used to
create the target volume.
29. Click the Create a Contour Using 3D Auto-Margin button to create

the breast target structure. XiO shows the 3-D Auto-Margin dialog box.
30. Type target as the structure name and change the color to red.
XiO® 7-5
Breast IMRT
Breast IMRT
31. Under the Structure list, select BreastBridge as your first structure.
32. Type –0.8 as the margin and Include. XiO creates the internal target
edge inside the beam border by 8 mm.
33. Select the structure RT Lung and Exclude by 0.5.
34. Select the structure Liver and Exclude by 0.5.
35. Set Clip at Patient’s Surface to Yes and Clip inside by 0.8. XiO creates
the surface margin of the target structure 8 mm inside the patient’s
surface.
36. Click the Create 3D Auto-margin button. You should now have a target
contour that looks like the one shown in the following window.
37. Click the Accept 3D Auto-margin button.
38. Click Cancel to close the 3D Auto-margin dialog box.
NOTE: Margins used are for the purpose of this demonstration

only, you will want to assess these and determine the
appropriate margins in your clinic.
7-6
Breast IMRT
Breast IMRT
39. Click the Beam button on the PFM toolbar to enter Teletherapy. XiO
shows a Yes/No dialog box.
40. Click Yes to save the changes made in PFM.
41. Read and acknowledge the yellow message about the data having been
changed.
42. Once in Teletherapy, press the C key on your computer keyboard to

show the Enhance Contour dialog box.
43. Turn all structures off. Turn on the following highlighted structures.
44. Click OK. XiO closes the dialog box.
XiO® 7-7
Breast IMRT
Breast IMRT
In this task, verify and change calculation settings when necessary. It is not
required that you complete this task for every IMRT plan, but it helps to
understand the settings in the dialog box and how they affect IMRT
calculations.
1. Click the Dose drop down menu and select the Calculation and Settings

mouse. To use the mouse, right-click in a transverse, sagittal, or
coronal window and select Calc Size. Adjust the calculation region
highlighted in red in any or all of these windows.
4. Set your grid spacing to 0.3 cm along the width, height, and depth.
NOTE: We recommend a 0.2 cm grid spacing for all final

segmented MLC IMRT plans, and a 0.25 cm grid spacing
for all IMRT plans using compensating filters. You are
using 0.3 cm for this exercise to speed up the calculation
time.
7-8
Breast IMRT
Breast IMRT
Task 4. Place Lateral IMRT Beam
At this point, mirror the Medial Tangent field and evaluate the conventional
tangent open field plan.
1. Activate beam 1 and click the Mirror Beam button. XiO shows the
Photon Beam dialog box for the new beam.
2. Enter the description as Lateral.
3. Edit the Gantry angle to 238, the Collimator angle to 356, and the Couch
angle to 352.
The beam parameters used are just one example of an acceptable

arrangement. You can set your own beam parameters to match what is
done in your clinic. Be sure to have an adequate field size to cover the
target with a 1 cm margin superior/inferior and posterior and open the
field out by at least 2.5 cm anterior to allow for flash.
XiO® 7-9
Breast IMRT
Breast IMRT
1. Click the IMRT button on the XiO Main toolbar.
OR
2. Click the IMRT Parameters button on the supporting IMRT toolbar.
OR
Parameters dialog box. Use MLC as the Modulator type.
3. Click OK.
• Deliver 5040 to the target volume with at least 90% coverage.
A valid prescription example is shown at the end of this exercise.
7-10
Breast IMRT
Breast IMRT
Treatment Goal
4. Click the IMRT Prescription button.
OR
5. Locate the structure named target in the structure list and set the type
to Target.
6. Assign the structure target a rank of 1.
7. Right-click in the objective box and enter your prescription. Enter a

Minimum, Maximum, and (optionally) Goal.
8. Leave the weight and power at their default settings for now.
9. Click OK when you have completed the prescription table with the
target structure values.
XiO® 7-11
Breast IMRT
Breast IMRT
In this case, you do not need to turn on any critical structures (OARs). If this
were a left breast, you might turn on the heart as an OAR. In some cases, you
may want to turn on the right or left lung as an OAR.
1. Click the Start Optimization button on the toolbar.
OR
Press the F7 key on your computer keyboard. XiO shows the Start IMRT
Optimization dialog box.
2. Complete the fields in the above window for Step Increment and the
Initial and Beam Weight Optimizations. A large step increment is used in
this plan because there are no small structures involved. If you would
like to use different values for any of these items, you may do so.
3. Click the Start button to begin the optimization. XiO shows the
"Optimization Complete" message when it has reached the selected
criteria.
initialize the optimizer after you click the Start button. The
Status indicator at the bottom of the Start IMRT
7-12
Breast IMRT
Breast IMRT
Once the plan is optimized, it is important to review the optimized DVH and
For this training exercise, the DVH goal is to have at least 90% of the volume
of the target structure receive a prescribed dose of 5040 cGy.
1. Click the Histogram button on the IMRT supporting toolbar. XiO

shows the DVH dialog box.
3. Type 5 in the DVH Window field.
4. Click OK. XiO shows the Histogram dialog box.
5. Click the off button in the Status column to turn on the display of the
target structure.
6. Click OK to keep the DVH viewable.
7. Evaluate the DVH using the DVH Statistics tab. Add goals in the Goal
Type column to view Dose/Volume information for specific
Dose/Volume criteria.
8. Evaluate the DVH using the tools found when you right-click in the DVH
window. Use the Histogram Cursor to show the volume of a structure
and the dose it is receiving.
NOTE: This DVH is based on the intensity map calculation. This

gives you an idea of how the optimization is doing up to this
point. This represents an idealized situation. If the DVH is
not acceptable, you would probably not want to continue, but
rather, you would go back and examine/change the IMRT
prescription, and possibly, the beam arrangement.
8. Click the Isodose Lines button to define and review the isodose
lines.
XiO® 7-13
Breast IMRT
Breast IMRT
Task 8. Review/Edit Ideal intensity Maps (optional)
At this point, you can turn on the ideal intensity map that is created based on
the optimized plan. You also have the capability of sampling and editing
individual pixel intensities.
option.
OR
Click the Display Intensity Maps/BEV button on the toolbar.
2. Movie through each IMRT beam to review the intensity maps. Turn off
all contours, if necessary.
5. Edit the intensity map by clicking your right mouse button in the ABV
window and selecting the Edit Intensity option.
7. Over the selected pixel, hold down the left mouse and move right or left
to increase or decrease the intensity of that pixel. The relative value
8. If you would like to restore the originally calculated intensities, right-

click in the ABV window and select the Restore Intensity option.
7-14
Breast IMRT
Breast IMRT
If the target dose needs adjustment, return to the prescription table and
change the weight and/or power, then re-optimize.
1. Return to the IMRT Prescription and make adjustments to the

prescription.
2. Once you have made the changes to the prescription, click the Start
Optimization button to re-optimize.
3. Repeat this as many times as necessary until the optimized DVH is

acceptable.
XiO® 7-15
Breast IMRT
Breast IMRT
Task 10. Extend Ideal Map

extending the ideal map to account for flash, then generate and review the
MLC segments.
OR
Click the F8 key on your computer keyboard. XiO shows the IMRT
2. To extend the intensity map to account for flash, enter 2.0 for Distance
to Extend and 2.0 for Averaging Distance.
3. Click the Extend Map Edges button to extend the intensity map. XiO
extends the intensity map beyond the patient’s surface 2.0 cm and
averages the intensity value over a 2.0 cm distance before extending.
4. Try different values for distance to extend and averaging distance with
the intensity map turned on to see the effects.
5. Enter 7 for Discrete Intensity Levels and 1 for Minimum Segment Size.
(These are only suggested values.)
7-16
Breast IMRT
Breast IMRT
2. Click the IMRT Delivery Summary button. For some plans, the total
number of segments may produce treatment times that are too long. If
the number of segments is unacceptable, you can try a different
number of intensity levels and/or a different minimum segment size.
3. Click Quit to close the IMRT Delivery Summary index.
5. Using the Next buttons, you can review all segments for all beams. You
can also delete any unnecessary segments using the Delete Segment
button.
6. Click OK on the MLC Leaf Segment Review window.
7. Click Cancel on the IMRT Segmented MLC Parameters window to

launch the final dose calculation.
8. Click OK to acknowledge the yellow message about the grid spacing.
XiO® 7-17
Breast IMRT
Breast IMRT
Task 12. (Optional) Editing MLC Segments
1. Click the Isodose Lines button .
2. Click the All Isovalues Off button .
3. Type the value of the isodose you want to remove in the first open
Isovalue (cGy) box.
4. Click the off/on button next to the isodose value you entered to change
the status to ‘on’. XiO shows the isodose line you typed.
5. Click OK. XiO closes the Isodose Lines box.
6. Click Dose | Dose in BEV. XiO shows the isodose line in the BEV.
7. Click Beam | Beam Spreadsheet. XiO shows the beam spreadsheet.
8. Click Segments on the beam spreadsheet to select the Segments tab.
9. Click the Next and Prev buttons to

review the MLC segments. XiO shows the Active Segment in the Beam’s
Eye View.
10. Click the Delete Segment button to delete a segment

you don’t want.
11. Type a number in the Beam # field to display a different

beam.
12. Click the Edit Segment button. XiO shows the Edit
Multileaf Collimator Leaf Pairs dialog box.
7-18
Breast IMRT
Breast IMRT
Task 12. (Optional) Editing MLC Segments (CONT.)
13. Select Edit Leaf from the mouse menu in the BEV.
14. Use the mouse to pull the MLC leaves over the hot spot for one
segment. You want to minimize the effect of the edits, so edit the leaves
in the segment which requires the least amount of leaf movement.
15. Click OK. XiO closes the Edit Multileaf Collimator Leaf Pairs dialog box.
16. Wait for dose to calculate.
17. Repeat the process of editing MLC leaves and reviewing the new dose
distribution until you are satisfied with the results. See the Forward
Planning Breast Technique exercise in this section for additional
information about this tab.
18. Click OK. XiO closes the Beam Spreadsheet dialog box.
XiO® 7-19
Breast IMRT
Breast IMRT
Task 13. Using DVH, Isodoses and Intensity Maps to Evaluate IMRT Plans
Once XiO finishes calculating the final plan, you can evaluate the plan using
the DVH tool, isodose lines, and intensity maps.
1. Click the Histogram button. XiO redisplays the DVH of the

structures that were originally shown.
2. You can evaluate the DVH Statistics using the DVH Statistics tab. XiO
updates the Doses and Goal information you defined.
3. Evaluate the DVH using the additional tools found in the DVH sub-
window.
• Use the Histogram Cursor to show the volume of a structure and the
dose it is receiving.
• Use Movie to toggle the active structure information.

4. Verify that you meet or exceed the following criteria. The DVH goal is
to have at least 90% of the volume of the target structure receive its
prescribed dose.
5. The isodoses entered earlier should re-display. Verify that the coverage
of the volume is acceptable.
6. Intensity maps should already be viewable. Movie through each IMRT
beam to review the intensity maps. Turn off all contours if necessary.
prescription proceed by clicking the IMRT button then the Prescription
button.
10. Edit the prescription as needed. XiO automatically forces the
recalculation of the open beams before the re-optimization.
7-20
Breast IMRT
Breast IMRT
save it.
2. Enter a Plan ID and (optional) description.
3. Click OK.
Task 15. Creating a Flash Margin When Planning with Compensating Filters
Creating flash for comp filter plans is a two-step process that includes
creating an expanded target volume and using bolus to let the algorithm
calculate dose to beamlets in the flash region.
This exercise shows you how to create 1cm of flash. Different

protocols/patients require different flash margins.
The amount of flash is the sum of the distance the target is expanded beyond
the patient surface plus an additional 5mm of bolus (applied during
optimization)
Create an Expanded Target Volume
1. Click the Contour button on the Teletherapy main toolbar. XiO toggles
you into contouring.
2. Click the Create a Contour Using 3D Auto-Margin button to create a

volume for optimizing the flash only. XiO shows the 3D Auto-Margin
dialog box.
3. Type FLASHVOLUME as the structure name and change the color to

cyan.
4. Select Variable Margin to YES.
XiO® 7-21
Breast IMRT
Breast IMRT
Create an Expanded Target Volume (cont.)
5. Below the Structure list, select Target as your structure.
6. Extend the margin Anteriorly and Right OR Left depending on the side
that you are treating. Enter a margin sufficient enough to extend the
Flash Volume outside the patient skin by 0.5cm.
7. Set Clip at Patients Surface to NO.
8. Click the Create 3D Auto-margin button. You should now have a Flash
Volume contour that looks like the one shown in the following window
(cyan structure).
7-22
Breast IMRT
Breast IMRT
Create an Expanded Target Volume (cont.)
9. Click the Accept 3D Auto-margin button.
10. Click Cancel to close the 3D Auto-margin dialog box.
11. When you enter your IMRT prescription, make sure you use
FLASHVOLUME as your target prescription.
NOTE: The structure FLASHVOLUME should be used as your target in

your prescription. However, the dose coverage should be
evaluated based on your TARGET.
XiO® 7-23
Breast IMRT
Breast IMRT
(cont.)
Create an Expanded Flash Margin
1. Click the Beam drop-down menu and select Bolus – New. Add 1cm
bolus to the flash area. You should now have a bolus drawn that looks
like the one shown in the following window.
2. Click the Beam drop-down menu and select Bolus – Assign. Select Yes
and assign the Bolus to both beams.
3. Set up your IMRT plan using compensating filters, enter your

prescription and optimize the plan. You should now have FLASH as
shown in the transverse SPV window below.
7-24
Breast IMRT
Breast IMRT
(cont.)
3. Generate the compensating filters and calculate dose.
4. After the dose calculation is complete, click the Beam drop-down menu
and select Bolus – Assign. Select No to un-assign the bolus for both
beams.
NOTE: The bolus was only used to generate the compensators and
is not needed for the final dose calculation.
XiO® 7-25
Breast IMRT
Breast IMRT
The following is an example of a valid prescription for this patient.
7-26
Breast IMRT
Forward Planning Breast Technique
Overview
You can also create segmented IMRT beams with the Forward Planning
functionality. You are not required to have an IMRT license to use Forward
Planning. But, you must use a treatment machine setup for IMRT planning
purposes so it includes all the IMRT specific parameters. See the XiO Beam
Modeling Guide for more information.
This exercise demonstrates how you can apply the forward planning
technique for breast using XiO. This exercise contains all necessary steps to
create two tangential beams with a prescribed dose of 50Gy.
Forward Planning For Breast
Task 1: Open the Patient
1. Start XiO and select Teletherapy.
2. Select File | New Teletherapy Plan.
3. Select Breast2 in the Patient ID field.
4. Type Forward Planned in the Description field.
5. Select 1 in the Studyset ID field.
6. Select 4TACS in the Graphics Area Setup field.
XiO® 7-27
Breast IMRT
Task 1: Open the Patient (cont.)
7. Select OK. XiO loads the patient.
8. Recommended Graphics Setup:
Calculation Volume/Area Turn off the display

Patient Orientation Icon Turn off the display
Patient Spherese Turn off the display
Structure Display Turn off all structures
PTV1 Turn on the display of PTV1 with T75
rendering
7-28
Breast IMRT
Forward Planning For Breast (cont.)
Task 2: Put the Beams on the Plan
1. Select the New Beam button .
2. Type 1a in the Field ID field.
3. Type Forward Planned in the Description field.
4. Select EktaMLCi2 in the Machine ID field.
5. Select OK. XiO closes the New Beam dialog box and opens the Photon
Beam dialog box.
6. Move the beam’s isocenter to the center of the target.
• Type -12.14 in the Isocenter X: field.

• Type -105.00 in the Isocenter (cm) Y: field.
• Type 12.09 in the Isocenter (cm) Z: field.
7. Rotate the Gantry to get the oblique field.
XiO® 7-29
Breast IMRT
8. Type 64 in the Gantry field.
7-30
Breast IMRT
Task 2: Put the Beams on the Plan (cont.)
9. Increase the field length so that you cover the whole target.
10. Select UL/LL Jaws from the mouse drop-down menu in the Beam’s Eye
View.
11. Use the mouse to drag the length jaws out so the field covers the target.
12. Increase the field width so there is a margin around the target.
13. Select LW/RW Jaws from the mouse drop down menu in the Beam’s
Eye View.
14. Use the mouse to drag the width jaws out so the field covers the target
with enough margin to accommodate flash.
15. Weight the beam to deliver half the requested dose in 25 fractions.
16. Type 2500 in the Weight (cGy) field. Type 25 in the Number of
Fractions field.
XiO® 7-31
Breast IMRT
7-32
Breast IMRT
Task 2: Put the Beams on the Plan (cont.)
17. Any beam with multiple control points (MLC segments) is considered
to be an IMRT beam in XiO. You must use Convolution, Fast
Superposition or Superposition for the calculation algorithm. Select
Convolution in the Calculation Algorithm field.
18. Select Port | Conform MLC | Active Beam to conform the MLC to the new
jaw positions.
19. Select the Mirror Beam button . XiO creates a mirrored beam.
20. Rotate Beam 2 so the interior edges of Beam 1 and Beam 2 are parallel.
21. Click in sub-window 1 which contains the Transverse slice and select
Gantry Angle from the mouse menu.
22. Use the mouse to rotate Beam 2 until the edge of Beam 2 is parallel
with the edge of Beam 1. The Gantry Angle is approximately 238
degrees.
23. (Optional) Type 1b in the Field ID.
XiO® 7-33
Breast IMRT
24. (Optional) Type Forward Planned in the Description field.
25. Select OK. XiO closes the Photon Beam dialog box for Beam 2.
7-34
Breast IMRT
Task 3: Set the Dose Calculation Grid Spacing
The Segmented IMRT dose calculation requires a 2 mm grid spacing.
1. Select Dose | Calculation | Settings.
2. Select Yes for Heterogeneity Correction?
3. Select Yes for Pixel by Pixel Calculation?
4. Type 0.200 for the Distance between Calculation Points Along

Width(cm), Along Height(cm) and Along Depth(cm).
XiO® 7-35
Breast IMRT
5. Select OK. XiO closes the dialog box and updates the dose calculation
with the new parameters.
7-36
Breast IMRT
Task 4: Set the Plan Normalization and display the isodoses
In this exercise, you use the 100% isodose line as a reference. Set the Plan
Normalization so the 100% line is equal to the prescribed dose (50 Gy).
1. Once dose has calculated, select Dose | Normalization.
2. Type 5000 in the (cGy) field.
3. Select the Selected Dose button. XiO changes the plan’s normalization.
4. Select CANCEL.
5. Select Dose | Isodose Lines. XiO displays the Isodose Lines dialog box.
6. Type 114 in the first Isovalue (%) box. 114% is the first overdose you
will remove.
7. Type 100 in the second Isovalue (%) box.
XiO® 7-37
Breast IMRT
8. Select Yes for Thick Lines?
7-38
Breast IMRT
Task 4: Set the Plan Normalization and display the isodoses (cont.)
9. Review the 100% isodose line to make sure it adequately covers the
breast and does not intrude into the lung. If the breast is not
adequately covered, return to Task 2 and increase the field sizes
and/or rotate the gantry until you are satisfied with the coverage.
XiO® 7-39
Breast IMRT
10. Click the On button in the On/Off column for the 100% isovalue line.
XiO turns off the display of the 100% isodose line. You are now ready
to block the 114% isodose line.
11. Click OK. XiO closes the Isodose Lines dialog box.
7-40
Breast IMRT
Task 4: Set the Plan Normalization and display the isodoses (cont.)
12. Select Dose | Dose in BEV to show the isodoses in the Beam’s Eye View.
Task 5: Creating the First MLC Segment (Control Point)
1. Select 1 Forward Planned in the Active Beam dialog in the upper right
corner of the screen .
2. Click the Beam button .
3. Click the Beam Spreadsheet button .
4. Click the Segments tab. You can now add segments to the beam and
change it from a 3D beam to a beam with multiple segments (control
points).
5. Click the Copy Segment button . XiO adds a segment to

the beam which is a copy of the active segment (in this case segment
#1). The beam now contains two segments.
6. Click the Next and Prev buttons until segment 2 is the Active Segment.
XiO® 7-41
Breast IMRT
Task 5: Creating the First MLC Segment (Control Point) [cont.]
8. Click in the Beam’s Eye View (sub-window 2).
9. Select Edit Leaf from the mouse menu.
10. Use the mouse to pull in the MLC leaves to cover the 114% hotspot. XiO
forces the width jaws to be flush with the most retracted MLC leaf in
the segment for the Elekta MLCi machine. You do not need to edit the
jaw positions.
NOTE: The Head Scatter Factor calculation has very strict

requirements on how MLC leaves and jaws are positioned
in MLC segments. Therefore, XiO limits your ability to
edit segment jaws based on the specific requirements of
the MLC model being used. See the On Line Help Topic
What is Forward Planning for the details.
11. Select OK. XiO closes the Edit Multileaf Collimator Pairs dialog box.
7-42
Breast IMRT
12. Use the left and right arrows in the Weight column to increase the
weight of Segment #2 until the 114% isodose line disappears. You have
to wait for the dose to calculate after each edit.
14. Click Dose | Isodose Lines. XiO shows the Isodose lines dialog box.
15. Change the 114 % isovalue to 112%.
17. Type Alt+b, s to use the keyboard shortcut to redisplay the Segments
tab of the Beam Spreadsheet dialog box.
NOTE: Turn off Num Lock if the keyboard shortcut does not
work.
18. Type 2 in the Beam # field
19. Click the Copy Segment button. XiO adds a second segment to Beam #2.
20. Wait for dose to calculate.
21. Click the Next and Prev buttons until segment 2 is the Active Segment.
XiO® 7-43
Breast IMRT
23. Click in the Beam’s Eye View (sub-window 2). Select Edit Leaf from the
mouse menu.
24. Use the mouse to pull in the MLC leaves to cover the 112% hotspot.
7-44
Breast IMRT
26. Use the left and right arrows in the Weight column to increase the
28. Click Dose | Isodose Lines. XiO displays the Isodose lines dialog box.
NOTE: Turn off Num Lock if the keyboard shortcut does not work.
XiO® 7-45
Breast IMRT
33. Click the Prev button until the Active Segment is segment 1.
34. Click Copy Segment. XiO adds segment #3 to the beam.
35. Click the Prev and Next buttons until the Active Segment is 3.
36. Click the Edit Segment button.
37. Use the mouse to pull in MLC leaves to cover the 110% hotspot.
7-46
Breast IMRT
39. Type values in the Weight(%) column for Segment #3 to increase the
40. Click OK. XiO Closes the Beam Spreadsheet dialog box.
41. Click Dose | Isodose Lines. XiO displays the Isodose lines dialog box.
NOTE: Turn off Num Lock if the keyboard shortcut does not
work.
46. Click the Prev button until the Active Segment is segment 1.
47. Click Copy Segment. XiO adds segment #3 to the beam.
XiO® 7-47
Breast IMRT
48. Click the Prev and Next buttons until the Active Segment is 3.
49. Click the Edit Segment button.
50. Use the mouse to pull in MLC leaves to cover the 108% hotspot.
7-48
Breast IMRT
52. Type values in the Weight(%) column for Segment #3 to increase the
53. Continue adding segments to further decrease the global maximum

dose. The dose distribution with 3 segments per beam looks like the
image below.
XiO® 7-49
Breast IMRT
7-50
Breast IMRT
Task 6: Additional Optional Functionality
Subtask 1: Locking a Segment’s Weight
1. You can lock the relative weight of a segment. Click the no button under
the Locked heading to lock the weight.
2. You can still edit the segment’s leaves and jaws when the segment is
locked.
3. XiO updates the MU of a locked segment if you change the Total Beam
Weight (cGy) and/or the Total Beam MU.
4. Select OK to save the changes.
5. Select CANCEL to discard the changes. XiO will remove your changes.
Subtask 2: Deleting Segments
1. Select the Delete Segment button to delete one or

more segments from the beam.
2. Click OK to save the changes.
XiO® 7-51
Breast IMRT
3. Click CANCEL to discard the changes. XiO will remove your changes.
7-52
Breast IMRT
Task 6: Additional Optional Functionality (cont.)
Subtask 3: Adding Segments
1. Select the Add Segment button . XiO adds a new segment

to the beam with a default size of 10 cm x 10 cm. XiO defaults the
weight of the new segment to 0.
Subtask 4: Reweighting a Beam
1. Type a new value in the Total Beam Weight (cGy) field to reweight a
beam. XiO updates the MU of each segment according to the new beam
weight.
2. Type a new value in the Total Beam MU field to change the monitor
units for a beam. XiO updates the MU of each segment according to the
new beam weight.
Subtask 5: Renumbering Segments
1. You can renumber segments once the system calculates the dose.
2. Type the new segment numbers in the column headed by the # sign.
3. You cannot have two segments with the same number. You cannot
have a segment numbered higher than the total number of segments in
the beam.
4. You must renumber two segments to change their order.
5. Click the # button to reorder the display of the segments.
XiO® 7-53
Breast IMRT
Task 7: Editing a MLC Segments Using the Port Menu
Subtask 1: Mouse Functionality
1. Select the Port button .
2. Click in the Beam’s Eye View.
3. Select Edit Leaf from the mouse menu.
4. Use the mouse to edit the MLC leaves.
7-54
Breast IMRT
Task 7: Editing a MLC Segments Using the Port Menu (cont.)
Subtask 2: Dialog Box Functionality
1. Select Port | Keyboard | MLC. XiO shows the Edit Multileaf Collimator
Leaf Pairs dialog box.
2. Use the Auto Margin To: option to conform an individual segment to a

structure .
3. Type in values to edit individual leaf positions.
4. Type in values to edit individual jaw positions. XiO prohibits some edits
based on the MLC type due to dose calculation and delivery
restrictions.
5. Select Next and Prev after Current Segment to edit a different segment.
6. Select Next and Prev after Current Beam to edit a different beam.
XiO® 7-55
Additional Practice Plans
The plans discussed in this section are additional practice plans you can use in
your classroom training session. At this point, you should be familiar with the
IMRT process in XiO, so only the treatment goals and example prescriptions
have been provided. Contours have already been drawn. If necessary, use the
lecture notes described in Section 1 of this training guide to step you through
IMRT.
Head and Neck including Lower Neck Nodes
Patient ID: HEADandNECK

Studyset ID: 1
Prescription
Target Structures
PTV70 95% of PTV70 is at or above 7000 cGy 30 fx
PTV56 95% of PTV56 is at or above 5600 cGy 30 fx
Organs at Risk
(OAR)
Spinal Cord Max dose 4500 cGy
Rt Parotid Dose as low as possible
Lt Parotid Max Dose 3000 cGy
The target volume is the tumor on the right side of the neck and the lower neck
nodes. Use any beam arrangement and any IMRT prescription to meet the above
described prescription goals. Refer to the following prescription example for
assistance with your plan.
XiO® 8-1
Head and Neck including Lower Neck Nodes (cont.)
Example
A clinically acceptable plan was achieved using seven beams (evenly spaced)
and the following IMRT Prescription.
8-2
Brain
Patient ID: HEADandNECK

Studyset ID: Brain
Prescription
Target Structures
PTV1 5400 cGy 30 fx
PTV2 6000 cGy 30 fx
Organs at Risk
(OAR)
Optic Chiasm Max dose 5400 cGy
Optic Nerves Max dose 5400 cGy
Lens Max Dose 800 cGy
Uninvolved Brain Limit dose as much as possible
The target volume is the brain tumor contoured on this studyset. The example
prescription is for a concurrent treatment. You may want to try this prescription
as a composite plan using the composite method as well as the synchronous
method for purposes of evaluating them to determine the clinical method you
would like to use. Refer to the following prescription example for assistance
with your plan.
XiO® 8-3
Brain (cont.)
Example
8-4
Prostate with Iliac Nodes
Patient ID: ProstIliac
Studyset ID: PelvisAndNodes
Prescription: Option 1
Target Structures
95% to receive 7020 cGy
PTV2 (prostate + margin) Limit to hot spot of 10% (7720 cGy)
PTV1
(prostate, seminal vesicles,
iliac nodes + margin) 95% to receive 4500 cGy
Organs at Risk (OAR)

17% to receive less than 6500 cGy
Rectum 35% to receive less than 4000 cGy
Bladder 50% to receive less than 4000 cGy
Small Bowel Max Dose 5000 cGy
Femurs 10% to receive less than 5000 cGy
Prescription: Option 2 (escalated dose)
Target Structures
95% to receive 7560 cGy
PTV2 (prostate + margin) Limit to hot spot of 10% (8310 cGy)
PTV1
(prostate, seminal vesicles,
iliac nodes + margin) 95% to receive 5040 cGy
Organs at Risk (OAR)

Rectum 35% to receive less than 4000 cGy
Bladder 50% to receive less than 4000 cGy
Small Bowel Max Dose 5000 cGy
Femurs 10% to receive less than 5000 cGy
XiO® 8-5
Plan Comparison and Evaluation
The objective of this exercise is to give you suggestions to use different

prescriptions, parameters, and tools. This lets you produce multiple plans to
compare and see the effect on the plans. It is mostly intended for users who plan
with MLCs. You can use any of these suggestions or make up your own plan
combinations to compare.
• Select any patient from the database to plan on or start a new patient
from scratch.
• Select a treatment machine that best matches one you use in the clinic.
• Create a typical beam arrangement (for your clinic) for the type of
patient you selected.
• Enter a prescription based on a previous exercise or what you would use
in the clinic.
1. Create identical plans with and without a smoothing parameter. Use the
Sliding Window segmentation method. Try out the different smoothing
options to see the affects it has on the plan. You could even try creating a
plan with and without a smoothing parameter using a different segmentation
method.
2. Create a plan with the Sliding Window segmentation method. Compare it to

an identical plan with the Smart Sequencing segmentation method.
3. Create identical plans with each segmentation method with and without
SWO. Compare SWO plans to each other and to plans that did not use SWO
(created in Step 2).
8-6
Are You Ready for IMRT?
Are You Ready?
The slides in this section are used during classroom training to cover
topics concerning the equipment and resources necessary for starting
an IMRT program. Establishing the appropriate QA programs,
collecting data, beam modeling, personnel training, etc. are considered
in order to encourage discussion of these topics with all personnel.
The following references were used during a training classroom lecture

to support the slides shown in this section.
• Beam Modeling Guide (www.elekta.com)

• IMRT Training Guide
• QA of IMRT Technical Reference Guide
(XiO Reference Library- Online Help)
• IMRT Beams Technical Considerations (XiO
Reference Library- Online Help)
Are You Ready?
Now that I’ve bought it, how do I make it happen?

Overview of the issues your facility should address when
initiating an IMRT program:
• Equipment
• Commissioning and Testing
• Equipment QA
• Patient-by-Patient QA
• Equipment Complications
• Immobilization and Localization
• Personnel Requirements and Training
• Reimbursement
Training
Available Resources:
• XiO IMRT Training Class

• XiO Reference Library
• Beam Modeling Guide
• QA of IMRT Beams
• IMRT - Technical Reference
• IMRT Training Guide
• RTOG Contouring Specifications
• Miscellaneous Symposia
• Colleagues who have IMRT experience
Equipment
Do you have the necessary equipment? Budget?
• Film Analysis Software – How will QA/Commission the

system?
• Phantom Materials – For Dosimetry verification
• Micro-Chamber – For small field measurements
• IMRT Phantom – Must provide a way to localize measurement
• MU Verification Software – Optional
• Network Interfaces – Not Optional!
• Fast XiO Workstation – High resolution calculations take a
long time and use a lot of disk space. Faster and bigger is
better!
Beam Modeling
• Take new measurements
• Create a specific IMRT model
• See Beam Modeling Guide for details
Commissioning
• What tests will you run to commission the
system?
• Do you have the equipment to do this?
• Must consider MU accuracy and Relative Dose

Accuracy
Ongoing Equipment QA
• Establish an appropriate MLC QA Program

- Daily QA performed by therapist
• Picket Fence tests
• Initialization frequency
- Monthly QA performed by physicist
• MLC performance is critical for high quality delivery
• Must be Precise and Repeatable

Per-Patient QA
• What will your routine, Patient-by-Patient QA procedure be?
- Equipment
- QA Protocol
- New Forms and Documentation
-Do you understand the results?

QA Process
QA plan setup is as important as the treatment plan setup.
• What system will you use for QA Plans?

• Place Reference Points in strategic locations
• Don’t QA the QA Plan!
• Visually inspect the MUs to be used to treat the patient for
correctness
Delivery Interruptions
Do you have a procedure in place to deal with:
• Segmented delivery interruptions

• Accelerator Fault
• MLC lock-up
• Power Outages
• R&V snags
How will you restart the delivery?

Immobilization and Localization
• Because of the characteristics of IMRT dose

distributions, patient immobilization must be taken to a
new level.
• For targets that can vary in position relative to bony

landmarks, daily localization may be required.
• Setup verification and reproducibility are essential.
• It is vital to educate and train staff on how to minimize

inter and intra-fraction setup variation using the tools
available in your facility.
Personnel Training
• Have Personnel been scheduled for training?
- Does schedule properly coincide with need?
- Physicist should attend training before commissioning
- Dosimetrist needs training before first clinical use
• Is the Physician ready?
- Contouring style and Rx regimens may differ from

Conventional Therapy
Dose Considerations
• Use heterogeneity corrections to account for innate variabilities in

the anatomy, density and geometry of individual patients.
• Discuss dose levels and escalation protocols with everyone

involved prior to implementing an IMRT program.
• Don’t take dose levels from an example given in a training course

or manual - all sites contour differently and every machine delivers
dose differently.
Contouring Considerations
Field sizes are smaller and more conformal in IMRT plans than in 3D plans,
so it is imperative that contours accurately represent the structure volumes.
• Contours shouldn’t be in the build up region

• Verify there are no gaps between contours
• Transition volumes can be utilized
• Refer to ICRU Reports 62 and 80
Overlapping PTV and OAR
PTV2
Transition
PTV1
Gap in contours
Contour is in build-up region

Billing Considerations
What will you charge?
Simulation
77290 Therapeutic radiology simulation-aided field setting; complex
Treatment Planning and Physics

77263 Therapeutic radiology treatment planning; complex
77417 Therapeutic radiology port film(s)
77301 Intensity modulated radiotherapy plan, including dose-volume histograms
for target and critical structure partial tolerance specifications
Treatment Delivery
77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams (example, binary, dynamic
MLC), per treatment session
Etc …
Data Requirements
and Beam Modeling
Overview
Overview
The slides in this section are used during classroom training to

cover IMRT-specific data requirements and the general beam
modeling procedure. Data collection and measurement
techniques are also reviewed.
The Beam Modeling Guide (located on www.elekta.com) was

used as a reference to support the slides shown in this section.
Beam Modeling Guide
• XiO Beam Modeling Guide is available on:

Elekta Website – User Access
• XiO Beam Modeling Guide is updated for each release

Create IMRT Specific Machine
The Best Starting Point is a good Beam Model

IMRT machine models may be created from scratch if necessary;
however, it is advantageous to create an IMRT specific machine
model by Copy/Duplicating your previously modeled conventional
therapy photon machine for that energy.
A conventional therapy machine that has been modeled correctly will
accommodate a clinical range of field sizes — open fields, wedges,
MLC, blocks, etc. and has already been put through the rigors of data
testing.
You can use Flattening Filter Free machines for IMRT.
IMRT Specific Data Requirements (additional)
• Open field PDDs for 2x2, 3x3, 4x4
- It is best to measure all PDDs with the same setup and ion chamber. It is
not necessary to use a micro chamber for PDDs down to 2x2.
- (Optional) Measure 1x1 fields if you can measure them accurately
• TSCFs down to 1x1
- Use an appropriately sized detector (example, micro-chamber, diamond
detector, etc.).
- Take care to ensure these data points are consistent with data obtained
with a more familiar chamber (duplicate measurements for some other
small fields).
• MLC transmission and Collimator transmission
- For IMRT models, use transmission values measured in air with a suitable
build-up cap or mini-phantom. See BMG for linac-specific suggestions.
• Profiles for a 2x10 MLC formed field
- The 2 cm direction should be formed by the MLC; you should scan across
the 2 cm direction.
• Radiation versus light field leaf offset (Varian™ and Siemens™ 160 users)
- Film evaluation of MLC position versus radiation.
Measuring PDDs
Best accomplished with a scanning ionization Conventional + IMRT

chamber or a diamond detector. Micro chamber not
Field Sizes Field Sizes
required.
3x3 cm 1x1 cm*
• The easiest way is to use the scanning
mode. Make sure that the reference 4x4 cm 2x2 cm
chamber does not effect the measurement. 5x5 cm 3x3 cm
• Make measurements for small field PDDs in 7x7 cm 4x4 cm
conjunction with all other PDDs for
12x12 cm 5x5 cm
Conventional Therapy.
15x15 cm
• Scan from the bottom of the tank toward the
surface to reduce water motion artifacts and 20x20 cm
to avoid dragging the meniscus downward. 25x25 cm
• If you are measuring on a point-by-point 30x30 cm

basis, be sure to characterize the build-up
35x35 cm
region accurately.
40x40 cm
*You should only measure a 1x1 field if you can measure them accurately
Measuring TSCF
Can be measured with film, micro chambers, TLDs, or diamond Conventional + IMRT
detectors
Field Sizes Field Sizes
• Diodes/micro chambers
Make measurements in a scanning tank so that the FWHM of 3x3 cm 1x1 cm
the field may be verified prior to making the measurement. It
4x4 cm 2x2 cm
will also allow you to locate the chamber/diode directly in the
center of the field. Get the field size as close as possible; 5x5 cm 3x3 cm
record the true field size for entry into the RTP system.
7x7 cm 4x4 cm
• Film
Shoot a film, develop it, and verify the field size before 10x10 cm 5x5 cm
making the measurement. Take several measurements so
that an average output can be deduced. Take appropriate 12x12 cm
H&D data.
15x15 cm
• TLD
Follow the procedure for verifying the field size for film. 20x20 cm
Irradiate TLD as you would normally. Make several
25x25 cm
measurements so that an average output can be deduced.
• Diamond detectors 30x30 cm
De Angelis C., et. al., “An investigation of the operating
35x35 cm
characteristics of two PTW diamond detectors in photon and
electron beams”, Med Phys 2002 Feb; 29(2) 248-254 40x40 cm
Measuring Collimator Transmission
Use build-up cap or mini-phantom

• Measure the dose rate on the CAX of the beam for the smallest collimator
setting at isocenter that covers the entire build-up cap or mini-phantom.
• Close the width jaws down to as close to zero as obtainable and move the
build-up cap/mini-phantom as needed to make sure no beam is
intercepting the cap/phantom. Measure the dose rate.
• The ratio of these readings is the width collimator transmission.
• Take a measurement for the length jaw.
• Enter the average into XiO.
Measuring MLC Transmission - 1
Use build-up cap or mini-phantom

• Inter-leaf leakage is averaged into transmission measurement.
• Collimator jaws and back-up jaws should be held back.
Varian™ Setup:
• Set collimator to 25x25 cm.
• Set an X by 26 MLC port, where X is wide enough to encompass the
entire build-up cap/mini-phantom.
• Make a measurement on CAX at isocenter.
• Leave the collimator setting at 25x25 cm and make the MLC portal
completely blocked with the leaves. Move the probe and
cap/phantom sufficiently off-axis so that it is not under a collimator
jaw and is not intercepting any radiation escaping from the closed
leaf abutments and repeat.
• The ratio of the two measurements should be entered into the
system.
Measuring MLC Transmission - 2
Siemens™ Setup:
• MLC replaces the lower jaws
so the transmission can be
assured the same way it was
for the collimator.
Elekta™Setup:
• MLC replaces upper jaws
and has back-up jaws.
• Make a measurement on CAX.
• Move the probe so that it is
between the jaw and the MLC.
• Take the ratio to find the MLC
transmission.
• Minimize the amount of
material intercepted by the beam.
Measuring MLC Edge Profiles
MLC profiles are measured to establish an accurate value of MLC
sigma.
• Use a micro-chamber for this
measurement if scanning in
water. Measure in 0.1 – 0.25
mm increment for best
resolution. Scan slowly.
• Use of a standard scanning
chamber will blur the penumbra
and lead to incorrect results.
• Film may be used to
characterize this penumbra (10
cm depth is OK).
• Data cannot be imported
directly into XiO for fitting. It
must be plotted.
• Avoid scanning in the inter-leaf
leakage plane. Offset the scan
profile if necessary.
Workflow - 1
• Use IMRT specific Machine ID (example, IMRT06x,

Varian06xIMRT) and description.
• Enter smallest achievable Minimum Field Size (0.1-0.3
cm).
• Enter the target to mid-jaw distances for the upper and
lower jaws (if the MLC replaces one of these jaws enter
none for that jaw).
• Enter the radiation vs. field size leaf offset (optional and
for Varian™ only).
• Enter the small field TSCFs.
• Transfer the small field PDDs.
Workflow - 2
• Enter the measured Collimator and MLC Transmission.

• Set the Collimator and MLC sigmas to 0.10 (good starting
value).
• Perform on-screen dose calculations for smallest to mid-size
field PDDs; modify spectra for best results. (Verify fits up to
20x20 and check wedges too.)
• For Compensator IMRT, it is critical that modified spectra
maintain sufficient wedge hardening.
• Delete Wedges and Clarkson Parameters.
• Validate.
• Determine MLC sigma for 2x10 MLC scan (hardcopy overlay).
• Set Collimator sigma to same value.
• Re-validate.
Radiation vs. Light Field Offset
Varian™ and Siemens™ 160 MLC Only

• Accounts for transmission through rounded leaf tips
• XiO makes automatic correction to MLC Export file so R&V
delivers appropriate segments
• Only affects IMRT Segmented MLC files
Light field
Radiation Field
• Use Shaper or other method to generate MLC segments.
• Increment MLC by 0.02 cm in pairs, symmetrically, on one
leaf bank.
• Initialize MLC before making measurements.
• Measure with film (example, XV ready-pack) – 50 MU works
well.
• No buildup is required.
• Evaluate the film for smooth gray dose bands and determine
offset.
• Enter XiO Parameter as ½ of determined offset (in cm
because only one leaf bank was modified during experiment).
• Typical XiO value is 0.05 – 0.09 cm.
Head Scatter Correction Factor
Varian™ Segmented MLCs only

• See the Beam Modeling Guide for complete recommendations
and protocol for determining this value.
• You can only adjust after beam modeling is complete.
• On the day that HSCF is measured, verify that TSCFs for small
fields are consistent with those entered into XiO. If they are
consistent, proceed to measure HSCF and adjust the parameter
accordingly.
• Do not use this parameter to compensate for poorly measured
small field TSCFs!
XiO IMRT Optimization
and Calculation Physics
Objectives
At the end of this presentation you will be able to:

1. Define optimization as it relates to XiO IMRT
2. Understand how the Conjugate Gradient algorithm is used in the
optimization
3. Describe the formalism used for the Pencil Beam Algorithm
4. Name the available segmentation algorithms and their benefits
Optimization: Definition
Optimization is the process of finding the best combination of beamlet weights

in order to achieve the planning objective.
IMRT dose is developed by :

1. The planner who optimizes the plan setup (2/3 of the optimization).
2. The computer that optimizes the dose.
There are two stages of the optimization:

1. The first stage is when the optimizer uses the inverse planning
objectives, anatomy contours, and beamlets to produce IDEAL
intensity maps and doses.
2. The second stage is when the ideal beamlet intensities are converted
to segments or compensators. Then, the new deliverable doses are
recalculated and the beam weights of deliverable beam doses are
modulated.
Optimization: Prescription Panel(I)
XiO IMRT supports three different types of objectives:
1. Minimum dose objectives

2. Maximum dose objectives
3. Dose volume objectives(DVH)
Additional Features:
• Up to 5 DVH Objectives per structure

supported
• Up to 25 structures may have active
objectives
• Objectives can be mixed (DVH and max
dose)
• Voxel ownership is determined by the rank
• Graphical Editing Capability
Optimization: Prescription Panel (II)
• Type: Target or OAR
• Rank: Determines which structure owns the voxels in regions of

overlap
• Objectives-min, max dose volume, threshold
• Weight (or importance weight): A linear multiplier for that objective

that relates to the relative importance of objectives
• Power: The exponent used in the non-linear portion of the penalty
• Threshold: The dose below where NO penalty is applied
(assumed to be zero unless specified)
Optimization: Prescription and Objectives
• It is usually best to not directly translate the entire prescription into a

collection of corresponding objectives. (Ask for more.)
• It is better to start the inverse planning with active objectives for a

target; then, add one objective at a time for OARs. This way, the target
dose homogeneity can be evaluated.
• When OAR objectives are added, they tend to compete with target
dose objectives and degrade target dose homogeneity.
• By adding one-by-one objectives for OAR, it is easier to determine

which, if any, of the OAR objectives may compete with target
objectives.
• With fewer objectives, better solutions can often be found faster.

Optimization: Cost Function/Penalty
Optimization: Cost Functions (General)
For a simple goal dose quadratic error Total cost to be minimized:
approach, the cost per voxel would be:
M
gσ ( Di ) = ( Di − D0 ) 2 F = ∑ fσ
σ =1
Where D is the goal dose for the objective • Where σ
f is the individual
subcost of objective. M is theσ
0
1 number of objectives 3
A typical subcost function:

N
wσ
fσ =
N
∑ g σ (D )
i =1
i
wσ is an importance weighting
N is the number of structure voxels
Di is the dose at voxel i

g σ ( Di ) is the cost per voxel at voxel i. 2
Optimization: Cost Per Voxel for Maximum Dose Objective
gσ ( Di ) = 0 0 ≤ Di ≤ D0
if
gσ ( Di ) = mM ⋅ ( Di − D0 ) D0 < Di ≤ DM
gσ ( Di ) = ( Di − DM ) k + mM ⋅ ( Di − D0 ) DM ≤ Di
where
D0 is a goal dose.
DM is a maximum desired dose.
mM is a linear penalty for doses greater than the goal dose.
k is a penalty power.
Optimization: Cost Per Voxel for Minimum Dose Objective
gσ ( Di ) = ( Dm − Di ) k + mm ⋅ ( D0 − Di ) 0 ≤ Di < Dm
if
gσ ( Di ) = mm ⋅ ( D0 − Di ) Dm ≤ Di < D0
gσ ( Di ) = 0 D0 ≤ Di
where
D0 is a goal dose.
Dm is a minimum desired dose.
mm is a linear weighting for doses less than the goal dose.
k is a weighting power.
Di is the dose in the voxel i.
gσ is the cost per voxel when the dose in voxel is Di.
Optimization: Cost Per Voxel for Dose-Volume Objective
gσ ( Di ) = 0 0 ≤ Di ≤ D0
gσ ( Di ) = m+ ⋅ ( Di − D0 ) D0 < Di ≤ D0+
gσ ( Di ) = ( Di − D0+ ) k + m+ ⋅ ( Di − D0 ) D0+ < Di ≤ Dv
gσ ( Di ) = m+ ⋅ ( Di − D0 )
Dv < Di
where
D0 is the threshold dose (if it is specified).
D0+ is some specified dose equivalent.
m+ is a linear weighting for doses greater than the goal dose.
Dv is the dose at which the volume requirement would be satisfied given the
current dose distribution.
k is a weighting power.
Di is the dose in the voxel i.
gσ is the cost per voxel when the dose in voxel is Di.
Optimization: Cost Per Voxel for Dose-Volume Objective(II)
Only points between D0 + and Dv are penalized quadratically. As

optimization progresses, D approaches D . Example:
v 0+
The prescribed DVH objective indicates only 35% of the volume may
have voxels at or below 40Gy (40Gy, 35%).
At the current iteration, 55% of the voxels in the OAR have 40+ Gy.
a) Determine how many voxels need to get the dose at/below 40 Gy to meet
the prescription. (In this case, 20% of volume.)
b) Sort the voxels above 40Gy by dose.
Apply the penalty to the first

X voxels that will add up to
this volume.
D0+ Dv
No more than 35% of the volume

should get a dose of more than
40Gy.
Optimization: Cost Per Voxel for Maximum Dose Objective (III)
A penalty is applied to the voxels closest in dose to the Rx value

that make up the percent volume needed to meet the objective.
Example:
The prescribed DVH objective indicates only 35% of the volume
has voxels at or below 40Gy (40Gy, 35%).
At the current iteration, 55% of the voxels in the OAR have 40+
Gy.
a) Determine how many voxels need to get the dose

at/below 40 Gy to meet the prescription. (In this case,
20% of volume.)
b) Sort the voxels above 40Gy by dose.
c) Apply the penalty to the first X voxels that will add up to
this volume (20%).
Optimization: Start Page
Optimization: Control Definitions
Step Increment—Controls Beamlet (bixel) width (at isocenter).
Minimum Transmission Multiplier — Helps improve the agreement between the optimized dose
distribution and the final dose distribution by increasing the background scatter which is present. The
product of this value, the MLC transmission from SFM, and the maximum beamlet intensity are used to
establish the minimum beamlet intensity value.
Iterations between DVHs—Controls the update frequency of the displayed scored DVHs.
Convergence Criterion—At every iteration, the difference in the current cost function and the previous
iteration’s CC is computed. When the difference falls below the CC, the optimization will cease. The
suggested default for the convergence criterion is 0.001.
Maximum Iterations- The hard maximum number of iterations the optimizer will run. The suggested
default for maximum iterations is 60. The job is done in the first 30 iterations. (When higher order
penalties are used, more iterations are required.)
Scatter Extent—The distance any beamlet contributes dose beyond its geometric edges; if the scatter
extent is set to zero, the optimization algorithm ignores scatter altogether. Suggested value: less than 1
cm for prostate and greater than 1.5 for head and neck plans.
Optimization Margin—A margin around the targets in the Rx. Any bixels falling beyond the projection of
this margin in a BEV will not be optimized.
Smoothing Parameters — The selected set of parameters are used by the smoothing function applied
during the fluence optimization to remove 'spikes' in the intensity map. Selecting 'None' turns smoothing
off. XiO includes default smoothing parameters. However, you may define your own.
Optimization: Start Page(I) Step Increment
1cm step with 0.5 cm MLC 0.5cm step with 0.5 cm MLC
9991-959-08C
Optimization: Start Page (II) Optimization Margin
0.5 cm optimization margin 0 cm optimization margin

Optimization Process
Optimization process
Beamlet Creation
Assigned beams are
divided into beamlets
Pencil Beam Algorithm

Lateral Dose Distribution
Gradient calculation, Line search
Iterate until Cost Function Converges
Beamlet Calibration
Dose calibrated with
3D Algorithm
(Superposition, Fast Superposition, FFT Convolution)
Optimization Process: IMRT Inverse Planning I
• Commencing with a
contoured field and
beam arrangement
• Through either FFT

Convolution or
Superposition, the dose
across the entire field
is calculated
Optimization Process: IMRT Inverse Planning II
• Each beam is subdivided
into identical beamlets, all
with the same weight that
project from the machine
source to the isocenter
plane.
• Beamlets are subdivisions
of beams that represent an
ideal relationship between
fluence cross sections and
dose to voxels in the
patient.
• The legal range of the
beamlet weights assumes
no negative beamlet
weights and no beamlets
weighted zero.
• A grid consisting of the
beamlet dimensions is
applied to field.
- User-defined step increment x MLC width, when MLC is the modulator
- User-defined resolution when the compensating filter is the modulator
Optimization Process: Pencil Beam Algorithm I
• Dose to the individual beamlets is

now calculated using Pencil Beam
Algorithm.
• First, an analytical formula defining the lateral dose distribution is

employed.
• Here, x0 is the width of the Pencil Beam and b is a parameter that

controls the fit.
Optimization Process: Pencil Beam Algorithm II
• An example of a beamlet profile for a • No commissioning is required by you,

b = 0.5 and different halfwidths since b can be determined from
penumbra (your sigma)
Optimization Process: Pencil Beam Algorithm III
• Next, the TERMA calculated for the original contoured field is multiplied
with the lateral dose distribution for each beamlet to obtain the beamlet
dose.
dose( x, y, d ) = TERMA(x p , y p , d )⋅ f ( xr , bx , x0 ) ⋅ f ( yr , by , y0 )
• The combined lateral dose distribution of all beamlets for a beam
calculated using TERMA, as above, is a very simple dose estimate that
doesn’t take into account photon and electron transport or the presence
of electron contamination. It has no buildup region, and the dose at
maximum is incorrect, among other things. In order to account for
these phenomena, a calibration of the dose with the dose calculated
with one of the algorithms has to be done.
Optimization Process: Beamlet Calibration
• A correction between the original field dose and the beamlet dose
produces a calibrated matrix for the individual beamlets.
beamlet dose
original field dose
Optimization Process: Intensity Map
• The calibration matrix is applied to the beamlets. Now, the

combined beamlet dose exactly mimics the open field photon
dose. From the calibrated beamlets, an open field intensity map
is generated and stored until the optimization of the beamlets
ends.
• Now, optimization of beamlet weights can begin.

Optimization Process
• The weights for each beamlet

must be optimized until the
prescribed DVH and scored
DVH are matched
(convergence criterion is met
or number of iterations is met).
• Beamlet weights are

systematically changed in
order to simulate the
dosimetric effect of increasing
or decreasing fluence for
different beamlets.
• The optimization must allow

you to follow a quick and
cohesive path.
Optimization Process: The Cost Function
• To follow a logical path for optimization, a cost function is created,

allowing for objectives as well as constraints and penalties for
constrain violations.
Where:
Oσ is the objective
indexed over σ
• The cost function must incorporate all objectives across OARs and
Target (min,max,dvh, threshold, goal dose).
Optimization Process: Example
Two voxel patient example
Where:
T = Target
N = Normal Tissue
(or OAR)
Optimization Process: Objectives and Weights (I)
One Target Objective

Cost Function
One OAR Objective F ( D T , D N ) = O T ( D T ) +O N ( D N )

= ( DT -D GT )2 + (DN - D GN ) 2
If you apply the following constraints to your objectives
DGT = 64 Gy,
DGN = 0 Gy,
wi = 1.0 (starting value for the beamlets weights is 1 before beginning

the optimization and at each iteration), during optimization, the beamlet
weights are systematically changed in order to simulate the dosimetric
effect of increasing or decreasing fluence for different beamlets.
Optimization Process: Objectives and Weights (II)
If you apply the following constraints to your objectives,
DGT = 64 Gy,
DGN = 0 Gy,
wi = 1.0
the four beamlets, when weighted 1.0, should equally contribute 16 Gy to
the dose at voxel T.
Example, if the dose to N from beamlet 1 is 15Gy, and the dose from
beamlet 3 is 17 Gy, (physically reasonable, but arbitrary, dose values).
Voxel Beamlet 1 w1 Beamlet 2 w2 Beamlet 3 w3 Beamlet 4 w4
T 16 1.0 16 1.0 16 1.0 16 1.0
N 15 1.0 - 1.0 17 1.0 - 1.0
Note that the beamlet weights relate to fluence differences in a treatment

field and are NOT the same as the Importance weights that relate to the
relative importance of the objectives.
Optimization Process: Objectives and Weights (III)
Here you have… D T = 16 ⋅ w1 + 16 ⋅ w2 + 16 ⋅ w3 + 16 ⋅ w4
= 64
D N = 15 ⋅ w1 + 17 ⋅ w3
= 32
If you apply dose values

from 0 to 64 Gy to
,
you can plot the range of
the target objective OT
and normal tissue
objective ON.
Optimization Process: Objectives and Weights (IV)
When applying these dose constraints, you have the following:
F ( D T , D N ) = ( D T - 64 ) 2 + ( D N ) 2
= (64 − 64 ) + (32 − 0 )
2 2
= 1024
• Your next task is to

work out in which
direction to go.
• Random applications
of weights gives you
an impossible surface
over which to search
for the optimum
doses.
Optimization Process: Conjugate Gradient (I)
If you take the derivative of each cost function with respect to the weight
of each beamlet wi , you can see how changing the weights will change
the cost function F…; this is known as the gradient descent method. The
gradient for such a cost function is a normalized vector composed of
partial derivatives of the cost function objectives with respect to the
beamlet weights. Your objective is to find the minimum value for F given
all our objectives.
∂F ∂O ∂F ∂OT ∂ON
=∑ σ in our case this = +
∂wi σ ∂wi function becomes ∂wi ∂wi ∂wi
• There are many methods of finding the gradient of cost functions for
optimization.
• XiO employs a conjugate gradient algorithm to search for the minimum

value of the cost function (which is a member of the gradient descent family
of optimization methods).
Optimization Process: Conjugate Gradient (II)
The gradient for such a cost function is a normalized vector
composed of partial derivatives of the cost function objectives with
respect to the beamlet weights.
∂F ∂OT ∂ON ∂OT ∂DT ∂ON ∂DN
= + = +
∂wi ∂wi ∂wi ∂DT ∂wi ∂DN ∂wi
∂F ∂D ∂DN
= 2 ⋅ (64 − 64 ) ⋅ T + 2 ⋅ 32 ⋅
∂wi ∂wi ∂wi
∂DN
= 2 ⋅ 32 ⋅
∂wi
∂F ∂F ∂F ∂F
= 960 =0 = 1088 =0
∂w1 ∂w2 ∂w3 ∂w4
You normalize the derivatives and your gradient equation becomes
∂F ∂F ∂wi
= − ∇F = −0.66 w
ˆ 1 − 0.75w
ˆ3
∂wi
1
 2
2
∑ (∂F ∂wi ) 
 i 
Optimization Process: Line Search (I)
Line search magnitude is defined as the normalized distance in a line search direction
from some starting point in the search space.
You must now figure out how large a jump each wi must experience so as not to by-
pass a global minimum. In the spreadsheet line search in the example below, a fixed
step size is selected by trial and error. Real line search algorithms try successively, to
bring values closer and closer to the true minimum, until some convergence criterion is
met or the number of iterations is accomplished.
The relationship between wi and the line search magnitude L is wi = 1 − ∇Fwi ⋅ L .
Line Search Dose Per Beamlet (Target) Target Dose Per Beamlet (OAR) OAR Total w1 w2 w3 w4
Magnitude B1 B2 B3 B4 Dose B1 B2 B3 B4 Dose Cost 1.00 1.00 1.00 1.00
0.00 16.00 16.00 16.00 16.00 64.00 15.00 0.00 17.00 0.00 32.00 1024.00 0.93 1.00 0.93 1.00
0.10 14.88 16.00 14.88 16.00 61.76 13.95 0.00 15.81 0.00 29.76 890.68 0.87 1.00 0.85 1.00
0.20 13.92 16.00 13.60 16.00 59.52 13.05 0.00 14.45 0.00 27.50 776.32 0.80 1.00 0.78 1.00
0.30 12.80 16.00 12.48 16.00 57.28 12.00 0.00 13.26 0.00 25.26 683.23
0.74 1.00 0.70 1.00
0.40 11.84 16.00 11.20 16.00 55.04 11.10 0.00 11.90 0.00 23.00 609.28
0.67 1.00 0.63 1.00
0.50 10.72 16.00 10.08 16.00 52.80 10.05 0.00 10.71 0.00 20.76 556.42
0.60 1.00 0.55 1.00
0.60 9.60 16.00 8.80 16.00 50.40 9.00 0.00 9.35 0.00 18.35 521.68
0.70 8.64 16.0 7.68 16.0 48.32 8.10 0.00 8.16 0.00 16.26 510.25
0.54 1.00 0.48 1.00
0.80 7.52 16.00 6.40 16.00 45.92 7.05 0.00 6.80 0.00 13.85 518.71 0.47 1.00 0.40 1.00
0.90 6.56 16.00 5.28 16.00 43.84 6.15 0.00 5.61 0.00 11.76 544.72 0.41 1.00 0.33 1.00
1.00 5.44 16.00 4.00 16.00 41.44 5.10 0.00 4.25 0.00 9.35 596.38 0.34 1.00 0.25 1.00
1.10 4.32 16.00 2.88 16.00 39.20 4.05 0.00 3.06 0.00 7.11 665.59 0.27 1.00 0.18 1.00
1.20 3.36 16.00 1.60 16.00 36.96 3.15 0.00 1.70 0.00 4.85 754.68 0.21 1.00 0.10 1.00
1.30 2.24 16.00 0.32 16.00 34.56 2.10 0.00 0.34 0.00 2.44 872.67 0.14 1.00 0.02 1.00
1.40 1.28 16.00 -0.80 16.00 32.48 1.20 0.00 -0.85 0.00 0.35 993.63 0.08 1.00 -0.05 1.00
1.50 0.16 16.00 -2.08 16.00 30.08 0.15 0.00 -2.21 0.00 -2.06 1154.81 0.01 1.00 -0.13 1.00
Optimization Process: Line Search (II)
Graphically, your
initial line search
would look like this.
Line Dose Per Beamlet (Target) Target Dose Per Beamlet (OAR) OAR Total
Search B1 B2 B3 B4 Dose B1 B2 B3 B4 Dose Cost
0.70 8.64 16.0 7.68 16.0 48.32 8.10 0.00 8.16 0.00 16.26 510.25
If you use these calculated values for the doses, you would reset
wi to 1.00 and repeat the process.
Optimization Process Line Search (III)
0.70 8.94 24.0 7.46 24.0 64.31 8.38 0.00 7.93 0.00 16.32 266.28
0.87 3.86 25.0 2.62 25.0 56.42 3.50 0.00 2.86 0.00 6.36 97.95
Optimization: Process Convergence
In this example, after three
iterations, the cost function value
has reduced.
Cost
Iteration OT ON Total Cost
0 0.00 1024.00 1024.00
1 245.86 264.39 510.25
2 0.10 266.18 266.28
3 57.53 40.43 97.95
Iteration
The dose to the target and OAR
has been modified as follows:
Iteration DT DN
0 64.00 32.00
1 48.32 16.26
2 64.31 16.32
3 56.42 6.36
Cost Convergence:
The Cost Function should decrease with every
iteration. If the cost value does not decrease,
optimization stops.
Optimization Process: Optimized or Ideal Doses
• Evaluate
optimized doses
before
segmenting.
• Save the
optimized plan
before
segmenting or
re-optimizing.
• Delete
intermediate
plans once a
plan is final.
Generate Treatment Aids (1)
Treatment aids
Final Calculation
Segment Fields Create Compensators

convert beamlets convert beamlets
into field segments into compensator
contour
Generate Treatment Aids (II)
If comp filters are to be generated:
Generate Treatment Aids (III)
If segmented MLC are to be generated:
Generate Treatment Aids (IV)
MLC Segmentation Intensity Levels
Choose the number of intensity levels.
The more intensity levels, the more segments will be used to

deliver the IMRT beam.
2 Intensity Levels
4 intensity levels
Generate Treatment Aids(V): Reviewing Segments
Generate Treatment Aids (VI): Reviewing Compensators
SWO
Segmentation Weight Optimization
• Improve the agreement between the optimized and final dose
distribution.
• Compensate for loss of dose coverage to target volumes.
• Improve OAR sparing.
• Reduce the number of segments in a plan.
Why Do We Need SWO?
• Optimized intensity maps are divided into equal intensity levels
• To make up for loss of a huge amount of information and
degradation of the final dose distribution when going from an
optimized plan to a final plan
• The fewer number of intensity levels used, the more degraded
the final dose distribution
Equally Divided intensity levels
Optimized Intensity
Where information is lost

SWO: How It Works
• An optional step after MLC segments are generated.

• SWO uses the same optimizer and dose constraints as that used
for IMRT fluence optimization to optimize the weights of individual
segments.
• The dose constraints can be altered before SWO.
• Doses are calculated using the beams’ algorithm (FFT
convolution, Fast Superposition, Superposition) for all segments
on selected beams.
SWO Workflow
• Run IMRT optimization as usual.

• Use 6~8 intensity levels to extract MLC segments from
optimized intensity map.
• Setup SWO parameters.
• Start SWO, it will go through the following:
• A Major Cycle
• Several Revise Cycles
SWO Page and Parameters
SWO Results
• SWO will run one cycle of major

optimization, then several cycles of
revised optimization.
• SWO provides information on

uncalculated and removed
segments.
Calculation Algorithm Option
SWO Save Plan
• You are given the option to save segment dose files for
future use.
IMRT Summary Report
SWO Output
Pre-SWO Post-SWO
• Uniform Segment Weights • Non-uniform Segment
Weights
Example of SWO results
Summary
• SWO can improve the agreement between the optimized

and final dose distribution.
• SWO can be used to decrease segments while keeping
the target dose coverage and OAR sparing.
Final Dose Calculation (I)
• The final dose calculation is

performed for the composite fluence
map using either the FFT Convolution
or Superposition algorithm.
• Once the segments have been

produced, it is time to launch the final
dose calculation.
• For compensators, a final calc grid

spacing of 2.5 mm is recommended.
• For Segmented-MLCs, a final calc • The segments are generated

grid spacing of 2.0 mm is based on the LINAC MLC
recommended (due to small parameters and the optimized
segments). intensity map.
• A head scatter correction factor is

calculated for each segment.
Final Dose Calculation (II)
The optimized doses can be compared to the final doses using
the plan comparison tools, if the plan was saved prior to
segmenting.
Field Splitting (I)
• Fields that violate the carriage

restriction will automatically be
split (14.0 cm for Varian
Standard models, 14.5 cm for
Varian Millennium models).
• If the minimum segment size or

number of intensity levels is
changed after the initial
segmentation, the re-
segmentation will be done for
the child beams.
Field Splitting (II)
The user-controlled preferences for split-field creation are accessed through the Edit,
Preferences, IMRT dialog box.
Minimum Field Width

This is the minimum field width when XiO
creates child beams.
Default is 6.0 cm
Range 0.5 cm - 10.0 cm
Overlap Extent
This is the extent, in the width direction, where the fields of the child beams
overlap. An algorithm determines the location of the overlap extent, and
the value you enter will determine the width. The overlap extent spans
across the same set of bixels from row to row on an intensity map.
Default is 4.0 cm
Range 0.0 cm - two-thirds of the Minimum Field Width
Field Splitting (III)
• The Split Extent cannot be larger than the Overlap Extent. The actual
voxels that the split extent spans will be determined using a linearly-
constrained optimization.
• This is the distance along an intensity row over which the dose
delivered from the first child beam goes from 100 % to 0 % and the
dose delivered from the second child beam goes from 0 % to 100 %.
• This allows for dose feathering in the beam abutment region. The
split extent will be the same width, but may be in a different location
from row to row on the intensity map.
• XiO searches each row within the overlap extent to find the lowest
contiguous average intensity over the width defined for split extent.
This is where the dose feathering between child beams will occur for
that row.
• Delete (Parent) beams? controls whether the original (parent) beams

are deleted after being split.
Field Splitting (IV)
Row One
Overlap Extent
1.800
1.600
1.400 Split Extent
1.200 Optimized Intensity

Intensities
1.000
Discrete Intensity
0.800
Split 1 Discrete
0.600 Intensity
Split 2 Discrete
0.400
Intensity
0.200
0.000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37
Bixel Num bers

Field Splitting (V)
Row Two
Overlap Extent
1.800
1.600
1.400 Split Extent
1.200 Optimized Intensity

Intensities
1.000
Discrete Intensity
0.800
Split 1 Discrete
0.600 Intensity
0.400
Split 2 Discrete
Intensity
0.200
0.000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37
Bixel Num bers

Field Splitting (VI)
• Child beams are named after

their parent beam. The name is
B##Snn, where B## is the
number of the parent beam, and
nn is the nth child beam which
was generated. Note, any
original beam that was split has
been turned off.
• The child beams will be assigned

new weight points and collimator
widths. The beam weight, gantry
and collimator angles, and
isocenter will remain the same
as the parent beam.
Reference Material
• IMRT Technical Reference
• QA of IMRT Beams Technical Reference
• IMRT Training Manual
• Beam Modeling Guide

QA Tools and Methods
IMRT QA Choices
1. Quantitative per beam Dose QA using the IM QA Tools

(Absolute Dose QA)
2. Quantitative Composite or Per Beam Dose QA using

the QA Plan and Dose Plane Tools (Absolute Dose
QA)
3. Qualitative Per Beam Delivery QA using the

Intensity/Relative Fluence Maps Tools
(Non-dosimetric delivery verification QA)
IMRT QA Strategies
Choose the method best suited for your needs, equipment, and
QA objectives.
Our output file formats are supported by most third party

analysis software packages. When considering purchase,
confirm this with the manufacturer.
All QA output files are ASCII text files.

• They can be viewed with Microsoft® WordPad or other
text editors.
• The File extension is always .txt.
• They can be imported into spreadsheet applications if
you set the import properties to the appropriate comma
or tab-delimited text file.
1. IM QA Tool
• A QA tool inside of the 3D plan or IMRT plan
• Works for 3D conventional plans with compensators, and
IMRT plans
• Takes plan beams, sets them to nominal gantry angle and
nominal collimator angle, and delivers them in a phantom
• Exports automatically absolute dose outputs for each
beam, no cumulative dose outputs
QA Film plane
1.1. IM QA - QA Workflow
With Plan Dose valid , select:
Tools  Modulation QA (if Comp Filter plan) or,
Optimize  IMRT  IM QA (if IMRT plan)
• Enter your measurement SSD and depth.
• Enter the phantom material and relative electron

density.
• Name each QA file and turn on the beams for

QA.
• Select OK to output the ASCII text (.txt) file.
• The files are stored in

/FOCUS/tmp/network/compf/QA, for solid
modulators and /FOCUS/tmp/network/mlc/QA
for MLC modulators Note: IMQA files are not generated with
plan changes. You must manually
• The output files are imported into the third party regenerate them.
analysis software, and compared with
measurements.
1.2. IM QA Tool - File Format
Example Format of the IMQA Output file
File type and version

Date and time of file
creation, and
documentation number
XiO Patient ID
XiO Beam number and description
Calculation algorithm
Modulator type
Source to field size definition distance (mm)
Collimated rectangle width & length at the QA plane (mm)
QA output area width & length at the QA plane (mm)
SSD of the QA measurement setup (mm)
Depth of the QA measurement (mm)
Relative electron density of the QA phantom (mm)
The index locator for the CAX fanline in the 2-D dose array
The index locator for the weight point fanline
Number of dose points in the x and y directions
2-D dose array resolution (currently always 1 mm)
2. QA plan - Quantitative Composite or Per Beam
Dose QA
• A QA tool outside IMRT plan
• Works for 3D plans with MLC and for IMRT plans, but not for
3D plans with compensators
• Take plan beams and delivers them in a user’s choice

phantom
• Lets you either maintain the treatment’s beam geometries or

set all gantry angles to nominal
• Lets you change each beam’s monitor units to fit the

dosimetry method
• Lets you export dose planes per beam and cumulative dose
2.1. QA plan – Composite Plan Workflow (Create/Choose
Phantom)
1. Install the CMS phantom, adding slices in
each study set, adding interest points, or
scanning the phantom that you use for QA
measurements, bringing it to PFM.
2. Contour the external surface of the

phantom and the chamber holder. Add
Interest points
3. In XiO, start a New QA Plan

Teletherapy  File  New QA Plan
4. Choose your QA Phantom & Studyset.
5. Use Absolute Dose Mode.
6. Select Graphics Windows Setup.

2.2. QA plan – Composite Plan Workflow (Import the
plan for QA)
7. Select Patient ID and Plan.
8. You can set all the gantry angles

to nominal or keep the original
angles.
9. Place the isocenter to a predefined

interest point.
10. Double check MU in the QA plan

versus IMRT plan.
11. Let the system calculate the dose.

2.3. QA plan – Composite Plan Workflow
(Generate dose plane output )
12. Set up a graphics window SPV at the
appropriate plane of analysis.
13. Go to: Dose  Dose Profile  Dose Plane

Output.
14. Select Subwindow number. This identifies which

SPVs dose plane to extract and save
15. Click on Dose plane output button. Enter a file

name in the dialogue box.
16. Click OK to export the Dose Plane
Repeat these steps for any/all dose planes

you wish to analyze.
2.4. QA plan – Composite Plan Workflow (measurement
comparison )
17. Proceed to perform the measurements using the actual patient’s

treatment plan transferred to the treatment machine.
18. Compare the point doses.
19. Compare planes of dose by importing the Dose output files from the
XiO into the third party analysis software.
2.5. QA Plan-Dose Plane File Format/Location
The system saves the Dose Planes in the following directory:
/FOCUS/tmp/network/QA/
Format of the QA Dose Plane file for a plan Format of the QA Dose Plane file for a plan
with absolute dose Beam Weighting mode and with absolute Beam Weighting mode and
absolute normalization. normalized to 300 cGy.
2.6. QA Plan- Beam-by-Beam QA Workflow
1. Create a QA Plan on your phantom with all the beams in the nominal
(beam down) position (i.e. repeat steps 1-11 from Composite Plan
Workflow).
2. On the Beam Weight dialog box adjust the beam weights to get the
original patient treatment plan MUs, or adjust to fit the dosimetry
system.
3. Turn off all beams except for the one that you would like to produce the
outputs.
4. Set up a graphics window SPV at the appropriate plane of analysis.
5. Export the dose plane.
6. Go back to the Beam Weight dialog box and turn off the current beam;
turn on the next beam for which outputs are to be produced.
7. Repeat previous 2 steps until all dose plane outputs have been
produced.
8. Deliver beam by beam from the plan at nominal gantry angle/adjusted
MU.
9. Do the comparison.
2.7. QA Plan- Dose Profile
Dose  Dose Profile  ASCII Data Output
This file is saved in the directory:
/FOCUS/tmp/network/dose_profile
Solid IMRT Profiles
60
Calculated Dose-y (cGy)
Measured Dose-y (cGy)
50
40
Dose
(cGy)
30
20
10
0
-6 -4 -2 0 2 4 6
Distance (cm)
Above is an example of a calculated dose profile

exported from XiO (solid line) overlaid with a measured
film profile (dotted line).
2.8. QA Plan- Dose Profile File Format
Example of Dose Profile (Tab Delimited) ASCII File Format
3. Intensity Map and Relative Fluence Maps
Qualitative Per Beam QA – Non Dosimetric QA
• View or print out an image of the intensity

or fluence maps for visual comparison.
• You have the ability to output a planar

intensity or fluence map ASCII text (.txt)
file for numerical comparison.
• Relative comparisons may be made from

ASCII intensity maps using third party
software if you can measure fluence.
• You can use this method to quickly,

qualitatively verify the delivery sequences
or compensator.
Just a reminder, visual comparison of

fluence maps does not constitute QA for
IMRT.
3.1. Intensity Map and Relative Fluence Maps -Types
• XiO lets you view, print, and produce ASCII output files for relative
fluence maps for any non-rotational beam and three different
kinds of intensity maps:
- Optimized Intensity Maps (after optimization, but before the
final calc)
- Segmented MLC Intensity Maps or Compensating Filter
Intensity Maps (3D Comp Filters only)
- Relative Fluence Maps for any non-rotational beam after final

calculation
• The system outputs the maps with the values projected to the
machine reference distance (that is, isocenter plane).
• The fluence map values are normalized to the central axis of the
reference field size.
3.2. Intensity Map and Relative Fluence Maps - Workflow
• Select an IMRT plan in Teletherapy.

• Access the Intensity/Relative Fluence Maps feature by completing
these steps:
- Select the Display Intensity Maps/BEV icon on the Beam,
Dose, Port, Tools, or IMRT toolbars. This button toggles the
intensity or fluence map display on and off.
- Select the Tools | Display Intensity Maps pull-down menu
option to open the dialog box. You can then choose from
several display options.
The ASCII file is located in the following directory:

/FOCUS/tmp/network/QA/IMAP/
The format of the ASCII file is similar to the output file for IM QA.
3.3. Intensity Map and Relative Fluence Maps -Example of Intensity
Fluence Maps
• The step and shoot and dynamic segmented MLC intensity maps are
available after you generate the MLC segments.
Step and Shoot Segmented MLC intensity map Dynamic Segmented MLC intensity map
3.4. Intensity Map and Relative Fluence Maps - Example
of Compensating filter map and Relative Fluence
• The compensating filter intensity map is available after you add a 3-D compensating
filter to a beam. Compensating filter maps reflect the transmissions of the fans in the
fan grid through the compensating filter
• Relative Fluence maps become available at the completion of the dose calculation for
any non-rotational beam computed using FFT Convolution, Fast Superposition, or
Superposition.
Compensating filter map for an IMRT generated Relative fluence map for an IMRT beam
compensating filter with a step and shoot segmented MLC
Pros and Cons of IMRT QA Choices
IM QA
Advantage: Phantom dose files are automatically calculated for you without the need to
create a separate QA plan.
Disadvantage: The QA analysis is based on a single beam. Can not perform composite
dosimetry.
QA Plan
Advantage: Comparison of the absolute dose from XiO to the absolute measured dose.
You have control over what phantoms and setups are used to meet analysis needs. You
can change beam weights, algorithms, geometries, etc., like in a regular Teletherapy plan.
Disadvantage: You must create a separate QA plan.
Intensity/Relative Fluence Maps

Advantage: Provides a quick way to see if your sequences or compensators are correct.
Disadvantage: Typically, not used in a quantitative manner. It is difficult to measure
fluence (although quantitative comparisons could be made against a computed
fluence from another software package) and intensity maps are idealized
constructs.
Segmented MLC QA Warnings
WARNING: There may be slight differences between calculated and measured dose due to the “tongue and groove” effect
present in some manufacturers’ MLC models. XiO currently does not model the tongue and groove effect in the dose
calculation. In general, tongue and groove will tend to create slightly lower dose along leaf edges within the IMRT field. This
is because the leaf “tongue” protrudes from the leaf and attenuates the beam, but the software calculation does not model the
MLC tongue. The dMLC segmentation algorithm was specifically chosen to minimize tongue and groove effects; the Step and
Shoot algorithm does not account for tongue and groove effects.
WARNING: Inter-Leaf leakage (dose in-between MLC leaves) is not explicitly modeled in the XiO dose calculations. The
average transmission through the leaf is used for the best overall calculation performance.
WARNING: For beams with small total MU and using a machine that requires integer MU values, rounding of individual
segment MU may produce errors in total MUs. XiO displays an index (available from the Reports menu) providing, for each
segment, the relative error for beams that may use integer MUs.
WARNING: Calculated dose may be lower than measured dose in areas that see no direct exposure from segments but only
abutting penumbras. While these areas are low dose regions, these regions may be located in and around critical structures,
such as the spinal cord.
WARNING: IMRT MU values for MLC segments will be corrected based on output factors considerations for each segment. It
is important that the user accurately measure output factors for small field sizes (down to 1x1 cm) and enter these in SFM, if a
beam is to be used with MLC-based IMRT.
WARNING: IMRT MU values for MLC segments are a function of collimator scatter ratios, namely the collimator scatter for the
entire field versus the collimator scatter for the individual segment. The head scatter can be significantly influenced by small
segments and segments which are significantly off-axis. DMLC will have a large number of small, off-axis segments, and
Step and Shoot segments can now contain multiple apertures, some of which will be small and off-axis. For Step and Shoot
segments, the collimator scatter ratios are computer for the largest aperture in a segment.
WARNING: XiO accounts for rounded leaf tips only in the exported leaf positions. Consequently, when a leaf is stationary,
the tip leakage can contribute to the delivered dose exceeding the planned dose.
WARNING: The dMLC implementation assumes variable dose rate modulation to avoid leaf speed violations. Users should
validate the behavior of their delivery system in the case where leaf position tolerances and dose rates are exceeded.
Compensator QA Warnings
WARNING: Solid modulators for IMRT may have steep thickness

gradients. For very steep gradients, there may be small areas
where the beam traverses more/less of the compensator than the
dose calculation models. However, this effect is very small
unless large fields are employed.
WARNING: XiO uses a smoothing method to insure mill-ability of

solid modulators. The method has proven satisfactory in the
clinical cases examined. However, it may be possible that some
modulators may have small regions where the modulator cannot
be milled exactly to the shape modeled in the dose calculation. If
such a case arises, the user will be notified by the manufacturer
and should perform QA analysis to quantify the difference. If the
user is manufacturing his/her own modulators, they assume the
responsibility of ensuring they are milled to specification.
More Information
The following references provide information on related subjects:
• QA of IMRT Beams – Technical Considerations in the Technical References

section of the XiO Reference Library
• Compensating Filters – Technical Considerations in the Technical References

section of the XiO Reference Library
• QA Dose Plane Output in the XiO Reference Library under Feature

Discussions
• Unix System Utilities in the Utilities Section of the XiO Reference Library
• XiO Beam Modeling Guide – IMRT Section
• XiO Help – The XiO Online Help IMRT and Quality Assurance dialog box,
reference, and procedure topics
QA Phantoms
QA Phantoms
Overview
There are two methods of creating a QA phantom in XiO. You can either
create a phantom from scanned CT images, or use wireframe contours. This
tutorial shows you how to do the following:
• Create a CT-to-ED file (Task 1)

• Create a QA Phantom using wireframe contours (Task 2)
• Create a QA Phantom using scanned CT images (Task 3)
Create a QA plan and perform typical QA tasks (Task 4). It is not necessary
to create both a wireframe contour phantom (Task 2) and a scanned
phantom (Task 3). Choose whichever method is most relevant to your
needs. You can use Task 4, (the use of Dose Profile and exporting of Dose
Planes), with any patient or phantom. If you do not want to create a CT-to-
ED file or a QA phantom, you can perform the steps in Task 4 using the
patient ‘cmsPHANTOM’.
Practice Exercise
Task 1. Create a CT-to-ED file
The following steps illustrate how to create the file that XiO uses to convert
the raw CT values into electron density values. Task 3 shows you how to
change the file for a MapCheck phantom. XiO uses values in the CT-to-ED file
during the dose calculation.
1. Start XiO.
2. Select Settings | Patient Data | CT to Rel Elec Dens Files. XiO shows
the Enter/Edit CT to Relative Electron Density File dialog box.
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Task 1. Create a CT-to-ED file (cont.)
3. Type a Mfr/Model ID of DICOM3.
4. Type a File ID of Phantom.
5. Click OK. XiO shows the CT Number Assignment dialog box.
6. Type -1024, -700, -550, -250, 0, 250, 700, 1024, 1250 in the fields.
These points correspond to the points in the conversion graph. It is
important to define points that cover the whole range of CT numbers
that are present in the CT images.
7. Select OK. XiO shows the page where you enter the Relative Electron
Densities. CT Numbers are not editable from this page.
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8. Type 1.0 in all Relative Electron Density fields. You calculate the
actual densities in Task 3.
9. Click OK to save the CT-to-ED table you defined.
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10. Click No to use this as the default CT to Relative Electron Density file.
Use this file only for the Phantom exercise. Do not use it on exercises
that use patient data.
NOTE: Even though the file is called a CT-to-ED file, the proton
calculation algorithms do not use Relative Electron
Density values in the CT conversion. The Proton Pencil
Beam and Broad Beam algorithms require Relative
Stopping Power values to be entered. The Proton Spot
Scanning algorithm requires Mass Density values.
11. Click CANCEL to close the Enter/Edit CT to Relative Electron Density

File dialog box.
XiO 13-5
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Task 2. Creating a Non-Image Based Phantom
The following steps illustrate how to create a non-image based phantom

using Patient File Maintenance.
NOTE: This Task is optional. You do not have to do it if you perform

Task 3 Creating an Image Based Phantom, or if you plan to use
the existing patient cmsPHANTOM for Task 4.
Subtask 1 Naming the Patient
1. Select the Patient File Maintenance button to start Patient File

Maintenance.
2. Click File | New | Patient. XiO shows the New Patient dialog box.
3. Type the Patient ID ContourPhantom.
4. Type Wireframe Contours in the Patient Name field.
5. Click the drop-down arrow in the Sex: field and select Unknown.
NOTE: The Date of birth, Telephone, and Address fields are

optional.
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Task 2. Creating a Non-Image Based Phantom (cont.)
6. Click the drop-down arrow in the Create field and select

Nonimagebased Studyset. There are three different data types.
(1) Imagebased Studyset is used to import image data.
(2) Nonimaged Studyset is used to create a studyset that does not

contain images. For example, you would select this option
when you create a QA Phantom for a water phantom which
can’t be scanned.
(3) No Studyset is used to create a patient which doesn’t contain a

studyset.
7. Click OK. XiO shows the New Non-Image Based Studyset Definition
dialog box.
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Subtask 2 Slice Definition
This dialog box defines the phantom’s dimensions and the slices included in
the phantom.
1. Type 40x40 in the Studyset ID field. If you create more than one
studyset for this phantom, make sure the Studyset ID is unique and
descriptive.
2. Select supine in the Patient Position field.
3. (Optional) Type Position Comments
4. Select No in the For Prostate Preplanning field.
5. This is a 40 cm x 40 cm phantom, so slice positions will be defined

over the depth of the phantom. Type -20 in the From(cm) field. Type
20 in the To(cm) field. Type 1 in the Step (cm) field. XiO
automatically populates the Cross Section Reference Distance
Positions (cm) fields.
6. Click OK to close the dialog box and start the contouring mode of
Patient File Maintenance.
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Subtask 3 Generating the Patient Contour
1. Click the drop-down arrow in the Group field and select General.
2. Click the drop-down arrow in the Contour: field and select Patient.
You should always choose the correct Group and Contour Name
before contouring begins.
3. Left-click in the middle of the screen and activate the Transverse

window.
4. Use the Page Up/Page Down keys on the keyboard to movie to slice
T: -20.0.
5. Click the Create Contours from Predefined Shapes Using the Keyboard
button. XiO shows the Keyboard Entry of Simple Shapes dialog

box.
6. Type 0 in the Center A(cm) and B(cm) fields.
XiO 13-9
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7. Type 40 in the Width(cm) and Length(cm) fields.
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Task 2. Creating a Non-Image Based Phantom
Subtask 3 Generating the Patient Contour (cont.)
8. Click the Add Rectangular Contour button. XiO creates a square

contour using the dimensions you entered.
9. Use the Page Up/Page Down keys on the keyboard to movie to slice
T: 20.0.
10. Click the Add Rectangular Contour button. XiO creates a square
contour using the dimensions you entered.
11. Click CANCEL to close the dialog box.
12. Click the Edit Existing Contours button.
13. Click the Interpolate between Contours button . XiO generates a

Patient Contour on all slices in the phantom.
14. Select File | Exit to save the phantom and exit Patient File
Maintenance.
15. Click Yes to save the patient data.
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Task 3. Creating an Image Based Phantom
Subtask 1. Naming the Phantom
This is the second method to create a QA Phantom in XiO. Follow these steps
to import scanned phantom CT images and contour the outline. In Task 2
Creating a Non-Image Based Phantom, you created a phantom without using
scanned CT images.
NOTE: Before you begin this exercise, make sure you have scanned the
phantom and sent the CT images to XiO. You do not have to
complete this task if Task 2 Creating a Non-Image Based
Phantom was done, or if you complete Task 4 using the existing
patient cmsPHANTOM.
The following steps illustrate how to create an image based phantom using
Patient File Maintenance.
1. Start XiO.
2. Click the Patient File Maintenance button to start Patient File

Maintenance.
3. Click File | New | Patient. XiO shows the New Patient dialog box.
4. Type the Patient ID MapCheck
5. Type Phantom QA in the Patient Name field.
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Subtask 1. Naming the Phantom (cont.)
6. Click the drop-down arrow in the Sex: field and select Unknown.
NOTE: The Date of birth, Telephone, and Address fields are

optional.
7. Click the drop-down arrow in the Create field and select Imagebased
Studyset. There are three different data types.
(1) Imagebased Studyset is used to import image data.
(2) Nonimaged Studyset is used to create a studyset that does not

contain images. For example, you would select this option
when you create a QA Phantom for a water phantom which
can’t be scanned.
8. Click OK. XiO shows the Start Image Transfer dialog box.
NOTE: XiO shows a yellow message when the XiO Patient Name
differs from the Patient ID in the DICOM file. Click OK to
acknowledge the message. Verify the patient
identification if you see this message while working with
your patient data.
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Task 3. Creating an Image Based Phantom (cont.)
Subtask 2. Importing the Images
Use this dialog box to bring data into XiO along with pertinent information.
1. Middle-click in the Image type field if you have more than one media
type from which to choose and select the Computed Tomography
option. Image Type refers to the type of data being transferred (that
is, CT, MR, PET). If only one media is licensed, XiO automatically fills
in this field.
2. If you have more than one Image Media type to choose from, middle-
click in the Image Media: field and select the Network option. The
available options for image transport are Network, Optical Disk, and
Dat Tape. If only one interface is licensed, XiO automatically
populates this field.
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Subtask 2. Importing the Images (cont.)
3. The Mfr/Model ID field defaults to DICOM3. This is the manufacturer

and model of the scanner/file format associated with the images
being transferred. DICOM is a standard file format by which many
new scanners comply, and therefore is also a valid answer. If only
one model is available, XiO automatically fills in this field.
4. The Host/Device field defaults to merge. This is the location where

the transferring device is attached to the system (that is, file location,
dat drive, CD…).
5. Middle-click in the Source PID: field and select the MapPHAN2

option. The Source PID is a directory of available patient exams for
import. The total range of image numbers from the selected exam
appear as defaults. However, you can edit this range to import as
many or few of the images from the selected exam.
NOTE: If the preference is turned on, you may encounter a

yellow screen warning you that the Source patient ID
does not match the ID entered in XiO. This warning is
intended to prevent you from transferring in images of
one patient to the ID of another patient.
6. Type Phantom in the Studyset ID: field. The studyset is the entire set
of image data used for planning. The Studyset Description is an
optional field. You can use this field to describe the studyset you are
creating.
7. Middle-click in the CT to ED Conversion File: field and select

Phantom. The conversion file is used to convert CT numbers to
electron densities.
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Subtask 2. Importing the Images (cont.)
8. Select All in the Exam data to remain for future transfer: field. The
All option means that the raw CT images remain in the Source PID
directory after they are transferred into PFM. Use the All option
when you need to be able to import the same images over and over
again into XiO. However, if you frequently select the All option, the
image directory can become full and reduce system performance.
Clinically, select None so that XiO removes all images from the image
directory upon the image transfer.
If you are importing plans from a source other than Focal, select the
Non-transferred option so that the plan files are not deleted after the
images are imported.
9. Click OK. XiO transfers the image data and shows the Finish Image
Transfer dialog box.
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Subtask 3. Finish Image Transfer
Use this page to check the transferred images for the following:
• Image order correctness

• Orientation (head to foot, right to left, flipped)
• Position
• Scale factor
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Subtask 3. Finish Image Transfer (cont.)
1. The Left/right display and Patient Position fields are populated from
the imported DICOM file. You should only have to edit these fields if
the information was entered incorrectly at the time the scan was
acquired. When these fields are set up correctly, the patient
orientation icon will match the orientation of the displayed images.
Edit the Left/right display: field, if needed. The images in the
graphical area are flipped about the vertical axis if you change the
Left/right display answer.
Edit the Patient Position field, if necessary. You can choose from
supine, prone, or rolled (patient was placed into a rolled position
using a sponge or pillow or other means). Should you choose rolled,
XiO shows the Roll Angle field making it a required field. The patient
orientation icon is rotated to match the Patient Position if you edit
this field.
2. (Optional) You can add Position Comments (that is, pillow, sponge
support, tilt board, bite block, or face mask).
3. In the Reference distances increase towards head: field, select Yes. If
the direction arrow on the coronal image points toward the superior
of the patient, select Yes. If the arrow points to the inferior of the
patient, select No.
4. (Optional) Use the Set zero offset at DICOM location(cm) to set a
selected plane (y-coordinate) to zero (for example, set the y-
coordinate to the fiducial marker plane if not done at the time of
simulation).
(1) Type the position-offset value to be used by the transferred
images.
OR
(2) Right-click on the coronal image and select Position Offset to set
the y-coordinate graphically.
(3) Hold down your left-mouse button and move superiorly or
inferiorly. The Position Offset automatically updates to the
selected slice.
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Subtask 3. Finish Image Transfer (cont.)
5. (Optional) The Superior and Inferior Couch Readings fields should

match the showed Superior and Inferior Reference Distances. On
occasion, the DICOM fields that XiO reads in for the couch positions
(Reference Distances) are not representative of the actual readings
on the machine. If this is the case, you can re-synch the reference
distances with the actual couch readings. This is only necessary if
you intend to report shifts (Setup Reference Definition or Mark
Anatomical Reference) in Absolute Coordinates rather than Relative
to the Scan Reference Point. Without doing so, shifts reported in
Absolute Coordinates will not be correct.
6. (Optional) Use the coronal slice to evaluate the head-foot direction.

If you want to view a different coronal slice, type a new value in the
Coronal location (cm) field.
7. Click OK. XiO orients the cross sections according to the entries and
imports the images to the contouring module. If the value of
Left/right display is ‘reversed from DICOM’ and/or the Patient
Position does not match the value in the original DICOM file, the
exported frame of reference will be XiO Generated, even if the
DICOM Installation setting is ‘Original DICOM’.
13-20
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QA Phantoms
Subtask 4. Create the Patient Contour Using Auto-by-Threshold (Multiple

Slices)
Use this function to automatically create contours along an edge of high

contrast in an image. Adjust the Window/Level settings to obtain high
contrast around the desired structure.
You can either Place Auto Points on all Selected Cross Sections for Auto-by-
Threshold by clicking the multi slice mode button or Place Auto Points
on a Single Cross Section for Auto-by-Threshold by clicking the single slice
mode button. In XiO, Multi-slice mode is the default.
Adjusting the Window/Level settings may improve the performance of

Auto-by-Threshold. Structures like bone, lungs, and patient exterior are
good candidates for this contouring method because the structures are well
delineated.
1. Click the Create Contours Using Auto-by-Threshold button.
2. Click the drop-down arrow in the (Save) W/L field and select
Custom.
3. Type 1760 in the W field to set the Window Value.
4. Type 445 in the L field to set the Level Value
5. Click the drop-down arrow in the Group field and select General.
6. Click the drop-down arrow in the Contour: field and select Patient.
The correct Group and Contour Name should always be chosen
before contouring begins.
XiO 13-21
QA Phantoms
QA Phantoms

Slices) [cont.]
7. Place the mouse pointer anywhere within the Cross Section

Thumbnail View.
8. Right-click and select the Select All option. XiO highlights all cross
sections with a yellow border.
9. Right-click anywhere within the Single Plane View and select the
Place Point option. This action lets you place auto points to identify
where the drawing of contours begins.
13-22
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QA Phantoms

Slices) [cont.]
1. Place the mouse pointer above the anterior surface of the patient and
left-click to place a set of auto points. With multiple-slice mode and a
range of all slices selected, XiO automatically places a point in the
same position on all slices.
2. Right-click anywhere within the Single Plane View and select the
Generate Cont option.
OR
Middle-click within the Single Plane View. XiO automatically creates

contours, after which the patient skin appears shaded in the Cross
Section Thumbnail View, as a wire frame in the 3D View, and as an
outline in the Single Plane View. This action also shows the Accept
Auto-by-Threshold dialog box.
XiO 13-23
QA Phantoms
13-24
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QA Phantoms

Slices) [cont.]
3. Scroll through the images to review the contours. Click the Accept
the new contours button to keep the contours you just created.
OR
If an undesirable contour is found, edit the Point position using one

of the following methods:
(1) Move all points (multi slice button highlighted) by

placing the cursor near any point. When the point turns
red, drag it to a new position by holding down your left
mouse button. XiO updates all points to the new location.
OR
(2) Move a single point (single slice button highlighted) by

placing the cursor near the point. When the point turns
red, drag it to a new position by holding down your left
mouse button. Only the selected point is affected by the
move.
4. After you edit the point, regenerate the contours.
NOTE: Should you elect to make manual edits to the auto-by-

threshold contours, you can do so in edit mode after the
auto-by-threshold contours are accepted
5. Click the Accept the new contours button when the contour outline is
satisfactory.
XiO 13-25
QA Phantoms
QA Phantoms

Slices) [cont.]
Follow these steps to optionally apply the Area of Interest Tool when you
use auto-by-threshold. The Area of Interest tool helps you exclude the table
or part of the patient when contouring using auto-by-threshold.
1. Select all your slices to be contoured. But, before you place your
point, right-click and select Place AOI.
2. Hold down your left mouse button and drag to create a box around
your contours.
3. Movie through each slice, or look at the 3D view to determine if all

the slices are encompassed appropriately by the AOI box.
4. Redraw the AOI box, if necessary.
5. Place the point inside the box, but above the patient surface (if
contouring the patient).
6. Generate the contours and verify that you get the expected results.
13-26
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Subtask 5. Verifying the CT-to-ED file
The phantom is now ready to use in Teletherapy to verify the CT-to-ED file.
1. Select File | Exit to save the phantom.
2. Click Yes to save the data.
3. Click the Teletherapy button to start Teletherapy.
4. Select File | New Teletherapy Plan. XiO shows the New Teletherapy
QA Plan dialog box.
4. (Optional) Type Initial Test in the Description field
5. Select 6TSCMxA in the Graphics Area Setup Field, or any Graphics

Area setup which shows a Transverse, Coronal and Sagittal slice.
6. Click OK
7. Right-click in the Transverse view and select Maximize to enlarge the

display of the Transverse slice.
XiO 13-27
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Subtask 5. Verifying the CT-to-ED file (cont.)
8. Select Tools | Measure to show the Measure dialog box.
9. Middle-click in the Transverse view and select Place Measure Point

from the menu. Click once with your left mouse button to place a
point at the detector plane. Hold down your left mouse button while
moving your mouse to edit the point’s location. Alternatively, you
can type in the coordinates of the points. X(cm) should be the same
for Point Location 1 and Point Location 2. This ensures the points are
aligned correctly.
13-28
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QA Phantoms
10. Middle-click on the patient contour directly above the first point
which was placed. Use the scales to aid in point placement.
11. Verify the Radiological Distance is 5.0 for the MapCheck phantom. If
the Radiological Distance is not 5.0, calculate the updates to the CT-
to-ED file which are needed. The new Electron Densities are
5.0/Radiological Distance. In this example, 5.0/4.1 = 1.22.
NOTE: This value is specific to this phantom. Confirm the actual

radiological depth to the chamber or measurement plane
with your phantom’s manufacturer.
12. Click CANCEL to close the dialog box.
13. Select File | Exit to exit Teletherapy.
14. Return to Task 1 to open the DICOM3.Phantom CT-to-ED file and

update the Relative Electron Densities.
OR
Continue with Task 4 ‘Using the Phantom in Teletherapy’ if the CT-

to-ED file is acceptable.
XiO 13-29
QA Phantoms
QA Phantoms
15. Type 1.22 in all Electron Density Fields.
16. Click OK to save the updated values
17. Click No to use this as the default CT to Relative Electron Density file.
This file is only used for the Phantom exercise. Do not use it on
exercises that use patient data.
13-30
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QA Phantoms
18. Click CANCEL to close the Enter/Edit CT to Relative Electron Density

File dialog box.
19. Repeat Task 3, Subtask 8 to verify the Radiological Distance is 5.0.
XiO 13-31
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QA Phantoms
Task 4. Using the Phantom in Teletherapy
Subtask 1. Creating a QA Plan
The phantom is now ready to use for a QA plan, and export dose profiles and
planar doses. You can export Dose Profiles and planar doses from any
patient, including a scanned phantom. However, this exercise shows how to
use the tools with the wire contour phantom you just created.
1. Click the Teletherapy button to access Teletherapy.
2. Click File | New QA Plan to start a new QA plan using an existing

phantom.
3. Middle-click in the Patient ID field and select the Patient ID

ContourPhantom or MapCheck.
4. (Optional) Type a description for this plan, for example “Prostate

IMRT QA.”
13-32
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QA Phantoms
Subtask 1. Creating a QA Plan (cont.)
5. Edit the treatment date, if necessary. The default is today’s date.
6. Leave the Create as 2D Plan field at No.
7. Leave the Head/Feet Toward Gantry at Head.
8. Middle-click in the Graphics Area Setup field and select the Graphics
Area Layout 4TACS, or any other layout which has at least one
Transverse, Coronal or Sagittal slice shown.
9. Click OK. XiO shows the Retrieve Plan for Quality Assurance dialog
box.
10. Middle-click in the Patient ID field and select the Patient ID

HEADandNECK.
11. Middle-click in the Plan ID field and select the Isodose Treatment
Plan IMRTHN, if necessary.
XiO 13-33
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QA Phantoms
Subtask 1. Creating a QA Plan (cont.)
12. Set the Set Non-Rotational Gantry Angles to Nominal to Yes. XiO
places all the beams in the plan at the nominal gantry angle (the
setup which will most likely be used if QA is being done using film).
Answering No leaves the beams at the gantry angles used in the
original treatment plan.
13. Select OK. XiO imports the beams and shows the Isocenter Location
dialog box.
14. Middle-click in the Isocenter field and select center of patient. XiO
populates the X, Y and Z coordinates of the isocenter. All beams are
placed at the same isocenter, even if they had different isocenters in
the original plan. The isocenter coordinates are editable.
15. Select OK. The dose calculation starts. Wait for the dose calculation
to finish before continuing. XiO automatically sets the number of
fractions to 1 and the monitor units to the monitors units for one
fraction. However, if the initial dose calculation is interrupted XiO
retains the beam weights. If this happens, you need to manually
type in the monitor units.
13-34
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QA Phantoms
Task 4. Using the Phantom in Teletherapy (cont.)
Subtask 2. Setting the Dose Calculation Parameters
It is important to calculate all Segmented MLC IMRT plans at 2mm grid

resolution and all Compensator IMRT plans at 2.5 mm grid resolution in
order to have the most accurate results.
1. Select Dose | Calculation | Settings to bring up the Dose Calculation

Settings dialog box.
2. Type 0.2 in the Along Width(cm), Along Height(cm) and Along

Depth(cm) fields under the Distance between Calculation Points
heading.
3. Select OK. XiO starts a new dose calculation using the updated
parameters.
XiO 13-35
QA Phantoms
QA Phantoms
Subtask 2. Setting the Dose Calculation Parameters (cont.)
4. Select the Beam Spreadsheet button to open the Beam

Spreadsheet dialog box.
5. Select the Beam Weight tab on the dialog box. XiO shows the Beam
Weight tab.
6. Verify the fractions are set to 1 and the monitor units are
appropriate for the detection devices being used (for example the
monitor units are low enough that film won’t be saturated). If
necessary, adjust the beam weights and/or monitor units to match
the QA protocol.
7. Click the Dose Status button to turn off the dose contribution from all
beams. This lets you export a dose plane containing only the dose
from Beam 1.
8. Click the off button for Beam 1, immediately under the Dose Status
button. This turns on the dose contribution from beam 1.
9. Select OK to close the dialog box. XiO updates the dose calculation
with any new parameters you entered.
13-36
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QA Phantoms
Subtask 3. Drawing Dose Profiles
1. Select Dose | Dose Profile to open the Dose Profile dialog box. You
can evaluate the dose profile across a plane using this dialog box.
You can also export Dose Planes.
2. Select SPV Subwindow Number 3. This makes the Coronal slice

(which corresponds to the slice orientation of the film setup) the
active subwindow. You can set a subwindow containing any of the
three slice orientations, Transverse, Coronal or Sagittal as the active
subwindow. You are not able to select subwindows containing
Beam’s Eye Views or MPVs.
XiO 13-37
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QA Phantoms
Subtask 3. Drawing Dose Profiles (cont.)
3. Select DP Subwindow Number 2. Dose profiles appear in this

subwindow.
4. Select DP Normalization Absolute. This affects the relative scaling of

the dose profiles which will be drawn.
5. Left-click in Subwindow 3 (the coronal slice) and hold the mouse

button down and drag the mouse pointer across the beam display to
draw a horizontal line. XiO shows a red line corresponding to the line
just drawn.
6. If necessary, move the Dose Profile dialog box so it is not covering

subwindow 2. XiO shows a dose profile along the line just drawn.
You control the X and Y axis ranges and tick mark displays using the
Min, Max, Major and Minor fields. Type 30 in the Max field for
Dist(cGy). XiO shows X axis with a maximum value set to 30.
7. You can change the location, length and color of the line by editing
the X(cm), Y(cm), Angle and Color fields. Type -20 in the X(cm) field
for DP1. Type 0.1 in the Y(cm) field for DP1. Type 0.0 in the Angle
field for DP1. XiO updates subwindow 3 and the dose profile to
reflect the new location and length of the line.
8. Type 2.0 in the X(cm) field for DP2. Type 0.5 in the Y(cm) field for
DP2. Type 90 in the Angle field for DP2. Select cyan in the Color field
for DP2. XiO shows a vertical cyan line in subwindow 3 which
corresponds to the parameters you just entered. XiO updates the
dose profile graph in subwindow 2 to include this dose profile.
9. Type -15 in the Min field for Dist(cm). XiO expands the display of the
graph so the complete dose profile can be seen.
13-38
QA Phantoms
QA Phantoms
Subtask 3. Drawing Dose Profiles (cont.)
10. Click the 1 button under the DP heading. XiO turns off the
display of DP1, the first dose profile. Click the 1 button again. XiO
turns on the display of DP1.
11. Type 1 in the DP field. Type 12 in the Dist(cm) field. XiO shows the
dose value at that location.
XiO 13-39
QA Phantoms
QA Phantoms
Subtask 4. Exporting Dose Planes
You can export dose planes from the Dose Profile dialog box as an
alternative to the IMQA dose plane feature. The IMQA feature assumes a flat,
infinite phantom of uniform density. Additionally, the IMQA feature only lets
you calculate and export doses for individual beams. Exporting dose planes
from the Dose Profile page lets you export a dose plane where all beams in
the plan contribute dose, and where the phantom is not a uniform phantom.
1. Click the ASCII Data Output button . XiO

exports the displayed dose profiles. See On Line Help for the
location where the files are placed and the file format.
2. Click the Dose Plane Output button . XiO

shows a dialog box where you type in the name of the file to be
exported.
3. Type Coronal.txt. XiO names the saved file Coronal.txt.
4. Select OK. XiO exports a dose plane corresponding to the dose plane
selected in the SPV Subwindow field. Refer to the On Line Help for
the location of the file placement and file format. You can import
these into a third party QA system and compare them against
measured doses.
5. (Optional) Type 1 in the SPV Subwindow Number field. XiO makes

subwindow 1 the active subwindow.
6. (Optional) Click the Dose Plane Output button

. XiO shows a dialog box where you type
in the name of the file to be exported.
7. (Optional) Type Coronal.txt. XiO names the saved file Coronal.txt.
8. Select OK. XiO exports a dose plane corresponding to the dose plane
selected in the SPV Subwindow field.
9. Select OK to close the Dose Profile dialog box.
13-40
QA Phantoms
QA Phantoms
Subtask 5. (Optional) Exporting Dose Planes for Other Beams
1. Select the Beam Spreadsheet button . XiO shows the Beam

Spreadsheet dialog box.
2. Select the Beam Weight tab on the dialog box. XiO shows the Beam
Weight tab.
3. Click the Dose Status button to turn on the dose contribution from all
beams. This lets you export a composite dose plane.
4. Select OK to close the dialog box. XiO updates the dose calculation
with any new parameters you entered.
5. Follow the steps in Task 4, Subtasks 2-4 to show the output dose
planes and dose profiles for the plan with all beams turned on.
XiO 13-41
ADS in XiO
(Adaptive Diffusion Smoothing)
ADS Introduction
Purpose of Smoothing Function
• Intelligently reduce high degree of modulation in IMRT plan.
• Maintain optimal target coverage and high delivery efficiency.
Adaptive Diffusion Smoothing
• ADS preferentially smoothes 3D inverse plans through weighted cost

function and discreet diffusion equation.
• ADS distinguishes between significant and insignificant modulated

areas, allowing for intelligent tradeoffs between cost function and
smoothing criteria.
IMRT Optimization Workflow
Start Iteration: Dose optimization based on varying

Beamlet Intensity (I ) via Cost Function
(CF) i.e. IMRT Rx
Smoothing applied to Beamlet Intensities

Optimization: based on gradient of overall CF and I …
(
∂CF ∂I 0,ij )
Total CF based on combination of Dose

Optimization and Smoothing
Convergence/Max Check if convergence of Total CF is attained

Iteration Check: or maximum iterations is reached
ADS Function
Time dependent diffusion equation
∂I s
(x, y, t ) = ∇ ⋅ D(x, y )∇I s (x, y, t )
∂t
The diffusion equation describes the beamlet intensity fluctuations in a
medium undergoing spread of higher and lower regions of intensity.
Is(x,y,t) is the time dependent D(x,y) is a spatially variant diffusion

smoothed beamlet intensity at coefficient, and the divergence or div is:
time t, and the grad or del is:
 ∂D( x, y ) ∂D( x, y ) 
 ∂I ∂I ∂I 
∇I s ( x, y, t ) =  s , s , s  ∇ ⋅ D( x, y ) =  + 
 ∂x ∂y ∂t   ∂x ∂y 
The Time Dependent Diffusion Coefficient
10
Dij = n Here:
 ∂CF ∂I 0,ij 
1 + a 
s is a gradient scaling factor
CF is the prescription cost function
 s  Iij are the beamlet intensities
  a&n are adjustable parameters
You can describe the diffusion coefficient as the proportionality constant

between the flux of the diffusion, and the gradient of the intensity change
(Fick’s First Law).
XiO Smoothing
Function
Access to the smoothing parameters:

Teletherapy->Edit->Preferences->IMRT-
>Smoothing
w = Time step
a = Multiplier
n = Power
Weight = A weighting factor applied to the smoothing component
The Time Step (w) X-plane
w
I s ,ij ∝ I 0 + 2 Dij
h w = 0.1
Here:
Is is the smoothed Beamlet Intensity
I0 is the unsmoothed Beamlet
Intensity
w is the Time Step parameter
h2 is the are of the Beamlet
w = 1.0
The Time Step factor, w, is
related to the beamlet intensity.
A small w results in
greater smoothing
A large w results in w = 10.0

less smoothing
The range of w is In-plane

from 0.1 to 20.0
w = 20.0
The Multiplier (a)
10
Dij = n
 ∂CF ∂I 0,ij 
1 + a  a = 0.1
 s 
 
The Multiplier, a, operates linearly

on the cost function/intensity
gradient. a = 1.0
A small a results in
greater smoothing.
A large a results in
less smoothing. a = 10.0
The range of a is
from 0.1 to 10.0.
a = 20.0
The Power (n)
10
Dij = n
 ∂CF ∂I 0,ij  n = 0.1
1 + a 
 s 
 
The Power, n, also operates

on the cost function/intensity n = 1.0
gradient.
A small n results in
greater smoothing.
A large n results in n = 5.0
less smoothing.
The range of n is
from 0.1 to 10.0.
n = 10.0
The Smoothing
Weight (SW)
• Overall weight for the ADS
results
• It is applied post ADS Weight = 0.0
CFTotal = SW ⋅ CFsmoothed + (1 − SW ) ⋅ CFDose

In-plane
Here:
CF Cost Function
CFTotal is the Total CF value
Cfsmoothed is the post-smoothing CF
CFDose is the Dose Optimization X-plane
CF Weight = 0.3
SW is the Smoothing Weight
When the weight is small,
smoothing effect is small.
When the weight is large,

smoothing effect is large.
The range of the smoothing
weight is from 0.0 to 0.9. Weight = 0.9
Smoothing Templates:
w a n Weight
1 ComplexHighSmoothing CHS 1.0 5.0 0.3 0.5
2 ComplexLowSmoothing CLS 1.0 5.0 0.3 0.2
3 IntermediateHighSmoothing HIS 1.0 0.5 2.0 0.5
4 IntermediateLowSmoothing ILS 1.0 0.5 2.0 0.2
5 SimpleHighSmoothing SHS 1.0 0.2 2.0 0.5
6 SimpleLowSmoothing SLS 1.0 0.2 2.0 0.2
7 GeneralHighSmoothing GEN 0.5 0.3 0.3 0.5
In this example, we use a lung phantom to
show the behavior of the smoothing
templates with the following structures:
• PTV
• OAR_LARGE
• OAR_SMALL
• LEFT_LUNG
• RIGHT_LUNG
• BONE
• PATIENT
The Rx applied to
the IMRT plans:
Smoothing Templates: Coronal Dose
CHS CLS IHS ILS SHS SLS GEN

Shown below is the effect on MU and Segment number

per beam by each of the smoothing templates.
CHS CLS HIS ILS SHS SLS Gen

Beam
MLC Seg MU MLC Seg MU MLC Seg MU MLC Seg MU MLC Seg MU MLC Seg MU MLC Seg MU
1 2 18.02 2 15.58 2 18.52 2 14.79 2 18.41 2 17.17 2 19.20
2 3 35.98 3 33.14 3 34.23 3 29.35 3 33.47 3 29.10 5 65.49
3 3 53.98 2 33.03 3 51.89 3 41.01 2 34.40 3 43.11 2 41.62
4 2 32.49 2 42.33 2 35.6 2 45.58 2 29.47 1 43.74 3 59.85
5 3 54.05 3 87.08 3 43.87 3 70.27 2 52.02 3 60.50 3 65.13
6 3 55.08 3 38.98 3 30.18 4 45.76 2 28.10 4 36.37 4 63.87
7 4 102.15 5 107.26 3 94.52 4 90.84 3 84.60 4 93.43 2 45.37
8 4 110.81 5 125.35 4 101.25 4 120.21 4 107.70 4 112.52 3 34.67
24 462.56 25 482.75 23 410.06 25 457.81 20 388.17 24 435.94 24 395.2
Smoothing Templates: DVH
Summary
• ADS is prescription-based and therefore plan specific.
• Default templates permit quick and simple application of ADS.
• You can adjust smoothing parameters to create unique

templates. However, behavior of ADS can become confusing
without research.
13723 Riverport Drive, Suite 100 Maryland Heights, MO 63043
European Union Authorized
Manufacturer Representative
Elekta Business Area Software Systems

Elekta Limited
IMPAC Medical Systems, Inc. Linac House, Fleming Way
13723 Riverport Drive Crawley, West Sussex
Suite 100 RH10 9RR,
Maryland Heights, MO 63043 United Kingdom
USA Phone: +44 129 365 4242
Phone: +1 800 878 4267 Fax: +44 1293 471347
Fax: +1 314 812 4491 eu_ar@elekta.com
XiO
www.elekta.com Human Care Makes the Future Possible

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XiO® 5.

Document ID: LTGXIO0510 / 1.0

Revision Version Date Task Number Changes

Use of trademarks and trade names statement

Acknowledgement of other trademarks and trade names

Section 1. Introduction to IMRT (Presentation)

Section 2. IMRT Planning and Workflow

Section 2. IMRT Planning and Workflow (cont.)

Section 2. IMRT Planning and Workflow (cont.)

Section 3. Planning Suggestions

Section 3. Planning Suggestions (cont.)

Section 4. IMRT Prostate Plan

Section 4. IMRT Prostate Plan (cont.)

IMRT Prostate Plan Part 3 (Planning with SWO)

IMRT Prostate Plan Part 4 (Planning and Smoothing)

Section 5. Adjusting Objectives

Section 6. Head and Neck

Section 7. Breast IMRT

Section 7. Breast IMRT

Forward Planning Breast Technique.................................................................................................................. 7-27

Section 8. Additional Practice Plans

Section 9. Are You Ready for IMRT? (Presentation)

Section 10. Data Requirements and Beam Modeling (Presentation)

Section 11. XiO IMRT Optimization and Calculation Physics

Section 12. QA Tools and Methods (Presentation)

Section 13. QA Phantoms

Section 14. ADS in XiO — Adaptive Diffusion Smoothing

• Define clinical goals in the Rx. Then, let the optimization

• Beams are divided into beamlets, each representing a

• These beamlets can have varying intensities as defined by

• Segments/Compensators are generated from the intensity

DPTV1 : Min 7000 cGy

DRECTUM: <15% of the

This could be a clever

But, computers are not

This is the intensity

Start with an open field.

The intensity is uniform

Based on the prescription,

PTV1= high intensity

Rectum = lower intensity

Intensity levels are

Now the system has to recreate it using treatment aids: MLC

New Choice of Sequencing Options:

If using MLCs and Sliding Window:

If using MLCs and Sliding Window:

Two (2) levels are

Three (3) levels are

Better resolution with

Note: The resulting segment monitor

Note: The collimator is rotated 90° for this example.

Note: The collimator is rotated 90° for this example.

• Use Segment Weight Optimization to re-weight

- Potentially reduces the number of

- May be run multiple times, changes to the

- Not useful for all types of IMRT plans

IMRT Planning and Workflow

The Intensity Modulated Radiation Therapy (IMRT) lecture is a preliminary

In the traditional approach to treatment planning, you create a plan based

Task 1. Contour all Targets and Organs at Risk