Treatment Simulation: Large Tumor Tutorial

The tutorial involves a very large tumor that extends from the ora to the optic disc. This case was selected for the tutorial because it illustrates treatment planning using primarily CT and ultrasound. You will gain experience:

  • Using the multiple image loader.
  • Approximating the tumor location, shape, size and apex using primarily CT and ultrasound images.
  • Using the standard tumor sheet to set the model's tumor location, shape, size and apex to fit the CT and ultrasound images.
  • Using the model EP2340NP slot collimated plaque.
  • Comparing the fast vs complex ray-trace collimation models for EP plaques.
  • Using the retina dose area histogram (RDAH) to evaluate dosimetric coverage of the tumor base and its surrounding margin.
  • Calculating scleral suture eyelet coordinates.
  • Printing documents.
LargeTutorialIntro


These are steps that you will accomplish in this tutorial.

1. Preparing for the tutorial

Plaque Simulator fuses images and measurements derived from CT (or MR), fundus camera photographs and ultrasound studies to build a three dimensional model of each patient's eye and tumor. A simulation session begins by preparing these images for import into Plaque Simulator. Note: this tutorial does not use fundus images.

Full size versions of the screen captures in this tutorial can be viewed by simply clicking on the pictures. Use the 'back' button of your browser to return to the tutorial after downloading the full size picture.

Please familiarize yourself with the basics of image based planning for eye plaques by following the links below before proceeding with this tutorial.

After the images have been prepared, they will be imported into Plaque Simulator, typically as .jpg files, and calibrated. A 3D model of the eye will be created and the tumor location and altitude entered. Please review these links before proceeding with this tutorial.

Please familiarize yourself with the Basic, Posterior and Anterior tutorials before proceeding with this tutorial.


2. Find the tutorial images

The sample images used in this tutorial can be found in Plaque Simulator Patients/(Tutorials)/PS6/Large Tutorial which should have been installed in the Documents folder of the logged-in PS user as part of your original installation or update of Plaque Simulator.


LargeTutorialInFinder

3. Launch PS and create a new patient plan

From the File menu:

  • If you have been working on other plans since launching Plaque Simulator, select New Patient...to reset Plaque Simulator and create a new patient.
PatientIDs

From the Plan menu:

  • Select Patient IDs... to open the Patient ID window.
  • Name this planning session 'Large Tutorial'.
  • Optionally fill in any other patient or institutional identifiers.
  • Leave the plan name blank.
PatientIDs
LTPatientIDs

4. Open the Images window

If the Image window is not visible or frontmost, make it the frontmost window by clicking the cursor in its window or by selecting Images from the Window menu (in the menu bar at the top of the screen).

Images
  • Increase the window size to fill a significant portion of your available screen by dragging the lower right corner of the window, or by clicking the window sizing button
    WndwSize to open the Window Size sheet and selecting one of the preset sizes (e.g. 512 x 512) or manually entering dimensions.

    ImageWindowResize
  • ImageWindow512

    5. Open the MPR and US images
    AxialPlane

    In the Image window

    Hold down the Option button on the keyboard while clicking the Axial button in the MPR controls group to load multiple images.


    CTGroup
    • A file navigation dialog will open.
    • Navigate to the patient folder Large Tutorial.
    • Open the image entitled axial.jpg.
    • All of the other images in the patient folder that adhere to the PS image file naming conventions will open at the same time.
    • Note: If you have not yet entered a name in Patient IDs..., PS will suggest a patient name based on the name of the folder (e.g. Large Tutorial) from which the images are loaded.

    • Using the image enhancement tools in the toolbar, adjust the image brightness & contrast (or bias, gain and level) to best visualize the sclera.
    • Calibrate the axial image using the MPR ruler and copy the calibration to the other MPR images as described in Importing and calibrating MPR images. You can safely copy the axial calibration to the other MPR images because all of the MPR images in this tutorial were created in OsiriX using exactly the same window scale settings.

    • AxialCalibrationSheet

    • Fit the interactive Eye tool to the eye as described in Fitting the eye model.
    OpenAxial
    AxialOpened

    6. The equator image
    EquatorialPlane

    In the Image window

    • The equator image will already be closely calibrated, typically within about a tenth of a mm, because you copied the axial calibration to all the other MPR images and the images were all exported from OsiriX using the same window scaling. To fine tune the equator calibration, zoom in on the calibration tool handles, drag them over the exact green ruler pixels in the equator image, and recalibrate without copying the new calibration to any other images.
    • Center the Eye tool on the eye. The eye tool appearance varies with the image context, for equatorial and coronal images the tool represents the equator circle of the retinal diagram.
    • Rotate the tool using the red handle so that 12 o'clock is superior in the image.
    • If you aligned the yellow and purple crosshairs (representing the sagittal and axial planes of the eye) accurately when you created the equatorial image in OsiriX, the vertical yellow line in the image should pass through 12 and 6 o'clock on the eye tool, and the purple line through 3 and 9 o'clock as illustrated.
    EquatorFineTuned
    EquatorOpened

    7. The sagittal image
    SagittalPlane

    In the Image window

    • The sagittal image will already be closely calibrated because you copied the axial calibration to all the other MPR images. Optionally fine tune the sagittal calibration as described in step 6.
    • Center the sagittal Eye tool on the eye.
    • Rotate the tool using the red handle to fit the image.
    • If you aligned the blue and purple crosshairs accurately when you created the sagittal image in OsiriX, the vertical blue line which represents the equatorial plane in the image should should be close to the white and green equatorial handles on the PS sagittal eye tool, while the purple line, which represents the axial plane, should pass through the apex of the cornea and posterior pole of the PS tool. The OsiriX alignment was close but not perfect in this example.
    SagittalOpened

    8. The tumor-coronal image
    T-CoronalPlane


    CTGroup

    In the Image window

    • The tumor-coronal image will already be calibrated because you copied the axial calibration to all the other MPR images. Optionally fine tune the tumor-coronal calibration as described in step 6.
    • The eye tool appearance varies with the image context, for equatorial and coronal images the tool represents the equator circle of the retinal diagram. Center the Eye tool on the eye and rotate using the red handle to match its alignment on the equatorial image.
    • The coronal eye tool always represents the diameter of the eye at the equator. The tumor-coronal plane may not be near the equator, so it may be smaller in diameter than the tool.
    • Observe that circumferentially the tumor covers the range between about 7 and 10:30 o'clock.
    • Note that the yellow crosshair line in the OsiriX image now represents the tumor-meridian plane rather than the sagittal plane as it was in the equator image.
    TCorOpened

    Drag the ruler tool to measure the tumor height (e.g. 11.42 mm) and the circumferential base chord dimension (e.g. 17.5 mm) as it appears in the tumor-coronal plane.

    TCorHeight
    TCorBase

    9. The tumor-meridian image
    T-MeridianPlane

    In the Image window

    • The tumor-meridian image will already be calibrated because you copied the axial calibration to all the other MPR images. Optionally fine tune the tumor-meridian calibration as described in step 6.
    • Center the Eye tool on the eye.
    • Rotate the tool using the red handle to fit the image.
    • If you aligned the crosshairs accurately when you created the tumor-meridian image in OsiriX, the yellow line should pass through the apex of the cornea and posterior pole of the PS tool.
    • The blue crosshair line in the OsiriX image now represents the tumor-coronal plane rather than the equatorial plane as it was in the sagittal image.
    • The OsiriX alignment was very close in this example.
    TMerOpened

    Drag the ruler tool to measure the tumor height (e.g. 11.43 mm) and the radial (meridian) base dimension (e.g. 17.53 mm) in the meridian plane. Note that the tumor height measurement depends upon the location of the tumor apex, the angle at which the imaging plane passes through the tumor and the curvature of the sclera below the tumor. As a result, the meridian plane is generally the most reliable image for measuring the tumor height.

    TMerHeight
    TMerBase

    10. The ultrasound image

    In the Image window

    • Click the U.Snd. button in the Ultrasound controls group.
    • The ultrasound image will already be loaded if you used the multiple image loader but is not yet calibrated.

    CTGroup
    • Enable the Ultrasound control group ruler tool.
    • Drag the tool to overlay the calibration ruler or any object of known length in the image (e.g. 13.13 mm).
    • Click the Ultrasound control group Calib. button and enter the calibration distance in the sheet.
    • Use the ruler tool to estimate the inner scleral surface and then measure the tumor height (e.g. 11.4 mm, illustrated) and base width. These measurements should be consistent with the tumor base and height as measured from the CT images.
    USOpened

    Drag the ruler tool to measure the tumor height (e.g. 11.4 mm) and the nominal base dimension (e.g. 17.5 mm). The tumor height measurement is consistent with the CT measurement, the tumor base may be larger or retinal detachment.

    USTumorHeight
    USTumorBase

    11. The fundus collage

    In the Image window

    • Click the Fundus button in the Fundus controls group.
      CTGroup
    • The fundus image will already be loaded if you used the multiple image loader but is not yet calibrated.
    • Set the collage centers popup menu to 3.
    • Adjust the slider to fit and estimate the location of centers 2 and 3. The posterior pole marker is always considered as center 1, even if its not exactly centered.
    • In this case the tumor overlies the disc. Estimate the location of the optic disc by extrapolating the large blood vessels. In this example, the tumor size is so large that it can be modeled from the CT images alone, so precise calibration of the fundus image is not critical.
    • Click the Calib. button and import the distance from the eye model.
    • Click the OK to accept the calibration and exit the sheet.
    FundusOpened

    12. Create the tumor base

    In the Retinal Diagram window

    • If the Retinal Diagram window is not visible, bring it to the front by selecting Retinal Diagram item from the Window menu (in the menu bar at the top of the screen).
    • Click the Std. button and use the Standard Tumor sheet to model the tumor base.
    • The anterior of this eye is a slightly oblate spheroid. Adjust the radial and circumferential tumor spherical size fields to achieve the desired tumor measurements (17.5 x 17.5 mm) in the oblate column .
    • Enter the best estimate of tumor apex height (e.g. 11.4 mm).
    • Adjust location longitude and latitude to place the anterior edge of the proposed standard tumor (plotted in orange) at the ora, the posterior edge overlaying the disc and the circumferential edges between 7 and 10:30 o'clock as was observed in step 8 above.
    • Click the OK button to accept the proposed tumor and exit the sheet.
    • In the Retinal Diagram window click the Peak button to set the tumor to a conicoid shape which will be the best approximation for this tumor.
    StandardTumorSheet

    13. Overlay tumor model on MPR images

    The objective of this step is to verify that the tumor location, shape, size and apex as created in the Retinal Diagram window is consistant with the tumor as it appears in the MPR images. Cross-sections of the tumor in the meridian and coronal dosimetry planes are tinted brown. The brown tinted regions should closely overlay the tumor in the MPR images. If the model and MPR do not overlay, further refinement of the model may be necessary.

    In the Planar Dosimetry window

    • In the toolbar controls, change the layout to side-by-side.
      LayoutControl
    • Note: the Meridian and Coronal buttons are now disabled (dimmed) because in this layout both planes are already displayed in side-by-side panes. These buttons are only active when the window is in single pane layout.
      LayoutControl
      In side-by-side layout, the meridian plane is always on the left, the coronal on the right.
    • Activate the meridian (left) pane by clicking anywhere within the pane. The active pane is indicated by a thin black frame around the pane and the matrix indicator in the lower right corner of the pane has a black background.
    • In the Overlay Image controls group along the right side of the window, click the T-Mer button.
    • Using the upper pair of buttons in the Rotate group
      RotateGroup
      rotate the meridian dosimetry plane projection (dashed purple line) to match the tumor-meridian imaging plane (represented by the diagonal yellow line in the OsiriX tumor-coronal image) or as an approximation to pass through the tumor apex in the Retinal Diagram window. The meridian plane appears as a translucent purple line bisecting the retinal diagram. You could also use the plaque control group center button in the Retinal Diagram window to achieve the same effect if Planes Track Plaque Motion is enabled. You may need to click the Flip 180 if the tumor appears on the wrong side of the eye when using meridian plane auto tracking and/or auto-centering.
    • Activate the coronal pane by clicking anywhere within the pane. The active pane is indicated by a thin black frame around the pane and the matrix indicator in the lower right corner of the pane has a black background.
    • In the Overlay Image controls group along the right side of the window, click the T-Cor button.
    • Using the lower pair of buttons in the Rotate group, translate the coronal dosimetry plane projection (dashed purple line) to match the tumor-coronal imaging plane (represented by the vertical blue line in the OsiriX tumor-meridian image).
      RotateGroup
    MeridianPlaneOnDiagram
    CompareMeridianWithMPR

    The Standard Tumor sheet always returns the tumor apex to a point directly above the geometric center of the elliptical tumor base. Observe that the apex of this tumor needs to be shifted anteriorly to better model the tumor and the measurements. Set the Retinal Diagram window cursor mode to drag apex in the toolbar and then nudge the tumor a bit anteriorly along the meridian plane projection until the tumor matches in the Planar Dosimetry window.

    DragApexAnterior
    AfterDraggingApex

    After moving the tumor apex slightly anterior the standard model and the CT images match nicely.


    14. Select a plaque

    In the Plaque Loading window

    From the Plaque menu select Plaque Files.

    PlaqueFiles

    From the Plaque Files menu select the EP2340NP file.

    PlaqueFilesEP2340NP
    EP2340NPOpened

    The EP2340NP is a large diameter 2nd generation EP plaque. The 'NP' at the end of the file name indicates that the plaque is notched and the file includes an embedded picture of the face of the plaque.

    The EP2340NP plaque was selected because:

    • The shape and size are a good physical and dosimetric fit for this large, tall tumor.
    • The collimating slots for the radionuclide sources create a fairly steep dose gradient outside the tumor perimeter and help reduce scleral hotspots near the center of the plaque.

    15. Center the plaque under the tumor

    In the Retinal Diagram window:

    • You can manually drag and rotate a plaque on the diagram by setting the cursor to drag-plaque mode.
      DragPlaqueMode Click within the projection of the plaque perimeter on the retina to drag. The control and command keys rotate the plaque while dragging.
    • Clicking the Center button in the Plaque controls group
      PlaqueGroup will automatically center the plaque under the tumor base and rotate the plaque so as to balance the suture eyelets at equal distances from the limbus. Balancing the eyelets is not required, but it does slightly simplify surgical placement.
    • The small arrows at the corners of the rotation control rotate the plaque CW and CCW in 1 or 90 degree increments.
    • Rotate the plaque CCW to achieve a symmetric fit of the notch to the nerve as illustrated.
    DiagramCentered

    Auto-centered, eyelets balanced


    EP917RotateCW

    In the planar dosimetry window the anterior edge of the plaque lifts slightly from the sclera due to the oblate curvature of the anterior eye but it is such a small amount that we will ignore it for this tutorial. You could optionally tilt the plaque a degree around its Y axis.


    16. Enter prescription

    In the Prescription window we will set the prescription (Rx) dose, the Rx point, dose calculation modifiers, and the implant and removal dates and times.
    Note: subsequent planning activities are simplified by establishing the Rx at this stage of the planning process, but the Rx can be revised at any time.

    When the EP2340NP plaque file was opened, the dose calculation modifiers in the Prescription window's toolbar were automatically set to:
    ModifiersEP

    • Linear, anisotropic source
    • No silicone seed carrier
    • Gold flourescence corrections enabled
    • No air scatter correction
    • No shell collimation (Note: shell collimation is redundant for Eye Physics plaques such as the EP2340NP where virtually all collimation occurs at the slot edges close to the seed rather than at the perimeter of the plaque shell. In this case, disabling the shell collimation modifier accelerates the collimation ray tracing computation.)
    • Slotted collimation enabled
    • Do NOT change these modifier settings until and unless you are VERY familiar with PS.

    For this tutorial, we will begin with a Rx of 85 Gy to the tumor apex to be delivered in 168 hours (1 week) with the implant scheduled for 10 AM on July 2, 2014.

    • Set the Rx units to Gy.
      UnitsButton
    • Set the Rx dose to 85 Gy..
      DoseField
    • In the insertion controls group set the implant date and time to 10AM on June 23, 2014.
      InsertionGroup
    • In the removal controls group click the 1 Week button.
      RemovalGroup
    RxSetDate

    Notes:

    • The insertion and removal calendar buttons open the Calendar dialog where you can set date and time with an expanded user interface.
      CalendarButton
    • The initial state of the 'P1 Central AXis table' is zero because the plaque is currently empty.
    • The background of the 'Rx point' field is red because the Rx has not been satisfied.
    • The background of the 'time' field is green because the implant duration is within the bounds that were set in PS preferences. Implant durations between 4 and 7 days (96 to 168 hours) are typical.

    17. Create a new radionuclide inventory entry
    • From the Plaque window click the Source button to open the radionuclide inventory window.
      SourceButton42x42
    • To create a new entry in the inventory database click the Show only radio button to enable physics model selection.
    • Select a seed physics model from the menu. In this example model IAI-125A (IsoAid) has been selected. This physics model is designed for source strength to be entered in units of mCi as described in the Physics Dose Constants section.
    • Click the New button to create a new inventory entry.
    • The new entry will automatically be selected (highlighted in blue in the scrollview). It will inherit the implant date and time from the current prescription as its calibration, will be named for the current patient and will contain the number of sources in the currently active plaque (plaque #1 was selected as currently the active plaque in step 18 above). The source strength will be initialized to 1.0 (either mCi or U depending upon the physics settings for the model seed selected).
    • To select a different inventory with which to load the plaque, simply click in the list.
    • Click the Edit button to review or change the selected inventory entry parameters.
    NewInventory

    NewInventorySheet

    18. Load sources into the plaque

    Organize your windows so the Plaque window and the Retinal Diagram window are both visible alongside one another.

    • In the Plaque window click the Load button to fill the plaque with 40 sources from the currently selected radionuclide inventory (that we created in the previous step).
      LoadButton42x42
    • Click the Labels button to display the source strength.
      LabelsButton42x42
    EP2340NPLoaded
    DiagramLoaded

    In the Retinal Diagram, the source placeholders change from brown to the color of the inventory sources (e.g. cyan) to indicate that they are occupied.


    19. Calculate source strength

    1. In the Prescription (Rx) window

    • In step 16 we set the prescription (Rx) to deliver 85 Gy to the apex of the tumor in 168 hours.
    • The 40 sources in the plaque are currently all 1.00 mCi (at the time of implant) because that is how we initialized them when we created their inventory in step 17.
    • The state of the 'P1 Central AXis table' reflects the current plaque loading. The dose to the Rx point (tumor apex) of 41.855 Gy is less than the Rx of 85 Gy. The background color is red indicating that the Rx has NOT been fulfilled.
    • Click the Implant Calculator button.
      ImplantCalc41x41
      to open the Implant Calculator window.
    RxApex1mCiSeeds
    Plaque1mCiSeeds

    2. In the Implant Calculator window

    • Click the Calc. Sources button. This will rescale the source strengths in the plaque to deliver the prescription of 85 Gy to the tumor apex in 168 hours.
      ImplantCalcuator1mCiSeeds
    • The Prescription (Rx) and Plaque Loading windows will update to reflect the revised source strengths of 2.031 mCi per source.
    RxApex203Seeds

    The 'P1 Central AXis table' now lists the dose at the Rx point (tumor #1 apex at 11.4 mm) as 85 Gy and the background color has changed from red to green indicating the Rx has been fulfilled.

    Plaque203Seeds

    The sources in the plaque are now 2.03 mCi at the time of implant.


    20. Choose an isodose legend

    In the Isodose window

    • From the Select menu choose the MyFavorite.idos6 legend file.
    • PS6 isodose legend files bundle instructions regarding isodose values, colors, absolute vs normalized plotting, and which isodose lines and surfaces to display.
    • Note: the column of checkboxes simultaneously affects all 2D isodose displays; the Retinal Diagram, the meridian and coronal Planar Dosimetry surfaces, and any 2D dosimetry surfaces being rendered in the Patient Setup window.
    • Note: the column of radio buttons selects one or more 3D isodose surface(s) (e.g. 85 Gy) for 3D rendering in the Patient Setup window.
    IsodoseWndwFileMenuX
    IsodoseMyFavorite

    21. Calculate isodose distributions and the retina dose area histogram

    From the Dosimetry menu:

    • Select Calculate 2D matrices. This calculates dose to the meridian and coronal planar surfaces, and to the retina.
    • Select Calculate RDAH. This calculates the Retina Dose Area Histogram.
    Calculate2DMatrices
    CalculateRDAH

    22. Compare fast vs complex ray-tracing

    The EP2340NP plaque is very broad and the fast slot-only collimation ray-tracing approximation does not completely account for shallow angle radiation that crosses the plaque just above its face. To illustrate this, in the left column, the dose calculation uses the fast approximation that just ray-traces the immediate slot and ignores the shell. In the right column is the slower, complete ray-trace collimation calculation that also includes the shell. Indicated times also include calculation of the retinal surface.

    Fast slot-only collimation approximation

    1.7 secs

    RXNoShell

    PlanarDosimetryNoShell

    Full slot & shell collimation calculation

    26.5 secs

    RxWithShell

    PlanarDosimetryWithShell

    On the right is a composite isodose overlay of the two collimation calculations. The differences between the two versions are exemplified by the 30 and 40 Gy isodose lines outside the eye at the edge of the plaque. Within the eye the two calculations yield identical results, with a calculation time difference of 1.7 vs 26.5 secs.

    This example illustrates that the fast collimation approximation for EP slotted plaques that bypasses ray-tracing the entire shell is adequate for typical treatment planning purposes. The remainder of this tutorial is based on the fast collimation approximation.

    ShellNoShellComposite

    23. Review dosimetry
    LT203RetinaDosimetry
    LT2038PlanarDosimetry
    LT203RDAHDocument
    LT203RDAHPreferences

    In the RDAH Document window

    • The X axis of the RDAH is plotted over the range 0..600 Gy. This range was set by clicking the Fixed button in the Histogram axes group of the Histogram document preferences pane.
    • The retina dose area histogram (RDAH) shows that the tumor base (brown line on the histogram) and the the tumor + 2 mm retinal margin surrounding the base (green line on the histogram) both receive at least 85 Gy. The 2 mm margin surrounding the tumor base is similar to the PTV concept, it accounts for microscopic tumor extension and uncertainty in surgical placement of the plaque.
    • The prescription to the apex and tumor base have all been satisfied.

    24. Calculate 3D dosimetry

    From the Dosimetry menu:

    • Select Calculate 3D Matrix.
    • Each plaque in PS6 maintains its own 3D dosimetry matrix.
    • In PS6 3D dose calculations are offloaded to a separate thread so that you can continue to perform non-dosimetric activities such as rotating the eye or entering patient ID information during the calculation. The 3D calculation progress can be followed in the status line just below the toolbar of the Patient Setup window. 3D calculations for some of the larger BEBIG Ru plaques can take awhile...
    Calculate3D

    25. Review 3D model

    In the Patient Setup window

    • Click the 3D Dose button to render the selected 3D isodose surface.
      DoseGroup
    • Optionally enable Mer. Dose and Ret. Dose.
    • Click the setup appearance button to open the appearance window window.
      Appearance_34x15
    • Experiment with the 3D model and the appearance controls to create pictures for the setup document.
    • For example, enable the Meridian Plane checkbox.
    LT203Setup2
    LT203SetupAppearance

    26. Review documents
    LT203TreatmentPlanPage1

    The Treatment Plan is a 3 page document that summarizes the entire simulation. Page 1 provides a table of patient identifiers, date & time of treatment, some radionuclide, plaque and tumor properties, a facial picture of the plaque and a miniature retinal diagram showing tumor location.

    LT203TreatmentPlanPage2

    On page 2 there is a table of point dose calculations along the central axis of the plaque (or tumor), at the prescription point, lens, macula, etc..., a thumbnail of the fundus image (no fundus image was used in this plan), and an optional picture. The default picture is a radiation safety survey form.

    LT203TreatmentPlanPage3

    Page 3 of the treatment plan contains thumbnails of the CT or MR images used to model the eye and any ultrasound images used to measure or model the tumor dome.

    LT203Loading

    The Loading Diagram document is a "road map" to the plaque. Everything needed to order or manufacture the seeds and assemble the plaque is in this document.

    LT203RetinaPage1

    The Retinal Diagram document is a VERY useful "road map" to have in hand during surgery because it illustrates the tumor and plaque location, muscle insertion regions, lists the suture eyelet coordinates and the distance between the coordinates. Everything the surgeon needs to place the plaque at the planned position is in this document.

    LT203RetinaPage2

    The optional 2nd page of the Retinal Diagram document is labeled in degrees CCW (instead of clock hours) in the manner of toric intraocular lens (IOL) axis marking tools such as the Duckworth & Kent Axis Marker model 9-841.
    AxisMarker

    LT203MeridianDocument

    The Isodose document prints the current meridian and coronal dosimetry planes.

    LT203RDAHDocument

    The Histogram document prints the Retina Dose Area Histogram (RDAH). The RDAH is a metric for comparing competetive treatment plan options.

    LT203SetupDocument

    The Setup document prints the contents of the 3D Patient Setup window.

    LT203QADocument

    The QA document prints a table containing all of the information needed to manually duplicate Plaque Simulator's simplified (isotropic point source in water) QA check point calculation located at 6 mm on the plaque central axis.


    27. Print documents

    The Print Group button in the toolbar of the Document Preview window prints the group of documents selected by the Document group checkboxes to either paper or to a .pdf file.

    Toolbar
    • To print to a .pdf file click the PDF button in the OSX printing sheet.
    • Select Save as PDF... from the menu.
      PDFMenu
    • To send a multipage .pdf print file by email you may need to create an encrypted version to satisfy HIPAA regulations and you may also need to limit the file size to under 10 MB by compressing the embedded images. Both of these tasks can be accomplished using the OSX Preview application and a custom filter. Contact Eye Physics for details.
    PrintPDF