1. Preliminary Steps

1.1 Create Treatment Prescription

1. Open Prescription Interface

• Quicklinks > Prescribe treatment

2. Create New Course

• Create new treatment course if one doesn't exist
• Naming convention: Use suffix a (indicates brachytherapy)
• Example: C1a

3. Select Template

• Template: HDR Cylinder (Shared)
• Verify auto-populated fields match patient requirements

4. Verify Prescription Parameters

The template auto-populates the fields. Confirm the following values match patient requirements:

• Fractions: 3 (with EBRT boost) or 5 (monotherapy)
• Total Prescribed Dose: 3000.0 cGy
• Dose per Fraction: 600.0 cGy
• Primary/Boost: Select appropriate option
• Notes: Record cylinder diameter (e.g., "2.5 cm diameter cylinder, 4 cm treatment length")

5. Save Draft

• Click SAVE AS DRAFT

2. Contouring

2.1 Confirm Cylinder Dimensions

6. Measure Cylinder Diameter

• Open patient in contouring application
• Click Distance tool to measure
• Measure cylinder diameter
• Round to nearest standard size (2.5 cm or 3.0 cm)

7. Update CT Study Name

• Right-click CT study icon > Properties
• ID field: Rename to HDR_CYL_XXmm (where XX = diameter in mm)
• Alternative naming: HDR CYL X.X cm (some physicists prefer cm)

2.2 Load Contour Template

8. Add Structure Set

• Option A: Structure menu > New Structures From Clinical Protocol > HDR CYL Dunn > Attach... > OK
• Option B: Right-click CT > New Structures From Clinical Protocol

2.3 Contouring Guidelines

General Principles:

• Contour ≥2 cm superior to cylinder tip (dose becomes negligible beyond this point)
• Skip 2–3 slices between contours, then use Interpolate Structure
• Verify interpolated contours on all slices before proceeding
• Use abdominal windowing to distinguish bowel wall from contents
• Check coronal and sagittal views to ensure anatomical continuity

2.3.1 Cylinder

9. Contour Cylinder

• Method 1 (Adaptive brush): Set radius large enough to capture full cross-section with single click
• Method 2 (Fixed brush): Use circular brush matching cylinder diameter; adjust near dome and tip

2.3.2 Rectum

10. Contour Rectum

• Inferior boundary: Start ≥2 cm below active treatment length
• Superior boundary: Extend to rectosigmoid junction (where bowel deviates laterally/anteriorly, ~S2–S3 level)
• Critical: Maintain clear tissue plane between rectum and cylinder (should not touch)

2.3.3 Sigmoid Colon

11. Contour Sigmoid

• Starting point: Rectosigmoid junction (where rectum curves anteriorly/laterally)
• Superior extent: Continue 2–3 cm above cylinder tip
• Include all visible segments even if appearing discontinuous on axial slices
• Verify continuity using coronal/sagittal views

2.3.4 Bowel Bag

12. Contour Bowel Bag

• Definition: Small bowel and remaining bowel loops not contoured as rectum/sigmoid
• Superior boundary: 2 cm above cylinder tip
• Inferior boundary: Top edge of cylinder
• Exclude: Muscle, bone, bladder, uterus, major vessels, rectum, sigmoid

3. Plan Creation

3.1 Load Patient Data

13. Open Course and Structure Set

• Open Objects
• Highlight Patient > Select relevant course > Apply
• If not already done, name the course C1a
• Expand All Structure Sets > Highlight CT_1 > Apply

3.2 Add Clinical Protocol

14. Insert Protocol Reference

• Select course (e.g., C1a) > Insert > New Clinical Protocol Reference
• Click Next > Select HDR CYL Dunn > Select

3.3 Create Plan from Template

15. Insert New Plan

• Select course > Insert > New Plan from Template
• Select prescription (e.g., HDR Vaginal Cuff) > Next

16. Select Plan Template

• Enable viewing of approved and unapproved templates
• Search for HDR CYL Xcm (where X = cylinder diameter)
• Select matching template

17. Configure Plan Settings

• Target structure: Cylinder > Next

• Primary reference point: Cylinder > Next

• Verify dose per fraction and total dose match prescription > Next

3.4 Position Applicator

18. Orient CT Views

• Use Rotate tool to align cylinder vertically
• Align sagittal and coronal planes so orthogonal plane markers run along cylinder middle

19. Align Template with CT

• Click applicator to select (turns blue when selected)
• Use Move applicator and Rotate applicator tools
• Align template with CT-visible cylinder

3.5 Configure Dose Display

20. Set Isodose Levels (Choose preferred option)

Option A (Three levels):

• Click elements on top left corner of axial plane
• 200% = Yellow
• 100% = Red
• 50% = Blue
• Units: Set to absolute by clicking [%] symbol so it becomes [cGy]

Option B (Two levels):

• Right-click Dose > Uncheck Absolute Dose (if checked)
• Right-click Dose again > Isodose Levels
• Keep only 100% (red) and 200% (white) checked in 2D and 3D
• Apply > OK

3.6 Set User Origin and Default Views

21. Position Crosshairs

• Move sagittal and coronal crosshairs so planes run along cylinder central axis
• Move axial plane to 3 mm (one slice) above cylinder tip

22. Set User Origin

• Right-click User Origin > Set User Origin
• Under Set to Predefined Target: Viewing Plane Intersections > Apply > OK

23. Set Default Viewing Planes

• Return to User Origin
• Zoom out to display entire dose distribution
• Click Set Default Viewing Planes button
• Set to Current > OK

• Click Reset Geometry to return to this setup

3.7 Add Clinical Goals

24. Configure Plan for Single Fraction

• Verify plan properties show no Protocol Plan
• Confirm Number of fractions: 1

25. Load Clinical Goals

• Planning > Add or Edit Clinical Goals...
• In Clinical Goal Templates, find and select HDR Cylinder Dunn_1Fx

26. Verify Goals

• Right-click top right window > Show Dose Volume Histogram View
• Dose Statistics tab: Check all OARs (except body) for DVH display
• Plan Objectives tab: Confirm all goals are green/passing

27. Complete Treatment Planning Task

• Option A: QuickLinks > EMR > Care Path > Right-click task > Completed
• Option B: Check Tasks in Aria > Change Physics-Brachy status to Completed

4. Mobius Secondary Calculation

4.1 Create Reference Point

28. Position Reference Point

• Double-click User Origin icon
• On coronal slice, align sagittal crosshairs with cylinder edge
• Use Measure Distance tool : Measure 2 cm down/inferior from user origin
• Move crosshairs to cylinder surface at this distance

29. Create Mobius Point

• Right-click Reference Points > New Reference Point And Location
• Click anywhere on images
• Name: Mobius
• Type: Target
• OK

30. Position Point Precisely

• On coronal plane, move horizontal (axial) and vertical (sagittal) plane indicators to intersect cylinder side
• Right-click Mobius > Move Reference Point To Viewing Planes Intersection

4.2 Export to Mobius

31. Send Plan to Mobius

• Right-click plan name (e.g., HDR_CYL_3cm) > Export > Mobius3D - Server 3
• Click blue arrow (left corner) > Authorize
• Verify all files transferred successfully

Mobius Server IPs:

5. Post-Planning Documentation

5.1 Mobius Verification

32. Access Mobius Report

• Navigate to Mobius Server (IP: 10.110.16.21)
• Log in with credentials
• Click patient name > Open PDF Report (third icon from left)

33. Verify Agreement

• Scroll to bottom of plan data
• Confirm percent difference shows green checkmark (Mobius 2nd Check & Eclipse agree within tolerance)
• Save report to P-drive as 4-mobius
• Path: P:\1. Methodist Dunn\3B. HDR Bravos Dunn\1. HDR Patient QA

34. Clean Up

• Return to Eclipse plan
• Delete Mobius reference point

5.2 Generate Eclipse Documentation

35. Create Plan Report

• File > Print > Report
• Printer: Adobe PDF
• Layout: BrachyFull.tml
• OK
• Save to patient path as 1-report

36. Create DVH Report

• Dose Statistics tab: Check all structures for DVH display
• Click DVH panel (top right)
• Right-click > Print DVH Report > OK
• Save to patient path as 3-dvh

37. Create Orthogonal Views Screenshot

• Double-click User Origin
• Display Clinical Goals tab in bottom panel
• File > Print > Screen
• Properties > Layout: Change to Landscape
• Save as 2-iso

38. Combine Documents

• Select all files (1-report, 2-iso, 3-dvh, 4-mobius)
• Right-click > Combine files in Acrobat

5.3 Create Imaging Course

39. Add New Course

• QuickLinks > Treatment Planning > External Beam Planning
• Insert > New Course...
• Name: C1a-Imaging (or C2a-Imaging for second brachytherapy course)

40. Create Imaging Plan

• Insert > New Plan from Template... > DunnBravosSU > Next
• Select C1a-Imaging course > Next
• Treatment unit: Omega > Next
• Keep default dose settings > Next
• Target: Cylinder or check No plan target
• Primary reference point: User Origin > Next
• Isocenter placement: At image origin > Next
• Patient position: Head First-Supine

41. Configure DRR

• Right-click DRR icon > Edit DRR
• Select Abdomen.dps
• Check Apply to all fields > Apply

42. Set Treatment Parameters

• QuickLinks > Treatment Management > Treatment Preparation
• Tolerance table: Non-Index
• Imager Vrt: 50.0 cm

5.4 Configure Dose Limits

43. Set Reference Point Limits

• Return to Brachytherapy Planning
• Double-click reference point (Cylinder, CTV, etc.)
• In Dose Limits section:
  • Total: (Number of fractions × 600 cGy)
  • Daily Dose Limit: 600 cGy (or 1200 cGy for BID regime)
  • Session Dose Limit: 600 cGy
• Apply > OK

5.5 Approve Plans

44. Approve HDR Plan

• Right-click plan > Plan Approval > Planning Approved
• Acknowledge minor warnings (unapproved/rejected structures)
• Enter credentials for verification

45. Approve Imaging Course

• Right-click DunnBravosSU plan > Plan Approval > Planning Approved > Next
• Check Continue planning approval without calculating dose and/or MUs
• Continue until prompted for password

6. Import Documents to Aria

6.1 Upload Combined Plan Document

46. Import Combined PDF

• Quicklinks > Documents
• Click Import (NOT "New")
• Select combined PDF from patient folder

47. Configure Document Properties

• Authored By: Your name
• Supervised By: Dr. Farach (or treating physician)
• Document Type: Treatment Plan - Initial
• Template Name: HDR Cylinder

48. Save Document

• Click OK (NOT Sign Off)

6.2 Additional Documents (First Planning Only)

6.2.1 HDR Vaginal Cylinder Consult

49. Create Consult Document

• Quicklinks > Documents > New
• Click Template > Check Show All Templates
• Select HDR Vaginal Cylinder Consult > OK
• Supervisor: Physician name
• UNCHECK 'Completed'

50. Complete Template Fields

• Treatment Length: 4 cm (standard for Dr. Farach)
• Diameter of Cylinder: X cm (measured value)
• Dose to Depth: 600 cGy to depth of 0.0 cm
• D2cc Bladder: ___ cGy (from Plan-COMBO PDF ÷ 5)
• D2cc Rectum: ___ cGy (from Plan-COMBO PDF ÷ 5)
• Click OK (NOT Sign Off)

6.2.2 Treatment Plan Note

51. Create HDR Treatment Plan Note

• New > Template > Check Show All Templates
• Select Tx Plan HDR Note - HMH > OK
• Supervisor: Physician name
• UNCHECK 'Completed'
• Complete fields:
  • Plan type: 3D Plan (because CT-Sim is used as basis)
  • Number of Channels: 1 (only 1 channel in cylinder)
  • Number of Basic Dosimetry Calculations: 1 (secondary calculation via Mobius with one reference point)
• Click OK (NOT Sign Off)

7. Scheduling and Billing

7.1 Schedule Treatment

52. Schedule Fractions

• Quicklinks > Treatment Management > Plan Scheduling
• In Scheduling Overview panel: Shift+Click+Drag across boxes equal to number of fractions
• Click Insert to add blue treatment blocks
• Click Save icon

7.2 Billing

53. Open Charge Manual

• Location: Physics Drive > 1. Methodist Dunn > HDR Main > Charge Manual

• Navigate to HDR Vaginal Cylinder sheet
• Note all CPT codes in Plan Day section with PHY as responsible party

54. Access EMR Summary

• Quicklinks > EMR > Summary
• Click Tasks tab

55. Create Prepare Plan Task

• Click New button
• Activity: Select Prepare Plan from dropdown

56. Add Physics Staff

• Click Add below Activity box
• Find and highlight Physics in Resource/Staff menu
• Add to right side
• In Staff list below, find your name and add to right side
• Check your name > OK

57. Complete and Capture Task

• Set Status: Completed
• Click OK at bottom of Task Dialog
• Back in Tasks tab, scroll to Prepare Plan activity
• Right-click > Activity Capture!

58. Add Billing Codes

• Click Add More Procedure Codes
• Check Show All Procedure Codes
• Add all codes from Step 53
• Special note: If CT-Sim used, check 77295 INSTEAD of 7731X codes
• Click Save Edits

8. Subsequent Fractions

8.1 Create Decay-Corrected Plans

59. Copy Plan for Next Fraction

• Quicklinks > Treatment Planning > Brachytherapy Planning
• Open course
• Right-click PLAN (e.g., HDR_CYL___cm) > Copy Plan
• Right-click COURSE (e.g., C1a) > Paste Plan

60. Rename Plan

• Plan ID: Cylfx___ (fill in fraction number)
• Example: Cylfx2, Cylfx3, etc.

61. Adjust Plan Date

• Open plan properties
• Update date to match scheduled treatment date
• Ensures correct source decay calculation

8.2 Generate Decay Calculation Report

62. Create Brief Report

• Window > Brief Report Window
• Press Ctrl+P
• Printer: Microsoft Print to PDF
• OK
• Save as: DecayCalc_CYL_XXmm_FxN
• Example: DecayCalc_CYL_25mm_Fx2

8.3 Upload Fraction Reports

63. Import on Treatment Day

• On day of treatment: Quicklinks > EMR > Documents
• Click Import
• Select DecayCalc_CYL_XXmm_FxN from patient folder
• Click Open

64. Configure Document Properties

• Authored By: Your name
• Supervised By: Dr. Farach
• Document Type: Treatment Plan - Decay Calc
• Template Name: Cylinder Fx___
• UNCHECK 'Completed'
• Click OK (NOT Sign Off)

Appendix A: Keyboard Shortcuts

Appendix B: Manual Planning (Training Only)

B.1 Orient Cylinder and Set User Origin

1. Orient Cylinder (see Section 3.4)

• Rotate sagittal and coronal planes to ensure cylinder is roughly vertical
• Define user origin at tip of applicator

B.2 Manual Plan Creation

2. Insert Plan Manually

• Select course > Insert > New Plan
• Click Next with course highlighted
• Highlight treatment prescription > Check Select > Next
• Highlight cylinder as target > Next

3. Configure Plan Properties

• ID & Name: HDR Cyl___cm
• Protocol Plan: Cylinder Dunn\Cylinder
• Target Volume: Cylinder
• Technique: Intracavitary
• Treatment Percentage: 100%
• Dose per Fraction: 600 cGy
• Number of Fractions: 5
• Click OK

B.3 Insert Applicator

4. Add Applicator

• Insert > New Applicator > Bravos - Dunn
• Configure Applicator Properties:
  • Channel Length: 125 cm (always for HMH cylinders)
  • Step Size: 0.5 cm
  • 1st Source Position: 0.3 cm
  • Last Source Position: 4.3 cm
• Click OK

B.4 Digitize Applicator

Method 1: Two-Point Method

5. Draw Applicator

• After inserting applicator, drawing button becomes active
• Navigate to cylinder tip in axial view (where low intensity cavity vanishes)
• Click at center of channel (defines end of source positions)
• Move inferiorly to applicator base
• Click at center of channel (defines start)

Method 2: Multi-Point Method

• Ensure proper rotation (channel vertical)
• Use Contour Editor button
• Click multiple points along central channel from base to tip

B.5 Create Reference Line

6. Add Reference Line

• Highlight CT study (e.g., CT_1)
• Insert > New Reference Line > OK
• On coronal plane containing User Origin:
  • Click along cylinder surface from one side to other
  • Position at level of last dwell position
• Click Selection Tool to exit reference line mode

B.6 Initial Dose Calculation

7. Run Volume Optimization

• Planning > Modify Dose > VEGO TG-43 Volume Optimization
• Click OK at normal tissue structure creation prompt

8. Configure Optimization

• Set Smoothness: Middle of meter (Top High = Coarse, Top Low = Finer DVH)
• Create objectives:
  • Highlight Reference Line
  • Click Add Upper & Lower Objective
  • Desired dose: 3000 cGy (prescription amount per fraction) > OK

9. Set Lower Objective

• Volume: 99%
• Dose: 3000 cGy (100%)
• Priority: 100

10. Set Upper Objective

• Volume: 1%
• Dose: 3005 cGy (100.17%)
• Priority: 100

11. Optimize and Calculate

• Click Optimize
• Click Calculate 3D dose button

B.7 Modify Isodose Display

12. Set Isodose Levels (see Section 3.5)

B.8 Dose Shaping

13. Shape Dose Distribution

• Click Dose Shaper tool
• Right-click in views > Dose Shaping Effect > Select Local > OK
• On frontal/sagittal views: Ctrl+Drag near 100% red isodose line
• Shape onto cylinder surface

14. Save Plan

Appendix C: Troubleshooting

Common Issue: Improper Template Positioning

Problem: Template positioned inferior to correct location

Identification:

• End of digitized channel does not coincide with end of channel cavity
• Low attenuation region in cylinder center misaligned

Solution:

• Use Move applicator tool to reposition template
• Align digitized channel end with visible cavity end
• Verify alignment in all three planes