BRT LIVER PLAN EVALUATION SHEET.docx

1. HCC SBRT PLAN EVALUATION CHECK LIST
1. NAME UMR
2. DIAGNOSIS
3. PRIOR TREATMENT
4. IMAGING FINDING
NUMBER
SIZE
LOBE
SEGMENT
CHIRHOSIS
THROMBUS BLAND TUMOR
VOLUME GTV NORMAL FUNCTIONAL FUNCTIONAL-GTV
ARTERIAL PHASE ENHANCEMENT
VENOUS WASHOUT
DELAYED PSEUDOCAPSULE
5. CHILD SCORE[BEAP]
6. MOTION MANAGEMENT
7. LIVER VOLUME LIVER-GTV VOLUME LIVER-PTV VOLUME
8. LOCATION SIDE SIZE max [mm] PTV MARGIN VOLUME-CC DOSE
GTV PTV
9. PLAN TYPE-[3DCRT/VMAT/DCR/IMRS]
10. PRESCRIBED MARGINAL ISODOSE BED
D MAX
D95%
D100%
V95%
V100%
V120%
V130%
DISTANCE BETWEEN 80% ISODOSE AND 60% ISODOSE-[<2mm]
DISTANCE BETWEEN 80% ISODOSE AND 40% ISODOSE-[<8mm]
CONFIRMITY INDEX [IDEAL 1] VOLUME OF PRESCRIPTION ISODOSE/VOLUME OF PTV
HOMOGENITY INDEX [BETWEEN 1.1-1.3] MAX DOSE/ PRESCRIPTION DOSE
GRADIENT INDEX [BETWEEN 0.3-0.9] [RADIUS OF PRESCRIPTION ISODOSE - RADIUS OF HALF PRESCRIPTION ISODOSE]
PRESCRIPTION DOSE LIVER-GTV [>700CC]
NEEDED ACCEPTABLE UNACCEPTABLE ACHIEVED
50 Gy ≤13 Gy 13-13.2 Gy > 13.2 Gy
45 Gy ≤15 Gy 15-15.2 Gy > 15.2 Gy
40 Gy ≤15 Gy 15-15.2 Gy > 15.2 Gy
35 Gy ≤15.5 Gy 15.5-15.7 Gy > 15.7 Gy
30 Gy ≤16 Gy 16-16.2 Gy > 16.2 Gy
27.5 Gy ≤17 Gy 17-17.2 Gy > 17.2 Gy
11. NON-LIVER OAR CONSTARINTS NEEDED ACCEPTABLE UNACCEPTABLE ACHIEVED
Esophagus max (to 0.5 cc): 32 Gy > 32 but ≤34 Gy > 34 Gy
Stomach max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Duodenum max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Small bowel max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Large bowel max (to 0.5 cc): 32 Gy >32 but ≤34 Gy > 34 Gy
Cord + 5 mm max (0.5cc): 25 Gy >25 but ≤28 Gy > 28 Gy
Kidneys: Bilateral mean ≤10 Gy >10 but ≤12 Gy > 12 Gy
Chest wall
Gall bladder
CBD <50Gy