Liver Non-SBRT Sim Directive Free Breathing Tx or 4DCT (60 min) 4DCT Motion Assess or ?SDX tolerance (90 min) SDX (90 min) Match &Adjust Anatomy with Portal Imaging to establish isocenter daily for the entire course of treatment. Match &Adjust Anatomy with Portal Imaging to establish isocenter on days 1 and 2. If isocenter is within tolerance limits continue to use Match and Adjust Anatomy every 5th fraction to verify patient setup. (If tolerance is out of limits follow portal imaging policy.) Daily CBCT, only physics review Research Protocol: 2003.081 IC Green Patient immobilization: Supine or Thorax Board or Arms up or Head rest Knee Fix Other CBCT: Choose Scheduling/Authorization Approval Simulations will not be scheduled unless filled out Stage: ECOG status: Choose Treatment method: VMAT Total Gy: Scheduling Needs (optional): # Fractions: Concurrent Chemo: Choose Start Date: CBCT: Choose Scan Parameters: Motion Assessment Strategy: SDX only (expiration scan for planning – PREFERRED OPTION) SDX if patient can tolerate. Otherwise 4DCT immediately after exhale breath hold scan 4DCT scan to determine SDX or Free-breathing tx Free-breathing tx (shallow expiration and shallow inspiration breath hold scans for planning) Upper Border @ 7 cm above diaphragm or Note: Consider potential Lower Border @ 2cm below Pelvic Brim or use of non-axial treatment Slice thickness 3mm fields in determining length CT reference point midline at level of xyphoid tip or of scan Is IV Contrast needed for the Simulation? Choose (If yes, answer the questions below) Bolus tracking (for HCC, provide diagram of ROI) in addition to standard delayed imaging Contrast screening: 1) Do you have a CT IV contrast (x-ray dye) allergy? Choose 2) Do you require a steroid prep? Choose 3) Have you had a Renal Transplant? Choose 4) Do you have kidney disease or failure? Choose Additional Simulation Instructions: (e.g., placement of markers, wires, etc.) Page to check CT Attending Resident Simulation Directive Completed By: <Entered By> Simulation Ordered by: <Signed By> <Current Date> <Signed date time> Electronically signed by controlled access password Simulation Note: I was present to Choose Copyright * 2008 The Regents of The University of Michigan Attending Signature: <Approved By> <Approved date time> Electronically signed by controlled access password Tumor location and image registration: Paste image here: Imaging and Registration Primary Imaging: CT SDX: Yes No Secondary Imaging: MRI Date: Series: Registration Technique: Rigid Deformable Local Region of Importance: Select Comments: Intended use of Registered Images: Tumor Definition Normal Tissue Definition Treatment Adaptation Images: CT Patient Activity Document Interpreter (Language) Pre-Simulation Screening Schedule: When Provider is in Clinic Consent or Reconsent Completed: _ Protocol consent submitted to Data Manager: _ Anesthesia 90 min (Peds Scheduling 5-5841; <24 Hrs 3-2430) Pacemaker or AICD Patient (if so call 5-3968 for urgent consult) Woman age 11-55 (pregnancy screening form ) _ Medical Assistant has completed test _ Prior RT at outside institution and records (including treatment Plan) needed _ If yes, please provide location/physician name and approximate dates of treatment and notify Record Room @ 64286 : Special Scheduling Instructions Blood Draw order entered into Mi-Chart Schedule Lupron Injection Date Child Life Specialist Pediatric patient (18 and under), Adult Page 30435 with patient name, registration number and appointment information Radiation Oncology Protocol Coordinator Rad Onc Protocol No. Check Rad Onc Protocol Coordination below: April Proudlock 936-9521 (Pager 35596) Mary Akagi 936-3187 (Pager 34329) Michelle Castle 615-8492 (Pager 34592) Kevin Doyle 232-3841 (Pager 34665) Copyright * 2008 The Regents of The University of Michigan