Large Breast Plan Sim Directive -
Right (60 min)
Left (90 min)
Bilateral (120 min)
Use Match and 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.)
Use Match and Adjust Anatomy for Portal Imaging to establish isocenter daily for the entire course of treatment.
Treatment site: Choose
Patient immobilization:
Supine: Breast Board, Head rest, Arms up, knee fix
+ Asses if breast immobilization needed (departmentsupplied bra)
Prone: head and arm positions determined during simulation
+ Assess for abdominal compression to limit normal tissue
adjacent to catheter placement
Page to mark patient after immobilization: Choose
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: Choose
Total Gy:
Scheduling Needs (optional):
Boost:
Total # of Fx:
MROQC
Marking patient/catheter placement:
Superior supraclavicular:
Cricothyoid notch
1st 3 intercostal spaces:
Horizontal lines just lateral to midline between ribs 1 & 2, 2 & 3, 3 & 4
Superior breast/chest wall:
Horizontal line just below clavicle to include all visible breast tissue.
Inferior breast/chest wall:
Horizontal line 1.5 cm below inframammary crease or lower part of breast
Medial breast/chest wall:
Vertical line at midline
Lateral breast/chest wall:
Vertical line at mid-axillary line to include breast with a 1.5 cm margin
Surgical Scar
Page attending to check markings or
Assess if Need SDX Choose
If left-sided and supine, assess if Need SDX: Choose
Scout: If prone and/or right-sided supine: 1 scout at free-breathing
If left-sided supine & assess SDX: Scouts at voluntary exhale and voluntary inhale to assess.
(Page physics**faculty to do an SDX assessment.)
Scan Parameters:
Upper Border @ C2 or
Lower Border @ interspaces of L1-2 or
Slice Thickness 3mm or
If supine: CT reference point at middle of tangent on medial border or
If Prone: CT reference point at middle of treatment breast or
Additional Simulation Instructions: (e.g., placement of markers, wires, pacemaker, etc.)
Page attending
Resident to check scan
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
Attending Signature: <Approved By>
<Approved date time>
Electronically signed by controlled access password
Copyright * 2008
The Regents of The University of Michigan
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