SBRT Renal Planning Directive
Primary Physician: <Primary Care Physician-Name (Default)>
Imaging:
CT
SDX/ABC employed
MRI Scan Date
Image Series
Target(s)
GTV1
if 4DCT
ITV1
PTV(s)
Priority
2 or
Dataset
CT
4DCT
Image numbers (if not entire scan)
Instructions
MR
Drawn By Physician or
GTV1 Expansion /Physics Consult
Expand GTV(s) by 5mm axially, 8mm sup + inf
Consider additional margin for smaller PTV based on distance
formula
CT
(**Consider adding 3-5mm PRV, especially for IMRT and deformable regions with multiple OARs)
Normal Structures & Goals:
Normal Structures
Contralateral Kidney
Ipsilateral (KidneyPTV)
Spinal Cord
Priority
1 or
2 or
Parameter
Max (0.5cc)
Max 67%
Limit (5fx)
10Gy
15Gy
6Gy
12Gy
1 or
Max (0.5cc)
25Gy
18Gy
Heart
1 or
Max (0.5cc)
30.0 Gy
Esophagus
1or
Max (0.5cc)
Spleen
1 or
Max (0.5cc)
52.5 Gy and
<15cc ≥ 32Gy
52.5 Gy and
< 5 cc ≥ 27.5Gy
< Rx Dose
Stomach
1 or
Max (0.5cc)
27.5 Gy
22.5 Gy
1 or
Max (0.5cc)
30 Gy
24 Gy
1 or
Max (0.5cc)
30Gy
25Gy
1 or
Max (0.5cc)
32 Gy
30 Gy
1 or
NTCP
(EQD2 α/β 2.5)
mm PRV
Duodenum
mm PRV
Small Bowel
Colon
Limit (3fx)
Comments
27.0 Gy
< Rx Dose
mm PRV
Liver
5%
5%
Other
Target Goals:
3D
Cover PTV with approx. 80% IDS (75% - 85%). Rx IDS covers 99.5% of PTV
IMRT
Maximize EUD, use a-value = -10 or
dose in GTV
Try to achieve Rx dose subject to OAR limits, with 20% max
Other
password
Copyright * 2008
The Regents of The University of Michigan
For information, questions, or permission requests please
Contact: (Kathy Lash, BS, RT (R) (T), Radiation Oncology, B2C511, 734-936-4291
SBRT Renal Planning Directive
Dose Prescription:
3 Fractions:
20Gy/fx to 60Gy or
Gy/fx to
Gy
5 Fractions:
10Gy/fx to 50 Gy or
Gy/fx to
Gy
Other:
Fractions of
Gy/fx to
Gy
Plan Parameters:
Energy:
As planning dictates or
Density Correction:
ON or
Treatment Devices:
MLC/Block
SDX/ABC
IGRT GUIDANCE INFORMATION
SDX/ABC Breath hold
IGRT Imaging
CBCT daily at breath hold
CBCT Goals
1) Align Target using GTV, ITV
1) Avoid overlap of
with
GTV, PTV, Dose Limiting Structure (
Download
for guidance 2) Check rotation of patient
Gy IDL 2) Align Target
) with
Gy IDL,
,
Additional Notes:
Free Breathing
IGRT Imaging
CBCT daily free breathing
CBCT Goals
1) Align target using
2) Check for excess diaphragm motion
1) Avoid overlap of
with
Gy IDL 2) Align Target
GTV, ITV, PTV, KIDNEY, Dose Limiting Structure (
) with
Gy IDL,
Download
Additional Notes:
Patient Alerts that may Require Additional Planning Effort:
Previous RT relevant to area? Choose Yes or No
Multiple Tx Sites? Choose Yes or No
CIED/ Pacemaker? Choose Yes or No
Concurrent Chemo? Choose Yes or No
Medical Necessity: Reason to justify extra Special Treatment Procedure Charge 77470
Extra effort Choose One
Other Instructions:
Completed by: <Authored By>
<Current Date>
Copyright * 2008
The Regents of The University of Michigan
For information, questions, or permission requests please
Contact: (Kathy Lash, BS, RT (R) (T), Radiation Oncology, B2C511, 734-936-4291
,
SBRT Renal Planning Directive
Attending Signature: <Approved By>
<Approved date time>
Electronically signed by controlled access password
Copyright * 2008
The Regents of The University of Michigan
For information, questions, or permission requests please
Contact: (Kathy Lash, BS, RT (R) (T), Radiation Oncology, B2C511, 734-936-4291