SRS BRAIN MET PLAN EVALUATION

1. BRAIN METASTASIS SRS PLAN EVALUATION CHECK LIST
1. NAME UMR
2. DIAGNOSIS
3. PRIOR TREATMENT
4. DISEASE SPECIFICGRADED PROGNOSTICASSESSMENT SURVIVAL
5. PRIOR WBRT YES NO DOSE INTERVAL
6. PRIOR SRS YES NO DOSE INTERVAL
7. NUMBER OF METASTASIS/CAVITY
8. LOCATION SIDE SIZE max [mm] PTV MARGIN VOLUME-CC DOSE
1. GTV PTV
2. GTV PTV
3. GTV PTV
4. GTV PTV
5. GTV PTV
9. PLAN TYPE-[3DCRT/VMAT/DCR/IMRS]
10. PRESCRIBED MARGINALISODOSE
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D MAX
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D95% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D100% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V95% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V100% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V120% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V130% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
DISTANCE BETWEEN 80% ISODOSE AND 60% ISODOSE-[<2mm]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
DISTANCE BETWEEN 80% ISODOSE AND 40% ISODOSE-[<8mm]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
CONFIRMITYINDEX [IDEAL 1] VOLUME OF PRESCRIPTION ISODOSE/VOLUME OF PTV
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
HOMOGENITYINDEX [BETWEEN 1.1-1.3] MAX DOSE/ PRESCRIPTION DOSE
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
GRADIENT INDEX[BETWEEN 0.3-0.9][RADIUS OF PRESCRIPTION ISODOSE -RADIUS OF HALF PRESCRIPTION ISODOSE]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
11. 1. BRAIN-GTV[12Gyvolume]<10cc and D50% <5Gy
2. BRAIN-GTV[4Gyvolume] <20CC-MULTIPLE FRACTION
12. OAR SINGLE FRACTION 5 FRACT. [ALT. DAY] ACHIEVED
1. RIGHT EYE MAX<8Gy MAX <22.5Gy
2. LEFT EYE MAX<8Gy MAX <22.5Gy
3. RIGHT OPTIC NERVE MAX<8Gy MAX <22.5Gy
4. LEFT OPTIC NERVE MAX<8Gy MAX <22.5Gy
5. OPTIC CHIASM MAX<8Gy MAX <22.5Gy
6. BRAIN STEM MAX <15Gy MAX <31Gy
7. RT.HIPPOCAMPUS
8. LT.HIPPOCAMPUS
9. RT.COCHLEA MEAN <9Gy MEAN <25Gy
10. LT.COCHLEA MEAN <9Gy MEAN <25Gy