RTOG Prostate Brachytherapy Protocol Compliance Form

 
Institution Name:*   RTOG #:*   Protocol #:*    
Patient initials:*   case_no:
 
Name Phone No Email address
Oncologist:*        
Physicist:*        
Dosimetrist:  
Data Manager:  
 
Treatment Type:*   Number of insertions:
Nuclide:*        
Manufacturer of Source: Model:
Average activity per seed on day of implant: (U)    
Number of seeds implanted/Dwell positions: Number of needles used:    
Prostate is defined on: slices.    
Post implant CT was taken days after implant.  
Post-Implant Prostate Volume (ETV) as determined from post-implant CT is cm3.    
 
For HDR implants:
Implant# Date Prescribed Dose (Gy) Peripheral Dose (Gy) V150(%) V125(cc) V75(cc) Rectum Max Dose (Gy) Urethra Max Dose (Gy)  
 
 
 
  Total Dose:        
                   
For LDR implants:
Implant Date Prescribed
Dose (Gy)
Peripheral
Dose (Gy)
V150(%) V100(%) V90(%) V80(%) D90(Gy) Urethra Max
Dose(Gy)
U200(cm3) Rectum Max
Dose(Gy)
R100(cm3)
 
Submit the following information to TRIAD:
• Ultrasound or CT images for all implants.    
• Treatment plans for all insertions (RT structure set, RT dose file).    
 
* This is a required field.