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:
*
?
LDR
HDR
Number of insertions:
Nuclide:
*
?
I
125
Pd
103
Ir
192
Other
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
cm
3
.
For HDR implants:
Implant#
Date
Prescribed Dose (Gy)
Peripheral Dose (Gy)
V
150
(%)
V
125
(cc)
V
75
(cc)
Rectum Max Dose (Gy)
Urethra Max Dose (Gy)
Total Dose:
For LDR implants:
Implant Date
Prescribed
Dose (Gy)
Peripheral
Dose (Gy)
V
150
(%)
V
100
(%)
V
90
(%)
V
80
(%)
D
90
(Gy)
Urethra Max
Dose(Gy)
U
200
(cm
3
)
Rectum Max
Dose(Gy)
R
100
(cm
3
)
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.