SBRT Plan Evaluation

Patient Name: Patient MRN:

Treatment Site:
Physician: Dosimetrist:
Physicist: Date of Review: 2/16/2018
Number of Fields: Modality: Technique:
Energies:: No. of Fx: PD (cGy):

YES/NO YES/NO
MU Check Passed? IMRT QA Passed?

Maximum Dose (:Dose Statistics / DVHs): PD (cGy) Dmax (cGy) PD (%) YES/NO
Is Maximum dose within PTV?
Is prescription dose ≥ 60% and < 90% of the maximum dose?

Prescription Isodose Surface Coverage (: Cumulative DVHs): PTV VRx YES/NO

Is 95% of PTV conformally covered by the prrescription dose (PTV V100%PD ≥95%)?
Does 99% of PTV receive a minimum of the prescription dose (PTV V90%PD ≥99%)?

High Dose Spillage (:105% Isodoes Volume minus PTV):

The cumulative volume of all tissue outside the PTV receiving V(cc) V(%) YES/NO
a dose >105% of the prescription dose should be no more than
15% of the PTV volume.

Falloff Gradient Ratio (RTOG 0813 / 0915):

PTV volume (cc) = TVPIV (cc) = CI = GI =

100% VRx (cc) = CIPaddick (³ 0.8 & £ 1.0) = V20Gy (%) =
50% VRx (cc) = D2cm (cGy) = D2cm (%) =