RT PRESCRIPTION WORKSHEET FOR A

DEVELOPING CONCEPT

Section I. Administrative
Date of Submission:      
Title of Concept:      
Principal Investigator:      
Submitted by (if different than PI)      
Contact Information (phone and e-mail)      

Section II. Treatment and Planning Techniques

Describe the treatment modalities allowed for dose delivery in your protocol. Check one or more item(s)
within each category as appropriate.

1. Treatment equipment:
Linear accelerator Tomotherapy CyberKnife Gamma Knife
Protons Scatter beam Scan beam

2. Planning technique:
3D Conformal RT
IMRT
Both 3D-CRT and IMRT
2D (drawn field outlines using patient anatomy)
CyberKnife using inverse treatment planning
Gamma Knife using multiple isocenters

Section III. Prescription Method

1. Describe the prescription method.
Will sub-regions within the target receive different doses? Y N
Is it possible to have separate target regions that are not connected? Y N
Will a boost be used to treat some sub-regions to a higher dose? Y N
Will this boost be treated simultaneously with the lower dose regions? Y N
Will 3D-CRT be used followed by IMRT for boost? Y N

2. Prescribed Dose Coverage

Prescribe to a point Y N
Prescribe to the PTV periphery (selected isodose line touches surface) Y N
Prescribe to a fixed percentage of the PTV Y N
What is the % volume of the PTV included?      %
Will this % volume remain the same for all the PTVs listed below? Y N
If No, please elaborate.      

3. Dose Levels (prescribed and max doses) (use a “-“ when the max dose is not easily estimated)

Table 1
High Dose PTV       Gy Max allowed dose       Gy
Intermediate Dose Region PTV       Gy Max allowed dose       Gy
Lowest Dose Region PTV       Gy Max allowed dose       Gy

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4. Do you want to introduce an intermediate point to better anchor the DVH curves?

Y N

If yes, state the dose value below with the assumption that you want the % volume to be at or
above this dose.

Table 2
High Dose PTV      Gy       % of volume
Intermediate Dose Region PTV      Gy       % of volume
Lowest Dose Region PTV      Gy       % of volume

5. For 3D-CRT, the dose levels in Table 1 above can be used to normalize separate plans. For IMRT
using a simultaneous boost delivery technique, the treatment plan must be normalized for just one of the
above dose levels. At which dose level in Table 1 above do you want the plan to be normalized to give
the stated volume coverage?

High dose PTV region Intermediate dose PTV region Low dose PTV region

State the lowest dose you will allow within this selected PTV (use either a number value or a
percentage of the prescribed dose for this region).

     Gy or % of prescribed dose      

The selected PTV is referred to here as the “Dose Normalization PTV” and can be followed by
the subscript LD, ID or HD to identify it as applying to the low, intermediate, or high dose region.

Section IV. Compliance Criteria for Targets

Per Protocol specifications:
The Per Protocol specifications are given above in Section III of this form.

Variation Acceptable specifications:

Note: For IMRT treatment planning using a simultaneous boost approach, it is impossible to
produce ideal dose distributions when there are multiple PTVs being carried to different doses.
Thus, it is common practice in RTOG protocols to develop strict compliance criteria only at the
dose level specified in Section III-5 above. However, you can add additional compliance criteria
for the other dose levels by duplicating these pages and marking them as the High Dose PTV,
Intermediate Dose PTV, and the Low Dose PTV.

Table 3
Do you want the dose normalization to provide the exact prescribed
dose and percentage volume coverage given in Table 1 above for the Y N
dose level PTV selected for Section III-5? (This is the preferred method
of dose prescription.)
If No, give the range of doses you will allow. You can express this range       Gy or
in either Gy or as a percentage of the prescribed dose (e.g., 98 to       %
102%).
What is the lowest dose you will allow in the Dose Normalization PTV
under the variation acceptable compliance criteria? Use either a stated       Gy or
dose number or a % of the prescribed dose. (The number stated here       %
should be slightly lower than the number given in Section III-5 so that
dose variation resulting from complex geometries are accommodated.)

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 Deviation Unacceptable specifications:
The deviation unacceptable dose limits are defined by the numbers given above. That is,
treatment plans falling outside the variation acceptable limits are defined as deviation
unacceptable

Section V. Compliance Criteria for Critical Structures

In order to set the Critical Structure Compliance Criteria for your protocol, you are asked to
complete the following information relating to the acceptable DVH for relevant critical structures:

Table 4a
Critical structure #1 Name:      
Point 1 on DVH
Per Protocol % of total structure volume you would like to use to control the dose     %
specification Acceptable dose to this point      Gy
Overall Max dose for this structure      Gy
(to a point that is at lease 0.03 cc in size)
Variation Dose limit for a Variation Acceptable     Gy
Acceptable (must be slightly larger than # above)
specification Overall Max dose for this structure defining a variation acceptable (to a point
that is at lease 0.03 cc in size)     Gy (This number should be slightly larger than the
number given above under Per Protocol specification.)

Deviation A deviation unacceptable is reached whenever either of the numbers given

Unacceptable above is exceeded.
specification

Point 2 on DVH (if needed for better specification of DVH)

Per Protocol % of total structure volume you would like to use to control the dose     %
specification Overall Max dose for this structure       Gy
(to a point that is at lease 0.03 cc in size)
Variation Dose limit for a Variation Acceptable     Gy
Acceptable (must be slightly larger than # above)
specification Overall Max dose for this structure defining a variation acceptable (to a point
that is at lease 0.03 cc in size)     Gy (This number should be slightly larger than the
number given above under Per Protocol specification.)
Deviation A deviation unacceptable is reached whenever either of the numbers given
Unacceptable above is exceeded.
specification

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Table 4b
Critical structure #2 Name:      
Point 1 on DVH
Per Protocol % of total structure volume you would like to use to control the dose     %
specification Acceptable dose to this point      Gy
Overall Max dose for this structure      Gy
(to a point that is at lease 0.03 cc in size)
Variation Dose limit for a Variation Acceptable     Gy
Acceptable (must be slightly larger than # above)
specification Overall Max dose for this structure defining a variation acceptable (to a point
that is at lease 0.03 cc in size)     Gy (This number should be slightly larger than the
number given above under Per Protocol specification.)

Deviation A deviation unacceptable is reached whenever either of the numbers given

Unacceptable above is exceeded.
specification

Point 2 on DVH (if needed for better specification of DVH)

Per Protocol % of total structure volume you would like to use to control the dose     %
specification Overall Max dose for this structure      Gy
(to a point that is at lease 0.03 cc in size)
Variation Dose limit for a Variation Acceptable     Gy
Acceptable (must be slightly larger than # above)
specification Overall Max dose for this structure defining a variation acceptable (to a point
that is at lease 0.03 cc in size)     Gy (This number should be slightly larger than the
number given above under Per Protocol specification.)
Deviation A deviation unacceptable is reached whenever either of the numbers given
Unacceptable above is exceeded.
specification

Note: To accommodate additional critical structures just copy the above table as many times as
needed.

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Section VI. Image-guided Radiation Therapy

Will your protocol use IGRT that is integrated Yes No

into the treatment unit or in-room process?

Will the use of IMRT be a protocol Mandatory Optional

requirement?

Will the use of IGRT be linked to margin Yes No

reduction? PTV margin without IGRT      mm
1 margin with IGRT      mm
Which forms of IGRT will you allow? Integrated cone-beam CT
kV
MV
In-room helical CT

Tomotherapy

2D kV imaging

2D MV imaging

Are you prepared to describe in detail how the Yes No

image registration process for your protocol
will be carried out? This information must
include details of the exact anatomy to be
used in the registration process and the action
levels for position shifts.

Do you intend to use routine repeat imaging to Yes No

verify the positioning of treatment fields?

At what point should an investigator contact IGRT utilization      

you with regard to the amount of IGRT used in
the protocol to discuss corrective action? (For
example: 3 IGRT procedures for three
separate days in a one week period) State
your limit in the box on the right.

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Section VII. Adaptive Radiation Therapy
Do you intend to use functional imaging as an IGRT method for adapting treatment after an
initial course decreases the tumor size?

Yes No, please elaborate.      

Section VIII. General Questions

1. Do you intend to check each institution’s treatment approach using any of the following
techniques? Check one or more.
PI review of sample or benchmark case treatment plan before any patients are entered
on the protocol
PI review of first patient’s treatment plan as a rapid review turnaround
PI review of institution’s contouring for first case
Other (please explain)      

2. What data do you need for your case review?

Note: Data submission and archiving is automatic for all 3D and IMRT protocols.
Simulation CT
Structure contours
Dose distributions

3. Would you like to obtain IGRT data? Y N

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