Download Treatment Planning Directive: Lung

Pelvis GYN HDR – Triple Tandem Sim Directive (30 min)
Projected # Treatments: 3 or
Projected Dose per fraction: 5 Gy or
Required
MRI Date:
MRI Date:
Series #
Series #
Scheduling/Authorization Approval
Simulations will not be scheduled unless filled out
Stage:
ECOG status: Choose
Treatment method: HDR
Total Gy:
# Fractions:
Pre Simulation:
Insert Foley catheter and inject with 7cc contrast.
Physician place packing before scout image or
Patient Immobilization:
Light blue pad or
Pillow or
Arms on chest or
Legs straight or
Scan Parameters:
Superior border at L3/L4 interspace or
Inferior border ischial tuberosity/introitus or
Slice thickness: 1 mm slices (at least through tip of tandems) or
Set kVp to 140
CT reference point 2 cm superior of umbilicus or
Additional Simulation Instructions: (e.g., placement of wires, markers, BB’s etc.)
Verify that Foley has been tugged
Verify that contrast has been injected into Foley (at least for first fraction)
Verify tandem tips and orientation.
Verify that the tandem necks are even on scout, and print for comparison.
Once scan has been approved, mark levels and lateral lasers for ease of repositioning during
verification scans.
Page Physics
Attending
Resident to check CT scan
Simulation Directive Completed By: <Entered By>
<Current Date>
Simulation Note:
I was present to Choose
Attending Signature: <Approved By>
<Approved date time>
Electronically signed by controlled access password
Copyright * 2008
The Regents of The University of Michigan