Dosimetry Review

Spinal cord

Brain Stem

PTV1

PTV2

OTT

• Full DICOM radiotherapy plan (planning CTs, structures, dose)
• Radiotherapy prescription sheet
• Clinical Data Summary
• Treatment delivery record with the date of each fraction
• Patient set-up weekly images
• Neck dissection prior to CRT?

Review criteria		Definitive ChemoRT or RT	Post-Operative ChemoRT or RT	Points
H&P	Relevant history stated	Duration of symptoms. Alcohol and tobacco history and current usage detailed.	Duration of symptoms. Alcohol and tobacco history and current usage detailed.	1 2 3 4 5
	Comments
	Relevant physical findings	Full H&N exam including indirect mirror exam or fiberoptic exam. Review of prior video stroboscopy allowed.	Full H&N exam including statement regarding current state of post-operative healing.	1 2 3 4 5
	Comments
	Appropriate staging	TNM stage should be based on all available data including from physical exam and CT scan. PET information if available. MRI if clinically indicated.	T and N stage confirmed by pathology report.	1 2 3 4 5
	Comments
	Pathology report/Surgical reports	Diagnosis of malignancy confirmed by biopsy.	Histology, size of primary tumor, margin status, size, number and location of involved nodes, presence of extracapsular extension, LVSI, perineural invasion.	1 2 3 4 5
	Comments
	Appropriate patient selection for treatment/Discussion of options	If appropriate was surgery first or induction chemotherapy discussed as possible treatment options?	If chemotherapy given, are the indications given: positive surgical margins, extracapsular extension, other?	1 2 3 4 5
	Comments
Simulation	Appropriate consent form listing side effects	mucositis xerostomia Altered taste/smell Hoarseness Skin erythema Ear pain and/or pressure Fatigue Weight loss Loss of teeth, cavities, hypersensitivity of teeth thyroid dysfunction Damage to spinal cord, nerves in neck, jawbone, voicebox, skin, or other parts of head and neck that could require surgical correction Brachial Plexopathy Breathing problems Difficulty with swallowing or eating that may require a long term or permanent feeding tube Possibility of inhaling food and/or liquids into the lungs which could result in pneumonia Serious ear infections and/or hearing loss Damage to the spinal cord leading to permanent weakness and/or symptoms like a stroke	mucositis xerostomia Altered taste/smell Hoarseness Skin erythema Ear pain and/or pressure Fatigue Weight loss Loss of teeth, cavities, hypersensitivity of teeth thyroid dysfunction Damage to spinal cord, nerves in neck, jawbone, voicebox, skin, or other parts of head and neck that could require surgical correction Brachial Plexopathy Breathing problems Difficulty with swallowing or eating that may require a long term or permanent feeding tube Possibility of inhaling food and/or liquids into the lungs which could result in pneumonia Serious ear infections and/or hearing loss Damage to the spinal cord leading to permanent weakness and/or symptoms like a stroke	1 2 3 4 5
	Comments
	Appropriate treatment plan note	Definition of what is to be included in the PTV high dose and elective dose. Plans on using chemotherapy. Rationale for using IMRT if done.	Definition of what is to be included in the PTV high dose and elective dose. Plans on using chemotherapy. Rationale for using IMRT if done.	1 2 3 4 5
	Comments
	Appropriate simulation note/process	CT-based, slice thickness of ≤ 3mm, images from top of head to carina. Set up documentation.	CT-based, slice thickness of ≤ 3mm, images from top of head to carina. Set up documentation.	1 2 3 4 5
	Comments