Planning Notes

[ramsesthenice]

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How this actually played out where I was, was that the senior residents would be the ones who actually taught the junior residents. It was very rare for the attendings to spend anytime teaching contouring and the nuts and bolts of their disease sites. I was at a place where residents were to always do all normal OAR contours except for lungs and bones because it was good “practice” to give some idea. Places was busy as residents could expect to log 1,000+ cases in residency. Program was kinda on the acgme’s radar for a bit for the poor educational quality but nothing ever really happened. It is almost always listed on these list of places to avoid.

That sucks. I know there a different styles but I think there is one superior way to teach contouring (which is my style that I learned as a resident): have the resident contour the case. Then, I turn their contours off, do my own, and we compare them together and discuss the differences. Makes it much easier to distinguish style vs key aspects. I also have them write a planning note (with me right when we finish reviewing the contours) with specific dose objectives. It helps dosimetry but also repetition is the best way to learn these things. Takes time, but that’s the point of working at an academic center.

 

[drewdog1973]

That sucks. I know there a different styles but I think there is one superior way to teach contouring (which is my style that I learned as a resident): have the resident contour the case. Then, I turn their contours off, do my own, and we compare them together and discuss the differences. Makes it much easier to distinguish style vs key aspects. I also have them write a planning note (with me right when we finish reviewing the contours) with specific dose objectives. It helps dosimetry but also repetition is the best way to learn these things. Takes time, but that’s the point of working at an academic center.

What is this planning note you speak of? No scorecards ?

 

[ramsesthenice]

What is this planning note you speak of? No scorecards ?

I use a combination. Our planners do have score cards but I think it’s good practice to explicitly state your priorities and they won’t always be the same. Take a pancreatic case. Do you care more about the duodenal max point dose or absolute volume receiving > 50 or 54 Gy? Kinda depends right? If the anatomy is bad you might not get to pick. You might know you won’t be able to make your normal goal and they need to know if you are more willing to accept less PTV coverage or higher normal tissue dosing. You are more likely to be happy with the plan if you give them a more detailed idea of what you are looking for upfront. They can use the score cards for things that are not going to be problematic (like cord for 99.9% of pancreatic IMRT plans) but I want them to have my priorities.

It’s also good to know tricks to simplify your instructions. If your pancreatic RX dose is 50 Gy you know what the easiest way to meet all of your luminal dose objectives is? Limit the plan max to 105%. Very doable with VMAT. No need to list every single objective. Keep the plan cool, and you will meet your goals.

Residents need to know how to prioritize tumor coverage vs OAR goals and memorize dose limits. Dependency on score cards can do residents a major disservice.

 

[gmsquid]

I use a combination. Our planners do have score cards but I think it’s good practice to explicitly state your priorities and they won’t always be the same. Take a pancreatic case. Do you care more about the duodenal max point dose or absolute volume receiving > 50 or 54 Gy? Kinda depends right? If the anatomy is bad you might not get to pick. You might know you won’t be able to make your normal goal and they need to know if you are more willing to accept less PTV coverage or higher normal tissue dosing. You are more likely to be happy with the plan if you give them a more detailed idea of what you are looking for upfront. They can use the score cards for things that are not going to be problematic (like cord for 99.9% of pancreatic IMRT plans) but I want them to have my priorities.

It’s also good to know tricks to simplify your instructions. If your pancreatic RX dose is 50 Gy you know what the easiest way to meet all of your luminal dose objectives is? Limit the plan max to 105%. Very doable with VMAT. No need to list every single objective. Keep the plan cool, and you will meet your goals.

Residents need to know how to prioritize tumor coverage vs OAR goals and memorize dose limits. Dependency on score cards can do residents a major disservice.

Agree with above. Very true in HN. All my patients get unique constraints depending on anatomy, gtv volune, location, etc. if you don’t constrain properly and individually you can get overly toxic plans for people with small tumors.

 

[ramsesthenice]

I have had enough PMs that I am just going to start a public thread. I don't know of any formal templates for planning notes. What I like to do is a combination of things I picked up along the way. I feel like there are 3 key elements that I want physics/dose to consider when planning my cases:

1) Define your target volumes - its nice to remember exactly what you did and occasionally physics or dose catch where I expanded incorrectly or grabbed the wrong structure for expansion. For residents, it is also very good to be able to describe it words and details what you did and be able to go back and review at a later date. When I was a resident, I I can't count the number of times I would be contouring a complicated case late in the evening and trying to remember what we did for a similar case before.

2) Prescription - needs to include total dose, dose per fraction, and number of fractions as well as whether you want an SIB or sequential boost. There are a lot of ways of getting to 50 or 60 Gy right? I know of cases where attendings approved plans only to get a call from billing after the patient started wanting to know why they requested approval for 16 fractions but are now delivering 25 (you can guess what disease site that is...)

3) Dose limits - again, prioritize

I'll share an example from this week. This is a good one because even though I treat a lot of esophageal cancers, this is not a typical case. Young lady with a metastatic esophageal cancer to non-regional lymph nodes. She had a pretty good response to palliative chemo + herceptin but still has pretty bulky gastrohepatic nodes abutting the stomach and a number of aortocaval nodes. She is starting to get platinum toxicity so we are transitioning to "definitive" chemorads. Realistically our goal is durable local control but there is a small chance of cure (think Lloyd Christmas from Dumb and Dumber kind of small). These can be tough because you want to give her the best shot but also not cause undo toxicity. I ended up doing a weird dose/fractionation. In non-surgical cases I would normally want to give 45/25 to the nodal CTV and 54/30 to the gross disease if possible but there would be no way of getting that much dose without a very high risk of gastric ulceration in her case. So I opted to go to 52 Gy. What is the easiest way to get to 52 Gy? 2 x 26. But wait, do you really want to do a single fraction sequential boost (if the nodes go to 45/25)? No, thats a lot of work and silly. I opted to just do an SIB in 26 fractions to both volumes (1.8 and 2.0 x 26). I've never done this dose/fractionation before and I am pretty sure dosimetry has never seen it before either. Without writing it down I am almost assured to either get at least 1 phone call or have to ask for a re-plan.

Target Volumes
GTV = nodal and primary GTV on BH and Insp scans
ITV Primary = union of GTVs
CTV Primary = ITV Primary + 3 mm
Nodal CTV = regional and involved nodes contoured on BH (minimal motion so not contoured on Insp)
PTV 4680 = Nodal CTV + CTV primary + 5 mm
PTV 5200 = CTV Primary + 5 mm

Prescription
Single plan, SIB
180 cGy x 26 = 4680 cGy prescribed to PTV 4680
200 cGy x 26 = 5200 cGy prescribed to PTV 5200

Dose Limits
Liver V30 < 30%, Mean < 20 Gy
Kidneys Mean < 18 EACH
Duodenum/stomach V54 < 1 cc, Keep plan max < 105%

In 4 hours, I had an amazing plan that met all of my goals with a plan max 5378. I love pleasant surprises 🙂

And before anyone asks, how long these are depends on specifics of the case. I basically don't do much of a note for a standard 3 field rectal plan (I rarely contour any target volumes for these, the doses are standard and there is rarely anything to add to the score card). Prostate notes tend to be short unless the rectum is likely to cause problems.

 

[RickyScott]

I have had enough PMs that I am just going to start a public thread. I don't know of any formal templates for planning notes. What I like to do is a combination of things I picked up along the way. I feel like there are 3 key elements that I want physics/dose to consider when planning my cases:

1) Define your target volumes - its nice to remember exactly what you did and occasionally physics or dose catch where I expanded incorrectly or grabbed the wrong structure for expansion. For residents, it is also very good to be able to describe it words and details what you did and be able to go back and review at a later date. When I was a resident, I I can't count the number of times I would be contouring a complicated case late in the evening and trying to remember what we did for a similar case before.

2) Prescription - needs to include total dose, dose per fraction, and number of fractions as well as whether you want an SIB or sequential boost. There are a lot of ways of getting to 50 or 60 Gy right? I know of cases where attendings approved plans only to get a call from billing after the patient started wanting to know why they requested approval for 16 fractions but are now delivering 25 (you can guess what disease site that is...)

3) Dose limits - again, prioritize

I'll share an example from this week. This is a good one because even though I treat a lot of esophageal cancers, this is not a typical case. Young lady with a metastatic esophageal cancer to non-regional lymph nodes. She had a pretty good response to palliative chemo + herceptin but still has pretty bulky gastrohepatic nodes abutting the stomach and a number of aortocaval nodes. She is starting to get platinum toxicity so we are transitioning to "definitive" chemorads. Realistically our goal is durable local control but there is a small chance of cure (think Lloyd Christmas from Dumb and Dumber kind of small). These can be tough because you want to give her the best shot but also not cause undo toxicity. I ended up doing a weird dose/fractionation. In non-surgical cases I would normally want to give 45/25 to the nodal CTV and 54/30 to the gross disease if possible but there would be no way of getting that much dose without a very high risk of gastric ulceration in her case. So I opted to go to 52 Gy. What is the easiest way to get to 52 Gy? 2 x 26. But wait, do you really want to do a single fraction sequential boost (if the nodes go to 45/25)? No, thats a lot of work and silly. I opted to just do an SIB in 26 fractions to both volumes (1.8 and 2.0 x 26). I've never done this dose/fractionation before and I am pretty sure dosimetry has never seen it before either. Without writing it down I am almost assured to either get at least 1 phone call or have to ask for a re-plan.

Target Volumes
GTV = nodal and primary GTV on BH and Insp scans
ITV Primary = union of GTVs
CTV Primary = ITV Primary + 3 mm
Nodal CTV = regional and involved nodes contoured on BH (minimal motion so not contoured on Insp)
PTV 4680 = Nodal CTV + CTV primary + 5 mm
PTV 5200 = CTV Primary + 5 mm

Prescription
Single plan, SIB
180 cGy x 26 = 4680 cGy prescribed to PTV 4680
200 cGy x 26 = 5200 cGy prescribed to PTV 5200

Dose Limits
Liver V30 < 30%, Mean < 20 Gy
Kidneys Mean < 18 EACH
Duodenum/stomach V54 < 1 cc, Keep plan max < 105%

In 4 hours, I had an amazing plan that met all of my goals with a plan max 5378. I love pleasant surprises 🙂

And before anyone asks, how long these are depends on specifics of the case. I basically don't do much of a note for a standard 3 field rectal plan (I rarely contour any target volumes for these, the doses are standard and there is rarely anything to add to the score card). Prostate notes tend to be short unless the rectum is likely to cause problems.

I think this is an excellent approach for an academic center. In smaller community center, I will usually have this conversation with the planner (who typically know what I want) or perform optimization myself (to ensure that have the "best" plan, not just met constraints.

 

[Krukenberg]

I have had enough PMs that I am just going to start a public thread. I don't know of any formal templates for planning notes. What I like to do is a combination of things I picked up along the way. I feel like there are 3 key elements that I want physics/dose to consider when planning my cases:

1) Define your target volumes - its nice to remember exactly what you did and occasionally physics or dose catch where I expanded incorrectly or grabbed the wrong structure for expansion. For residents, it is also very good to be able to describe it words and details what you did and be able to go back and review at a later date. When I was a resident, I I can't count the number of times I would be contouring a complicated case late in the evening and trying to remember what we did for a similar case before.

2) Prescription - needs to include total dose, dose per fraction, and number of fractions as well as whether you want an SIB or sequential boost. There are a lot of ways of getting to 50 or 60 Gy right? I know of cases where attendings approved plans only to get a call from billing after the patient started wanting to know why they requested approval for 16 fractions but are now delivering 25 (you can guess what disease site that is...)

3) Dose limits - again, prioritize

I'll share an example from this week. This is a good one because even though I treat a lot of esophageal cancers, this is not a typical case. Young lady with a metastatic esophageal cancer to non-regional lymph nodes. She had a pretty good response to palliative chemo + herceptin but still has pretty bulky gastrohepatic nodes abutting the stomach and a number of aortocaval nodes. She is starting to get platinum toxicity so we are transitioning to "definitive" chemorads. Realistically our goal is durable local control but there is a small chance of cure (think Lloyd Christmas from Dumb and Dumber kind of small). These can be tough because you want to give her the best shot but also not cause undo toxicity. I ended up doing a weird dose/fractionation. In non-surgical cases I would normally want to give 45/25 to the nodal CTV and 54/30 to the gross disease if possible but there would be no way of getting that much dose without a very high risk of gastric ulceration in her case. So I opted to go to 52 Gy. What is the easiest way to get to 52 Gy? 2 x 26. But wait, do you really want to do a single fraction sequential boost (if the nodes go to 45/25)? No, thats a lot of work and silly. I opted to just do an SIB in 26 fractions to both volumes (1.8 and 2.0 x 26). I've never done this dose/fractionation before and I am pretty sure dosimetry has never seen it before either. Without writing it down I am almost assured to either get at least 1 phone call or have to ask for a re-plan.

Target Volumes
GTV = nodal and primary GTV on BH and Insp scans
ITV Primary = union of GTVs
CTV Primary = ITV Primary + 3 mm
Nodal CTV = regional and involved nodes contoured on BH (minimal motion so not contoured on Insp)
PTV 4680 = Nodal CTV + CTV primary + 5 mm
PTV 5200 = CTV Primary + 5 mm

Prescription
Single plan, SIB
180 cGy x 26 = 4680 cGy prescribed to PTV 4680
200 cGy x 26 = 5200 cGy prescribed to PTV 5200

Dose Limits
Liver V30 < 30%, Mean < 20 Gy
Kidneys Mean < 18 EACH
Duodenum/stomach V54 < 1 cc, Keep plan max < 105%

In 4 hours, I had an amazing plan that met all of my goals with a plan max 5378. I love pleasant surprises 🙂

And before anyone asks, how long these are depends on specifics of the case. I basically don't do much of a note for a standard 3 field rectal plan (I rarely contour any target volumes for these, the doses are standard and there is rarely anything to add to the score card). Prostate notes tend to be short unless the rectum is likely to cause problems.

I really like this, but I don’t understand how a dosimetrist could create a plan without prescription dose to PTVs and OAR constraints for the optimizer. We have a planning document we must submit and I guess I just assumed that was standard everywhere.

it doesn’t include how volumes were constructed however. Have you ever had concerns this could make a lawsuit much easier for a plaintiff’s attorney?

 

[OTN]

I have had enough PMs that I am just going to start a public thread. I don't know of any formal templates for planning notes. What I like to do is a combination of things I picked up along the way. I feel like there are 3 key elements that I want physics/dose to consider when planning my cases:

1) Define your target volumes - its nice to remember exactly what you did and occasionally physics or dose catch where I expanded incorrectly or grabbed the wrong structure for expansion. For residents, it is also very good to be able to describe it words and details what you did and be able to go back and review at a later date. When I was a resident, I I can't count the number of times I would be contouring a complicated case late in the evening and trying to remember what we did for a similar case before.

2) Prescription - needs to include total dose, dose per fraction, and number of fractions as well as whether you want an SIB or sequential boost. There are a lot of ways of getting to 50 or 60 Gy right? I know of cases where attendings approved plans only to get a call from billing after the patient started wanting to know why they requested approval for 16 fractions but are now delivering 25 (you can guess what disease site that is...)

3) Dose limits - again, prioritize

I'll share an example from this week. This is a good one because even though I treat a lot of esophageal cancers, this is not a typical case. Young lady with a metastatic esophageal cancer to non-regional lymph nodes. She had a pretty good response to palliative chemo + herceptin but still has pretty bulky gastrohepatic nodes abutting the stomach and a number of aortocaval nodes. She is starting to get platinum toxicity so we are transitioning to "definitive" chemorads. Realistically our goal is durable local control but there is a small chance of cure (think Lloyd Christmas from Dumb and Dumber kind of small). These can be tough because you want to give her the best shot but also not cause undo toxicity. I ended up doing a weird dose/fractionation. In non-surgical cases I would normally want to give 45/25 to the nodal CTV and 54/30 to the gross disease if possible but there would be no way of getting that much dose without a very high risk of gastric ulceration in her case. So I opted to go to 52 Gy. What is the easiest way to get to 52 Gy? 2 x 26. But wait, do you really want to do a single fraction sequential boost (if the nodes go to 45/25)? No, thats a lot of work and silly. I opted to just do an SIB in 26 fractions to both volumes (1.8 and 2.0 x 26). I've never done this dose/fractionation before and I am pretty sure dosimetry has never seen it before either. Without writing it down I am almost assured to either get at least 1 phone call or have to ask for a re-plan.

Target Volumes
GTV = nodal and primary GTV on BH and Insp scans
ITV Primary = union of GTVs
CTV Primary = ITV Primary + 3 mm
Nodal CTV = regional and involved nodes contoured on BH (minimal motion so not contoured on Insp)
PTV 4680 = Nodal CTV + CTV primary + 5 mm
PTV 5200 = CTV Primary + 5 mm

Prescription
Single plan, SIB
180 cGy x 26 = 4680 cGy prescribed to PTV 4680
200 cGy x 26 = 5200 cGy prescribed to PTV 5200

Dose Limits
Liver V30 < 30%, Mean < 20 Gy
Kidneys Mean < 18 EACH
Duodenum/stomach V54 < 1 cc, Keep plan max < 105%

In 4 hours, I had an amazing plan that met all of my goals with a plan max 5378. I love pleasant surprises 🙂

And before anyone asks, how long these are depends on specifics of the case. I basically don't do much of a note for a standard 3 field rectal plan (I rarely contour any target volumes for these, the doses are standard and there is rarely anything to add to the score card). Prostate notes tend to be short unless the rectum is likely to cause problems.

I'm going to be honest, I don't think this level of detail is necessary or even desirable for an official "treatment planning note" that has to be submitted for billing purposes. It's great for intra-department communication, but it contains a lot of information that isn't necessary or required.

Again, every department does things differently, and it sounds like this works well for you, which is great. We follow more of a templated process, so document creation takes less than 30-60 seconds, including tx planning note, dose limits, etc.

 

[drewdog1973]

I'm going to be honest, I don't think this level of detail is necessary or even desirable for an official "treatment planning note" that has to be submitted for billing purposes. It's great for intra-department communication, but it contains a lot of information that isn't necessary or required.

Again, every department does things differently, and it sounds like this works well for you, which is great. We follow more of a templated process, so document creation takes less than 30-60 seconds, including tx planning note, dose limits, etc.

Yes, it's fine but I think above and beyond what is needed. Scorecards and templated planning documents have served me well. More documentation probably doesn't hurt, but less than that is still going to get the job done.

If you are doing something non-standard, and want to establish documentation, that is a reasonable idea. 95% of times I follow my cookbook and there really isn't a benefit over evidence-based scorecards. So, 19/20 times a standard scorecard/template should do the job. If more than 5% of cases are "non-standard" or doing something odd, maybe your practice may not reflect generally accepted standards of care (which is fine - no judgment on that - people at various centers do things their own way, and I take no issue with that).

 

[ramsesthenice]

I'm going to be honest, I don't think this level of detail is necessary or even desirable for an official "treatment planning note" that has to be submitted for billing purposes. It's great for intra-department communication, but it contains a lot of information that isn't necessary or required.

Again, every department does things differently, and it sounds like this works well for you, which is great. We follow more of a templated process, so document creation takes less than 30-60 seconds, including tx planning note, dose limits, etc.

This has nothing to do with billing at all. Just goes in the planning system for communication with physics and dosimetry. No one else should care about this kind of detail or frankly even know what it means. This is not a departmental thing, its just what I do. And if I were in a small community practice with 1-2 dosimetrists and I were the only doc I don't think I would do it quite this way. And for the record, the above note only took me about 90 seconds or so to write. Its not that arduous 🙂

 

[RadOncDoc21]

This has nothing to do with billing at all. Just goes in the planning system for communication with physics and dosimetry. No one else should care about this kind of detail or frankly even know what it means. This is not a departmental thing, its just what I do

 

[drewdog1973]

 

[scarbrtj]

I have had enough PMs that I am just going to start a public thread. I don't know of any formal templates for planning notes. What I like to do is a combination of things I picked up along the way. I feel like there are 3 key elements that I want physics/dose to consider when planning my cases:

1) Define your target volumes - its nice to remember exactly what you did and occasionally physics or dose catch where I expanded incorrectly or grabbed the wrong structure for expansion. For residents, it is also very good to be able to describe it words and details what you did and be able to go back and review at a later date. When I was a resident, I I can't count the number of times I would be contouring a complicated case late in the evening and trying to remember what we did for a similar case before.

2) Prescription - needs to include total dose, dose per fraction, and number of fractions as well as whether you want an SIB or sequential boost. There are a lot of ways of getting to 50 or 60 Gy right? I know of cases where attendings approved plans only to get a call from billing after the patient started wanting to know why they requested approval for 16 fractions but are now delivering 25 (you can guess what disease site that is...)

3) Dose limits - again, prioritize

I'll share an example from this week. This is a good one because even though I treat a lot of esophageal cancers, this is not a typical case. Young lady with a metastatic esophageal cancer to non-regional lymph nodes. She had a pretty good response to palliative chemo + herceptin but still has pretty bulky gastrohepatic nodes abutting the stomach and a number of aortocaval nodes. She is starting to get platinum toxicity so we are transitioning to "definitive" chemorads. Realistically our goal is durable local control but there is a small chance of cure (think Lloyd Christmas from Dumb and Dumber kind of small). These can be tough because you want to give her the best shot but also not cause undo toxicity. I ended up doing a weird dose/fractionation. In non-surgical cases I would normally want to give 45/25 to the nodal CTV and 54/30 to the gross disease if possible but there would be no way of getting that much dose without a very high risk of gastric ulceration in her case. So I opted to go to 52 Gy. What is the easiest way to get to 52 Gy? 2 x 26. But wait, do you really want to do a single fraction sequential boost (if the nodes go to 45/25)? No, thats a lot of work and silly. I opted to just do an SIB in 26 fractions to both volumes (1.8 and 2.0 x 26). I've never done this dose/fractionation before and I am pretty sure dosimetry has never seen it before either. Without writing it down I am almost assured to either get at least 1 phone call or have to ask for a re-plan.

Target Volumes
GTV = nodal and primary GTV on BH and Insp scans
ITV Primary = union of GTVs
CTV Primary = ITV Primary + 3 mm
Nodal CTV = regional and involved nodes contoured on BH (minimal motion so not contoured on Insp)
PTV 4680 = Nodal CTV + CTV primary + 5 mm
PTV 5200 = CTV Primary + 5 mm

Prescription
Single plan, SIB
180 cGy x 26 = 4680 cGy prescribed to PTV 4680
200 cGy x 26 = 5200 cGy prescribed to PTV 5200

Dose Limits
Liver V30 < 30%, Mean < 20 Gy
Kidneys Mean < 18 EACH
Duodenum/stomach V54 < 1 cc, Keep plan max < 105%

In 4 hours, I had an amazing plan that met all of my goals with a plan max 5378. I love pleasant surprises 🙂

And before anyone asks, how long these are depends on specifics of the case. I basically don't do much of a note for a standard 3 field rectal plan (I rarely contour any target volumes for these, the doses are standard and there is rarely anything to add to the score card). Prostate notes tend to be short unless the rectum is likely to cause problems.

Of course, you could just do the plan yourself in those "not typical" cases 😉

 

[evilbooyaa]

What is this planning note you speak of? No scorecards ?

Over-reliance on score cards eliminates the critical thinking involved with creating challenging, yet attainable dose constraints for each individual patient. For things with standard anatomy, maybe it's all the same.

But I have individualized dose constraints for every single patient I plan that I give to the dosimetrist planning the case. Are things copied and pasted from previous patients? Sure, if clinically similar/relevant.

Score cards as a double-check to make sure something was not missed (like spinal cord in a pancreas case, as per above) is fine, but I hate it when that's common place. This is how people end up with contralateral parotid mean doses of 25Gy when doing a unilateral neck plan since "it meets constraints" from a scorecard called "H&N radiation".

Doctors who don't think about their dose constraints in an individual case leads to frustration with dosimetry. I prefer to give hard constraints (sacrifice coverage for this) and soft constraints (OK to break slightly to make sure we're covering) and even that's a judgement call on 'how far' can you break a soft constraint.

Here's a recent example I had - can I shoot for larynx mean of 35 here as I usually ask for in a b/l neck case or is it not really feasible b/c I'm treating b/l bilaterally on neck coplanar with a 5mm PTV due to the extent of the field and I know it's a soft constraint that I would not want them to drop coverage, so maybe I'll ask for mean of 45.

 

[drewdog1973]

@evilbooyaa

You just gave two perfect examples of situations that arise that still work well with scorecards:

1. Make a unilateral HNC scorecard. Done. A good center has this already. And a separate scorecard for post op and for early stage larynx.
2. Secondary constraints - 45 Gy is the goal, 35 Gy if you can't meet that for larynx. You can have this for most of your organs.

The comments I am reading are regarding prioritization, and this appears to be the doctor's issue, not the scorecard or the dosimetrist. You have to do the prioritization a priori.

If you make detailed scorecards and think through these types of possibilities AND are coherent with regards to prioritization of goals of targets and OARs, 95% of the time, you won't need to do additional work (unless you practice outside of mainstream standard of care - which is okay - or are the gal doing all the re-irradiation train wrecks for your center).

@OTN, @medgator - you both have mentioned having 35-40+ on treatment and are running a quality shop. Is what I'm saying making sense? Or are you having to discuss >10% or have individual planning goals for each patient?

 

[medgator]

@OTN, @medgator - you both have mentioned having 35-40+ on treatment and are running a quality shop. Is what I'm saying making sense? Or are you having to discuss >10% or have individual planning goals for each patient?

Definitely the exception rather than the rule

 

[evilbooyaa]

@drewdog1973 I basically start with a 'default' in my own head that I adapt based on patient's anatomy and clinical situation. If that's similar to starting with a scorecard that can be adapted, then maybe we're just arguing toe-may-toe vs ta-mah-toe.

If a scorecard needs physician input on what prioritization is, then sure, that's useful.

Another scenario - H&N patient with a level III LN in close proximity to Larynx getting 70Gy. Affected what I was going to ask for as a larynx constraint. Or a case where I'm treating R IB - score card will show me 'failing' R SMG constraint b/c I don't care, and will affect what I ask for in a L SMG constraint.

I suppose I'm biased because during my residency, the "good" (IMO) attendings used score cards just as a double check while presenting dosi with individualized constraints for each patient and clinical scenario, while the "lazy" (IMO) attendings never thought about clinical and patient information and accepted V20 of 37% on any lung case, same for a T3N1 patient or a T2N3 patient.

I just worry that score cards make physicians and dosimetrists complacement. That being said, I'm not nearly as busy as 35-40 on treat - but, an e-mail with goals takes me less than 3-5 minutes.

 

[evilbooyaa]

I usually just throw basically this same concept in an e-mail to the dosimetrist(s) planning the case.

I like to provide more clarity than what may be necessary - I remember one time as a junior resident I wrote "PTVs 54 and 60" in an email to dosimetry expecting a single 30 fraction plan (at 1.8 and 2Gy/day) and got a 27 fraction plan at 2Gy/fx followed by 3fx cone down.

Again, if one is working with a stable group of people or one on one with a dosimetrist, then this level of detail is probably overkill. Whatever works for folks as an attending is OK with me, but I think it's valuable for residents to be cognizant that a dosimetrist who can read an attending's mind is not ubiquitous.

 

[FrostyHammer]

I'm going to be honest, I don't think this level of detail is necessary or even desirable for an official "treatment planning note" that has to be submitted for billing purposes. It's great for intra-department communication, but it contains a lot of information that isn't necessary or required.

Again, every department does things differently, and it sounds like this works well for you, which is great. We follow more of a templated process, so document creation takes less than 30-60 seconds, including tx planning note, dose limits, etc.

Totally on point. The sample note by the OP reeks of bureaucracy in having to define what the volumes were. Why should it matter to officially write all that nonsense? DVH criteria, great, dose stuff, great, the rest is not needed.

 

[nkmiami]

Of course, you could just do the plan yourself in those "not typical" cases 😉

Putting in your own avoidance structures nearby that a good plan should be able to meet is helpful, and often better than constraint sheets.

Example prostate: 1 cm posterior to PTV into rectum, dose should be almost always be able to fall off to 50%- and within the pelvis- 2 cm from PTV LN and ptv prosate, , dose should be able to fall off to around 63%. (without plan getting more than 10% hot) Have done a few plans recently where I generated these avoidance structures and contoured normal tissues in later after the planning. Semi-automatic way for generating plans in some sites.

 

[FrostyHammer]

@drewdog1973 I basically start with a 'default' in my own head that I adapt based on patient's anatomy and clinical situation. If that's similar to starting with a scorecard that can be adapted, then maybe we're just arguing toe-may-toe vs ta-mah-toe.

If a scorecard needs physician input on what prioritization is, then sure, that's useful.

Another scenario - H&N patient with a level III LN in close proximity to Larynx getting 70Gy. Affected what I was going to ask for as a larynx constraint. Or a case where I'm treating R IB - score card will show me 'failing' R SMG constraint b/c I don't care, and will affect what I ask for in a L SMG constraint.

I suppose I'm biased because during my residency, the "good" (IMO) attendings used score cards just as a double check while presenting dosi with individualized constraints for each patient and clinical scenario, while the "lazy" (IMO) attendings never thought about clinical and patient information and accepted V20 of 37% on any lung case, same for a T3N1 patient or a T2N3 patient.

I just worry that score cards make physicians and dosimetrists complacement. That being said, I'm not nearly as busy as 35-40 on treat - but, an e-mail with goals takes me less than 3-5 minutes.

Props to you, man, this is excellent. I didn't start doing this until about a year into practice.

 

[drewdog1973]

@drewdog1973 I basically start with a 'default' in my own head that I adapt based on patient's anatomy and clinical situation. If that's similar to starting with a scorecard that can be adapted, then maybe we're just arguing toe-may-toe vs ta-mah-toe.

If a scorecard needs physician input on what prioritization is, then sure, that's useful.

Another scenario - H&N patient with a level III LN in close proximity to Larynx getting 70Gy. Affected what I was going to ask for as a larynx constraint. Or a case where I'm treating R IB - score card will show me 'failing' R SMG constraint b/c I don't care, and will affect what I ask for in a L SMG constraint.

I suppose I'm biased because during my residency, the "good" (IMO) attendings used score cards just as a double check while presenting dosi with individualized constraints for each patient and clinical scenario, while the "lazy" (IMO) attendings never thought about clinical and patient information and accepted V20 of 37% on any lung case, same for a T3N1 patient or a T2N3 patient.

I just worry that score cards make physicians and dosimetrists complacement. That being said, I'm not nearly as busy as 35-40 on treat - but, an e-mail with goals takes me less than 3-5 minutes.

If you aren't okay with V20 < 37%, why include that on scorecard? That is one of those things where you'd want to consider secondary. (V20<30% to cover. If exceeding and can't cover, V20<35% acceptable, etc.). I think if you are putting V20<37%, the person making the scorecard is being complacent.

We treat a lot of head and neck. If treating oral cavity or oropharynx, why even consider constraining it? Take it off the card! If you have a standard definitive head and neck card and it's a T3N1 larynx, please tell you me don't have to explain not to constrain the larynx?

I don't think we are saying tomato / tomahtoe. I think we do things differently. Which is okay! You gotta do you!

Point is, if you do a lot of the thinking pre-emptively and have some experience (either personal or institutional), the scorecard with evidence based goals and thoughtful prioritization followed by quality peer review) is essential for a busy, high quality RO.

 

[Lamount]

@drewdog1973 I basically start with a 'default' in my own head that I adapt based on patient's anatomy and clinical situation. If that's similar to starting with a scorecard that can be adapted, then maybe we're just arguing toe-may-toe vs ta-mah-toe.

If a scorecard needs physician input on what prioritization is, then sure, that's useful.

Another scenario - H&N patient with a level III LN in close proximity to Larynx getting 70Gy. Affected what I was going to ask for as a larynx constraint. Or a case where I'm treating R IB - score card will show me 'failing' R SMG constraint b/c I don't care, and will affect what I ask for in a L SMG constraint.

I suppose I'm biased because during my residency, the "good" (IMO) attendings used score cards just as a double check while presenting dosi with individualized constraints for each patient and clinical scenario, while the "lazy" (IMO) attendings never thought about clinical and patient information and accepted V20 of 37% on any lung case, same for a T3N1 patient or a T2N3 patient.

I just worry that score cards make physicians and dosimetrists complacement. That being said, I'm not nearly as busy as 35-40 on treat - but, an e-mail with goals takes me less than 3-5 minutes.

We have a lot of scorecards for different scenarios (at least I do in the chest). Sometimes they suffice as the de facto constraints, and sometimes we use them as means of assuring the plan is safe.

For prototypical cases, our dosimetrists are pretty good and usually produce an optimal plan. They routinely make control structure rings in IMRT/VMAT cases to force the plan to be conformal.

For moderately complex cases, I will customize the actual constraints and ask the dosimetrists to push harder where I think we can get away with it..

For very complex cases (i.e. ablative case adjacent to bronchus, cardiac SBRT), I will sometimes use MCO so that I can decide my own tradeoffs.

 

[metallica81788]

@drewdog1973 I basically start with a 'default' in my own head that I adapt based on patient's anatomy and clinical situation. If that's similar to starting with a scorecard that can be adapted, then maybe we're just arguing toe-may-toe vs ta-mah-toe.

If a scorecard needs physician input on what prioritization is, then sure, that's useful.

Another scenario - H&N patient with a level III LN in close proximity to Larynx getting 70Gy. Affected what I was going to ask for as a larynx constraint. Or a case where I'm treating R IB - score card will show me 'failing' R SMG constraint b/c I don't care, and will affect what I ask for in a L SMG constraint.

I suppose I'm biased because during my residency, the "good" (IMO) attendings used score cards just as a double check while presenting dosi with individualized constraints for each patient and clinical scenario, while the "lazy" (IMO) attendings never thought about clinical and patient information and accepted V20 of 37% on any lung case, same for a T3N1 patient or a T2N3 patient.

I just worry that score cards make physicians and dosimetrists complacement. That being said, I'm not nearly as busy as 35-40 on treat - but, an e-mail with goals takes me less than 3-5 minutes.

Can you take the responses about scorecards, planning, etc, and move them over to the planning note thread?
There has been some very good discussion between here and that thread. IMO would be nice to have all the conversation in one relevant place.

 

[evilbooyaa]

Can you take the responses about scorecards, planning, etc, and move them over to the planning note thread?
There has been some very good discussion between here and that thread. IMO would be nice to have all the conversation in one relevant place.

Ask reasonably and ye shall receive expetidiiously

 

[StIGMA]

I also prefer to customize constraints to a particular case. I wont accept mean 22 on a contralateral parotid for an ipsilateral neck even if stock scorecard says goal is 26. It takes a moment to put in something else, but I'm really educated guessing what they would be able to meet. Well trained Dosi should know priorities and where to push, but there is a lot of variability out there. Can hippocampus mean be 4 Gy in this case or accept 12+ or unconstrainted in this low grade glioma case in a young patient... why not push lower if we can? Very few people that I work with think/work this way unfortunately.

 

[radoncopotamus]

How much of this is a Mosaiq vs Aria issue? Where I trained had Mosaiq and there was no easy way to give planning objectives without a separate document or email being needed. Now working with Aria it is much easier as the planning objectives are all part of the prescription. Its much easier to have a template for each disease site and then customize constraints for each case based on what you think is achievable after doing the contours.

 

[drewdog1973]

I also prefer to customize constraints to a particular case. I wont accept mean 22 on a contralateral parotid for an ipsilateral neck even if stock scorecard says goal is 26. It takes a moment to put in something else, but I'm really educated guessing what they would be able to meet. Well trained Dosi should know priorities and where to push, but there is a lot of variability out there. Can hippocampus mean be 4 Gy in this case or accept 12+ or unconstrainted in this low grade glioma case in a young patient... why not push lower if we can? Very few people that I work with think/work this way unfortunately.

Second time the contra parotid came up for an ipsi case. Make a ipsi score card! These make up a good proportion of head and neck cases!

I may be wrong, but people seem to be making 2 boxes: 1) Scorecards that are "fixed" and not customized for the most common alternate situations (ipsi neck, using same scorecard for N0 breast vs treating nodes) 2) Complete customization for every patient. Think outside these two boxes and aim to simplify life. In addition, when you are starting out, you "think" you need to customize everything, and it's just not the case. I've worked with the junior faculty constantly tinkering and asking for a little lower V20 blah blah blah. It's fine. Lets us mentally masturbate and relieves that intellectual tension, and I've done that. It's delightful. But, eventually, you may see that it doesn't matter as much as you think it does (or you may not).

I see the "well here is an example of when I needed to customize". I think scorecard rigidity/inflexibility and blindly following reflects on the clinician and the dosimetrist, not the score card. If you "violate" a scorecard by blasting the left submandibular on a L BOT CA, than you are doing scorecards wrong. That shouldn't even be on there, except to track it, maybe.

I'll give an example - for prostate we have 1) Intact prostate - no balloon/spacer - conventional fx 2) intact prostate - balloon/spacer - conventional fx 3) Mod hypofx (these will have a balloon or spacer) 3a) M1 definitive cases - 55/20 4) extreme hypofx (has spacer) 5) EBRT after brachy conventional fx 6) post prostactomy conventional fx . So, for these cases - 95% of prostates are taken care of. What isn't? Lymph node positive cases (rare), small cell prostate cancer (super rare), palliative cases (don't really need score card).

Breast - N0 cases, N+ cases, left side cases, right side cases, 5 fx PBI, 5 fx whole breast. What's left? I do mostly breast now, and I haven't had to deviate from the scorecard except for re-irradiation and inflammatory.

CNS - single fx SRS, 3 fx SRS, 5 fx SRS. Whole brain 30/10. Whole brain 20/5. Whole brain hippocampal sparing. High grade glioma. High grade glioma hippocampal sparing. Pretty much all my CNS cases. Weirdoma? No score card - tinkertime!

Head and neck - early stage larynx, post op HNC, intact/definitive advanced HNC, intact/early stage HNC. Ipsi HNC. NPC. What else is there that you'll see often enough to worry about? Re-irradiation - this is tinkertime!

GI pelvis - anal, long course rectal, short course rectal. definitive rectal. Etc. etc.

But, if you have 10-12 on tx or have lots of time on your hands, go ahead an tinker time with all! It's not unreasonable.

 

[Krukenberg]

Second time the contra parotid came up for an ipsi case. Make a ipsi score card! These make up a good proportion of head and neck cases!

I may be wrong, but people seem to be making 2 boxes: 1) Scorecards that are "fixed" and not customized for the most common alternate situations (ipsi neck, using same scorecard for N0 breast vs treating nodes) 2) Complete customization for every patient. Think outside these two boxes and aim to simplify life. In addition, when you are starting out, you "think" you need to customize everything, and it's just not the case. I've worked with the junior faculty constantly tinkering and asking for a little lower V20 blah blah blah. It's fine. Lets us mentally masturbate and relieves that intellectual tension, and I've done that. It's delightful. But, eventually, you may see that it doesn't matter as much as you think it does (or you may not).

I see the "well here is an example of when I needed to customize". I think scorecard rigidity/inflexibility and blindly following reflects on the clinician and the dosimetrist, not the score card. If you "violate" a scorecard by blasting the left submandibular on a L BOT CA, than you are doing scorecards wrong. That shouldn't even be on there, except to track it, maybe.

I'll give an example - for prostate we have 1) Intact prostate - no balloon/spacer - conventional fx 2) intact prostate - balloon/spacer - conventional fx 3) Mod hypofx (these will have a balloon or spacer) 3a) M1 definitive cases - 55/20 4) extreme hypofx (has spacer) 5) EBRT after brachy conventional fx 6) post prostactomy conventional fx . So, for these cases - 95% of prostates are taken care of. What isn't? Lymph node positive cases (rare), small cell prostate cancer (super rare), palliative cases (don't really need score card).

Breast - N0 cases, N+ cases, left side cases, right side cases, 5 fx PBI, 5 fx whole breast. What's left? I do mostly breast now, and I haven't had to deviate from the scorecard except for re-irradiation and inflammatory.

CNS - single fx SRS, 3 fx SRS, 5 fx SRS. Whole brain 30/10. Whole brain 20/5. Whole brain hippocampal sparing. High grade glioma. High grade glioma hippocampal sparing. Pretty much all my CNS cases. Weirdoma? No score card - tinkertime!

Head and neck - early stage larynx, post op HNC, intact/definitive advanced HNC, intact/early stage HNC. Ipsi HNC. NPC. What else is there that you'll see often enough to worry about? Re-irradiation - this is tinkertime!

GI pelvis - anal, long course rectal, short course rectal. definitive rectal. Etc. etc.

But, if you have 10-12 on tx or have lots of time on your hands, go ahead an tinker time with all! It's not unreasonable.

This is how I’ve been trained and how I plan to do things. I’ve taken more interest in error prevention/QI as I get close to independent practice, and the more standardization I can do the better IMO

 

[ramsesthenice]

How much of this is a Mosaiq vs Aria issue? Where I trained had Mosaiq and there was no easy way to give planning objectives without a separate document or email being needed. Now working with Aria it is much easier as the planning objectives are all part of the prescription. Its much easier to have a template for each disease site and then customize constraints for each case based on what you think is achievable after doing the contours.

I use mosaiq. There is a planning tab in the patient navigator.

 

[radoncopotamus]

I use mosaiq. There is a planning tab in the patient navigator.
[/QUOTE

Is that a newer version feature?

 

[evilbooyaa]

Second time the contra parotid came up for an ipsi case. Make a ipsi score card! These make up a good proportion of head and neck cases!

I may be wrong, but people seem to be making 2 boxes: 1) Scorecards that are "fixed" and not customized for the most common alternate situations (ipsi neck, using same scorecard for N0 breast vs treating nodes) 2) Complete customization for every patient. Think outside these two boxes and aim to simplify life. In addition, when you are starting out, you "think" you need to customize everything, and it's just not the case. I've worked with the junior faculty constantly tinkering and asking for a little lower V20 blah blah blah. It's fine. Lets us mentally masturbate and relieves that intellectual tension, and I've done that. It's delightful. But, eventually, you may see that it doesn't matter as much as you think it does (or you may not).

I see the "well here is an example of when I needed to customize". I think scorecard rigidity/inflexibility and blindly following reflects on the clinician and the dosimetrist, not the score card. If you "violate" a scorecard by blasting the left submandibular on a L BOT CA, than you are doing scorecards wrong. That shouldn't even be on there, except to track it, maybe.

I'll give an example - for prostate we have 1) Intact prostate - no balloon/spacer - conventional fx 2) intact prostate - balloon/spacer - conventional fx 3) Mod hypofx (these will have a balloon or spacer) 3a) M1 definitive cases - 55/20 4) extreme hypofx (has spacer) 5) EBRT after brachy conventional fx 6) post prostactomy conventional fx . So, for these cases - 95% of prostates are taken care of. What isn't? Lymph node positive cases (rare), small cell prostate cancer (super rare), palliative cases (don't really need score card).

Breast - N0 cases, N+ cases, left side cases, right side cases, 5 fx PBI, 5 fx whole breast. What's left? I do mostly breast now, and I haven't had to deviate from the scorecard except for re-irradiation and inflammatory.

CNS - single fx SRS, 3 fx SRS, 5 fx SRS. Whole brain 30/10. Whole brain 20/5. Whole brain hippocampal sparing. High grade glioma. High grade glioma hippocampal sparing. Pretty much all my CNS cases. Weirdoma? No score card - tinkertime!

Head and neck - early stage larynx, post op HNC, intact/definitive advanced HNC, intact/early stage HNC. Ipsi HNC. NPC. What else is there that you'll see often enough to worry about? Re-irradiation - this is tinkertime!

GI pelvis - anal, long course rectal, short course rectal. definitive rectal. Etc. etc.

But, if you have 10-12 on tx or have lots of time on your hands, go ahead an tinker time with all! It's not unreasonable.

This is a lot more options than what I was imagining when you said 'scorecards'. I suppose that this system works for you. If you can take a score card and quickly edit it where you see fit, then that's a fine system, IMO.

My one light caveat to that, is that I'm not a fan of listing what the planning goals were in the Rx, with a score card checklist of 'what OAR constraints were met and what ones were not'. IDK, this is just my own mumbo-jumbo about legal stuff - probably not a valid concern.

However, if I was at a place that had as robust of a planning score card in this scenario, then I wouldn't bat an eye. FWIW, some stuff is well standardized (intracranial SRS for 1, 3, 5fx) in terms of my recommended dose constraints case to case.

 

[drewdog1973]

This is a lot more options than what I was imagining when you said 'scorecards'. I suppose that this system works for you. If you can take a score card and quickly edit it where you see fit, then that's a fine system, IMO.

My one light caveat to that, is that I'm not a fan of listing what the planning goals were in the Rx, with a score card checklist of 'what OAR constraints were met and what ones were not'. IDK, this is just my own mumbo-jumbo about legal stuff - probably not a valid concern.

However, if I was at a place that had as robust of a planning score card in this scenario, then I wouldn't bat an eye. FWIW, some stuff is well standardized (intracranial SRS for 1, 3, 5fx) in terms of my recommended dose constraints case to case.

You may be right about it medico legal wise. Constraints are in the simulation order and in the score card in planning system. I’m not sure what actually gets submitted, that’s a reasonable question/concern, but hasn’t been an issue. Plus, there is robust QA / peer review.

 

[ramsesthenice]

You may be right about it medico legal wise. Constraints are in the simulation order and in the score card in planning system. I’m not sure what actually gets submitted, that’s a reasonable question/concern, but hasn’t been an issue. Plus, there is robust QA / peer review.

Regardless of what your upfront system of documentation is, if you absolutely blow by a commonly accepted objective you need to document your reasoning. We all accept things we’d rather not from time to time and if there is a justifiable reason it (generally) isn’t malpractice. But if you don’t document your decision making before something adverse happens it is a lot easier for a good lawyer to find some peers to say you might not be practicing safe medicine.

I don’t see the sense in documenting every missed objective, just the ones that make me hesitate before signing.