Radiation Therapy Treatment Planning & Dose Constraints Plan

Note Title: Radiation Therapy Treatment Planning & Dose Constraints Plan

Status: [Draft / Final]

Plan Version: [Plan v1 / Replan v2 / Addendum v#]

Course/Plan: [course name, plan name, treatment site]

Date: [creation date/time]

Radiation Oncologist: [name]

Clinical Context & Planning Intent

• [Diagnosis with laterality, primary site, histology]
• [Stage or staging status] (If pending, specify imaging used as planning basis.)
• [Treatment intent: curative / definitive / adjuvant / palliative / re-irradiation]
• [Special considerations impacting constraints] (e.g., concurrent systemic therapy, implanted device, connective tissue disease, clinical trial.)
• [Prior radiation therapy] (If applicable: prior site, dose/fractionation, dates, cumulative dose management approach. Document any unavailable records and risk mitigation.)

Prescription

(List one line per target or SIB level. State prescription normalization method explicitly.)

• [Treatment site and laterality] ([modality and technique]): [dose per fraction] × [number of fractions] = [total dose] prescribed to [normalization method: % isodose line / DVH endpoint].
• (Repeat for each additional target/SIB/boost as needed.)
• [Boost status] (If pending pathology or response assessment, indicate addendum will follow.)

Target Volumes & Margins

(Document actual numeric margins, motion management, setup uncertainty assumptions, and IGRT frequency. Include PRV structures if used.)

Structure	Clinical Description	Generation Rule/Margins
[GTV_xxx]	[Gross disease included]	[Imaging modality and date(s)]
[CTV_xxx]	[Subclinical/risk regions; postoperative bed if applicable]	[GTV to CTV margin: uniform/anisotropic, mm; anatomic rationale]
[ITV_xxx]	[Motion envelope] (If motion-managed)	[4DCT/respiratory method; phase range]
[PTV_xxx]	[Planning target for delivery robustness]	[CTV/ITV to PTV margin: mm; setup uncertainty; IGRT frequency; immobilization]
[PRV_structure]	[OAR with planning risk margin]	[OAR to PRV margin: mm; rationale]

Dose Constraints

(List target coverage objectives first, then serial OARs, then parallel OARs. Include metric definition, numeric limit, priority, and constraint source. Annotate fractionation applicability if mixing schemas.)

Structure	Metric	Limit	Priority	Source
[PTV_xxx]	[D95% coverage]	[≥ value Gy]	[Hard / High / Medium / Low]	[Protocol / QUANTEC / Institutional v#]
[PTV_xxx]	[D2% hotspot]	[≤ value Gy]	[Hard / High / Medium / Low]	[Source]
[Serial OAR / PRV]	[D0.03cc or Dmax]	[≤ value Gy]	[Hard / High / Medium / Low]	[Source]
[Parallel OAR]	[Dmean / VxGy]	[≤ value Gy / %]	[Hard / High / Medium / Low]	[Source]
[Additional OARs as clinically indicated]	[Metric]	[Limit]	[Priority]	[Source]

Overlap and Priority Rules: [PTV–OAR overlap handling; which constraints take precedence; acceptable coverage compromises with minimum thresholds.]

Technical Parameters

• Technique & energy: [VMAT / IMRT / 3D / SBRT / IMPT] with [beam energy/ion species]
• Imaging for contouring: [CT / 4DCT / MRI / PET-CT]; [contrast status]; registration method
• Immobilization & setup: [devices, position, prep instructions]
• Motion management: [None / DIBH / Gating / Tracking] (Include verification method if applicable.)
• IGRT: [imaging modality]; [frequency]; action thresholds
• Algorithm: [name/version] (Include robustness parameters for particle therapy.)

Attestation & Approval

"Planning goals and requirements, including target coverage objectives and OAR dose constraints, have been specified for this case as documented above."

Plan Status: [Planning directive only (pre-optimization) / Includes plan acceptance criteria (post-optimization)]

Referenced Artifacts: [Plan name/version, dose report, composite dose if applicable] (Do not state constraints met without documented achieved values or explicit artifact reference.)

• Radiation Oncologist: [name] — [signature] — [date/time]
• Physicist: [name] — [signature] — [date/time] (If required by institutional policy.)