KOLHAPUR CANCER CENTRE

DEPARTMENT OF RADIATION ONCOLOGY

ICRT / CVS BRACHYTHERAPY FORM

NAME________________________________________ SEX-M/F RTNO.___________PRN________

DIAGNOSIS____________________________ STAGE __________ FRACTION NO 1/2/3.___________
APPLICATOR TYPE

1. Three channel applicator (Fletcher Fixed Type)_______ Intra Uterine Length__________cm

2. Vaginal Stump Applicator
Applicator Data__________ Length cm ________ Source Travel Path Length________ cm
3. Two Ovoids
4. Ring Applicator
5. Esophagus Bougie Applicator / Ryles / Tube/
Applicator Data_________________cm__________Source Travel Path Length_________cm
______________________________________________________________________________

PRESCRIBES DOSE AT
1. Point ‘A’
2. __________cm from the surface of the Applicator
3. Other __________________________________________________________________________
External Dose Received_______________________________ in______________________#S
Planned Bachytherapy Dose in Fraction #1/2/3____________________________________Gy
Maximum Bladder Dose________________Gy ( ) %at Point B1/B2/B3
Maximum Rectal Dose _________________Gy ( ) %at Point R1/R2/R3/R4/R5
Source Position in Channel 1 _________________________________________________________
Source Position in Channel 2 _________________________________________________________
Source Position in Channel 3 _________________________________________________________
Source Stepping Distance _______mm, Treatment Time (in sec)
Date Point ‘A’ Dose (Gy) Bladder Dose (%) Rectum Dose (%) Other

1#___________ _______________ ______________ ______________ ______________

2#___________ _______________ ______________ ______________ ______________

3#___________ _______________ ______________ ______________ ______________

Total
__________________________________________________________________________________
REMARK
GOOD Modified Removed
CT/ FILM SIMULATION TPS PLANNING
ASSESSMENT

Physicist (Planning) Physicist (verification) Radiation Oncologist