This document contains a checklist for evaluating stereotactic body radiation therapy (SBRT) plans for treating liver lesions, including hepatocellular carcinoma and metastases. It lists patient information, treatment details, dosimetry requirements for the tumor and normal liver tissue, and constraints for nearby organs at risk. Acceptable dose limits are provided for the maximum and minimum doses to the tumor targets and several critical structures to ensure the plan meets protocol standards for safe and effective SBRT treatment.

1. LIVER[HCC.METS] SBRT PLAN EVALUATION CHECK LIST [RTOG 1112]
1. NAME UMR
2. DIAGNOSIS
3. PRIOR TREATMENT
4. MOTION MANAGEMENT
5. NUMBER OF LESIONs
6. CHILD SCORE[BEAP]
7. LIVER VOLUME LIVER-GTV VOLUME LIVER-PTV VOLUME
8. LOCATION SIDE SIZE max [mm] PTV MARGIN VOLUME-CC DOSE
1. GTV PTV
2. GTV PTV
3. GTV PTV
4. GTV PTV
5. GTV PTV
9. PLAN TYPE-[3DCRT/VMAT/DCR/IMRS]
10. PRESCRIBED MARGINALISODOSE BED
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D MAX
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D95% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
D100% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V95% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V100% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V120% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
V130% LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
DISTANCE BETWEEN 80% ISODOSE AND 60% ISODOSE-[<2mm]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
DISTANCE BETWEEN 80% ISODOSE AND 40% ISODOSE-[<8mm]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
CONFIRMITY INDEX [IDEAL 1] VOLUME OF PRESCRIPTION ISODOSE/VOLUME OF PTV
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
HOMOGENITY INDEX [BETWEEN 1.1-1.3] MAX DOSE/ PRESCRIPTION DOSE
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
GRADIENT INDEX[BETWEEN 0.3-0.9][RADIUS OF PRESCRIPTION ISODOSE - RADIUS OF HALF PRESCRIPTION ISODOSE]
LESION 1 LESION 2 LESION 3 LESION 4 LESION 5
PRESCRIPTION DOSE LIVER-GTV [>700CC]
NEEDED ACCEPTABLE UNACCEPTABLE ACHIEVED
50 Gy ≤13 Gy 13-13.2 Gy > 13.2 Gy
45 Gy ≤15 Gy 15-15.2 Gy > 15.2 Gy
40 Gy ≤15 Gy 15-15.2 Gy > 15.2 Gy
35 Gy ≤15.5 Gy 15.5-15.7Gy > 15.7 Gy
30 Gy ≤16 Gy 16-16.2 Gy > 16.2 Gy
27.5 Gy ≤17 Gy 17-17.2 Gy > 17.2 Gy
11. NON LIVER OAR CONSTARINTS NEEDED ACCEPTABLE UNACCEPTABLE ACHIEVED
Esophagusmax (to 0.5 cc): 32 Gy > 32 but ≤34 Gy > 34 Gy
Stomach max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Duodenum max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Small bowel max (to 0.5 cc): 30 Gy >30 but ≤32 Gy > 32 Gy
Large bowel max (to 0.5 cc): 32 Gy >32 but ≤34 Gy > 34 Gy
Cord +5 mm max (0.5cc): 25 Gy >25 but ≤28 Gy > 28 Gy
Kidneys: Bilateral mean ≤10 Gy >10 but ≤12 Gy > 12 Gy
Chest wall
Gall bladder
CBD <50Gy