Primary Central Nervous System (CNS)
Lymphoma Radiation Therapy
(As of 31 January 2017)
This worksheet is to be used for curative or palliative treatment of primary central nervous system (CNS)
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ / _______
a. Has the patient received chemotherapy?
b. If the patient has received chemotherapy, what was the response?
Complete response (CR)
Partial response (PR)
No response (NR)
Progressive disease (POD)
2. Will the patient be receiving concurrent chemotherapy? Yes No
What external beam radiation therapy (EBRT) technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1 Phase 2
Complex (77307) Complex (77307)
3D conformal 3D conformal
Intensity modulated radiation therapy (IMRT) Intensity modulated radiation therapy (IMRT)
Proton beam therapy Proton beam therapy
Rotational arc therapy Rotational arc therapy
Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT)
Number of fractions: _________________ Number of fractions: _________________
4. Will daily image-guided radiation therapy (IGRT) be used? Yes No
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