Fillable Form 1.: Primary Central Nervous System (CNS) Lymphoma (eviCore)

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Form 1.: Primary Central Nervous System (CNS) Lymphoma (eviCore)

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Primary Central Nervous System (CNS)
Lymphoma Radiation Therapy
Physician Worksheet
(As of 31 January 2017)
This worksheet is to be used for curative or palliative treatment of primary central nervous system (CNS)
lymphoma.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ / _______
1.
a. Has the patient received chemotherapy?
Yes No
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
3.
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)
Tomotherapy Tomotherapy
Number of fractions: _________________ Number of fractions: _________________
4. Will daily image-guided radiation therapy (IGRT) be used? Yes No
Continued on next page
Primary Central Nervous System (CNS)
Lymphoma
Radiation
Therapy
Physician Worksheet
(As of 31 Januray 2017)
5.
Note any additional information in the space below:
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Form 1.: Primary Central Nervous System (CNS) Lymphoma (eviCore)

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Completed 23 June 2021

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