Primary Central Nervous System (CNS)
Neoplasm Radiation Therapy
Physician Worksheet
(As of 17 April 2018)
This worksheet is to be used for curative or palliative treatment of primary central nervous system neoplasm.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)? ______ /______ /______
1.
What is the patient’s WHO grade or diagnosis?
WHO grade
I: Pilocytic astrocytoma
II: Low grade oligo/ astrocytoma/ependymoma
III: Anaplastic astrocytoma
IV: Glioblastoma multiform (GBM)
Diagnosis
Primary spinal tumor
Ependymoma
Recurrent primary CNS malignant tumor previously irradiated
Adult medulloblastoma
Supratentorial PNET (primitive neuroectodermal tumor)
Benign: Meningioma, Schwannoma, Pituitary Adenoma
Other: ______________________________________
2. What is the
patient’s
ECOG
performance
status?
0
Fully active, able to carry on all pre-disease performance without restriction
1
Restricted in physically strenuous activity but ambulatory and able to carry out
work of a light or sedentary nature, e.g., light house work, office work
2
Ambulatory and capable of all self-care but unable to carry out any work
activities. Up and about more than 50% of waking hours.
3
Capable of only limited self-care, confined to bed or chair more than 50% of
waking hours.
4
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
chair.
3.
What resection has been performed?
Biopsy only
Subtotal resection
Gross total resection
Other: ______________
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