Soft Tissue Sarcoma
Radiation Therapy Worksheet
(As of 19 January 2018)
This worksheet is to be used for curative or palliative treatment of soft tissue sarcoma. If the treatment is for metastases
from soft tissue sarcoma, please use the appropriate metastatic worksheet.
For NON-URGENT requests, please complete this document for authorization along with any relevant clinical
documentation requested within this document (i.e. radiation therapy consultation, comparison plan, etc.) before submitting
the case by web, phone, or fax. Failure to provide all relevant information may delay the determination. Phone and fax
numbers can be found on eviCore.com under the Guidelines and Fax Forms section. You may also log into the provider
portal located on the site to submit an authorization request. URGENT (same day) requests must be submitted by phone.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ / ______
1.
Where is the soft tissue sarcoma located?
2.
What is the intent of treatment?
Palliative, for relief of symptoms
Definitive, biopsy only and no resection completed or planned
Pre-operative, resection planned after pre-operative radiation
Borderline resectable, neoadjuvant radiation to convert from unresectable to resectable
Post-operative, resection performed no pre-radiation given
Post-operative, pre-operative radiation was given
Re-treatment of localized recurrent disease with curative, salvage intent
3.
a. What is the T stage?
T stage: __________
b. What is the N stage?
N stage: __________
c. Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
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Soft Tissue Sarcoma
Radiation Therapy Worksheet
(As of 19 January 2018)
4.
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.
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5.
What treatment will be used?
External beam radiation therapy (EBRT)
Brachytherapy
Brachytherapy and EBRT
6.
If EBRT is being used, what is the treatment plan?
Select a technique for each applicable phase and fill in the number of fractions.
Phase 1
Phase 2
Phase 3
3D conformal
3D conformal
3D conformal
Complex (77307)
Complex (77307)
Complex (77307)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Proton beam therapy
Proton beam therapy
Rotational arc therapy
Rotational arc therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Tomotherapy
Tomotherapy
Fractions: __________
Fractions: __________
Fractions: __________
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Soft Tissue Sarcoma
Radiation Therapy Worksheet
(As of 19 January 2018)
7.
If brachytherapy is being used, answer the following set of questions.
a. What is the dose rate?
Low dose rate (LDR)
High dose rate (HDR)
b. If HDR, how many fractions will be rendered?
Fractions: __________
c. If HDR, how many applications will be used?
Applications: _______
8.
Is the area to be treated abutting or overlapping a previously irradiated area?
Yes No
9.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
9.
Note any additional information in the space below: