Patient Order Intake

Patient Order Intake

Use this form to submit new patient case information. Alternatively, you can call us during business hours.

TeleDaaS Hours of Operation are Mon-Fri: 9am-5pm (EST)

Phone: (303) 500 - 7766

Institution Name*

Ordering Physician Name *

Contact Phone Number

Please provide a reliable number for us to reach you if additional information is needed. You may also contact the TeleDaaS team at (303) 500-7766.

Phone

Patient First Name*

Patient Last Name*

Patient DOB*

What type of order are you placing?*

Select or enter value

What was the activity at the time of treatment?

What was the residual fraction percentage? (If applicable)*

Enter "N/A" if not applicable

What is the intended day of the week for delivery?

Select or enter value

Please select all images you are submitting for the Pre-Treatment Planning.*

Note: please only submit imaging for what is required for the treatment plan.

Please select all images you are submitting for this Retrospective Pre-Treatment plan.

Note: please only submit imaging for what is required for the treatment plan.

Diagnostic CT/Multi-phase CT (some or all phases contrast-enhanced)/Multi-phase diagnostic MR (some or all phases contrast-enhanced)

Planar 99mTc-MAA NM

Multiple CBCTs (optional)

99mTc-MAA SPECT/CT

FDG PET/CT

Angio-CT

Simplicity Save session

Please select the Post-Treatment images your are submitting*

Note: please only submit imaging for what is required for the treatment plan.

Diagnostic CT/Multi-phase CT (some or all phases contrast-enhanced)/Multi-phase diagnostic MR (some or all phases contrast-enhanced, + Angio-CT )

Planar 99mTc-MAA NM

Y90 PET/CT

Y90 SPECT/CT

RTSS (if LSF is not provided then RTSS for planar data)

Please select the images your are submitting.*

Note: please only submit imaging for what is required for the treatment plan.

Y-90 PET/CT

Bremsstrahlung SPECT

Friendly reminder to send the images to TeleDaaS if not done already

Do you want TeleDaaS to use its default dosing methods?*

Please note that the following are utilized as the default dosing methods:

Lobar deliveries: The target of the dosimetry with be 250 Gy to the tumor based on a randomized controlled trial out of France(1).
For selective deliveries (defined as delivery to ≤2 segments) we will dose 400 Gy to the perfused volume based on a multicenter retrospective pathologic correlation showing 100% complete pathologic response in patients reaching this threshold(2). Please note that although this method will be used for dosing the customers will receive data indicating the predicted dose to tumor and normal tissue.

References:

(1) Garin E, Tselikas L, Guiu B, et al. Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomized multicentre, open-label phase 2 trial. Lancet Gastroenterol Hepatol. 2021;6(1):17-29.

(2) Gabr A, Riaz A, Johnson GE, et al. Correlation of Y90-absorbed radiation dose to pathological necrosis in hepatocellular carcinoma: confirmatory multicenter analysis in 45 explants. Eur J Nucl Med Mol Imaging. 2021;48(2):580-583.

Yes

If no, what dose would you like to target for GY to the perfused volume?*

Enter "N/A" if not applicable

If no, what dose would you like to target for GY to the tumor?*

Enter "N/A" if not applicable

If no, what dose would you like to target for GY to the normal perfused liver tissue?*

Enter "N/A" if not applicable

If providing LSF, please enter the value.

Enter "N/A" if not applicable

Previous dose to lungs that you know of?

Enter "N/A" if not applicable

What was the LSF value?

Please feel free to document any additional information for the TeleDaaS technologist or physician.

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