RadOnc Smart Review

This is Episode sixteen: Oropharynx Foundations, H.P.V. Biology, and A.J.C.C. Eighth Edition Staging.Today we begin a new block, and I want to set the stage with something fundamental: oropharynx cancer is not one disease. It is two biologically distinct diseases that share an anatomic region.H.P.V. positive oropharynx cancer is virally driven, occurs in a different patient population, and has dramatically better outcomes. H.P.V. negative oropharynx cancer is the traditional tobacco and alcohol-related disease with worse prognosis and different behavior.This distinction is so important that A.J.C.C...

Today, we simulate the oral board exam in five blocks. Each block has a multi-step main case, then a shorter twist that tests a different high-yield decision point for the same scenario. Treat this as a live exam. Pause after each question to formulate your response. Let’s begin.

This is Episode 15B: Subsite-Specific Coverage for Oral Cavity Cancer. You’re sitting at the contouring workstation with a post-operative oral cavity case loaded. The C-T simulation is fused with the best available preoperative imaging. The surgeon has sent you the operative report. And now you face the questions that define whether your plan is correct:Which nodal levels need coverage? Ipsilateral neck only or bilateral? How far do I extend my primary C-T-V? And what anatomic “must-include” structures are unique to this subsite? The oral cavity is not one disease. It’s a family of subsites with different drainage, differen...

This is Episode 15A: Perineural Invasion Tracking and Skull Base Extension.The pathology report lands on your desk: “Extensive perineural invasion involving a named nerve measuring zero-point-three millimeters in diameter. Inferior alveolar nerve identified at the deep margin.”Now what?Do you treat the tumor bed and call it a day? Do you track the nerve all the way to the skull base? How far is far enough? And what happens when your C T V starts encroaching on the brainstem and temporal lobe?

This is Episode 14C: Definitive Radiation and Brachytherapy for Oral Cavity Cancer.Throughout this oral cavity series, we’ve emphasized one principle above all: oral cavity cancer is a surgical disease. Surgery first. Radiation in the adjuvant setting. But what happens when surgery isn’t an option?

This is Episode fourteen B: Planning with Reconstruction - Flaps, Hardware, and the O.R.N. Trade-Off.In Episode eleven B, we built your planning vocabulary: simulation, volumes, nodal levels, and O.A.R. priorities. But that episode assumed a straightforward post-operative bed. What happens when surgery was more complex? When the patient has a fibular free flap reconstructing the mandible? When there's a titanium plate throwing streak artifact across your planning C.T.? When the tumor bed is now buried under transplanted tissue from the thigh or forearm?

In Episode eleven A, we established that oral cavity cancer is a surgical disease. We learned the anatomy, the staging, and why surgery wins. But here's the thing: when pathology comes back with adverse features, you become the treating physician. And that means you need to know how to plan.This episode builds your technical vocabulary. We're going to cover how to simulate an oral cavity patient, the philosophy behind G-T-V, C-T-V, and P-T-V, the nodal level anatomy you need to draw on a diagram, and the critical structures you must protect. By the end, you'll be able to describe...

This is Episode fourteen: Oral Cavity Four — Mandible, Reconstruction, and Bone Invasion Pitfalls.In the previous three episodes, we covered oral cavity anatomy, surgical management, the neck decision, and adjuvant therapy principles. Now we need to tackle what happens when the mandible is in play—and it often is.The mandible is the elephant in the room for oral cavity radiation. Floor of mouth tumors sit directly against the lingual cortex. Lower alveolar ridge cancers arise from the gingiva overlying the bone. Retromolar trigone tumors can extend to the ascending ramus. Even oral tongue cancers can invade the mandible through the...

This is Episode thirteen: Oral Cavity Three — PORT versus Post-op Chemo-RT: The "Big Two."In the last two episodes, we established that oral cavity cancer is a surgical disease and that the clinically node-negative neck requires elective treatment when depth of invasion exceeds three to four millimeters. Now the surgery is done. The pathology report is in your hands. The question becomes: what adjuvant therapy does this patient need?This is the domain of two landmark trials that every radiation oncologist must know cold: R-TOG ninety-five-oh-one by Cooper and E-O-R-T-C twenty-two-nine-three-one by Bernier—both published in the New England Journal of M...

This is Episode twelve: Oral Cavity Two — The Clinically Node-Negative Neck: Elective Dissection, Not Watchful Waiting.In Episode Eleven, we established that oral cavity cancer is a surgical disease and that depth of invasion drives staging and management. We introduced the concept of elective neck dissection for the clinically negative neck. Now we're going to go deep on the evidence. The cN0 neck is one of the classic oral board scenarios. The examiner will present a patient with early oral tongue cancer, clinically and radiographically negative nodes, and ask you what to do with the neck. Observation is only defensible in...

This is Episode eleven: Oral Cavity One — Subsites, Depth of Invasion, and Why Surgery Usually Wins.Over the next four episodes, we're going to master oral cavity cancer from the perspective of the radiation oncologist preparing for boards. And I want to be clear about something right up front: oral cavity is a surgical disease. Unlike oropharynx, where definitive chemoradiation is standard, oral cavity cancer is treated with surgery first. Our role as radiation oncologists is adjuvant—we come in after the surgeon, and our decisions are driven by what pathology tells us.

This is Episode 10: Foundations IX — Planning Workshop: IMRT, VMAT, Protons, and OAR Priorities.We’ve arrived at the “dark room” episode. Up to now, you’ve made clinical decisions: diagnosis, stage, intent, dose, and fractionation. Now you’re at the console, staring at a CT and a dose cloud, and the boards are essentially asking: “Do you know what matters, and can you keep the patient safe?”

This is Episode 9: Foundations VIII — Supportive Care II: Swallow, Aspiration, Trismus, and Osteoradionecrosis.Last episode was: “Don’t lose the patient during treatment.”This episode is: “Don’t ruin the next thirty years of their life.”Head and neck survivorship is different. We’re curing more patients, younger patients, and we’re curing them with treatments that permanently reshape function. Late effects are not side effects. They are the patient’s new baseline.

This is Episode 8: Foundations VII — Supportive Care I: Dental, Nutrition, and Mucositis.We have spent the last seven episodes talking about how to kill the cancer. Today, we talk about how to keep the patient alive while we do it. On oral boards, supportive care is the great differentiator. A candidate who can recite fractionation trials but cannot explain when to pull a tooth, when to place a PEG, or how to manage week-five mucositis is advertising inexperience.This is the “Don’t Lose the Patient” episode: the pre-treatment checklist, the on-treatment playbook, and the red lines you do not cross.

This is Episode 7: Foundations VI — Systemic Therapy With RT: Cisplatin, Cetuximab, and Alternatives.We’ve built the scaffolding: anatomy, staging, and fractionation. Now we add the lever that most reliably increases cure rates in locally advanced head and neck cancer: concurrent systemic therapy.And here’s the board-relevant truth: examiners don’t just test whether you know that “chemo helps.” They test whether you know **who** should get it, **which** regimen is the standard, **when** cisplatin is unsafe, and **why** cetuximab is not a “gentler substitute” in HPV-positive oropharynx.

This is Episode 6: Foundations V — Fractionation and Time: Why We Don’t Treat Head and Neck Like Prostate.In prostate cancer, a week off for a holiday can be inconvenient, but the tumor biology barely flinches. In head and neck squamous cell carcinoma, a week off is not “just a delay.” It is a biological advantage handed to the tumor.Today is the Time Factor episode: overall treatment time, accelerated repopulation, altered fractionation, and—most important for oral boards—what you actually do when treatment gets interrupted.

This is Episode 5: Foundations IV — AJCC Staging That Actually Changes Management.Most residents treat staging as paperwork—something you fill out after you’ve already decided the plan. That’s backward. In AJCC Eighth Edition, staging is a decoder ring: it tells you which disease biology you’re dealing with, what patterns of failure to respect, and which high-risk variables will force treatment intensification.

Welcome back to Rad Onc Smart Review, Head and Neck edition.This is Episode 4: Unknown Primary — The Neck Mass Without a Mucosal Home.In the last episode, we talked about the workup. We scoped, we scanned, and we biopsied. Most of the time, that process finds the culprit — a small tonsil cancer hiding in crypts or a base of tongue tumor you could miss on casual inspection. But sometimes, you do everything right — contrast imaging, PET, examination under anesthesia, directed biopsies, palatine tonsillectomy, and even tongue base sampling — and the pathology still comes back negative for a primary site. Now you have...

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 3: Foundations III — Workup Masterclass: Scope, PET, Pan endo, and Biomarkers.Today is about the discipline of diagnosis.On oral boards, there is a specific way to fail a head and neck case before you ever draw a contour: you jump to treatment before you have established the diagnosis and stage. That signals immaturity. The examiner is not just testing whether you can plan IMRT. They are testing whether you can think like the attending who owns the whole patient.

This is Episode 2: Foundations II — Cranial Nerves, PNI Highways, and the Skull Base.**Last episode, we mapped lymphatics. Today, we map nerves.Because in head and neck oncology, **perineural invasion is not just a pathology word. It is geography.** It is a route problem. When tumor gets into a nerve, it can travel **from a peripheral skin site or gland to the skull base foramina**, and from there into deeper skull base compartments. That is why PNI changes your clinical target volume.

This is Episode 1: Foundations I — Neck Levels and Spaces That Change Volumes.We are starting this season with anatomy because in head and neck oncology, anatomy is destiny. If you do not understand the drainage pathways, you cannot draw the target. And if you cannot draw the target, you cannot cure the patient—or worse, you cure them but leave them with avoidable, life-altering toxicity. Today, we are not just memorizing lists. We are building the visual framework—the grid—that you will overlay on every CT scan you scroll through for the rest of your career. This is high-yield for writ...

This is Episode 18: *Mock Oral Boards 2 – Vulvar, Vaginal, and Complex Recurrence Cases*. This is our **final episode in the GYN series**. In the **next series, we’ll move on to Breast cancer** and build a new mock oral framework there.**Examiner:** In Episode 17, we focused on cervical and endometrial cancer fundamentals and brachytherapy technique. Today we escalate to the “exam-separating” scenarios: unresectable vulvar and vaginal primaries, sentinel node management, pelvic recurrences, re-irradiation, and high-grade toxicities.When you hear the pause, answer out loud as if you are in the hot seat. I’ll then give you a polished performance script and a teac...

Today, we're not just reviewing content; we're practicing the *performance* of the oral boards. I will act as your examiner, providing board-style prompts for eight comprehensive cases, each with a contrasting twist. When you hear the pause, answer out loud, practicing a crisp, structured, and confident response.After each pause, I’ll give you a model answer—a polished performance script—followed by a key teaching pearl.We’ll cover definitive management of locally advanced cervical cancer, risk-stratified adjuvant therapy in endometrial cancer, and crucial techniques and plans for brachytherapy. Let’s begin.

Welcome back to Rad Onc Smart Review, GYN Series. This is Episode 16: GYN Brachytherapy — The Oral Boards Performance Guide. Today is a mock oral. I’ll ask; you answer. Then I’ll give teaching pearls. Focus on applicator selection, polished procedural scripts, hybrid escalation, plan read-outs, troubleshooting, and complications. Pause after each question to formulate your answer.

Ovarian cancer is dominated by surgery and systemic therapy. As radiation oncologists, we’re expert consultants who step in at critical junctures: to clarify staging and risk, to advise on maintenance systemic strategies that shape recurrence patterns, and to deliver highly conformal radiation for palliation or carefully selected oligometastatic disease. Today we’ll cover surgical staging and cytoreduction goals, the modern systemic landscape (including PARP inhibitors and HRD), and radiation’s niche roles—palliative EBRT and SBRT for oligometastatic or oligoprogressive disease.

Today we will master primary vaginal cancer from first principles to planning. We will start with epidemiology, pathophysiology, and the anatomy that dictates nodal targets. We will explain why definitive radiation is the backbone of curative therapy for most stages. Then we will design a complete plan that combines pelvic EBRT with a brachytherapy boost, including when to choose an interstitial implant rather than a cylinder. By the end, you will be able to choose the correct nodal basins based on tumor location, justify definitive radiation over morbid surgery, and construct a curative EBRT and brachy plan to seventy to...

Last time we built the algorithm for early vulvar cancer—who needs nodes, how sentinel mapping changes the plan, and when to radiate the vulvar bed and groins. Today we turn to the hard one: locally advanced, unresectable disease. We’ll start by defining “unresectable,” walk through the neoadjuvant chemoradiation evidence, and then do a planning workshop you can take straight to clinic: how to contour the inguinofemoral basins without the classic medial miss, how to set doses for elective versus high-risk volumes, and why you should not “midline-block” the vulva when you’re treating positive nodes. We’ll reinforce, repeat where it...

This is Episode twelve: Vulvar Cancer Part one—Foundations and evidence for surgery and adjuvant radiation. Today we build from first principles—epidemiology, pathophysiology, anatomy, workup, and staging—and then walk the decision tree for surgery, nodes, and radiation using four anchor studies: the depth-of-invasion rule from the GOG era, the GROINSS-V pathway for sentinel nodes, the Heaps margin criteria for the primary, and GOG-thirty-seven for node-positive adjuvant radiation. By the end, you’ll know when to observe, when to re-operate, and when—exactly—to radiate the vulva, groins, and pelvis.

Today is a hands-on planning workshop. We’ll simulate, contour, and plan adjuvant pelvic IMRT. Then we’ll master vaginal cuff HDR brachytherapy—from choosing the cylinder to writing the prescription and optimizing dwell times. You’ll also get two short “oral boards canned speeches” you can deliver verbatim on exam day.

Welcome back to Rad Onc Smart Review, Gyn cancer series. This is a special topics episode focused on three areas that trip people up on consults and in orals: uterine sarcomas, carcinosarcoma, and how to cure medically inoperable endometrial cancer with radiation.

This is Episode ten: Endometrial Cancer, Part three — high-risk histologies and Stage three through four-A disease, plus what to do when cancer comes back.Last time we mastered adjuvant therapy for early stage. Today we zoom in on who truly benefits from chemo-radiation, how to reconcile Portec-three with G.O.G. two fifty-eight, how molecular subtype changes the plan, and what first-line therapy looks like now for advanced or recurrent disease.

Last time, we mastered modern staging and SLN mapping. Today, we answer the question you get every week in clinic: Who needs observation, who gets VBT, and who still needs pelvic EBRT? We’ll build the algorithm from GOG 99, PORTEC-1, PORTEC-2, and key updates, and we’ll start with a quick Surgical Corner so we’re crystal-clear on what operation and pathology we’re planning around.

Today we pivot from cervical to endometrial cancer, the most common gynecologic malignancy in the U.S. While many patients present early, outcomes hinge on understanding the biology and the new 2023 FIGO staging that integrates molecular data. We’ll differentiate classic and molecular subtypes, walk the new staging system, and review why sentinel lymph node biopsy (SLNB) is now the standard for nodal staging.

For two decades, concurrent cisplatin-based chemoradiation was the uncontested standard for locally advanced cervix cancer. That foundation still stands—but 2023–2024 ushered in real upgrades. Today, we’ll cover what to add (and when) for definitive therapy, and how first-line systemic therapy has changed for metastatic and recurrent disease.

In our last episode, we established why brachytherapy is a mandatory, life-saving component of definitive cervical cancer treatment. Today, we get practical. This is a hands-on workshop covering the "how-to" of brachytherapy. We will walk through the key steps of a tandem and ovoids procedure, learn how to decide when to add interstitial needles, and most importantly, master the dose constraints—the "cheat sheet" of numbers that you absolutely must know to create a safe and effective plan.

In our last episode, we mastered the modern techniques for planning pelvic external beam radiation. But for the definitive treatment of cervical cancer, EBRT is only the first half of the story. The second, non-negotiable component for achieving a cure is brachytherapy. Today, we’re going to build the case for why brachytherapy is mandatory. We’ll review the powerful evidence demonstrating its survival benefit over external-beam boosts, the critical importance of overall treatment time, and the paradigm shift toward image-guided volumetric targets that has transformed outcomes.

In our last few episodes, we’ve focused on the “why” and “when” of treating cervical cancer. Today, we shift to the “how.” This is a practical, hands-on workshop: how to simulate, contour pelvic and para-aortic nodes with modern atlases, justify IMRT over 3D, choose an SIB for nodal disease, execute IGRT correctly, and manage toxicities proactively.

Today, we are tackling one of the most significant paradigm shifts in the history of radiation oncology: the establishment of concurrent chemoradiation as the definitive standard of care for locally advanced cervical cancer. This isn't just an incremental improvement; it was a revolution that dramatically improved survival for our patients. Understanding the key trials that drove this change is absolutely essential for both your clinical practice and your board exams.

In our last episode, we established the framework for managing newly diagnosed, early-stage cervical cancer. But what happens when the surgeon calls you for a post-op consult? This is one of the most common and highest-yield scenarios you will face. Today, we're going to master the post-operative decision framework, learning exactly when to recommend observation, when to give adjuvant radiation, and when to add concurrent chemotherapy.

Welcome back to Rad Onc Smart Review, Gyn cancer series. This is Episode 1: Cervix Cancer Part 1: Staging, Workup, and Early-Stage Evidence.Today, we're laying the foundation for our entire cervical cancer curriculum. We're going to tackle the critical first steps in managing a new diagnosis: understanding the disease's background, how to properly stage a patient using the modern FIGO system, what workup is essential, and how to counsel a patient on the fundamental choice between primary surgery and primary radiation.

This is our final episode in the C.N.S. block, Episode 20C: a comprehensive Case-Based Review of Benign C.N.S. Tumors and Stereotactic Radiosurgery cases.Over the last several episodes, we've systematically dissected the evidence that defines modern C.N.S. oncology, from malignant gliomas to a wide range of benign tumors. Let's continue to put that knowledge to the test. This episode is a mock oral board examination. I will present five comprehensive case blocks. Pause after each question to formulate your own structured response before I provide the model answer and a key teaching pearl.

Welcome back to Rad Onc Smart Review, C.N.S. Cancer series. Over the last several episodes, we've systematically dissected the evidence that defines modern C.N.S. oncology. We are continuing our mock oral style review of CNS oncology. I will present comprehensive case blocks, covering different clinical scenarios and then pose a series of questions designed to test your knowledge across all core competencies. Pause after each question to formulate your own structured response before I provide the model answer and a key teaching pearl.

Over the last several episodes, we've systematically dissected the evidence that defines modern CNS oncology. Today, we put that knowledge to the test. These episodes will follow a mock oral board examination. I will present comprehensive case blocks, covering different clinical scenarios and then pose a series of questions designed to test your knowledge across all core competencies. Pause after each question to formulate your own structured response before I provide the model answer and a key teaching pearl.

Episode 19D: Benign P3d: Rare Benign Rapid Review.Needs editing

This is Episode 19c: Benign P3c: Trigeminal Neuralgia – SRS for Functional Pain.Needs editing

This is Episode 19b: Benign P3b: AVM Part 2 - SRS Technique, Doses & Toxicity. Needs editing

This is Episode 19a, the first in our new two-part series on a fascinating and challenging benign condition: Arteriovenous Malformations, or AVMs. To build a foundational understanding of arteriovenous malformations (AVMs) by covering their biology and risk factors, applying the Spetzler-Martin scale to assess surgical risk, calculating annual hemorrhage risk, and critically dissecting the controversial ARUBA trial.

In our last episode, we mastered the management of non-functioning pituitary adenomas, where the primary goal of radiation is long-term tumor control. Today, we tackle the more complex world of functional, or secreting, pituitary adenomas. Here, the clinical challenge is entirely different. Our goal is not just to control the size of the tumor, but to achieve biochemical control—to shut down the hormonal overproduction that causes debilitating syndromes like Cushing's disease and acromegaly. This episode will master the distinct, subtype-specific management of these tumors, focusing on their unique goals, the higher radiation doses required, and the differing timelines for ho...

In our last two episodes, we mastered the management of vestibular schwannomas. Today, we shift our focus to another common sellar region tumor: the pituitary adenoma. While often discovered incidentally, these tumors can cause significant morbidity through mass effect. In this episode, we will focus specifically on non-functioning pituitary adenomas, covering their comprehensive workup, surgical management, the critical role of adjuvant radiation, and the evidence-based outcomes and toxicities.

In our last episode, we established the foundational framework for managing vestibular schwannomas. We worked up our patient, a 55-year-old man with a Koos Grade II tumor and serviceable hearing, and after reviewing the options, decided that stereotactic radiosurgery offered him the best balance of tumor control and functional preservation. Today, we take him to the treatment planning system. This episode is a deep dive into the technical aspects of radiation for vestibular schwannoma, covering simulation, precise dose prescriptions, critical cranial nerve dose constraints, and long-term follow-up.

Today we're tackling one of the most common non-malignant brain tumors you will treat: the vestibular schwannoma, also known as an acoustic neuroma. While histologically benign, these tumors can cause significant, life-altering morbidity by affecting hearing, balance, and facial function. The management is a masterclass in shared decision-making, balancing excellent tumor control rates against the critical goals of preserving cranial nerve function and quality of life. This episode will lay the complete foundation for managing these tumors, covering the detailed workup, classification, natural history, and the initial decision-making framework.

This is Episode 17b: Non-Glioma Part 2: Atypical & Anaplastic Meningiomas & Future Directions.In Episode 17a, we built the essential foundation for understanding meningiomas, covering their epidemiology, detailed WHO grading, and the management of WHO Grade I tumors. Today, we confront the more challenging and clinically critical aspects: the complex management of Atypical (Grade II) and Anaplastic (Grade III) meningiomas. We will dissect the nuances of adjuvant radiation for these higher-grade tumors, explore strategies for re-irradiation, provide specific radiation planning pearls, and look at the landscape of emerging systemic therapies.

This is Episode 17a: Non-Glioma Part 1: Meningioma Foundations & Grade I Management. While gliomas often take the spotlight, the single most common primary intracranial tumor you will encounter is the meningioma. But don't let its often-benign histology fool you; the management of meningiomas is deceptively complex, nuanced, and surprisingly lacking in high-level randomized evidence. Today, we will build a robust framework for managing these tumors, integrating the latest molecular insights. We'll differentiate WHO grades with precision, apply the classic Simpson surgical grades to predict recurrence, detail the comprehensive workup, and then dive into the evidence-based management of WHO Grade I tumors.

In our last episode, we laid the complete foundation for managing spinal metastases. Today, we transition from the broad strokes of conventional palliation to the high-precision, high-impact world of Stereotactic Body Radiation Therapy, or SBRT. This episode is a practical workshop. We will cover who to treat with SBRT, a deep dive into the conflicting evidence, how to delineate targets with a step-by-step guide, what critical dose constraints to respect, and finally, how to safely approach the challenge of re-irradiation.

In Episode 15a, we covered the comprehensive workup for a patient with suspected spinal metastases, from distinguishing pain types to detailed imaging interpretation and initial supportive care. Today, we move to the definitive decisions. We will master the assessment of spinal stability using the SINS score, delineate the Bilsky scale for grading cord compression, and define the evidence-based management of malignant epidural spinal cord compression, including the landmark Patchell trial and modern conventional RT options.

This is Episode 15a, the first in our new two-part foundational series on Spinal Metastases. Today's episode is titled: "Spine Mets Part 1: Anatomy & Initial Workup."Metastatic disease to the spine is one of the most common and challenging scenarios we face. It can cause debilitating pain, catastrophic neurologic injury, and profoundly impact quality of life. Correct management requires a rapid, systematic approach, and that starts with an impeccable understanding of spinal anatomy and how to interpret imaging. Today, we will build that foundation. We will cover the complete workup, from clinical presentation and imaging to the indications for biopsy. We’ll...

This is our mock oral boards for lower GI malignancies. I will present two comprehensive rectal cancer cases, walking you through each one from initial presentation all the way through treatment and follow-up. For each section, I want you to pause and formulate your own structured response before I walk you through the model answer and a key teaching pearl. The goal is to think like an attending and solidify your clinical decision-making from start to finish. Let's get started.

Over the last several episodes, we've systematically broken down the evidence that defines modern GI oncology. Today, we put that knowledge to the test. This episode is a mock oral board examination. I will present five comprehensive case blocks, covering Esophageal, Gastric, Pancreatic, Hepatobiliary, and Hepatocellular cancers. For each, I will present a clinical scenario and then pose a series of questions designed to test your knowledge across all core competencies. Pause after each question to formulate your own structured response before I provide the model answer and a key teaching pearl. Let's begin.

This episode is a mock oral boards session. I will present three distinct, challenging clinical scenarios. For each case, we will walk through the entire management process, from initial presentation all the way through treatment and follow-up, to sharpen your clinical decision-making.

Over the past decade, the landscape of systemic therapy has been transformed by the arrival of immunotherapy and highly effective targeted agents. Many of these drugs have significant intracranial activity, creating a new and complex challenge for the radiation oncologist: how do we sequence our treatments? The old paradigm of "radiation first" is no longer always correct. Today, we will provide a modern guide to navigating this new reality. We will discuss when it's appropriate to defer radiation entirely, compare the CNS efficacy of different systemic regimens, and detail the critical safety considerations and toxicity risks of combining SRS with...

Today, we address the frontiers of SRS. First, we'll ask: can we treat more than four metastases? Second, how do we safely and effectively treat large metastases that are too big for a single high dose of radiation? And finally, we will tackle the most common and challenging complication of SRS: how to differentiate radiation necrosis from tumor progression.

Today, we will conduct a practical workshop on postoperative stereotactic radiosurgery. We'll dissect the two landmark trials that define this practice, learn how to properly delineate a post-operative target volume, and discuss the dreaded complication of nodular leptomeningeal disease.

In our last episode, we laid the groundwork for managing brain metastases. Today, we tackle one of the most significant paradigm shifts in modern radiation oncology: the move away from routine whole-brain radiotherapy for patients with a limited number of brain metastases. For decades, WBRT was the standard. Now, for many patients, it's an inferior option. We will walk through the chronological story of the landmark trials that drove this revolution, culminating in the definitive evidence that establishes stereotactic radiosurgery, or SRS, alone as the standard of care for preserving cognitive function.

Brain metastases are the most common intracranial tumor in adults, and their management has undergone a complete revolution. Before we can treat, we must be able to prognosticate and have a firm grasp of the foundational principles. Today, we will cover the essential background, including epidemiology and workup. We will master the modern prognostic indices, including the Disease-Specific Graded Prognostic Assessment, or D-S-G-P-A. And finally, we will open the whole-brain radiotherapy toolkit, discussing the evidence for adding memantine and detailing the technique and landmark data for hippocampal-avoidance WBRT.

This is Episode 8: Low-Grade Glioma Part 3: Treatment Planning & Case-Based Review. Over the last two episodes, we've built the complete evidence-based framework for managing WHO Grade II gliomas. We've learned how to risk-stratify patients, when to treat, and what regimen to use. Today, we put that knowledge into practice. We'll start with a deep dive into the technical details of treatment planning and toxicity management. Then, we will consolidate our knowledge by working through a series of challenging, oral board-style case scenarios designed to test your clinical decision-making from start to finish.

This is Episode 7: Low-Grade Glioma Part 2: Evidence for Chemo, Dose, and IDH Inhibitors.In our last episode, we established the framework for managing Grade II gliomas, answering the crucial question of when to treat. Today, we address the next logical question: for those high-risk patients we decide to treat, how do we treat them? We will dissect the pivotal evidence that transformed our approach from radiation alone to combined-modality therapy, justify our standard radiation dose by looking at the specific data from the negative dose-escalation trials, and look to the future with the exciting new data on targeted IDH inhibitors.

This is Episode 6, and we are kicking off our new mini-series on Low-Grade Gliomas. Today's episode is titled: "LGG P1: Foundations, Risk Stratification & The Timing Debate."For years, the management of WHO Grade II gliomas has been one of the most debated topics in neuro-oncology. These tumors often occur in young, otherwise healthy individuals and have a long natural history, making the decision of when to intervene complex. Today, we will lay the foundation for managing these tumors by first establishing their modern molecular definition, then learning how to use the Pignatti risk factors to stratify patients, and finally, we...

In our first four episodes, we've established the "what" and the "why" of high-grade glioma management. Today, we get practical and move to the "how." Treatment planning is a core competency for any radiation oncologist, and for high-grade gliomas, it's a discipline of millimeters and nuanced judgments.

In our first three episodes, we mastered the standard approach for a "Stupp-eligible" patient with glioblastoma. But as you know, many of our patients do not fit this mold. They are older, have a lower performance status, or present with the formidable challenge of recurrent disease. Today, we address these special cases head-on. We'll build a framework for treating elderly and frail patients, review the evidence for re-irradiation, and discuss the role of the novel technology, Tumor-Treating Fields.

In our first two episodes, we built the modern diagnostic framework for high-grade gliomas, focusing on anaplastic oligodendrogliomas and astrocytomas. Today, we turn our attention to the most common and most formidable of these tumors: glioblastoma, IDH-wildtype. For years, this diagnosis came with a grim prognosis. But in 2005, one trial created a paradigm shift, establishing the bedrock of modern neuro-oncology. We will do a deep dive into the Stupp protocol and explore why, despite nearly two decades of research, it remains our standard of care.

In our last episode, we established the modern molecular framework for diagnosing high-grade gliomas and detailed the management of anaplastic oligodendroglioma. Today, we explore the other side of that coin. We will master the management of anaplastic astrocytoma by dissecting the pivotal CATNON trial, and we’ll tackle a challenging new entity introduced in the 2021 WHO classification: the IDH-mutant astrocytoma, Grade 4, a tumor that looks lower-grade under the microscope but carries a much graver prognosis based on its genetics.

Welcome back to Rad Onc Smart Review, CNS Edition.T his is Episode 1 of our new series on CNS oncology, titled: Modern Classification & Anaplastic Oligodendroglioma Evidence. For decades, we treated high-grade gliomas based on what a pathologist saw under a microscope. But in the last ten years, a molecular revolution has completely rewritten the textbook. You cannot treat what you can't accurately diagnose, and the modern diagnosis of glioma is now an integrated, molecular one. Today, we will establish this critical diagnostic framework. Then, we will apply it by taking a deep dive into the management of anaplastic oligodendroglioma, synthesizing...

This is Episode 20B: Anal Cancer Part 4: Guidelines, Toxicity, Follow-Up & Future Directions. Over the last three episodes, we've built a comprehensive understanding of anal cancer, from its foundational anatomy and staging, to the landmark trials that established definitive chemoradiation, and the technical details of modern IMRT planning. We've learned the 'what,' 'why,' and 'how' of our standard of care. In this final episode of our anal cancer series, we bring everything together. We will synthesize the key recommendations from the landmark 2025 ASTRO Clinical Practice Guideline, which now serves as our primary evidence-based roadmap. We'll then discuss practical strategies...

In our last episode, we established the foundations of anal cancer therapy, proving that definitive chemoradiation with 5-FU and Mitomycin-C is the organ-preserving standard of care. But while this approach is highly effective, it is also notoriously toxic. The older 3D radiation techniques often led to severe side effects and treatment breaks that compromised outcomes.Today, we focus on the modern "how." We'll explore how IMRT has revolutionized our ability to treat this disease. We'll walk through a detailed, dose-painted IMRT planning workshop. And finally, we'll use a case to discuss the management of special populations you will frequently encounter...

In our last episode, we laid the foundation for anal cancer management, establishing definitive concurrent chemoradiation as the sphincter-sparing standard of care, thanks to the pioneering work of Dr. Nigro and the pivotal ACT I and EORTC trials. We know why we use chemoradiation. Today, we focus on how to optimize it.Modern chemoradiation for anal cancer is a finely tuned balance of three critical components: the right chemotherapy, the right radiation dose, and the right timing. Getting any of these wrong can compromise cure rates or lead to unnecessary toxicity. Today, we’ll dissect the evidence for each of th...

We've arrived at our final primary site in the lower GI tract: anal cancer. In many ways, this disease is the ultimate success story for radiation oncology. It is one of the few solid tumors where we have moved from a paradigm of radical, mutilating surgery to a non-operative, organ-preserving standard of care, with definitive chemoradiation as the backbone. Today, we'll trace the history of this remarkable shift. We’ll start with the fundamentals of anatomy and staging that make anal cancer unique. Then we'll cover the revolutionary Nigro protocol that started it all, and finally, dive deep into the pi...

Today, we shift our focus to managing advanced and recurrent rectal cancer. We will outline the systemic therapy options for metastatic colorectal cancer, including the roles of specific chemotherapies and biologics based on molecular markers. We'll then discuss the critical management of lateral pelvic lymph nodes. Finally, we'll delve into the complex, yet often life-saving, principles of pelvic re-irradiation for recurrent rectal cancer.

Today, in our final episode on rectal cancer, we'll equip you with practical strategies for managing acute on-treatment toxicities. We'll then delineate evidence-based follow-up schedules, contrasting operative and non-operative approaches. Finally, we'll explore key survivorship considerations, including fertility preservation, bone health, and the crucial role of pelvic floor rehabilitation.

Today, we're stepping into the treatment planning suite. We'll walk through the entire process, from patient education and simulation setup to the meticulous art of target volume delineation and the critical science of dose selection and OAR constraint application. This episode is your hands-on guide to building a high-quality rectal cancer radiation plan.

Over the last three episodes, we have constructed the entire modern framework for rectal cancer management. We’ve established when to treat, how to treat, and who to treat with advanced strategies like TNT and immunotherapy. Today, we bring it all to the treatment planning console.This is the practical application episode. We will provide a step-by-step guide to modern rectal cancer contouring based on international consensus. We'll review critical dose constraints you must know. And finally, we will tackle one of the most complex scenarios in our field—using a case to outline a safe and effective approach to pelv...

In our previous discussions, we've firmly established the role of neoadjuvant radiation therapy for locally advanced rectal cancer. However, radiation, while life-saving, comes with its own set of acute and late toxicities—from sexual dysfunction and infertility to chronic bowel changes and the rare risk of secondary malignancies. This raises a crucial question in modern oncology: for whom can we safely omit radiation, de-escalating treatment without compromising oncologic outcomes? Today, we delve into this concept, focusing on a landmark trial that has reshaped our approach to low-risk rectal cancer: the PROSPECT trial. We'll analyze its design, uncover its key findings, an...

In our last episode, we explored Total Neoadjuvant Therapy, or TNT, which has revolutionized the management of high-risk locally advanced rectal cancer by increasing pathologic complete response, or pCR, rates and improving distant control. These impressive pCR rates have opened the door to one of the most exciting and debated topics in rectal cancer: avoiding major surgery through "Watch and Wait," or Non-Operative Management. Today, we dive deep into this organ-preserving approach, defining who is a candidate and what surveillance entails. We'll examine key trials like OPRA and data from the International Watch and Wait Database. Finally, we'll shift to...

In our last episode, we established the foundational principles of neoadjuvant radiation, proving that giving RT before surgery is superior and comparing the short-course and long-course approaches. That framework is perfect for standard-risk disease. But for patients with the highest-risk tumors, the primary driver of mortality isn't local failure—it's distant metastases.This reality has sparked a true revolution in rectal cancer care. Today, we dive into that revolution: Total Neoadjuvant Therapy, or TNT. We will define TNT and its rationale, dissect the blockbuster trials that have redefined the standard of care for high-risk rectal cancer, and cover the game-changing ma...

In our last episode, we established the fundamental clinical landscape of rectal cancer—the anatomy, the critical role of MRI in staging, and the surgical revolution of Total Mesorectal Excision. We learned that with high-quality TME, surgeons could dramatically reduce local recurrence. The question then became: could we improve upon this new surgical standard?

If there is one disease site that perfectly illustrates the power of multidisciplinary, evidence-based cancer care, it’s rectal cancer. The evolution of its treatment is a masterclass in how surgery, radiation, and chemotherapy can be integrated to dramatically improve outcomes. But before we can appreciate that evolution, we must master the fundamentals.Today, we lay the groundwork for this entire story. We will use a classic case to walk through the essential workup, the critical anatomy that dictates treatment, modern staging with MRI, and finally, the surgical innovation that changed everything—Total Mesorectal Excision.

Today, we conclude our liver mini-series by tackling these crucial topics.F irst, we’ll cover the evidence-based management for biliary tract cancers—including gallbladder cancer and cholangiocarcinoma—with a focus on the patterns of failure that guide our use of adjuvant radiation. Then, we’ll pivot to one of the most common clinical scenarios we face: treating colorectal liver metastases, discussing the role of SBRT in the context of other local therapies.

Today, we conduct our SBRT masterclass for HCC. We will make the definitive case for SBRT over other local therapies by citing the key comparative data. We'll detail the evidence for treating high-risk disease like portal vein thrombosis and walk through the critical dosimetric details—ablative doses, the RTOG 1112 de-escalation schema, and the crucial constraints you need to know to treat safely and effectively.

Welcome back to Rad Onc Smart Review, GI Series.T his is Episode 12: HCC Part 1: The HCC Toolkit – Staging, IR, and Systemic Therapy . Hepatocellular carcinoma, or HCC, is a unique beast in oncology. Unlike most cancers where our focus is solely on the tumor, in HCC we are fighting a war on two fronts: the cancer itself, and the often-diseased liver it inhabits. This dual challenge means that staging and treatment decisions are far more complex than just TNM. Today, we're opening up the HCC toolkit. We'll build a comprehensive framework for managing this disease, starting with the essential staging sy...

Over the last three episodes, we've journeyed through the complex evidence for pancreatic cancer. We’ve dissected the adjuvant debate, explored the neoadjuvant revolution, and held a masterclass on SBRT. Now, it’s time to put it all together. This is our synthesis episode, where we translate the data from landmark trials into practical, actionable plans.We will start by summarizing the key recommendations from the major guidelines. Then, we’ll move into a detailed treatment planning workshop, covering both postoperative conventional planning and modern SBRT. Finally, we'll work through a classic clinical dilemma to solidify your decision-making skills.

In our last two episodes, we focused on patients with resectable or borderline resectable pancreatic cancer—those for whom surgery is the ultimate goal. Today, we turn to a different, but equally challenging scenario: the patient with locally advanced, unresectable disease. These are the patients whose tumors are intimately involved with the major blood vessels, taking surgery off the table, but who do not yet have distant metastases. Here, the goals shift from cure to long-term control. This is where radiation therapy, particularly SBRT, has seen its most significant evolution. This is our SBRT masterclass: we’ll cover the data for...

Welcome back to Rad Onc Smart Review, GI Series. In our last episode, we wrestled with the difficult data for adjuvant therapy, where even after a grueling Whipple procedure, the prognosis remains guarded. This reality has fueled one of the most significant paradigm shifts in modern GI oncology: moving therapy from the postoperative to the preoperative setting. The rationale is simple yet powerful: select the right patients, improve the quality of surgery, and deliver systemic therapy when patients are strongest. Today, we explore this neoadjuvant revolution. We’ll start by defining who is and who is not a surgical candidate ba...

Welcome back to Rad Onc Smart Review, GI Series. Pancreatic cancer carries one of the most sobering prognoses in oncology. For the small fraction of patients who present with resectable disease, surgery offers the only hope for a cure. But even after a successful resection, the risk of recurrence is incredibly high, making effective adjuvant therapy a critical component of care. For decades, the question of "what to do after surgery" has been one of the most contentious debates in GI oncology, pitting aggressive systemic chemotherapy against the potential local control benefit of radiation.Today, we're going to trace this...

In our last episode, we established that for resectable gastric cancer, high-quality D2 surgery and effective perioperative chemotherapy with FLOT is the modern standard of care. But that raises a critical question for us as radiation oncologists: what is the role of radiation therapy in this disease? Today, we answer that question by dissecting the landmark trials of adjuvant chemoradiation, exploring the use of targeted therapy for HER2-positive disease, and putting it all together in a practical treatment planning workshop.

Welcome back to Rad Onc Smart Review, where we break down the clinical decisions that matter most in radiation oncology. This is Episode six: Gastric Cancer Part one, covering Surgery and Perioperative Chemotherapy.Gastric cancer remains a major global health challenge. While less common in the United States, it’s the third leading cause of cancer-related death worldwide, often because it's diagnosed at an advanced stage. For decades, the management of resectable disease has been an evolving story, a tug-of-war between more aggressive surgery and more effective systemic therapy. Today, we're going to trace that evolution, starting with the fundamentals of...

This is Episode 05: Esophagus Part 4: NOM, Advanced Disease & Treatment Planning.This is our capstone episode on esophageal cancer. We’ve covered the fundamentals, the landmark trials, and the modern debates. Today, we bring it all together. We’ll explore the exciting frontier of non-operative management, clarify the algorithm for using immunotherapy in advanced disease, and then roll up our sleeves for a practical treatment planning workshop where we’ll delineate volumes and apply critical dose constraints based on the latest evidence.

This is Episode 04: Esophagus Part 3: The Dose Escalation & Adjuvant IO Debates.In our last episode, we laid the foundation with the landmark trials establishing neoadjuvant and definitive chemoradiation. But a key principle in oncology is to always ask: can we do better? Today, we tackle the controversies and innovations that have attempted to improve upon those standards. We’ll dissect the decades-long, and largely disappointing, quest for dose escalation. Then, we’ll pivot to the modern era and explore how adjuvant immunotherapy is revolutionizing outcomes.

This is Episode 03: Esophagus Part 2: Neoadjuvant & Definitive CCRT.In our last episode, we laid the groundwork for esophageal cancer management. Now, we move to the heart of the matter: how we treat locally advanced disease. This episode is all about the landmark trials that defined the role of chemoradiation. We'll dissect the two pillars of modern esophageal radiation oncology: RTOG eighty-five-zero-one for definitive treatment, and the CROSS trial for the neoadjuvant setting. We’ll then see how these standards are being challenged by newer chemotherapy regimens.

This is Episode 02: Esophagus Part 1: Anatomy, Staging & Surgical Options.Getting the fundamentals right in esophageal cancer is everything. It's a disease where anatomy dictates treatment fields, staging dictates modality, and surgical approach dictates potential toxicities. Today, we'll build that crucial foundation, covering the anatomy and workup that drive our initial decisions, the nuances of the latest AJCC staging, and the surgical landscape before we even think about turning on the beam.

Welcome back to Rad Onc Smart Review, G.I. Oncology Edition. This is Episode 01: GI Principles: Re-RT, Toxicity, & Contouring Rare Sites.Before we dive deep into specific GI malignancies, we’re going to build a strong foundation. This episode covers four high-yield topics that cut across multiple disease sites: re-irradiation of the pelvis, management of chronic radiation proctitis, contouring inguinal nodes, and treating adrenal metastases. Mastering these principles will set you up for success throughout our entire GI series.

Welcome back to Rad Onc Smart Review! This is Episode 39C in our special series on Radiobiology Calculations. Today, we’re tackling the mathematics that underpins the very foundation of modern radiation therapy: fractionation. Why do we give many small doses of radiation instead of one big one? The answer lies in the numbers, and mastering these calculations is essential for both your board exams and for safe, effective clinical practice.