RadOnc Smart Review

This is Episode 31: Penile and Urethral Planning Workshop. These are rare, high-stakes plans. The anatomy is mobile, the setup can be awkward, the evidence base is limited, and sloppy field design can have major consequences. This workstation episode covers simulation, bolus, immobilization, penile brachytherapy, inguinal and pelvic nodal contouring using the InPACT framework, and key principles of urethral cancer planning.

This is Episode 30: Penile Cancer Primary Management, Nodes, and Organ Preservation.Penile cancer is rare, but it is very fair game on boards because it tests whether you can keep anatomy, staging, nodal logic, and quality-of-life tradeoffs straight in a disease most residents will see only rarely.

Today we will build a practical framework for workup, staging, histology, and multimodality management. We will also cover where radiation fits, including selected use of brachytherapy for early-stage female disease and definitive chemoradiation for selected locally advanced squamous tumors.

This is Episode 28: Upper Tract Urothelial Carcinoma perioperative therapy, patterns of failure, and where radiation enters the conversation.UTUC is one of those diseases that residents do not see often, but oral examiners love it because it looks familiar and then punishes shortcut thinking. The histology overlaps with bladder urothelial carcinoma, but the risk stratification, the surgical planning, the perioperative systemic-therapy logic, and the radiation role are not the same.

This is the workstation episode. This is the planning episode. The big idea is simple: kidney SBRT is usually a motion-management problem and an organ-at-risk problem before it becomes a dose problem. Your bowel, your duodenum, your stomach, and the remaining uninvolved renal parenchyma often decide the regimen.

This is one of the highest-yield modern RCC topics because it sits right where three practice changes collide. First, RCC was long treated as a disease that did not respond well to conventional radiation, but modern ablative radiation changed that conversation. Second, cytoreductive nephrectomy went from reflex dogma to a selective, risk-adapted decision. Third, immune checkpoint inhibitor–based combinations became the backbone of first-line metastatic therapy, which means local therapy now has to be placed carefully and honestly into the treatment sequence.

This is Episode 24: Renal Cell Carcinoma Localized Disease, Surgery, Ablation, and Primary SBRT. Here is the modern frame. Localized RCC is still primarily a surgical disease. Conventional fractionation never established a curative or adjuvant role in this setting. But stereotactic ablative body radiotherapy has changed the conversation for selected patients who are medically inoperable, technically high risk for surgery, or who decline surgery.

This episode is about what happens after cure. Testicular cancer is one of the great success stories in oncology, but that success creates a second job: taking care of survivors for decades. These are often young men with excellent cure rates and long life expectancy. So the real question is not just whether you cured the cancer. It is whether you protected fertility, recognized relapse on the right schedule, and minimized the long-term cost of treatment.

This is the episode where testicular cancer stops being mostly about stage I and stage II decision trees and starts becoming a sequencing problem. The questions are no longer just surveillance versus adjuvant therapy. Now the important questions are: how do you classify risk correctly, which chemotherapy backbone belongs to which group, when does PET help, when does it not help at all, who needs surgery after chemotherapy, and what exactly do you do when the disease comes back.

This is Episode 20: Testicular Stage II Seminoma, NSGCT, and Field Design. Last episode, we built the foundation: markers, orchiectomy, staging, and why surveillance is preferred for most stage I seminoma. Today we move into stage II disease, where the question is no longer just whether you know the basics. The question is whether you can choose treatment, explain why, and, if needed, describe a radiation field clearly and defensibly.

This is Episode 19: Testicular Cancer - Workup, Markers, Staging, and Stage I Seminoma. Testicular cancer is uncommon overall, but it is the most common solid malignancy in young men, and it is one of the great cure stories in oncology. That changes the way we think about treatment. The question is often not whether cure is possible. The question is how to preserve cure while minimizing overtreatment and long-term toxicity in a patient who may live for decades.

This is Episode 17: metastatic urothelial cancer, immunotherapy, and future directions. This is one of the fastest-moving areas in GU oncology. For years, first-line treatment for metastatic urothelial cancer meant platinum-based chemotherapy, with median overall survival in the mid-teens. That changed with EV-302. For many patients, the preferred first-line regimen is now enfortumab vedotin plus pembrolizumab. This is a major practice shift and is absolutely board-relevant.

This is Episode 16: Bladder Post-Cystectomy Radiation, Follow-Up, and Salvage Pathways. This episode is high-yield because it addresses two common bladder cancer mistakes. First, it corrects the simplistic answer that radiation has no role after cystectomy. Second, it clarifies the need to act promptly when a patient, previously treated with trimodality therapy, experiences an invasive recurrence. In modern board-style teaching, this episode covers selective postoperative radiation for high-risk pathology and the importance of recognizing when salvage cystectomy is necessary.

This is Episode 15: Bladder Planning Workshop - Definitive Preservation Cases. The last episode focused on who qualifies for trimodality therapy and why concurrent chemoradiation is preferred over radiation alone. Today's planning episode covers how to simulate, contour, choose volumes, and make technically defensible decisions when the bladder is moving, deforming, and sitting right next to the small bowel.

This is Episode 14: Bladder Trimodality Therapy, Radiosensitizers, and Hypofractionation. Here's the key takeaway: bladder-preserving trimodality therapy is a viable curative option, not a last resort. In the right patients, it's a legitimate strategy, deserving of discussion alongside radical cystectomy. To excel on exams, present it correctly: prioritize candidate selection, use concurrent radiosensitizers, and incorporate salvage planning from the outset.

This is Episode 13: Bladder Cancer – Non-Muscle-Invasive and Muscle-Invasive Workup and the Surgical Backbone. Here's why this episode matters: Bladder cancer is a disease where radiation oncologists can be indispensable members of a curative bladder-preservation team, or completely absent from meaningful treatment discussions. The difference often comes down to understanding the surgical and medical backbone of the disease. You cannot intelligently argue for trimodality therapy in a tumor board if you don't understand what a quality TURBT looks like, when repeat TURBT is needed, what cisplatin-based perioperative therapy aims to achieve, and which patients benefit most from radical cystectomy.

This is Episode 11: Prostate Follow-up, Toxicity, Survivorship, and Failure Patterns. This is a high-yield episode because most prostate teaching focuses on the front end: risk stratification, dose, fractionation, and ADT duration. However, in the real clinic, a huge share of what you do is follow-up. You will spend more time interpreting PSA trends, counseling men about late effects, and managing survivorship than you ever spent simulating the original plan.

This is Episode 10: Prostate Planning Workshop intact, post-op, and nodal cases. For the last several episodes, we've discussed what to treat in prostate cancer – risk groups, ADT duration, brachy boost candidates, and salvage triggers. Today, we're flipping the camera around and talking about how you actually deliver that plan. This is the episode where we sit down at the contouring station together.

Welcome back to Rad Onc Smart Review, Genitourinary Oncology edition. This is Episode 9: a discussion on prostate cancer across the metastatic continuum, including metastatic hormone-sensitive disease, nonmetastatic castration-resistant disease, metastatic castration-resistant disease, metastasis-directed therapy, and precision systemic therapy. We'll cover how to move from localized to advanced disease by defining the disease state, the burden, and how biomarkers impact management.

Episodes 3 through 7 covered definitive treatment. This episode covers what to do when definitive treatment fails. After prostatectomy, earlier salvage RT at lower PSA is associated with better outcomes. After prior RT or focal therapy, salvage can still be curative in selected patients, but it requires careful restaging and biopsy confirmation before local retreatment. Today we will cover four things: the shift from routine adjuvant RT to early salvage RT after prostatectomy, the selective role of ADT and pelvic nodal coverage in the salvage setting, the workup for recurrence after RT or focal therapy, and the major salvage options for radiorecurrent disease.

The first three episodes established the foundation – anatomy, risk groups, workup, and surveillance. Now, we begin treatment. This episode explores the physics and biology of dose delivery to the prostate. We'll cover three key areas: First, the benefits of higher doses for biochemical control and what long-term data reveals about distant metastasis and cancer-specific mortality. Second, the rise of moderate hypofractionation as the standard of care, including supporting trials, radiobiologic principles, and important toxicity signals. Third, the FLAME concept – boosting the MRI-visible dominant lesion – and the importance of prioritizing OAR constraints.

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This is Episode 1: Prostate – Anatomy, Pathology, Risk Groups, and Natural History. This foundational episode covers everything in the prostate series – dose escalation, hypofractionation, brachytherapy, ADT integration, salvage, and oligometastatic management – as we delve deep into three key areas. First, prostate anatomy, including zonal architecture, lymphatic drainage, and adjacent structures that influence local cancer extension and target volume design. Second, risk stratification using Grade Group, PSA, T stage, and biopsy tumor volume – the four key variables for prostate cancer patient classification. Third, natural history, examining landmark data to identify aggressive cancers, understand non-lethal cases, and apply competing-risk thinking to determine appropriate treatment strategies.

This is Episode 39a: Sinonasal II Maxillary and Ethmoid SCC and SNUC Management. In our last episode, we established the anatomic and histologic foundations for sinonasal cancers. Now, we apply that knowledge. This clinical decision-making episode will guide you through NCCN algorithms for maxillary and ethmoid sinus tumors. We'll cover recommending elective neck irradiation, orbital preservation vs. exenteration, and the induction chemotherapy paradigm for SNUC, which has revolutionized the management of aggressive sinonasal tumors. The episode uses two cases to represent the clinical scenarios you'll encounter on oral boards: a resectable maxillary sinus SCC and a SNUC with skull base involvement. By the end, you'll confidently navigate both algorithms.

This is Episode 38: Sinonasal I Anatomy, Histology Diversity, and Multimodality Logic. We are now entering a block of head and neck oncology that is genuinely unique. Sinonasal cancers represent fewer than 2,000 cases per year in the United States — less than 1% of all malignancies — yet they pack an outsized punch on written and oral board examinations. Why? Because these tumors test everything at once. You need to know complex three-dimensional anatomy at the interface of the skull base, orbit, and brain. You need to navigate a histologic landscape unlike any other site in the head and neck, where SCC predominates, but a long tail of histologically distinct tumors — esthesioneuroblastoma, adenoid cystic carcinoma, SNUC, mucosal melanoma, and others — each demand fundamentally different management algorithms. And you need to understand why multimodality therapy is the default — not because of randomized trials, which essentially do not exist — but because the retrospective evidence and the anatomic realities of this site demand it. This episode is your anatomic and conceptual foundation. We will map the sinuses and nasal cavity in board-relevant detail, walk through the histology types you must recognize on sight, learn two separate staging systems, and understand the evidence behind the multimodality paradigm. In subsequent episodes, we will tackle site-specific and histology-specific management, planning around the orbit and skull base, and esthesioneuroblastoma as its own entity.

Today we simulate the oral boards exam in three clinical blocks plus a lightning round. Block One walks through comprehensive postoperative management. Blocks Two and Three test specific decision pivots, perineural invasion stop points and metastatic biomarker-driven therapy. Then we close with rapid-fire pearls.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 37: Salivary Gland Four – Unresectable Disease and Advanced Approaches. This episode completes our Salivary Gland block. We have built the foundation – histology-driven biology in Episode 34, adjuvant R-T triggers and planning in Episode 35, and perineural invasion strategy in Episode 36. Today we address difficult cases: the patient who cannot undergo surgery, the tumor that recurs despite our best efforts, and the adenoid cystic carcinoma that metastasizes to the lungs years after we thought we had won. We will also cover a rapidly evolving area – biomarker-driven systemic therapy. This is where salivary gland oncology is changing fastest, and the board examiners know it.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 36: Salivary Gland Three — Perineural Invasion and Named Nerve Strategy. Perineural invasion is the defining challenge of salivary gland radiation oncology. It is why adenoid cystic carcinoma behaves differently from mucoepidermoid. This is why some tumors recur at the skull base years after treatment. And it is absolutely a topic you will face on oral boards. Today, we build the complete framework for understanding, imaging, and treating perineural disease. By the end of this episode, you will be able to distinguish histologic P-N-I from clinical perineural tumor spread, trace the major nerve highways to their skull base foramina, and deliver a board-safe statement about when and how to extend your C-T-V tothe skull base.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 35: Salivary Gland Two — Adjuvant RT Triggers and Planning. In Episode 34, we built the salivary gland paradigm: histology leads, surgery is primary, and adjuvant decisions are driven by risk factors that salivary tumors love to hide—especially perineural invasion and margin risk. Today is the bridge episode. We take our Episode 34 case back from the operating room and turn it into a board-safe, execution-ready postoperative plan. This is high-yield material for oral boards, where you will absolutely be asked to justify your P-O-R-T indications, define your target volumes, and defend your dose levels. By the end of this episode, you will be able to recite the complete P-O-R-T indication list with evidence citations, define the anatomic boundaries of the parotid surgical bed C-T-V, and explain exactly when and how to track the facial nerve in your target volumes.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 34: Salivary Gland One — Histology-Driven Biology and the Surgical Paradigm. This episode launches our salivary gland block, and I want to be direct: salivary gland cancers are a board favorite because they force you to think differently. Unlike mucosal squamous cell carcinomas, where HPV status and TNM staging drive almost everything, salivary tumors require you to lead with histology. The histologic subtype tells you about local aggressiveness, perineural invasion risk, nodal behavior, and distant metastasis timing. Get the histology wrong, and your entire management framework collapses. Today, we establish the foundational paradigm: anatomy, histology diversity, why surgery is primary, how the facial nerve changes surgical decision-making, and an overview of when postoperative R-T enters the picture. This episode is high-yield for both written boards and oral examinations, where you will absolutely see a parotid mass with facial weakness and need to walk through the management algorithm.

This is Episode 33: Hypopharynx Integration Decision Points and Surveillance. Episode 31 covered the biology, including the worst-actor paradigm, prognosis, and the four defaults. Episodes 32 and 32b focused on planning: contouring, extension, and coverage. Now, we address the integration question: Who receives which treatment, and what does success look like? This episode explores decision-making. We'll discuss organ preservation, when to prioritize surgery, response assessment, salvage expectations, and the role of early palliative care.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 32b: Hypopharynx Planning Workshop. Episode 32 gave you the rules, the four defaults, the nodal template, the inferior extent ladder, and the OAR priorities. Today, we build muscle memory. We're at the contouring workstation. Two complete cases. No new teaching pure application and narrated decision-making. Here's what I need from you: every time I state a default, say it back in your head. By the end of this workshop, those four defaults should fire automatically whenever you see a hypopharynx case.

In Episode 31, we established the foundational paradigm for hypopharyngeal cancer, the worst-actor subsite in head and neck oncology. We defined four defaults that govern our approach to these cases: Default one: retropharyngeal nodes on. Default two: bilateral neck on. Default three: inferior extent on. Default four: prognosis is brutal, plan accordingly. Today, we translate those defaults into actual treatment contours. This episode focuses on operationalizing principles into treatment plans that you can defend on oral boards and execute at the workstation.

This is Episode Thirty-One: Hypopharynx One — Anatomy, Prognosis, and the Worst-Actor Paradigm. Today we tackle the subsite that earns its reputation as the worst actor in head and neck oncology. Hypopharyngeal cancer presents late, spreads early, and hides submucosally—which means your default choices must be aggressive from the start. This episode is foundational. We will not contour a single structure today. What we will do is hard-wire the four defaults that will drive every planning and management decision in Episodes Thirty-Two and Thirty-Three.

Welcome back to Rad Onc Smart Review, Head and Neck edition. This is Episode 30: Larynx Capstone – Mock Oral Board Review. Today we simulate the oral boards exam in four clinical blocks. Each block features a case that escalates through workup, staging, treatment selection, planning priorities, and outcomes. We'll close each block with a twist testing a key decision pivot. Treat this like a live exam. After every question, you will hear: "Pause for listener to formulate response." Use that pause. Then compare your answer to the model response.

This episode, number 29, focuses on Advanced Larynx T4a and the Unpreservable. Building upon Episode 28's discussion of organ preservation, we explore instances where such preservation is not the optimal course of action. Specifically, we examine how to identify patients for whom maintaining the larynx is either impractical or detrimental. Given the natural inclination to offer preservation, this episode aims to equip listeners with the knowledge to counsel patients appropriately, whether advocating for preservation when suitable or recommending upfront laryngectomy when it is the more beneficial pathway. By the conclusion of this episode, listeners will possess a framework for recognizing the "unpreservable" patient and understanding the limitations of current landmark trials when applied to bulky T4a disease.

This episode, number 28, explores "Organ Preservation: The Landmark Trials." Prior to 1991, the standard treatment for advanced laryngeal cancer involved total laryngectomy and radiation, which, while ensuring patient survival, resulted in the loss of natural voice, the inability to breathe through the nose and mouth, and a permanent stoma. A pivotal question emerged: could equivalent survival rates be achieved while preserving the larynx? Landmark trials provided an affirmative answer, emphasizing the importance of appropriate patient selection and treatment strategies. However, long-term follow-up studies revealed concerning late toxicities associated with larynx-preserving treatments, which may impact survival in complex, still-unresolved ways. In this episode, we will analyze the VA Larynx, RTOG 91-11, and GORTEC 2000-01 trials, providing insights for both board preparation and clinical practice. By the conclusion, listeners will not only comprehend the trials' findings but also learn how to apply them effectively to real-world patient care.

This is Episode 27b: Early Larynx Planning Workshop. In Episode 27, we addressed the fundamental aspects, including the radiocurability of early glottic cancer, the standard fractionation of 2.25 Gy/fx, and the rationale for neck sparing due to a nodal risk of less than 5%. This session focuses on the practical application—transferring this knowledge to the planning stage to develop a defensible and clinically safe treatment plan. The reality is that early glottic failures are often preventable. They are rarely due to incorrect dose selection. Instead, they are often caused by setup errors, inadequate anterior commissure coverage, insufficient flash, or unintended undercoverage resulting from the pursuit of homogeneity. By the conclusion of this workshop, participants will be able to simulate patients accurately, construct classic opposed-lateral plans, elucidate wedge/bolus trade-offs, and clearly articulate the appropriateness of IMRT and the distinctions between proven and unproven techniques.

This is Episode 27: Early Glottic Cancer Fields, Fractionation, and Voice Preservation. Early glottic cancer represents the prototype of a radiation-curable malignancy. It is one of the few oncological sites where we routinely achieve patient cures through radiation therapy alone, preserving the organ while attaining functional outcomes that surgery often fails to match. For T1 glottic cancer, 5-year local control rates exceed 90%. For T2 disease, we still achieve 70-80% local control with radiation alone, and salvage laryngectomy remains an option for those who experience recurrence. The key to differentiating successful residents from their less-accomplished peers lies in understanding the rationale behind specific fractionation schemes, the reasons for neck sparing, and the methodology for designing fields that adequately cover the disease while avoiding underdosing the anterior commissure or overdosing posterior structures. Today, we will comprehensively address all these aspects. Upon completion of this episode, listeners will be equipped to accurately stage early glottic cancer, prescribe optimal fractionation, design classic opposed lateral fields, and counsel patients regarding anticipated voice outcomes.

This is Episode 26: Larynx I- Anatomy, Staging, and the Organ Preservation Philosophy. The larynx holds a unique position in head and neck oncology. It is the one subsite where we routinely achieve cancer cures while preserving organ function. In early glottic cancer, radiation therapy achieves local control rates exceeding 90 percent with excellent voice outcomes. In advanced disease, concurrent chemoradiation can preserve the larynx in approximately 80 percent of patients. However, making sound treatment decisions – whether to use radiation alone, add chemotherapy, or recommend upfront surgery – requires a deep understanding of laryngeal anatomy, a skill that distinguishes proficient residents from their less experienced counterparts. Today, we will establish this foundational knowledge. By the conclusion of this episode, listeners will be able to visualize the larynx in three dimensions, accurately stage any laryngeal cancer, explain the differential behavior of glottic and supraglottic cancers, and articulate the organ preservation philosophy that underpins contemporary management strategies.

This is Episode 25: Nasopharynx Capstone – Mock Oral Boards. Today, we will simulate the oral board examination through four clinical blocks. Each block presents a case that progresses from workup to staging, treatment selection, planning priorities, and outcomes. Each block concludes with a twist designed to test a key decision point. Please treat this as a live examination.

This is Episode 24b: The Nasopharynx Planning Workshop, which focuses on skull base abutment cases. In the preceding episodes, we established the clinical framework for nasopharyngeal carcinoma, encompassing anatomy, staging, EBV biology, systemic therapy sequencing, response assessment, and salvage strategies. We now transition to the planning workstation, where the decisions made within the next 45 minutes can determine whether a patient experiences acceptable function or suffers catastrophic late toxicity.

This is Episode 24: Nasopharynx IV Response Assessment and Salvage. Building upon the previous two episodes, we have established that nasopharyngeal carcinoma is a radiation-driven disease. We have reviewed the anatomy, EBV biology, staging, and evidence supporting concurrent chemoradiation, with or without induction. Now, we address the critical question patients will invariably pose: "Did it work?" More importantly, we will explore the appropriate course of action when the answer is negative. This episode delves into high-stakes scenarios. Recurrent NPC following definitive chemoradiation presents one of the most complex decision points in head and neck oncology. The available options include surgery, re-irradiation, or systemic therapy; however, an incorrect decision can have catastrophic consequences. Treatment-related mortality in the re-irradiation setting can exceed 10%. Risks such as carotid blowout syndrome, temporal lobe necrosis, and nasopharyngeal hemorrhage are not merely theoretical concerns but represent the daily realities of managing recurrent disease. By the conclusion of this episode, you will be equipped to assess response, determine appropriate intervention strategies, and counsel patients through what may be the most critical treatment decision of their lives.

This episode, number 23, focuses on Nasopharynx III Induction and Concurrent Systemic Therapy. Building on Episode 22, where we established NPC as a radiation-driven disease with unique anatomy and EBV biology, and Episode 22b, where we covered target volumes, we now delve into the systemic therapy backbone, the chemotherapy decisions that determine patient outcomes. This high-yield episode highlights the unique aspects of NPC systemic therapy compared to other head and neck cancers. Specifically, it explores why induction studies that failed in the oropharynx and larynx actually work in NPC, offering crucial insights for board exams.

In Episode 22, we framed nasopharyngeal carcinoma as a radiation-driven disease with distinct anatomy, EBV association, and AJCC 8 edition staging built around skull base landmarks. Now we do the part that oral boards loves: designing the plan.

This is Episode 22: Nasopharynx I Anatomy, E. B. V. Biology, and the Definitive R. T. Paradigm. Nasopharyngeal carcinoma is a board-favorite because it behaves unlike the rest of the head and neck. It is a radiation-first disease with skull base anatomy, retropharyngeal nodes as default, and a biomarker you are expected to talk about fluently: plasma E. B. V. D. N. A.