RadOnc Smart Review

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, rev...

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 mode...

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-mu...

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 accu...

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 sta...

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 mode...

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 criti...

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...

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.

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...

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 ba...

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...

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...

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...

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 enti...

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, discu...

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...

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 sta...

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 recomm...

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 w...

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...

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 q...

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, expl...