RadOnc Smart Review

Episode 2 draft

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.