RadOnc Smart Review

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.