RadOnc Smart Review

This is Episode 17b: Definitive Planning Workshop Simulation, Target Volumes, and OAR Constraints. In Episode 17, we covered the clinical decision-making for definitive chemoradiation—why we treat, who needs systemic therapy, and which agent to use. Now we're at the contouring workstation, and we need to answer the technical questions: *How* do we treat? This episode is high-yield for both written and oral boards. Examiners love to probe your understanding of target volume delineation, nodal coverage algorithms, and constraint trade-offs. They'll ask why you included or excluded specific nodal levels, how you balance tumor control against late toxicity, and what happens when your plan can't meet all constraints simultaneously. We're going to work through our case patient step by step—from simulation setup through plan evaluation. By the end, you'll have a systematic framework for definitive oropharyngeal cancer planning that you can defend on boards.

This is Episode 17: Definitive Chemo-RT Cisplatin is King. This episode is essential for boards. If you remember one thing from today, let it be this: *cisplatin is king*. Concurrent cisplatin with radiation is the standard of care for locally advanced head and neck cancer requiring systemic therapy—and multiple randomized trials have now proven that cetuximab is *not* an acceptable substitute, even though we once hoped it might be. We're going to work through the landmark trials that established concurrent chemoradiation, understand exactly which patients need systemic therapy and which don't, learn the framework for cisplatin-ineligible patients, dissect the cetuximab failures, and master dose-fractionation strategies. By the end, you'll be able to defend your treatment recommendations on oral boards with evidence-based precision.

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. eighth edition created separate staging systems for these two entities. That's unprecedented in head and neck oncology.By the end of today, you'll understand why a patient with a large cystic neck node can still have early-stage H.P.V. positive disease — and why that is actually biologically coherent.

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, different paths of spread, and different ways you get burned if you treat them all the same. Today we build subsite-specific contouring templates. You’ll learn which subsites have a low threshold for bilateral coverage, which can be treated ipsilaterally when truly well-lateralized, and what local extension pathways you must respect—every single time.

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 your simulation and volumes in thirty seconds, exactly the way you'll need to on oral boards.

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 floor of mouth.Understanding mandibular anatomy, invasion patterns, surgical options, and osteoradionecrosis prevention is essential for any radiation oncologist treating oral cavity cancer. This episode covers the practical planning considerations you'll face when bone is involved.After this episode, you should be able to answer: When does the mandible require full-dose coverage versus sparing? What drives ORN risk dosimetrically? And what changes when there's a reconstruction flap in the field?Let's get into it.