RadOnc Smart Review

This is Episode thirteen: Oral Cavity Three — PORT versus Post-op Chemo-RT: The "Big Two."In the last two episodes, we established that oral cavity cancer is a surgical disease and that the clinically node-negative neck requires elective treatment when depth of invasion exceeds three to four millimeters. Now the surgery is done. The pathology report is in your hands. The question becomes: what adjuvant therapy does this patient need?This is the domain of two landmark trials that every radiation oncologist must know cold: R-TOG ninety-five-oh-one by Cooper and E-O-R-T-C twenty-two-nine-three-one by Bernier—both published in the New England Journal of Medicine in 2004. These trials established the "Big Two" indications for concurrent chemoradiation: positive margins and extranodal extension.After this episode, you should be able to answer in one sentence: PORT versus chemo-RT, and why?This episode covers the evidence for post-operative radiation, when to add chemotherapy, the critical importance of timing, and how to apply these principles to real cases. Let's get into it.

This is Episode twelve: Oral Cavity Two — The Clinically Node-Negative Neck: Elective Dissection, Not Watchful Waiting.In Episode Eleven, we established that oral cavity cancer is a surgical disease and that depth of invasion drives staging and management. We introduced the concept of elective neck dissection for the clinically negative neck. Now we're going to go deep on the evidence. The cN0 neck is one of the classic oral board scenarios. The examiner will present a patient with early oral tongue cancer, clinically and radiographically negative nodes, and ask you what to do with the neck. Observation is only defensible in very superficial tumors with a depth of invasion of three millimeters or less; otherwise, elective treatment is standard. The D'Cruz trial changed everything—and you need to know it inside and out.

This is Episode eleven: Oral Cavity One — Subsites, Depth of Invasion, and Why Surgery Usually Wins.Over the next four episodes, we're going to master oral cavity cancer from the perspective of the radiation oncologist preparing for boards. And I want to be clear about something right up front: oral cavity is a surgical disease. Unlike oropharynx, where definitive chemoradiation is standard, oral cavity cancer is treated with surgery first. Our role as radiation oncologists is adjuvant—we come in after the surgeon, and our decisions are driven by what pathology tells us.

This is Episode 10: Foundations IX — Planning Workshop: IMRT, VMAT, Protons, and OAR Priorities.We’ve arrived at the “dark room” episode. Up to now, you’ve made clinical decisions: diagnosis, stage, intent, dose, and fractionation. Now you’re at the console, staring at a CT and a dose cloud, and the boards are essentially asking: “Do you know what matters, and can you keep the patient safe?”

This is Episode 9: Foundations VIII — Supportive Care II: Swallow, Aspiration, Trismus, and Osteoradionecrosis.Last episode was: “Don’t lose the patient during treatment.”This episode is: “Don’t ruin the next thirty years of their life.”Head and neck survivorship is different. We’re curing more patients, younger patients, and we’re curing them with treatments that permanently reshape function. Late effects are not side effects. They are the patient’s new baseline.

This is Episode 8: Foundations VII — Supportive Care I: Dental, Nutrition, and Mucositis.We have spent the last seven episodes talking about how to kill the cancer. Today, we talk about how to keep the patient alive while we do it. On oral boards, supportive care is the great differentiator. A candidate who can recite fractionation trials but cannot explain when to pull a tooth, when to place a PEG, or how to manage week-five mucositis is advertising inexperience.This is the “Don’t Lose the Patient” episode: the pre-treatment checklist, the on-treatment playbook, and the red lines you do not cross.

This is Episode 7: Foundations VI — Systemic Therapy With RT: Cisplatin, Cetuximab, and Alternatives.We’ve built the scaffolding: anatomy, staging, and fractionation. Now we add the lever that most reliably increases cure rates in locally advanced head and neck cancer: concurrent systemic therapy.And here’s the board-relevant truth: examiners don’t just test whether you know that “chemo helps.” They test whether you know **who** should get it, **which** regimen is the standard, **when** cisplatin is unsafe, and **why** cetuximab is not a “gentler substitute” in HPV-positive oropharynx.

This is Episode 6: Foundations V — Fractionation and Time: Why We Don’t Treat Head and Neck Like Prostate.In prostate cancer, a week off for a holiday can be inconvenient, but the tumor biology barely flinches. In head and neck squamous cell carcinoma, a week off is not “just a delay.” It is a biological advantage handed to the tumor.Today is the Time Factor episode: overall treatment time, accelerated repopulation, altered fractionation, and—most important for oral boards—what you actually do when treatment gets interrupted.

This is Episode 5: Foundations IV — AJCC Staging That Actually Changes Management.Most residents treat staging as paperwork—something you fill out after you’ve already decided the plan. That’s backward. In AJCC Eighth Edition, staging is a decoder ring: it tells you which disease biology you’re dealing with, what patterns of failure to respect, and which high-risk variables will force treatment intensification.

Welcome back to Rad Onc Smart Review, Head and Neck edition.This is Episode 4: Unknown Primary — The Neck Mass Without a Mucosal Home.In the last episode, we talked about the workup. We scoped, we scanned, and we biopsied. Most of the time, that process finds the culprit — a small tonsil cancer hiding in crypts or a base of tongue tumor you could miss on casual inspection. But sometimes, you do everything right — contrast imaging, PET, examination under anesthesia, directed biopsies, palatine tonsillectomy, and even tongue base sampling — and the pathology still comes back negative for a primary site. Now you have metastatic squamous cell carcinoma in a cervical lymph node and no mucosal home address. That is Unknown Primary.