RadOnc Smart Review

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 recommendations from the major guidelines. Then, we’ll move into a detailed treatment planning workshop, covering both postoperative conventional planning and modern SBRT. Finally, we'll work through a classic clinical dilemma to solidify your decision-making skills.

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 who do not yet have distant metastases. Here, the goals shift from cure to long-term control. This is where radiation therapy, particularly SBRT, has seen its most significant evolution. This is our SBRT masterclass: we’ll cover the data for conventional chemoradiation, justify ablative SBRT doses, and tackle the critical controversy of how to define our target volumes.

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: select the right patients, improve the quality of surgery, and deliver systemic therapy when patients are strongest. Today, we explore this neoadjuvant revolution. We’ll start by defining who is and who is not a surgical candidate based on the critical vascular anatomy. Then, we’ll dive into the landmark trials—PREOPANC-1 and Alliance A-0-2-1-5-0-1—that are shaping our current standards and fueling the ongoing debate.

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 question of "what to do after surgery" has been one of the most contentious debates in GI oncology, pitting aggressive systemic chemotherapy against the potential local control benefit of radiation.Today, we're going to trace this evolution. We’ll dissect the landmark trials that both built up and tore down the role of adjuvant radiation, and follow the rise of modern chemotherapy from single agents to the powerhouse regimens that are finally moving the survival needle.

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, exploring the use of targeted therapy for HER2-positive disease, and putting it all together in a practical treatment planning workshop.

Welcome back to Rad Onc Smart Review, where we break down the clinical decisions that matter most in radiation oncology. This is Episode six: Gastric Cancer Part one, covering Surgery and Perioperative Chemotherapy.Gastric cancer remains a major global health challenge. While less common in the United States, it’s the third leading cause of cancer-related death worldwide, often because it's diagnosed at an advanced stage. For decades, the management of resectable disease has been an evolving story, a tug-of-war between more aggressive surgery and more effective systemic therapy. Today, we're going to trace that evolution, starting with the fundamentals of surgical resection and nodal dissection, and then walking through the landmark trials that established and then redefined the standard for perioperative chemotherapy.

This is Episode 05: Esophagus Part 4: NOM, Advanced Disease & Treatment Planning.This is our capstone episode on esophageal cancer. We’ve covered the fundamentals, the landmark trials, and the modern debates. Today, we bring it all together. We’ll explore the exciting frontier of non-operative management, clarify the algorithm for using immunotherapy in advanced disease, and then roll up our sleeves for a practical treatment planning workshop where we’ll delineate volumes and apply critical dose constraints based on the latest evidence.

This is Episode 04: Esophagus Part 3: The Dose Escalation & Adjuvant IO Debates.In our last episode, we laid the foundation with the landmark trials establishing neoadjuvant and definitive chemoradiation. But a key principle in oncology is to always ask: can we do better? Today, we tackle the controversies and innovations that have attempted to improve upon those standards. We’ll dissect the decades-long, and largely disappointing, quest for dose escalation. Then, we’ll pivot to the modern era and explore how adjuvant immunotherapy is revolutionizing outcomes.

This is Episode 03: Esophagus Part 2: Neoadjuvant & Definitive CCRT.In our last episode, we laid the groundwork for esophageal cancer management. Now, we move to the heart of the matter: how we treat locally advanced disease. This episode is all about the landmark trials that defined the role of chemoradiation. We'll dissect the two pillars of modern esophageal radiation oncology: RTOG eighty-five-zero-one for definitive treatment, and the CROSS trial for the neoadjuvant setting. We’ll then see how these standards are being challenged by newer chemotherapy regimens.

This is Episode 02: Esophagus Part 1: Anatomy, Staging & Surgical Options.Getting the fundamentals right in esophageal cancer is everything. It's a disease where anatomy dictates treatment fields, staging dictates modality, and surgical approach dictates potential toxicities. Today, we'll build that crucial foundation, covering the anatomy and workup that drive our initial decisions, the nuances of the latest AJCC staging, and the surgical landscape before we even think about turning on the beam.