Comprehensive Management Paradigms & Dose Anchors
1. OLIGOMETASTATIC DISEASE & SBRT
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Systemic Oligometastasis (1-5 lesions) | SABR-COMET established an overall survival benefit for ablating 1-5 systemic metastases in selected primary histologies with a controlled primary tumor. | 30 - 45 Gy / 3 - 5 fx (Varies widely by site and proximity to OARs) |
| Spine SBRT | Ablation of spinal metastases; requires highly conformal planning to respect thecal sac and spinal cord dose limits (e.g., cord V14 < 0.03cc for single fx). | 24 Gy x 1 | 27 Gy / 3 fx | 30 Gy / 5 fx |
2. CNS MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Glioblastoma (Age <70, Good PS) | Maximal safe resection followed by concurrent chemoradiation (TMZ) and adjuvant TMZ (Stupp Regimen). | 60 Gy / 30 fx (CTV = GTV + 1.5-2 cm) |
| Glioblastoma (Elderly / Frail) | Hypofractionated RT +/- concurrent or adjuvant TMZ depending heavily on MGMT promoter methylation status. | 40.05 Gy / 15 fx (Roa) or 34 Gy / 10 fx |
| Low-Grade Glioma (High Risk) | Age ≥40 or subtotal resection triggers adjuvant RT followed by PCV or TMZ (RTOG 9802). | 50.4 - 54 Gy / 28-30 fx |
| Intact Brain Metastases (SRS) | Stereotactic radiosurgery for limited volume/number of brain mets to spare neurocognition (RTOG 9005 max tolerated doses). | <2 cm: 24 Gy | 2-3 cm: 18 Gy | >3 cm: 15 Gy |
| Post-op Brain Mets (Cavity SRS) | Cavity SRS to prevent local recurrence while sparing neurocognition compared to historical WBRT. | <2 cm: 20 Gy | 2-3 cm: 18 Gy | >3 cm: 14-15 Gy (Fractionation favored for large cavities) |
| Whole Brain RT (WBRT) | Numerous mets, leptomeningeal spread, or small cell histology. Always add Memantine and Hippocampal Avoidance if feasible. | 30 Gy / 10 fx |
| Meningioma | Grade I: observe if asymptomatic/GTR. Treat for symptoms/progression. Grade II/III: post-op RT standard. | Grade I: 50.4 - 54 Gy | Grade II: 54 - 59.4 Gy | Grade III: 59.4 - 60 Gy |
3. HEAD AND NECK MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Definitive CRT (Intact) | Dose-painted volume based on risk. High risk (gross disease) vs Intermediate risk (high-risk nodes) vs Low risk (elective nodes). | High: 70 Gy | Int: 59.4 - 63 Gy | Low: 50 - 54 Gy |
| Post-Operative RT | R1 margin or Extranodal Extension (ENE) triggers concurrent cisplatin and a higher boost dose to the high-risk bed. | High risk (R1/ENE): 60 - 66 Gy | Standard bed: 60 Gy |
| Early Glottic (T1/T2 N0) | Single-modality definitive RT; carefully spare carotids when possible. Hypofractionation (2.25 Gy/fx) improves local control. | 63 Gy / 28 fx (2.25/fx) or 66 Gy / 33 fx (2.0/fx) |
| Nasopharynx | Induction chemo followed by definitive CRT (locally advanced), or definitive CRT alone for early stage. | Gross disease: 70 Gy | High-risk nodal: 59.4-63 Gy | Low: 50-54 Gy |
4. SKIN MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| BCC / SCC (Definitive) | Excellent cosmetic and local control for inoperable or cosmetically sensitive facial lesions (eyelid, nose, lip). | <2 cm: 50 Gy / 20 fx or 35 Gy / 5 fx | >2 cm: 60 - 66 Gy |
| Melanoma (Post-op) | Selected high-risk nodal basins (extracapsular extension, ≥3 nodes, bulky) or mucosal sites. Systemic IO is changing this landscape. | 48 Gy / 20 fx or 30 Gy / 5 fx |
| Merkel Cell (Post-op) | High propensity for local recurrence mandates adjuvant bed RT for almost all cases (even with negative SLNB). | 50 Gy (R0) | 56 - 60 Gy (R1/Gross) |
5. BREAST MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Whole Breast Irradiation (WBI) | Hypofractionation is the standard of care across ages, stages, and breast sizes. Ultra-hypofractionation (FAST-Forward) is standard in Europe/UK. | 40 Gy / 15 fx or 42.5 Gy / 16 fx (Ultra: 26 Gy / 5 fx) |
| Accelerated Partial Breast (APBI) | Highly selected early-stage, older, ER+ patients with negative margins. | 30 Gy / 5 fx (daily/EOD) or 38.5 Gy / 10 fx (BID) |
| PMRT / Regional Nodal Irradiation | T3+, N1+, or high-risk features trigger post-mastectomy and comprehensive nodal RT (supraclavicular and IMNs). | Standard: 50 Gy / 25 fx | Mod Hypo: 40 Gy / 15 fx |
| Tumor Bed Boost | Age <50, close margins, or high-grade disease to maximize local control in the lumpectomy cavity. | 10 - 16 Gy (Sequential or SIB) |
6. GENITOURINARY MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Prostate (Low / Favorable Int) | Definitive RT alone; moderate or ultra-hypofractionation (SBRT) are preferred. | Mod: 60 Gy / 20 fx | Ultra: 36.25 - 40 Gy / 5 fx |
| Prostate (High Risk) | Definitive RT to prostate + pelvic nodes + long-term ADT (18-24 mos) +/- abiraterone. | 78 - 80 Gy to prostate; 44 - 46 Gy to elective nodes |
| Post-op Prostate (Salvage) | Salvage RT for biochemical failure; add ADT and pelvic nodes based on SPPORT criteria. | 64 - 68 Gy to prostate bed |
| Bladder Preservation | Maximal TURBT → concurrent chemoradiation (radiosensitizing chemo) for muscle-invasive bladder cancer. | Standard: 64 Gy / 32 fx | Hypo: 55 Gy / 20 fx |
| Testicular Seminoma (Stage I/IIA) | Stage I observation preferred; Stage IIA dogleg RT to retroperitoneal/ipsilateral pelvic nodes. | Stage I: 20 Gy / 10 fx | Stage IIA: 30 Gy / 15 fx |
| Renal Cell Carcinoma (Primary) | Medically inoperable primary RCC SBRT for excellent local control. | 26 Gy x 1 or 42 Gy / 3 fx |
7. GASTROINTESTINAL MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Rectal (Locally Advanced) | Total Neoadjuvant Therapy (TNT) is preferred (PRODIGE 23 / RAPIDO) to maximize downstaging and systemic control. | Short: 25 Gy / 5 fx | Long: 50 - 50.4 Gy / 25-28 fx |
| Anal Cancer | Definitive chemoradiation (5-FU + Mitomycin-C); surgery (APR) is strictly reserved for salvage. | T2N0: 50.4 Gy | T3/T4 or N+: 54 - 59.4 Gy |
| Esophagus | Neoadjuvant CRT (CROSS regimen) followed by surgery. Definitive CRT if medically inoperable. | Neoadjuvant: 41.4 Gy / 23 fx | Definitive: 50.4 Gy / 28 fx |
| Pancreas (BR / LAPC) | Borderline resectable or locally advanced; stereotactic/hypofractionated ablative doses are favored at high-volume centers. | 33 - 40 Gy / 5 fx (SBRT) or 50 Gy / 5 fx (SMART) |
| Hepatocellular Carcinoma (HCC) | Liver-directed SBRT for patients ineligible for ablation/resection, or as a bridge to transplant. | 30 - 50 Gy / 5 fx (Highly dependent on liver constraints) |
8. GYNECOLOGIC MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Endometrial (Adjuvant) | PORTEC risk grouping. High-intermediate gets vaginal brachy; high-risk gets pelvic EBRT. | Vag Brachy: 7 Gy x 3 (@ 0.5 cm) | Pelvic EBRT: 45 - 50.4 Gy |
| Cervix (Definitive) | EBRT + Concurrent cisplatin + Intracavitary brachytherapy boost. Overall treatment time <8 weeks is critical. | EBRT: 45 Gy | Total EQD2 to Point A/HR-CTV: 80 - 85 Gy |
| Cervix (Post-op / Peters) | Positive margins, positive nodes, or parametrial invasion mandates post-op CRT. | 45 - 50.4 Gy with concurrent cisplatin |
| Vulvar | Adjuvant RT for positive nodes/close margins. Definitive CRT for unresectable disease to spare stomas. | Adjuvant: 50.4 - 60 Gy | Definitive Gross: 60 - 64 Gy |
9. THORACIC MALIGNANCIES
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Early Stage NSCLC (Peripheral) | SBRT is standard for medically inoperable early-stage disease >2 cm from proximal bronchial tree. | 54 Gy / 3 fx or 48 Gy / 4 fx |
| Early Stage NSCLC (Central) | SBRT modified to respect central structures (within 2 cm of PBT). Risk of fatal hemoptysis with 3 fx. | 50 Gy / 5 fx |
| Locally Advanced NSCLC | Concurrent chemoradiation followed by consolidation immunotherapy (Durvalumab/PACIFIC). | 60 Gy / 30 fx |
| Limited Stage SCLC | Concurrent chemoradiation starting cycle 1 or 2 (Turrisi), followed by consolidation immunotherapy (ADRIATIC). | 45 Gy / 30 fx BID or 60 - 66 Gy / 30-33 fx daily |
| Prophylactic Cranial Irradiation | Standard for LS-SCLC with good response to initial therapy; debatable/selected in ES-SCLC based on MRI surveillance. | 25 Gy / 10 fx |
10. SARCOMAS
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Soft Tissue Sarcoma (Pre-op) | Standard backbone for limb-sparing extremity sarcoma; less late fibrosis/stiffness than post-op RT. | 50 Gy / 25 fx |
| Soft Tissue Sarcoma (Post-op) | Used for unplanned "whoops" excisions or positive margins when re-resection fails. Higher dose required. | 60 - 63 Gy (R0) | 66 - 68 Gy (R1) |
| Retroperitoneal Sarcoma | Pre-operative RT for selected histologies (e.g., well-dedifferentiated liposarcoma, STRASS trial). | 50.4 Gy / 28 fx |
11. PEDIATRIC RADIATION ONCOLOGY
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Medulloblastoma | Maximal safe resection → Craniospinal Irradiation (CSI) → Posterior fossa/bed boost. | Std CSI: 23.4 Gy | HR CSI: 36 Gy | Boost: 54 - 55.8 Gy |
| Wilms Tumor (Stage III) | Well-appearing child; upfront nephrectomy, then flank RT within 14 days of surgery. | Flank: 10.8 Gy |
| Neuroblastoma (High Risk) | Acutely ill child; biopsy only. High-risk receives intense induction, ASCT, and post-op RT to primary bed. | Tumor bed: 21.6 Gy |
| Rhabdomyosarcoma | Group III (Gross residual) gets definitive RT; embryonal vs alveolar dictates nodal management. | Group III: 50.4 Gy |
| Ewing Sarcoma | Definitive RT reserved for unresectable disease or when surgery entails unacceptable morbidity. | Definitive: 55.8 Gy |
12. LYMPHOMAS
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| cHL Early Favorable | Combined modality remains the clean board answer; ABVD x 2 + ISRT. | 20 Gy / 10 fx |
| cHL Early Unfavorable | Combined modality; ABVD x 4 + ISRT. | 30 Gy / 15 fx |
| DLBCL Limited-Stage | R-CHOP + ISRT; omission of RT only in highly selected complete metabolic responders. | 30 Gy after CR; 30 Gy + 6-15 Gy boost for PR/PET+ |
| Indolent NHL (Stage I/II) | Definitive RT alone is curative-intent for limited contiguous FL or MZL. | 24 Gy / 12 fx |
| Solitary Plasmacytoma | Definitive RT provides excellent local control; must rule out systemic myeloma via PET/Marrow. | 35 - 40 Gy (<5 cm) | 40 - 50 Gy (≥5 cm) |
| CAR-T Bridging | Treat dominant symptomatic sites or bulky chemoresistant sites prior to infusion. | 20 Gy / 5 fx or 30 Gy / 10 fx |
13. RADIOTHERAPY FOR BENIGN DISEASE
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Inflammatory (OA, Plantar Fasciitis) | Low-dose immune modulation for persistent pain after conservative failure. Typically age >40. | 0.5-1 Gy/fx, total 3-6 Gy (Classic: 3 Gy / 6 fx) |
| Keloids | Post-excision recurrence prevention; start within 24 hours ideally. | Guideline: 12 Gy | High BED: 18-21 Gy / 3 fx |
| Dupuytren / Ledderhose | Early active disease with nodules/cords; not for fixed mature contracture. | 3 Gy x 5, repeat after 8-12 weeks (Total 30 Gy) |
| Heterotopic Ossification | Preop within 4h or postop within 72h. Prevents new HO; does not dissolve mature HO. | 7-8 Gy x 1 |
| Endocrine Orbitopathy | Active inflammatory phase with muscle dysfunction. | 16-20 Gy / 8-10 fx (Classic: 20 Gy / 10 fx) |
14. RADIOPHARMACEUTICALS
| Clinical Scenario | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Radium-223 / Xofigo | mCRPC with symptomatic bone metastases and NO known visceral disease. Alpha emitter. | 55 kBq/kg q4wk x6 |
| 177Lu-DOTATATE / Lutathera | SSTR-positive GEP-NETs (Standard post-SSA, and emerging first-line). Beta emitter. | 7.4 GBq q8wk x4 (with amino acids) |
| 177Lu-PSMA-617 / Pluvicto | PSMA-positive mCRPC after ARPI (and/or taxane). Beta emitter. | 7.4 GBq q6wk x6 |
| I-131 MIBG / Azedra | Iobenguane-avid PPGL. Requires thyroid blockade. | Dosimetric dose → 296 MBq/kg x2 |