Comprehensive Management Paradigms & Dose Anchors
CNS
BRAIN METASTASES: CNS-ACTIVE SYSTEMIC THERAPY, SRS, AND WHEN TO HOLD RT
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Asymptomatic, small-volume disease with highly CNS-active drug option | Multidisciplinary deferral of RT can be reasonable when lesions are small, non-eloquent, non-hemorrhagic, minimally edematous, and close MRI follow-up is reliable. | If progression or symptoms develop, salvage with SRS/FSRS when feasible; common intact-met anchor for <2 cm lesions is 20-24 Gy x 1. |
| Symptomatic, large, hemorrhagic, edematous, or eloquent metastasis | Prioritize local therapy. Surgery is favored when diagnosis, mass effect, hydrocephalus, or decompression matters; otherwise SRS/FSRS is typical. | <2 cm: 20-24 Gy x 1; larger/eloquent: consider 24-27 Gy / 3 or 30 Gy / 5 depending on OARs and V12/V20/V24. |
| Limited intact brain metastases | SRS alone is standard for 1-4 lesions and now reasonable for selected 5-20 lesion patients when total volume, location, performance status, and follow-up support it. | Use lesion size/volume rather than lesion count alone; keep single-fraction brain V12 around ≤10 cc when feasible. |
| Resected metastasis | Postoperative cavity SRS/FSRS is preferred over WBRT for cognitive preservation and is better than observation for surgical-bed control. | Small cavity: single-fraction 12-20 Gy by cavity volume; larger/irregular/dural-risk cavities: 24-27 Gy / 3 or 30-32.5 Gy / 5. |
| Extensive brain metastases, not SRS-suitable, reasonable prognosis | Use HA-WBRT + memantine when hippocampal avoidance is oncologically safe. | Common WBRT regimen: 30 Gy / 10; hippocampi D100% ≤9 Gy, Dmax ≤16 Gy. |
| Poor prognosis / hospice-threshold brain metastases | Steroids, antiseizure therapy when indicated, supportive care, or short-course WBRT only if symptom palliation is likely and logistics are reasonable. | Short palliative WBRT anchor: 20 Gy / 5; QUARTZ-style data support avoiding reflex WBRT in poor-prognosis NSCLC patients. |
| Leptomeningeal disease or hippocampal-region disease | HA-WBRT may be inappropriate when disease involves or is very near the hippocampal avoidance region, or when leptomeningeal coverage is the goal. | Conventional WBRT 30 Gy / 10 is a common framework; focal boosts or CSI are individualized and uncommon in solid-tumor adults. |
GLIOBLASTOMA / WHO GRADE 4 ADULT-TYPE DIFFUSE GLIOMA
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Fit adult, usually <70 with KPS ≥60 | Max safe resection or biopsy → partial-brain RT with concurrent/adjuvant TMZ. Discuss tumor treating fields after chemoradiation for motivated patients who can manage device burden. | 60 Gy / 30 fx with daily TMZ, then adjuvant TMZ. |
| Molecular GBM / IDH-wildtype diffuse glioma with GBM molecular features | Treat like glioblastoma when IDH-wildtype diffuse glioma has TERT promoter mutation, EGFR amplification, or +7/-10 even without necrosis or microvascular proliferation. | Usually 60 Gy / 30 fx; target both enhancement/cavity and bulky non-enhancing disease. |
| Older but fit patient | Hypofractionated RT + TMZ is the clean board answer. Selected robust older patients may still receive standard 6-week chemoradiation. | 40.05 Gy / 15 fx + concurrent/adjuvant TMZ, especially if MGMT methylated. |
| Frail, poor PS, or RT-burden-sensitive patient | Short-course RT alone, TMZ alone if MGMT methylated and RT is impractical, or best supportive care depending on goals and symptoms. | 25 Gy / 5 fx for near-hospice threshold; 34 Gy / 10 or 40.05 Gy / 15 for intermediate fitness. |
| Recurrent disease | Clinical trial, re-resection, bevacizumab/syst therapy, LITT, or re-irradiation depending on interval, volume, location, and prior dose. | Common re-RT anchors include 25-35 Gy / 5-10 fx or highly selected SRS/FSRS; composite dose review is mandatory. |
IDH-MUTANT LOWER-GRADE GLIOMA
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Grade 2 IDH-mutant, low-risk after maximal safe resection | Observation remains appropriate for favorable, asymptomatic, reliably followed patients. Vorasidenib is an option for selected residual/recurrent non-enhancing disease after surgery when delaying RT/chemo is desirable. | No immediate RT; if RT becomes indicated, common dose is 50.4-54 Gy by histology/risk. |
| High-risk grade 2 IDH-mutant glioma | High-risk features include age ≥40, STR/biopsy, neurologic symptoms, large/unfavorable location, or unreliable surveillance. RT followed by PCV is the OS-improving board standard from RTOG 9802. | 50.4 Gy for oligodendroglioma; 54 Gy for astrocytoma; then PCV x6 when appropriate. |
| Grade 3 IDH-mutant astrocytoma | RT followed by adjuvant TMZ is the clean modern answer; concurrent TMZ is less clearly beneficial than adjuvant TMZ. | 57 Gy / 30 to 59.4 Gy / 33, then adjuvant TMZ. |
| Grade 3 IDH-mutant, 1p/19q-codeleted oligodendroglioma | RT followed by PCV is the classic evidence-based backbone; TMZ is often used when PCV tolerance is a concern while awaiting definitive CODEL interpretation. | 57 Gy / 30 to 59.4 Gy / 33, then PCV or TMZ depending on patient/trial context. |
| Recurrent/progressive IDH-mutant glioma | Consider surgery, vorasidenib if grade 2/eligible and not previously treated with RT/chemo, RT if not previously irradiated, systemic therapy, or re-irradiation in selected delayed recurrences. | Previously unirradiated: use grade-based definitive doses; re-RT usually requires tight margins and individualized composite-dose review. |
MENINGIOMA
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Grade 1, asymptomatic/incidental | Observation with serial MRI is often preferred, especially for small convexity or skull-base lesions without growth or symptoms. | No RT unless growth, symptoms, or difficult future salvage risk. |
| Grade 1, symptomatic, growing, unresectable, or recurrent | Surgery if safe decompression/pathology is needed; otherwise SRS/FSRT or fractionated RT based on size and optic/brainstem proximity. | SRS commonly 12-14 Gy x 1 for small lesions away from optic structures; FSRT 25 Gy / 5 or conventionally fractionated 50.4-54 Gy for larger/skull-base lesions. |
| Grade 2 after GTR | Discuss adjuvant RT vs close observation/trial. Many board-style scenarios favor adjuvant RT, especially if brain invasion, high mitotic index, high-risk location, or molecular concern. | 54-59.4 Gy; RTOG 0539 intermediate-risk regimen used 54 Gy. |
| Grade 2 after STR or recurrent grade 2 | Adjuvant/salvage RT is generally recommended because recurrence risk is high. | Commonly 59.4-60 Gy with generous dural CTV; selected dose escalation must respect brain/optic constraints. |
| Grade 3 or molecularly grade 3 | Adjuvant RT even after GTR; systemic/radioligand/immunotherapy approaches remain trial-oriented for progression. | About 60 Gy; RTOG 0539 high-risk used 60 Gy high-dose + 54 Gy low-dose region. |
| Recurrent / multiply treated meningioma | Re-review pathology/molecular risk, DOTATATE PET for extent when helpful, surgery if decompression/pathology is needed, and cautious re-irradiation or trial for selected patients. | Use composite-dose planning; margins and fractionation depend on grade, OARs, and prior RT. |
BRAIN TUMOR RE-IRRADIATION
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Brain metastasis after prior WBRT | SRS/FSRS is often feasible for limited relapse if performance status, systemic options, and normal-brain dose are acceptable. | Use standard SRS/FSRS dose by size with extra attention to cumulative brain V12/V20/V24 and prior WBRT dose. |
| Recurrent GBM / grade 4 glioma | Best for focal recurrence, interval usually ≥6-12 months, KPS preserved, volume modest, and no diffuse/leptomeningeal progression. | Common anchors: 25-35 Gy / 5-10 fx; consider bevacizumab when edema/radionecrosis risk is high. |
| Recurrent meningioma or benign skull-base tumor | Proceed only after careful surgical/pathology review because patients can live years with toxicity; fractionate when optic apparatus/brainstem/cochlea are limiting. | SRS/FSRT or conventional re-RT individualized; cumulative optic/brainstem/cochlea dose drives the plan more than nominal prescription. |
| Poor prognosis or diffuse recurrence | Supportive care, steroids, surgery/LITT for focal mass effect, systemic therapy, or short palliative RT may be better than aggressive re-irradiation. | Use the shortest regimen that plausibly improves symptoms; avoid treating scans when toxicity risk exceeds realistic benefit. |
SELECTED BENIGN / SKULL-BASE QUICK HITS — Management + Oral Board Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Pituitary adenoma | Surgery is typical first-line for symptomatic macroadenoma or optic compression; RT is for residual/recurrent growth or persistent hormone secretion when surgery/medical therapy is insufficient. Conventional RT/FSRT commonly 45-50.4 Gy; SRS can be used when safely separated from optic apparatus, with typical margins around 14-16 Gy for nonfunctioning adenoma and 20-25 Gy for secreting adenoma. Keep optic pathway max roughly 8-10 Gy for single-fraction SRS. | Embedded in board-management pearl |
| Vestibular schwannoma | Small minimally symptomatic tumors can be observed; SRS mainly improves tumor-volume control, not necessarily hearing/QOL. Typical SRS marginal dose is 12-13 Gy. Use FSRT or surgery for larger tumors, brainstem compression, poor geometry, or when decompression/pathology is needed. Warn about transient post-SRS swelling/pseudoprogression and possible disequilibrium. | Embedded in board-management pearl |
| Skull-base chordoma / chondrosarcoma | Max safe resection plus high-dose conformal RT, often proton/carbon ion when available, because durable control requires dose near critical skull-base OARs. Common dose anchors: chordoma often 70-78 Gy(RBE); low-grade chondrosarcoma often about 66-70 Gy(RBE). Chordoma is generally more aggressive and more dose-demanding than chondrosarcoma. | Embedded in board-management pearl |
Head & Neck
HPV+ OROPHARYNX
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Early / low-volume | T1-2 N0 or selected single node ≤3 cm: RT alone or surgery/TORS depending on exposure, laterality, functional tradeoffs, and likelihood of avoiding adjuvant therapy. | RT alone usually 68-70 Gy; selected hypofractionated 66-70 Gy at 2.1-2.2 Gy/fx. Elective neck 44-50 Gy sequential or 54-63 Gy SIB. |
| Locally advanced definitive | T3-4, multiple nodes, or node >3 cm: definitive CRT with cisplatin if eligible. Cetuximab is not an equivalent substitute for cisplatin. | Gross disease 70 Gy / 33-35 fx + cisplatin 100 mg/m2 q3wk or weekly 40 mg/m2. |
| Surgery-first / TORS path | Best for well-exposed, lateralized T1-2 tonsil/BOT tumors when surgery is likely to avoid triple-modality care. Pathology then drives observation vs PORT vs POCRT. | Low risk observe; selected intermediate risk 50 Gy; usual intermediate 56-60 Gy; ENE/+margin 60-66 Gy + cisplatin. |
| Recurrent / metastatic / palliative | Use salvage surgery or re-irradiation only for carefully selected localized recurrence; otherwise systemic therapy and symptom-directed RT. | Palliation commonly 30 Gy / 10, 20 Gy / 5, 8 Gy x 1, or QUAD shot 14-14.8 Gy / 4 BID repeated if benefit. |
HPV+ OROPHARYNX — Definitive Dose / Fractionation / Volumes
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Gross disease with concurrent systemic therapy | ASTRO strong recommendation | 70 Gy / 33-35 fx |
| Elective neck, sequential | Conventional elective range | 44-50 Gy |
| Elective neck, SIB | Typically 1.6-1.8 Gy/fx | 54-63 Gy |
| RT alone, conventional | T1-2 N0-1 single node ≤3 cm | 68-70 Gy |
| RT alone, hypofractionated | Fewer visits | 66-70 Gy at 2.1-2.2 Gy/fx |
| RT alone, accelerated | Shorter overall time | 68-72 Gy over 6 weeks |
| Hyperfractionated RT | Strongly recommended for T3-4 when treating RT-alone style regimens | 74.4-81.6 Gy, 1.2 Gy BID |
NASOPHARYNX CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Early stage | T1N0 and selected low-risk T2N0: definitive RT alone; add chemo as risk increases. | Primary/gross disease 70 Gy; elective/high-risk volumes commonly 54-60 Gy depending on risk and technique. |
| Intermediate risk | CRT backbone for nodal or more locally advanced disease that does not clearly need induction first. | 70 Gy + concurrent cisplatin; involved nodes treated to gross-dose or near-gross-dose levels. |
| Locoregionally advanced | Induction chemotherapy followed by CRT is the modern favored strategy for bulky / EBV-high-risk stage III-IV disease. GP and TPF are key induction regimens. | After induction: residual GTV 70 Gy; resolved pre-induction soft-tissue GTV can be reduced to about 64 Gy; high-risk CTV 60-62 Gy; low-risk CTV 54-56 Gy. |
| Field de-escalation / adjuvant nuance | Selected N0-1 patients can spare the contralateral lower neck. Metronomic capecitabine is a real adjuvant option for selected high-risk patients after CRT. | Capecitabine 650 mg/m2 BID x 1 year. Do not under-treat initially involved skull base/bone from pre-induction imaging. |
| Recurrent / metastatic | Local salvage for isolated recurrence when feasible; systemic therapy is central for disseminated disease. Palliative RT is symptom-directed. | Common palliation: 30 Gy / 10, 20 Gy / 5, 8 Gy x 1, or QUAD shot. |
EARLY GLOTTIC LARYNX
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Tis / T1a N0 | Definitive RT or transoral laser/microsurgery; single-vocal-cord or partial-larynx RT is increasingly attractive for well-selected T1a disease. | Classic RT 63 Gy / 28 preferred or 66 Gy / 33; selected hypofractionated 50-52 Gy. No elective neck for true glottic T1N0. |
| T1b / favorable T2 N0 | Definitive RT remains a clean organ-preservation answer; partial-larynx approaches are less settled as volume and bilateral/anterior commissure involvement increase. | T2 range 64.8-70 Gy, commonly altered fractionation or conventional IMRT/3D planning depending on anatomy. |
| Unfavorable T2 N0 | Impaired/sluggish cord mobility, bulky disease, subglottic extension, paraglottic concern, or substantial anterior commissure involvement may justify intensified RT or CRT discussion. | Gross dose 70 Gy if CRT-style; otherwise altered-fractionation RT to standard definitive dose. |
| Recurrent after RT | Salvage surgery is the classic curative route; re-irradiation is selective and anatomy-dependent. | Palliative options include 30 Gy / 10, 20 Gy / 5, or QUAD shot when cure is not realistic. |
EARLY GLOTTIC LARYNX — Dose Standards for Early Glottic RT
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| T1 N0 | Early glottic RT dose standard | 63 Gy / 28 at 2.25 Gy/fx preferred; or 66 Gy / 33; or 50-52 Gy at 3.12-3.28 Gy/fx |
| T2 N0 | Early glottic RT dose standard | 64.8 Gy at 2.4 Gy/fx up to 70 Gy / 35 |
LARYNX / HYPOPHARYNX, HPV-NEGATIVE: ELECTIVE NODAL DE-ESCALATION
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Early glottic contrast | T1-2N0 glottic disease generally treats the larynx only; elective neck treatment is not routine because occult nodal risk is low. | Larynx-only definitive dose per early glottic table. |
| Supraglottic / hypopharynx elective neck | These sites have meaningful bilateral nodal risk; elective nodal treatment is standard for definitive organ-preservation cases. | Conventional elective neck 44-50 Gy sequential or 54-63 Gy SIB; de-escalated 40-43 Gy is supported in selected modern series/trials. |
| Locally advanced organ preservation | Definitive CRT is a standard larynx-preservation strategy when surgery is avoidable and airway/swallowing function is appropriate. | Gross primary/nodes 70 Gy / 35 + cisplatin; elective dose as above. |
| Postoperative | PORT for adverse features; POCRT for positive margin or ENE. Preserve swallowing structures where safe. | Intermediate risk 54-60 Gy; high risk 60-66 Gy + cisplatin. |
| Recurrent / metastatic | Salvage laryngectomy/pharyngectomy for curable local recurrence; systemic therapy or palliative RT for disseminated or unresectable relapse. | Common palliation 30 Gy / 10, 20 Gy / 5, 8 Gy x 1, or QUAD shot. |
ORAL CAVITY: PORT, CRT, AND PERIOPERATIVE IMMUNOTHERAPY
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Early resectable | Surgery first with adequate margins and neck management based on depth/risk. Observation is appropriate only when pathology is truly low risk. | No RT for clean low-risk pathology. PORT discussion for close margin, PNI/LVI, DOI-driven risk, poor differentiation, or other adverse features. |
| Intermediate-risk postop | PORT for close margins, pT3-4, pN2-3, level IV/V nodes, PNI, LVI, or adverse primary features. | Typical 54-60 Gy to intermediate-risk volumes; start RT ideally within 6 weeks of surgery. |
| High-risk postop | Positive margin and/or ENE remain the cleanest board indication for postoperative CRT. | 60-66 Gy + cisplatin 100 mg/m2 days 1/22/43 or weekly 40 mg/m2. |
| Resectable locally advanced | Perioperative pembrolizumab is now an option for PD-L1 CPS ≥1 resectable stage III-IVA HNSCC, integrated around surgery and adjuvant RT/CRT. | Adjuvant RT/CRT dose still pathology-driven; pembrolizumab does not replace adequate surgery or indicated RT/CRT. |
| Recurrent / metastatic / palliative | Salvage surgery/re-irradiation for selected localized relapse; otherwise pembrolizumab-based systemic therapy and symptom-directed RT. | Palliation commonly 30 Gy / 10, 20 Gy / 5, 8 Gy x 1, or QUAD shot. |
Lung / Thoracic
EARLY-STAGE NSCLC
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Operable peripheral stage I | Surgery with mediastinal nodal evaluation remains reference standard; segmentectomy is reasonable for selected small peripheral tumors | SBRT considered after careful shared decision-making or if patient refuses surgery |
| Medically inoperable stage I | SBRT | Peripheral: 18 Gy x 3, 12 Gy x 4-5, or similar high-BED regimen |
| Chest-wall-adjacent peripheral lesion | Use more fractions if needed for ribs/chest wall | Common fallback: 50-60 Gy / 5 fx |
| Central lesion | SBRT with caution; avoid 3-fraction regimens | Common: 50 Gy / 5 to 60 Gy / 5; RTOG 0813 identified 12 Gy x 5 as MTD |
| Ultra-central lesion | More protracted SBRT / hypofractionation; prioritize airway, esophagus, and great-vessel constraints | SUNSET-style: 60 Gy / 8 fx with controlled hot spot |
| No safe biopsy | Empiric SBRT acceptable only after multidisciplinary review when malignancy probability is very high | Common threshold: pretest probability >85% |
| ILD / fibrotic lung disease | Major caution or alternate strategy | PFTs alone do not reliably predict fatal pneumonitis risk |
LOCALLY ADVANCED NSCLC
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Unresectable stage III, fit, no driver-directed post-CRT strategy | Concurrent platinum-based CRT followed by durvalumab if no progression | 60 Gy / 30 fx; durvalumab for up to 12 months |
| EGFR exon 19 del / L858R unresectable stage III | Definitive CRT followed by osimertinib, not routine durvalumab | Osimertinib 80 mg daily until progression or intolerance |
| CRT-ineligible / frail stage III | Sequential chemo then RT, RT alone, or clinical trial integrating IO without chemo | Common definitive anchor: 60 Gy / 30 fx; selected hypofractionated trials use 60 Gy / 15 fx |
| Potentially resectable N2 | Multidisciplinary decision; perioperative chemo-IO is established for appropriate surgical candidates | If surgery is abandoned, revert to definitive CRT principles |
| Dose escalation | Do not escalate whole thorax routinely | RTOG 0617: 74 Gy was worse than 60 Gy |
| Plan quality | Target coverage plus cardiac/lung/esophageal sparing | Heart mean ALARA, heart V40 <50%, lung V20 <35% historically, esophagus max EQD2 caution above 100-110 Gy |
POSTOPERATIVE (PORT) NSCLC
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| R0 pN0-1 | No PORT | Classic meta-analysis showed harm in older-technique pN0-1 patients |
| R0 pN2 after complete resection | No routine PORT after Lung ART; individualize for very high locoregional-risk features | If used selectively: often 50-54 Gy |
| Close / positive margin | Discuss PORT or postoperative CRT depending on margin, nodal risk, and systemic plan | Microscopic residual commonly 54-60 Gy |
| Gross residual disease | Definitive-style postoperative RT / CRT if safely deliverable | Gross residual commonly 60-66 Gy |
| After neoadjuvant or perioperative systemic therapy | Do not use PORT reflexively; base decision on final margins, residual nodal disease, and surgical quality | Coordinate timing so systemic therapy is not unnecessarily delayed |
SMALL CELL LUNG CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Very limited T1-2 N0 SCLC | Lobectomy + mediastinal staging in highly selected peripheral tumors; adjuvant platinum/etoposide | Add thoracic RT if nodal disease is found |
| Limited-stage, fit | Concurrent platinum/etoposide + thoracic RT, started early when feasible | Classic: 45 Gy BID; daily alternatives: 66 Gy / 33 or 70 Gy / 35 |
| Limited-stage after CRT without progression | Adjuvant durvalumab | Durvalumab q4wk up to 24 months |
| LS-SCLC complete/near-complete response | PCI vs MRI surveillance based on age, cognition, response, and patient values | PCI standard dose: 25 Gy / 10 fx; consider HA-PCI + memantine |
| Extensive-stage first line | Platinum/etoposide + atezolizumab or durvalumab | Median OS improvement is modest but standard |
| ES-SCLC chemo/IO responder with residual thoracic burden | Selective consolidative thoracic RT | Classic Slotman regimen: 30 Gy / 10 fx |
| ES-SCLC brain prevention | MRI surveillance is commonly favored; PCI remains individualized | Takahashi makes routine ES-SCLC PCI hard to defend with high-quality MRI access |
Sarcoma
FOUNDATIONAL RATIONALE FOR RT IN EXTREMITY STS
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Small, superficial, low-grade, widely resectable | Surgery alone can be appropriate after expert review | RT omission is most defensible when salvage morbidity is low and margins are clean |
| Deep, large, high-grade, close critical structures, or morbid salvage | Limb-sparing surgery + RT | Pre-op RT preferred: 50 Gy / 25 fx |
| Surgery already done first / adverse pathology found | Post-op RT if re-resection is not enough or not feasible | 45-50.4 Gy then cone-down to total 60-63 Gy if R0, 66-68 Gy if R1 |
| Unplanned excision / "whoops" surgery | Restage, expert pathology review, MRI of operative bed, then planned re-excision +/- RT | Treat based on residual disease risk and final oncologic plan, not the accidental operation alone |
| Positive margin after pre-op RT | Re-resection if feasible; do not reflexively add a post-op EBRT boost | Routine boost is especially hard to justify when the R1 margin is planned at bone or neurovascular structures |
| Adult elective nodes | No routine elective nodal irradiation | Exception: alveolar rhabdomyosarcoma; consider nodal workup for nodal-prone histologies |
| High-risk UPS / pleomorphic or dedifferentiated LPS of extremity | Consider perioperative pembrolizumab with pre-op RT in a SARC032-like patient | Do not generalize to all STS histologies |
RECENT PRACTICE-CHANGING RANDOMIZED TRIALS — Retroperitoneal Sarcoma Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Primary resectable RPS overall | Expert en bloc surgery is the core curative treatment | Routine RT for every RPS patient is not supported by STRASS |
| WDLPS / lower-grade DDLPS, expected close posterior or medial margin | Consider pre-op RT in multidisciplinary discussion | 50-50.4 Gy pre-op IMRT is the usual anchor |
| High-grade leiomyosarcoma or high distant-risk biology | Systemic therapy / trial discussion often matters more than RT | Local RT is less compelling when distant relapse is dominant |
| Post-op RPS after resection | Avoid routine post-op RT | Large bowel / kidney / liver often fall into the operative bed; toxicity and target uncertainty are major problems |
Gastrointestinal
ESOPHAGEAL / GEJ CANCER — Esophageal / GEJ / Gastric: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Mucosal early disease | Tis/T1a N0 → endoscopic resection (EMR/ESD) ± ablation; no routine RT. | RT generally not used |
| T1b N0 / low-risk T2N0 | Esophagectomy for fit distal/GEJ disease; cervical SCC or medically inoperable patient usually favors definitive CRT. | Definitive CRT 50-50.4 Gy; pre-op CRT if selected 41.4 Gy / 23 fx |
| Resectable esophageal / GEJ adenocarcinoma | Fit surgical candidate → perioperative FLOT-style systemic therapy is the default systemic-control answer; add/choose CRT when downstaging, margin risk, organ preservation, or FLOT fitness drives the case. | CROSS-style CRT 41.4 Gy / 23 fx; PET-directed CRT often 50.4 Gy |
| Squamous cell carcinoma / upper-mid esophagus | Pre-op CRT → surgery for trimodality candidates; definitive CRT is a strong organ-preservation answer, especially for cervical/proximal SCC or nonsurgical patients. | Pre-op 41.4 Gy / 23 fx or 40 Gy / 20 fx; definitive 50-50.4 Gy |
| Gastric / GEJ adenocarcinoma | Perioperative FLOT backbone; perioperative immunotherapy integration is a modern positive-trial concept for gastric/GEJ adenocarcinoma, while routine pre-op CRT is most useful for selected margin/downstaging problems. | Pre-op CRT in gastric/GEJ trials commonly 45 Gy / 25 fx |
| Post-trimodality residual disease | After neoadj CRT + R0 resection, path residual disease → adjuvant nivolumab; ypCR → observe/surveillance. | Nivolumab for up to 1 year; no RT boost after adequate neoadj CRT |
| Unresectable, recurrent, or palliation | Definitive CRT for curative-intent nonoperative cases; palliate dysphagia/bleeding with systemic therapy, stent, brachytherapy, or short-course EBRT as anatomy dictates. | Definitive 50-50.4 Gy; palliation often 20 Gy / 5 fx or 30 Gy / 10 fx |
PANCREATIC CANCER — Pancreatic Adenocarcinoma: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Resectable, favorable biology | Upfront surgery → 6 months adjuvant chemotherapy, usually mFOLFIRINOX if fit. RT is not routine for all-comers. | Post-op CRT, when selected, usually 50.4 Gy / 28 fx with fluoropyrimidine |
| Resectable with high-risk features | Neoadjuvant systemic therapy first when CA19-9, pain, nodes, weight loss, or indeterminate imaging suggests occult systemic risk; RT remains selective. | If CRT used: 50.4 Gy / 28 fx; older PREOPANC-style 36 Gy / 15 fx |
| Borderline resectable | Induction multi-agent chemotherapy → restage → consider CRT/ablative RT for margin sterilization and tumor-vessel interface control before surgery. | Conventional CRT 50.4 Gy / 28 fx; dose-escalated options 50 Gy / 5 fx, 67.5 Gy / 15 fx, or 75 Gy / 25 fx in expert workflows |
| Locally advanced unresectable | Start with 4-6 months systemic therapy. If no progression and performance/labs are favorable, consolidate with CRT, SBRT/SMART, or dose-escalated RT; conversion surgery is the prize when anatomy permits. | Standard CRT 50.4-54 Gy; SMART 50 Gy / 5 fx; ablative HART 67.5 Gy / 15 fx or 75 Gy / 25 fx |
| Pancreas SBRT volume caution | Pure GTV + 3-5 mm SBRT can miss triangle-volume/perivascular failures. For dose-escalated RT, include gross disease, involved vessels/TVI, and consensus high-/low-risk CTVs when safe. | NRG-style high/low dose per fraction: 10/6.6 Gy ×5, 4.5/2.5 Gy ×15, or 3/1.8 Gy ×25 |
| Oligometastatic / oligoprogressive | Systemic therapy remains the backbone; MDT/SBRT is reasonable for carefully selected low-volume patients when all active disease can be treated. | Examples include 50 Gy / 4 fx, 70 Gy / 10 fx, primary 40 Gy / 5 fx |
| Palliation | Treat pain, bleeding, gastric outlet/duodenal symptoms, or local progression threatening function; coordinate stent/biliary plans first. | Common palliative anchors: 20 Gy / 5 fx, 30 Gy / 10 fx, or individualized SBRT |
HEPATOCELLULAR CARCINOMA — HCC: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Resectable / transplantable | Resection or transplant when feasible; SBRT, protons, TACE/TARE, or ablation can bridge to transplant or control while awaiting definitive therapy. | Bridge SBRT commonly 35-50 Gy / 5 fx |
| Early liver-confined, not surgery/ablation candidate | SBRT or proton therapy is a definitive local option, especially when ablation is unsafe or technically poor. | Examples: 40 Gy / 5 fx, 36-54 Gy / 3 fx, PBT 66 GyE / 10 fx |
| Unresectable liver-confined / TACE alternative | Use SBRT/PBT as locoregional therapy, salvage after incomplete TACE/RFA, or consolidation after catheter therapy; protect uninvolved liver first. | Photon SBRT often 30-50 Gy / 5-6 fx; PBT example 70.2 GyE / 15 fx |
| Macrovascular invasion / locally advanced | Systemic therapy is central; SBRT can improve vascular response, local control, and time to progression in selected Child-Pugh A/B7 patients. | RTOG 1112-style 27.5-50 Gy / 5 fx |
| Oligometastatic / extrahepatic limited disease | Treat liver threat and selected extrahepatic sites only when liver reserve, systemic options, and total disease burden justify aggressive local therapy. | Individualized SBRT; obey liver, stomach, bowel, and biliary constraints |
| Painful liver tumor palliation | For liver pain refractory to medical management, single-fraction liver RT is a high-yield palliative answer. | 8 Gy × 1 with antiemetic/steroid premedication |
RECTAL CANCER — Rectal Cancer: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Favorable T1N0 | Local excision/ESD/TAMIS if small, mobile, well/moderately differentiated, no LVI/PNI, adequate margins, and no suspicious nodes. | No routine RT |
| T1-2N0 not local-excision candidate | TME surgery is standard; RT reserved for medically inoperable cases, organ-preservation strategies, or adverse postoperative findings. | If nonoperative CRT: typically 50.4-54 Gy |
| Favorable mid/upper LARC | For >5 cm from verge, cT2N1 or cT3a/b N0-1, clear CRM, no EMVI, and LAR planned: FOLFOX with selective CRT is reasonable if response is adequate. | If CRT needed: 50-50.4 Gy with fluoropyrimidine |
| High-risk LARC | TNT is the default board answer. Choose long-course CRT when distal tumor, threatened CRM/MRF, T4, EMVI+, lateral pelvic nodes, APR risk, or watch-and-wait goals matter. | Long-course CRT 50-54 Gy; short-course RT 25 Gy / 5 fx |
| Organ preservation / watch-and-wait | Consolidation chemotherapy after CRT gives the best OPRA-style TME-free signal; restage at 8-12 weeks and surveil intensively for 2 years. | CRT commonly 54 Gy; NOM-focused regimens 54-56 Gy / 27-31 fx |
| Small low-mid tumor boost strategy | Contact X-ray brachy boost can improve organ preservation in selected cT2-T3a/b tumors, especially <3 cm. | CXB 90 Gy / 3 fx to applicator surface with CRT |
| dMMR / MSI-H stage II-III | Test MMR/MSI up front. PD-1 blockade can produce durable cCR; defer CRT and TME if complete response is sustained in an expert surveillance program. | Dostarlimab trial schedule 500 mg q3wk × 9; no RT if cCR maintained |
| Metastatic / palliative | Systemic therapy ± liver/lung-directed MDT for selected oligometastatic disease; pelvic RT for bleeding, pain, obstruction risk, or unresectable local symptoms. | Palliative pelvic RT often 20 Gy / 5 fx or 30 Gy / 10 fx |
ANAL CANCER — Anal Squamous Cell Carcinoma: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Anal margin, very early favorable | Local excision if T1N0, well/moderately differentiated, no sphincter involvement, and adequate margin. Close follow-up is mandatory. | Margin goal ≥1 cm; superficially invasive anal canal margin ≥2 mm |
| Anal canal T1-2N0, small (<4 cm) | Definitive CRT remains the standard clean answer; de-escalated dose is promising for protocol/select settings but long-term control is still maturing. | Standard 50.4 Gy / 28 fx with elective 40-42 Gy; reduced-dose trial anchor 41.4 Gy / 23 fx |
| T3-4 or node-positive | Definitive IMRT + fluoropyrimidine/mitomycin. Include inguinal, pelvic, and risk-adapted external iliac coverage; do not substitute cisplatin routinely. | Primary/nodes typically 53.2-54 Gy; bulky escalation under study 58.8-61.6 Gy / 28 fx; elective 40-45 Gy |
| Persistent disease after CRT | Do not declare failure too early; many responses mature. Biopsy/progression-driven salvage APR is the board answer for true persistent/recurrent local disease. | Response assessment commonly around 8-12 wk, with final response often assessed by ~6 months |
| Metastatic or recurrent unresectable | Systemic therapy first; PD-1 inhibitors are relevant after progression. RT is for durable local control of symptomatic or oligoprogressive sites. | Palliation often 20 Gy / 5 fx or 30 Gy / 10 fx; SBRT individualized |
Genitourinary
INTACT PROSTATE: AS, RT, RP, FRACTIONATION, AND TECHNIQUE — Localized Intact Prostate: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Low risk | Active surveillance preferred; definitive treatment only for strong preference, progression, or hidden adverse features. | No ADT. If treating: prostate-only EBRT 60 Gy / 20 or SBRT 36.25-40 Gy / 5; brachy monotherapy is an option in selected anatomy. |
| Favorable intermediate risk | AS, RT, or RP depending on age, MRI/biopsy volume, cribriform/intraductal absence, genomics, and preference; RT alone is often enough. | No routine ADT. Prostate-only 60 Gy / 20 or SBRT 36.25 Gy / 5; consider DIL boost only when imaging-defined and constraints permit. |
| Unfavorable intermediate risk | Definitive RT plus short-course ADT; pelvic nodes are selective rather than automatic. | Prostate 60 Gy / 20 or SBRT in selected patients; ADT 4-6 months. Avoid focal therapy outside trial. |
| High risk | Definitive RT plus long-course ADT; dose escalation is best done by DIL boost or brachy boost in selected patients, not blind whole-gland escalation. | Prostate 60 Gy / 20 or conventional dose-escalated RT; ADT 18-36 months is the clean board answer. DIL SIB example: FLAME 77 Gy / 25 with boost to 95 Gy. |
| Very high risk / cN1 M0 | Curative-intent EBRT plus long-course ADT and systemic intensification, especially abiraterone for STAMPEDE-like biology or cN1. | Modern 20-fx schema: prostate 60 Gy / 20, elective pelvis 44 Gy / 20, involved nodes up to 55 Gy / 20; add long-course ADT + abiraterone/prednisone when appropriate. |
POST-PROSTATECTOMY, SALVAGE, AND RADIORECURRENT DISEASE — Post-Prostatectomy / Salvage: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Adverse pathology, PSA undetectable | Observation with early salvage is preferred for most; reserve adjuvant RT for unusually high-risk shared-decision cases. | No routine adjuvant RT for the average patient with pT3/positive margin and undetectable PSA. |
| Early salvage PSA rise | Do not wait for high PSA; salvage earlier is better, and PSMA-negative imaging should not block prostate-bed RT when clinically indicated. | Prostate bed commonly 64-66 Gy conventional or moderate hypofractionation per protocol/comfort; avoid routine escalation beyond about 66 Gy. |
| Salvage ADT decision | Pre-salvage PSA is prognostic and predictive. ADT benefit is small at very low PSA unless high-risk features are present. | Consider no ADT for PSA <0.5 and favorable features; consider 4-6 months ADT for higher-risk early salvage; higher PSA/later salvage supports stronger systemic discussion. |
| Pelvic nodes in salvage | Pelvic RT is an intensification strategy when nodal risk is meaningful; do not use pelvic RT alone as the intensification. | SPPORT-style treatment: prostate bed + pelvic nodes + short-course ADT; tailor to PSMA PET, pathology, PSA kinetics, and Decipher. |
| Biopsy-proven local recurrence after prior RT | Confirm local-only disease and urinary/rectal feasibility; salvage SBRT or brachytherapy are the strongest local RT options in selected patients. | Regimen is site/anatomy dependent; counsel carefully about urinary toxicity, fistula/rectal risk, and need for experienced salvage team. |
METASTATIC PROSTATE: PRIMARY RT, MDT, mHSPC, AND mCRPC — Metastatic Prostate: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| De novo low-volume mHSPC | Systemic intensification plus RT to the primary is standard for appropriately fit patients. | Primary RT anchors: 55 Gy / 20 daily or 36 Gy / 6 weekly; systemic backbone ADT + ARPI by current med onc strategy. |
| De novo high-volume / visceral mHSPC | Primary RT does not clearly improve OS; use for symptoms, local control, or selected prevention of serious GU events. | Systemic therapy drives survival; RT dose depends on palliative vs durable local-control intent. |
| Oligorecurrent HSPC | MDT/SBRT to all visible disease is a reasonable progression-delaying strategy in selected patients with limited lesions and good systemic options. | SBRT commonly 16-20 Gy x 1, 27-30 Gy / 3, or 30-40 Gy / 5 by site/OAR; PSMA PET improves lesion detection. |
| Oligoprogressive mCRPC | Consider SBRT when a few resistant clones progress while most disease remains controlled on a valuable systemic line. | Goal is delaying systemic switch; continue ADT and coordinate ARPI/chemo/radiopharmaceutical sequencing. |
| Symptomatic / polymetastatic disease | Palliative RT for pain, cord compression, fracture risk, hematuria/obstruction, or bulky local symptoms. | Common palliation: 8 Gy x 1, 20 Gy / 5, 30 Gy / 10; radiopharmaceuticals for appropriate bone/PSMA-positive mCRPC contexts. |
BLADDER CANCER — Bladder Cancer: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| CIS / NMIBC | No routine curative RT; manage with TURBT, intravesical therapy, surveillance, and cystectomy for appropriate high-risk/refractory disease. | RT only for unusual palliation or nonstandard salvage contexts. |
| Ideal MIBC bladder preservation | Maximal TURBT followed by continuous-course chemoRT for unifocal cT2-T4a N0-1 disease with good bladder function and no extensive CIS/hydronephrosis. | Preferred anchor 55 Gy / 20 with radiosensitizer such as 5-FU/MMC, gemcitabine, or cisplatin-based approach depending on fitness. |
| Less ideal but nonsurgical candidate | Bladder preservation may still be reasonable when cystectomy is unsafe, but counsel about lower complete-response/salvage options if hydronephrosis, bulky disease, or incomplete TURBT. | Continuous-course bladder-only CRT is usually preferred; elective pelvic nodes are not routine in modern BC2001-style practice. |
| Post-cystectomy high-risk | Adjuvant pelvic/cystectomy-bed IMRT is an option for pT3-4, positive margins, or node-positive disease where locoregional failure risk is high. | 50.4 Gy / 28 or about 50 Gy / 25; coordinate with diversion/stoma anatomy and systemic therapy. |
| Metastatic / bleeding palliation | RT for hematuria, pain, obstruction, or pelvic symptoms; systemic therapy controls distant disease. | Common palliation: 20 Gy / 5, 30 Gy / 10, or short hypofractionated hemostatic regimens by urgency. |
RCC, SEMINOMA, AND PENILE CANCER — RCC / Seminoma / Penile: Management Paradigm + Dose Anchors
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Primary localized RCC, medically inoperable or nephron-sparing need | SBRT is a real definitive option, especially when surgery/ablation is unsafe or renal preservation is central. | 26 Gy x 1, 42-48 Gy / 3, or 40 Gy / 5 -style regimens; use 4DCT/MRI fusion, motion management, and kidney/GI constraints. |
| Metastatic RCC | SBRT for oligometastatic/oligoprogressive disease, palliation, or consolidating resistant sites while systemic therapy continues. | Site-specific SBRT; RCC needs ablative BED when safe, not old low-dose conventional assumptions. |
| Stage I seminoma | Radical inguinal orchiectomy, then surveillance preferred for compliant patients; carboplatin is an alternative; RT is reserved for selected patients. | If RT: para-aortic 20 Gy / 10; avoid scrotal biopsy and use contralateral testis shielding. |
| Stage IIA/IIB seminoma | RT remains an option for low-volume nodal seminoma, but chemotherapy becomes increasingly favored as bulk rises. | IIA: dogleg/para-aortic-ipsilateral pelvis 20 Gy + boost to 30 Gy; IIB boost to 36 Gy. |
| Penile primary / nodes | Surgery is dominant; RT/CRT matters for organ preservation, positive margins, extranodal extension, bulky nodes, unresectable disease, or palliation. | Gross primary 65-70 Gy; ENE/gross nodal basin about 60 Gy; elective/adjuvant 45-60 Gy; include prepubic fat when high-risk anatomy warrants. |
Gynecologic
ENDOMETRIAL CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Low-risk stage I endometrioid | Surgery alone / observation after TAH-BSO ± SLN staging. | No RT. |
| High-intermediate risk stage I | Vaginal cuff brachytherapy is the clean board answer; EBRT only for higher pelvic-risk features. | 7 Gy × 3 at 5 mm or institutional equivalent. |
| Stage II / cervical stromal invasion or high pelvic-risk features | Pelvic EBRT ± VBT; add systemic therapy by histology/molecular risk. | 45–50.4 Gy pelvis; VBT boost if cuff risk. |
| Stage III / high-risk histology / p53abn | Combined systemic therapy and RT sequencing: chemoRT, chemo-first, or sandwich depending on residual disease and recurrence pattern risk. | 45–50.4 Gy pelvis ± PA; gross nodes often 55–60 Gy; VBT selective. |
| Medically inoperable uterine-confined disease | Definitive image-guided uterine brachytherapy alone for minimal invasion; EBRT + brachy for deep invasion, cervical extension, or nodal-risk features. | Brachy alone uterine CTV ~ 48–62.5 Gy EQD2; EBRT + HDR CTV ~ 65–75 Gy EQD2, GTV goal 80–90 Gy EQD2. |
| RT-naive vaginal / pelvic recurrence | Salvage pelvic RT ± brachytherapy; weekly cisplatin is not routine after GOG-238. | Pelvis 45–50 Gy + brachy/boost to ~ 70–80+ Gy EQD2. |
CERVICAL CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| IA1 without LVSI | Conization or simple hysterectomy depending fertility goals and margins. | No RT. |
| IA2 / IB1 ≤2 cm, low risk | Fertility-sparing trachelectomy or open surgery with nodal assessment; simple hysterectomy acceptable only in carefully selected SHAPE-style patients. | No RT unless adverse pathology. |
| Early operable IB–IIA | Open radical hysterectomy + nodes or definitive RT. Post-op RT for Sedlis; post-op CRT for Peters criteria. | Post-op pelvis 45–50.4 Gy; high-risk post-op CRT with weekly cisplatin. |
| Locally advanced / node-positive / IB3+ / IIB–IVA | Definitive weekly cisplatin chemoRT + brachytherapy. Do not omit brachytherapy. | EBRT 45 Gy / 25 fx ± nodal SIB 55–60 Gy; HR-CTV D90 goal ~ 85–95 Gy EQD2; package time <8 weeks. |
| FIGO 2014 III–IVA high-risk LACC | Add pembrolizumab to CRT/maintenance per KEYNOTE-A18 when appropriate; INTERLACE induction carbo/pac is another positive strategy, but not established to combine both. | RT dose same as definitive CRT; induction carbo AUC2 + paclitaxel 80 mg/m² weekly × 6 if using INTERLACE approach. |
| Metastatic / recurrent | Systemic therapy ± local RT for bleeding, pain, obstruction, oligoprogression, or durable control of limited sites. | Common palliation: 8 Gy × 1, 20 Gy / 5 fx, 30 Gy / 10 fx, or SBRT by site/OARs. |
VULVAR CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| T1a, DOI ≤1 mm | Wide local excision; no groin staging if truly microinvasive. | No RT. |
| T1b/T2 clinically N0, resectable | Radical local excision + SLN mapping if eligible; inguinofemoral LND if SLN-ineligible or clinically suspicious nodes. | Adjuvant vulva RT 45–50.4 Gy for selected negative-margin risk; 54–60 Gy for close/positive margins if no re-excision. |
| SLN micrometastasis ≤2 mm | Groin RT alone acceptable after GROINSS-V2. | Groin/elective nodal RT typically 45–50 Gy. |
| SLN macrometastasis >2 mm or multiple/ECE nodes | Inguinofemoral LND ± adjuvant nodal RT; RT strongly favored for ≥2 nodes or ECE. | LN+ no ECE 50–55 Gy; ECE 54–64 Gy. |
| Locally advanced / unresectable | Definitive or preoperative chemoRT, usually weekly cisplatin; reassess for surgery only if needed. | Elective vulva/nodes 45–50 Gy; gross primary/nodes 60–70 Gy (GOG-205 boost to 57.6 Gy ). |
| Metastatic / symptomatic recurrence | Systemic therapy and local RT for palliation or selected durable local control. | 20 Gy / 5 fx, 30 Gy / 10 fx, or individualized re-irradiation/SBRT. |
VAGINAL CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Stage IA, ≤2 cm superficial lesion | Vaginal brachytherapy preferred; surgery only when margin-negative resection is low morbidity. | Intracavitary VBT regimen individualized; often prescribed to surface or 5 mm by thickness. |
| Stage IB >2 cm or thicker lesion | Pelvic EBRT + intracavitary/interstitial brachytherapy boost. | EBRT 45–50 Gy + brachy to total ~ 70–80 Gy EQD2. |
| Stage II–IVA | Platinum-based chemoradiation + brachytherapy boost. | EBRT 45–50 Gy to vagina/nodes ± PA; total target dose often ~ 70–85 Gy EQD2 depending residual and OARs. |
| Lower-third vaginal involvement | Include bilateral inguinofemoral nodes in the elective field. | Groins typically 45–50 Gy; boost involved nodes. |
| Recurrent / metastatic | Salvage local therapy if encompassable and RT history permits; otherwise palliative/systemic approach. | 20 Gy / 5 fx, 30 Gy / 10 fx, interstitial salvage, or SBRT by site/OARs. |
OVARIAN / FALLOPIAN TUBE / PRIMARY PERITONEAL CANCER
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Apparent early-stage epithelial | Surgical staging/cytoreduction ± adjuvant platinum-based chemotherapy by stage, grade, and histology. | No routine adjuvant RT. |
| Advanced stage III–IV epithelial | Primary debulking if optimally cytoreducible, or neoadjuvant carbo/pac → interval debulking → additional platinum-taxane chemotherapy. | No routine consolidative RT. |
| CR/PR after first-line platinum | Maintenance is biomarker/systemic: BRCA, HRD, and bevacizumab exposure drive PARP ± bevacizumab vs observation/bev continuation. | No RT role for maintenance. Current U.S. niraparib first-line maintenance label is HRD-positive disease after platinum response. |
| Isolated symptomatic recurrence | Local RT for pain, bleeding, obstruction, nodal/soft-tissue mass, bone, brain, or other morbidity-prevention sites. | Common palliation: 8 Gy × 1, 20 Gy / 5 fx, 30 Gy / 10 fx; tailor to bowel/OARs. |
| Oligometastatic / oligoprogressive recurrence | Selected SBRT or conformal RT can provide durable local control when systemic disease is otherwise controlled. | Often ~ 24–40 Gy in 3–5 fx depending site, size, prior RT, and bowel proximity. |
| Rare ovarian germ cell tumors | Surgery + platinum-based chemotherapy usually curative; dysgerminoma is radiosensitive historically, but RT is now rarely used. | Reserve RT for unusual salvage/palliation after multidisciplinary review. |
Pediatric
NON-CNS MALIGNANCIES
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Wilms tumor | COG-style surgery first when classic presentation; do not biopsy unless diagnosis is unclear. RT for FH stage III-V and UH all stages. | Flank 10.8 Gy / 6 fx (FH stage III); diffuse anaplasia stage III 19.8 Gy; WAI 10.5 Gy / 7 fx; WLI 12 Gy / 8 fx or 10.5 Gy / 7 fx if <1 yr. |
| Neuroblastoma | Low/intermediate risk usually no RT. High-risk sequence: induction → surgery → ASCT → RT → anti-GD2 immunotherapy. | Primary site and selected persistent metastatic sites 21.6 Gy / 12 fx; no routine boost for gross residual after surgery. |
| Rhabdomyosarcoma | Group and FOXO1 status drive RT. Local therapy is usually after induction chemo; delayed primary excision is useful only if all gross disease can be removed with acceptable morbidity. | Group I FOXO1+ 36 Gy; Group II margin+ 36 Gy; node+ 41.4 Gy; orbit Group III 45 Gy; non-orbit Group III 50.4 Gy; WLI 15 Gy / 10 fx (>6 yo) or 12 Gy / 10 fx (<7 yo). |
| Ewing sarcoma | Systemic therapy is essential; local control is surgery, RT, or both. Surgery favored for expendable bones and when morbidity is acceptable; RT favored for unresectable or morbid surgical sites. | Definitive/gross residual 55.8 Gy; postop microscopic positive margin 50.4 Gy; preop RT 36 Gy; WLI 15 Gy / 10 fx or 12 Gy / 8 fx if <6 yo. |
CNS MALIGNANCIES
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Average-risk medulloblastoma | Age ≥3, M0, residual <1.5 cm². Max safe resection → CSI + boost → adjuvant chemo. | CSI 23.4 Gy → tumor-bed boost to 54 Gy. Do not routine-drop to 18 Gy outside a study-defined approach. |
| High-risk medulloblastoma | M+ disease, residual ≥1.5 cm², or diffuse anaplasia. | CSI 36 Gy → boost 54–55.8 Gy; focal/diffuse metastatic boost by site. |
| Ependymoma | Extent of resection is the key prognostic factor. Most intracranial ependymomas receive focal adjuvant RT; CSI only for metastatic disease. | Focal 54 Gy + boost to 59.4 Gy when age/target allows; CTV often only 0.5 cm. |
| Localized germinoma | Chemo-response-adapted ventricular RT + boost; bifocal pineal/suprasellar disease is treated as localized if no other dissemination. | If CR after chemo: WV 18 Gy + boost 12 Gy (total 30 Gy ); higher if <CR. |
| NGGCT | Chemo + second-look surgery if residual; spine coverage is back in the modern field strategy because WVI-only had spine failures. | WV + spine 30.6 Gy → primary boost to 54 Gy. |
| Craniopharyngioma | Biopsy/STR + RT often gives disease control comparable to aggressive GTR with less catastrophic hypothalamic/visual morbidity. | 52.2–54 Gy; re-image during RT because cysts can change. |
| Diffuse midline glioma / DIPG | RT is the only proven life-extending therapy; systemic/biologic approaches remain study-driven. | 54 Gy / 30 fx standard; recurrence re-RT often 20–30 Gy if performance status permits. |
Lymphoma
HODGKIN LYMPHOMA
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| cHL early favorable | Combined modality remains the clean board answer; PET-adapted chemo-alone is selected-patient de-escalation with a PFS tradeoff. | ABVD × 2 → ISRT 20 Gy / 10 fx. |
| cHL early unfavorable | ABVD-based combined modality is the standard oral-board anchor; intensified PET-adapted approaches are more systemic-therapy heavy. | ABVD × 4 → ISRT 30 Gy / 15 fx. |
| cHL advanced stage III-IV | N-AVD × 6 is a modern frontline reference. Do not give routine RT after complete metabolic response. | RT only for residual PET-positive, symptomatic, threatening, or selected bulky/residual sites; often 30–36 Gy if consolidative. |
| R/R cHL, transplant-eligible | Salvage systemic therapy → ASCT; add RT for localized relapse, bulky ≥5 cm, incomplete response, or morbidity-prevention sites. | Typical peri-transplant ISRT 30–36 Gy; gross refractory/residual may need 36–45 Gy. |
| NLPHL / nodular lymphocyte predominant B-cell lymphoma | Stage IA/IIA non-bulky contiguous disease can be treated with RT alone; higher-risk/noncontiguous disease often uses systemic or combined modality. | Generous ISRT, usually 30 Gy. |
| Palliation / urgent local control | Use local RT for cord/SVC/airway/nerve root/GI-GU obstruction, pain, or bleeding. | Common short courses: 20 Gy / 5 fx or 30 Gy / 10 fx, individualized to prior RT and intent. |
AGGRESSIVE NON-HODGKIN LYMPHOMA
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Limited-stage nonbulky low-risk DLBCL | R-CHOP-based therapy with PET-adapted omission of RT in selected low-risk patients; RT remains favored if chemo is abbreviated or local risk is high. | 30 Gy established after CR; 20 Gy is emerging after full chemo + Deauville 1-3. |
| Bulky, osseous, high-risk limited, or critical-site DLBCL | Full systemic therapy such as R-CHOP or Pola-R-CHP depending risk; consolidate sites where local failure is consequential. | CR: 30 Gy; PR/PET+ residual: 30 Gy + 6–15 Gy boost or ~ 36–45 Gy. |
| Advanced-stage DLBCL | Systemic therapy drives cure; RT is selective for bulky, osseous, residual PET-positive, or morbidity-prevention sites. | Same consolidation logic: 30 Gy after CR; higher for residual FDG-avid disease. |
| PMBCL | DA-EPOCH-R is commonly preferred. If Deauville 1-3 complete metabolic response, omit mediastinal RT; biopsy or individualize Deauville 4-5. | If RT needed: often 30–36 Gy; salvage/refractory mediastinum may require 36–45 Gy. |
| Primary testicular DLBCL | Radical inguinal orchiectomy + R-CHOP-based systemic therapy + CNS prophylaxis + contralateral testis RT. | Intact testis/scrotal contents 25–30 Gy; stage II nodal sites may receive ISRT by response. |
| Primary breast DLBCL | R-CHOP-based systemic therapy; consider CNS-risk discussion and ipsilateral breast/chest wall RT for local control. | Common consolidation 30–36 Gy to involved breast/chest wall region after chemo response. |
| Primary CNS lymphoma | HD-MTX-based induction; consolidation with ASCT, non-myeloablative therapy, or reduced-dose WBRT depending fitness/response. | CR consolidation WBRT option 23.4 Gy / 13 fx; salvage WBRT 24–30 Gy ± boost to ~ 45 Gy. |
| Extranodal NK/T nasal type | Asparaginase- or platinum-based chemotherapy plus definitive involved-site RT. | 50–54 Gy; avoid underdosing below 50 Gy for definitive intent. |
CAR-T AND LYMPHOMA RADIATION
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Before apheresis | Only for emergent organ-threatening symptoms when waiting is unsafe; avoid compromising collection when possible. | Short palliation such as 8 Gy × 1, 20 Gy / 5 fx, or tailored urgent RT. |
| Bridging after apheresis, before infusion | Best-planned RT window. Treat dominant symptomatic sites, all active sites if limited-volume and safe, or bulky chemoresistant sites. | Common: 20 Gy / 5 fx, 20 Gy / 10 fx, 30 Gy / 10 fx, 36 Gy / 12 fx, or 37.5 Gy / 15 fx. |
| Post-CAR-T residual disease | Consider for limited persistent FDG-avid disease when all active sites are encompassable and marrow/OAR constraints are acceptable. | Often salvage-like 30–36 Gy; escalate for gross refractory disease if safe. |
| Late limited relapse after CAR-T | More salvageable than very early failure; use RT when durable local control is realistic or symptoms threaten function. | Site- and intent-based: 20 Gy / 5 fx, 30 Gy / 10 fx, or definitive/salvage dosing. |
INDOLENT NHL AND OTHER HEMATOLOGIC RT
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Limited-stage FL / MZL / indolent B-cell NHL | Definitive RT alone is curative-intent for stage I or contiguous stage II disease; use a more generous ISRT volume than post-chemo lymphoma. | 24 Gy / 12 fx. |
| Very-low-dose / response-adapted indolent RT | Useful for palliation or selected de-escalation-friendly sites with reliable reassessment. | 4 Gy / 2 fx then reassess; escalate to 20–24 Gy if residual disease. |
| Orbital MALT / FL | Definitive conventional RT or response-adapted ultra-low-dose RT depending size, symptoms, and follow-up reliability. | Conventional 24–25 Gy; response-adapted start 4 Gy / 2 fx. |
| Gastric MALT | H. pylori eradication first if positive; RT for negative, persistent, progressive, symptomatic, or t(11;18)-associated disease. | 24–30 Gy to whole stomach + involved nodes; manage stomach filling/motion. |
| Primary cutaneous lymphoma | Local RT for symptomatic/localized lesions; match dose to histology and durability goal. | MF/CTCL often 8 Gy / 2 fx; pcALCL 20–30 Gy; pcMZL/pcFCL 24 Gy definitive. |
| Mantle cell lymphoma | Usually systemic therapy; rare localized presentations may receive ISRT, and palliation can be very low dose. | Localized 24–30 Gy; palliation 4 Gy / 2 fx. |
| Solitary plasmacytoma | Rule out myeloma first; definitive RT gives high local control. | 35–40 Gy if <5 cm; 40–50 Gy if ≥5 cm or higher-risk site. |
| Myeloma / chloroma / CNS leukemia / TBI | RT is palliative, local-control, CNS-directed, or conditioning-based depending disease context. | Myeloma 20 Gy / 8 fx; chloroma 24 Gy / 12 fx; CNS leukemia CSI ~ 23.4 Gy / 13 fx; TBI often 12–13.2 Gy fractionated. |
Benign Disease
PRACTICAL WORKFLOW — Benign RT Workup Checklist
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| OA / inflammatory LDRT | Common modern practical regimen | 0.5 Gy x 6 = 3 Gy |
| OA / shoulder / bursitis guideline range | 2-3 fractions weekly; repeat course possible | 0.5-1 Gy/fx to 3-6 Gy |
| Plantar fasciitis / heel spur | German evidence level 1b / recommendation A | 0.5 Gy x 6 = 3 Gy |
| Epicondylitis | Second series after 10-12 weeks if needed | 0.5 Gy x 6 = 3 Gy |
| Keloid guideline schedule | Post-excision, ideally within 24h | 3 Gy x 4 = 12 Gy |
| Keloid common higher-BED schedule | Earlobe lower, trunk/shoulder higher-risk sites higher | 18-21 Gy / 3 fx |
| Dupuytren disease | Total 30 Gy; active early disease | 3 Gy x 5, repeat after 8-12 wk |
| Ledderhose disease | Total 30 Gy; symptomatic progressive nodules | 3 Gy x 5, repeat after 8-12 wk |
| Peyronie disease | Active painful plaques; spare glans/scrotum | 2-3 Gy/fx to 10-20 Gy |
| Heterotopic ossification | Preop <4h or postop <72h | 7-8 Gy x 1 |
| HO high-risk fractionated option | Selected high-risk settings | 3.5 Gy x 5 |
| Endocrine orbitopathy | Classic active/moderate disease approach; lower-dose regimens exist | 16-20 Gy / 8-10 fx |
| Lymphatic fistula | Guideline range broader; stop when secretion ceases | 0.3-0.5 Gy/fx, often 1-3 Gy total |
| Vertebral hemangioma | Symptomatic stage 2-3 disease | 34-36 Gy |
| PVNS / TGCT diffuse | Adjuvant/selective after incomplete resection or high recurrence risk | 36-40 Gy |
| Desmoid | Selected progressive/morbid cases after multidisciplinary review | 50-65 Gy |
| Gorham-Stout disease | Progressive osteolysis | 36-45 Gy |
| Gynecomastia prophylaxis | Antiandrogen-associated; tamoxifen often more effective | 9-15 Gy / 3-5 fx or 10-15 Gy x 1 |
Radiopharmaceuticals
FOUNDATIONS: THERANOSTICS, ISOTOPES, AND THE CURRENT LANDSCAPE — Current Label vs Trial Frontier
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Xofigo / Ra-223 | mCRPC with symptomatic bone metastases and no known visceral metastatic disease; 55 kBq/kg q4wk x6 | 55 kBq/kg; PEACE-3 supports enzalutamide + Ra-223 with mandatory bone-protective therapy, but the clean board answer is still selection + bone protection |
| Lutathera / 177Lu-DOTATATE | Adult and pediatric age ≥12 with SSTR-positive GEP-NET; 7.4 GBq q8wk x4 | 7.4 GBq; NETTER-2 moves PRRT into the first-line conversation for advanced, higher-proliferation well-differentiated GEP-NET |
| Pluvicto / 177Lu-PSMA-617 | PSMA+ mCRPC after ARPI therapy, either appropriate to delay taxane or after prior taxane; 7.4 GBq q6wk x6 | 7.4 GBq; PSMAddition and LUNAR move PSMA-RLT into hormone-sensitive disease, but they are not universal routine practice yet |
| Azedra / I-131 MIBG | Iobenguane-scan-positive unresectable, locally advanced, or metastatic pheochromocytoma / paraganglioma requiring systemic therapy | Highly selected disease niche; useful for boards because it demonstrates theranostic selection and patient-specific dosimetry |
| Y-90 microspheres | Liver-directed radioembolization for selected HCC and liver-dominant tumors after mapping angiography and lung-shunt assessment | Modern Y-90 is increasingly dosimetry-driven rather than purely body-surface-area or empiric activity driven |
RADIUM-223 — Radium-223 Management Paradigm
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Best candidate | mCRPC with symptomatic bone metastases, adequate marrow reserve, and no known visceral metastases | See Ra-223 label dose: 55 kBq/kg q4wk x6 when appropriate |
| Soft-tissue / visceral disease | Do not expect Ra-223 to control visceral disease; choose systemic therapy or focal RT as appropriate | Embedded / selection anchor |
| Bone health | Use bone-protective agents when combining with modern androgen-axis therapy; ERA-223 is the cautionary fracture trial | Embedded / selection anchor |
| Response assessment | PSA can be misleading; alkaline phosphatase and symptom/skeletal-event trajectory are more informative, but imperfect | Embedded / selection anchor |
| Local symptom flare or impending event | Use EBRT / surgery for focal instability, cord compression, or dominant pain; Ra-223 is systemic bone-targeted treatment | Embedded / selection anchor |
177LU-DOTATATE (LUTATHERA)
| Clinical Situation | Preferred Paradigm & Rationale | Dose / Board Anchor |
|---|---|---|
| Required imaging | Confirm SSTR-positive disease on SSTR imaging; SSTR-negative or poorly differentiated NEC biology should push away from PRRT | Embedded / not separated in source table |
| Classic standard setting | Progressive well-differentiated SSTR+ midgut NET after somatostatin analog therapy: NETTER-1 | Embedded / not separated in source table |
| Earlier-line setting | Newly diagnosed advanced well-differentiated G2/G3 GEP-NET with higher proliferation: NETTER-2 supports first-line use | Embedded / not separated in source table |
| Standard course | 7.4 GBq q8 weeks x4, with octreotide LAR 30 mg after each Lutathera dose | Embedded / not separated in source table |
| Renal protection | Lysine/arginine amino acid infusion plus antiemetics; nausea often comes from the amino acids rather than the radioligand itself | Embedded / not separated in source table |