Comprehensive Management Paradigms & Dose Anchors

Note: This page compiles the definitive management paradigms, subclassifiers, and dose anchors from the individual disease-site reviews into a single high-yield reference. It is intended as a review scaffold, not a substitute for disease-site guidelines, multidisciplinary judgment, protocol details, normal-tissue constraints, or patient-specific planning.

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

SYSTEMIC THERAPY QUICK HITS — CNS

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Glioblastoma, fit adult	Temozolomide with RT, then adjuvant TMZ; MGMT promoter methylation predicts greater TMZ benefit.	Classic Stupp backbone is RT + concurrent/adjuvant TMZ. In older/frail patients, MGMT status helps choose TMZ vs RT-alone approaches.
IDH-mutant grade 2 glioma after surgery	Vorasidenib, oral dual IDH1/2 inhibitor, for selected residual/recurrent grade 2 IDH-mutant astrocytoma or oligodendroglioma.	Think "delay RT/chemo" in favorable non-enhancing grade 2 disease, not replacement for RT + PCV in high-risk disease needing definitive treatment.
High-risk lower-grade glioma	PCV after RT is the classic OS-improving regimen for high-risk grade 2 glioma and 1p/19q-codeleted anaplastic oligodendroglioma.	Board trap: TMZ is easier, but PCV is the historical survival-data answer in RTOG 9802 / oligodendroglioma trials.
Recurrent GBM edema / radionecrosis phenotype	Bevacizumab can improve edema, steroid dependence, and imaging appearance.	Symptom/radiographic benefit does not equal cure; helpful around re-irradiation or radionecrosis-risk scenarios.
Brain metastases with CNS-active systemic options	EGFR: osimertinib; ALK: alectinib/brigatinib/lorlatinib; HER2 breast: tucatinib + trastuzumab + capecitabine; melanoma: BRAF/MEK or IO.	RT deferral is only for small, asymptomatic, safe-to-watch disease with reliable MRI follow-up. Symptomatic/large/edematous lesions still need local therapy.

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.

SYSTEMIC THERAPY QUICK HITS — Head & Neck

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Definitive CRT, cisplatin-eligible HNSCC	Cisplatin remains the reference concurrent systemic agent: 100 mg/m2 q3wk or weekly 40 mg/m2.	Cetuximab is not equivalent to cisplatin for HPV+ oropharynx. Do not "de-intensify" to cetuximab for convenience.
Postoperative high-risk HNSCC	Cisplatin + PORT for positive margin and/or extranodal extension.	ENE and positive margin are the clean board triggers for POCRT; intermediate-risk features usually get PORT alone.
Resectable stage III-IVA HNSCC, PD-L1 CPS ≥1	Perioperative pembrolizumab with surgery and risk-adapted adjuvant RT/CRT is a new high-yield concept.	Does not replace surgery or indicated adjuvant RT/CRT. Best board framing: eligible resectable locally advanced PD-L1-positive disease.
Nasopharynx, locoregionally advanced	Gemcitabine/cisplatin or TPF induction followed by concurrent cisplatin CRT.	NPC is the H&N site where induction chemo is especially testable. Do not forget EBV DNA risk framing.
NPC after CRT, high-risk	Metronomic capecitabine is a real adjuvant option in selected high-risk patients.	Board pearl: capecitabine after NPC CRT is not the same as routine adjuvant chemo for all H&N cancers.
Recurrent/metastatic HNSCC	Pembrolizumab alone for high PD-L1 CPS, or pembrolizumab + platinum/5-FU; cetuximab/platinum/5-FU is the older EXTREME backbone.	For localized salvageable recurrence, surgery/re-irradiation selection still matters more than reflex systemic therapy.

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

SYSTEMIC THERAPY QUICK HITS — Lung / Thoracic

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Unresectable stage III NSCLC, driver-negative / wild-type	Concurrent platinum-doublet CRT followed by durvalumab for up to 12 months if no progression.	PACIFIC is the board anchor. Do not use durvalumab reflexively for EGFR-mutant stage III when osimertinib is the post-CRT strategy.
Unresectable stage III EGFR exon 19 del / L858R	Osimertinib after definitive CRT.	LAURA changed this space. Key distinction: EGFR-mutant stage III after CRT is now an osimertinib question, not a PACIFIC-only question.
Resectable NSCLC, tumors ≥4 cm or node-positive, no EGFR/ALK	Perioperative or neoadjuvant chemo-IO: nivolumab + platinum-doublet, pembrolizumab-based, or durvalumab-based regimens depending trial/label.	If surgery does not happen, fall back to definitive CRT principles. Do not give perioperative IO as a substitute for definitive local therapy.
Metastatic NSCLC biomarkers	EGFR: osimertinib; ALK: alectinib/brigatinib/lorlatinib; ROS1/NTRK/RET/MET/BRAF/KRAS G12C each has targeted therapy options.	High-yield board trap: check driver mutations before immunotherapy-first strategies in nonsquamous metastatic NSCLC.
Limited-stage SCLC after CRT without progression	Durvalumab consolidation/adjuvant therapy up to 24 months.	ADRIATIC is the new LS-SCLC systemic memory hook. Concurrent IO with CRT has not been positive in LS-SCLC.
Extensive-stage SCLC first line	Platinum/etoposide + atezolizumab or durvalumab.	Thoracic consolidative RT remains selective for responders with residual thoracic burden; systemic therapy is the survival backbone.

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

SYSTEMIC THERAPY QUICK HITS — Sarcoma

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Localized adult extremity STS	No single routine chemo standard for all. Doxorubicin/ifosfamide may be discussed for selected young/fit, large, deep, high-grade, chemosensitive histologies.	RT is for local control; chemo is histology- and risk-selective. Do not imply routine adjuvant chemo for every high-grade STS.
High-risk extremity UPS / pleomorphic sarcoma >5 cm	Pembrolizumab + pre-op RT improved DFS in SU2C-SARC032-like patients.	Do not generalize to all STS. Most board-relevant subset: extremity UPS/pleomorphic high-risk disease, with higher immune toxicity.
GIST	Imatinib for KIT/PDGFRA-sensitive disease; avapritinib is key for PDGFRA exon 18 D842V.	GIST is a targeted-therapy disease, not a routine EBRT disease. RT is uncommon except palliation or selected local problems.
Desmoid tumor	Active surveillance first; systemic options include nirogacestat, sorafenib, pazopanib, MTX/vinblastine, hormonal/NSAID historical approaches.	RT can control selected progressive/morbid desmoids but is not first reflex in young patients or abdominal wall disease.
Diffuse TGCT / PVNS	Pexidartinib is a CSF1R inhibitor for selected symptomatic unresectable diffuse TGCT.	Adjuvant RT is selective after incomplete resection/high recurrence risk; systemic therapy matters when surgery would be morbid.
Ewing / RMS / pediatric-type sarcoma	Ewing: VDC/IE; RMS: VAC/VI-style regimens by risk group.	Local therapy is never enough alone. RT dose/field is protocol-driven around systemic therapy timing.

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

SYSTEMIC THERAPY QUICK HITS — Gastrointestinal

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Resectable gastric / GEJ adenocarcinoma, FLOT-fit	Perioperative FLOT is the key modern backbone; perioperative durvalumab + FLOT is a new practice-shaping concept.	RT is most useful for margin/downstaging/local-control problems, not automatic for every FLOT-fit gastric/GEJ patient.
Esophageal / GEJ after neoadjuvant CRT + R0 resection with residual disease	Adjuvant nivolumab for up to 1 year.	CheckMate 577 trigger: residual pathologic disease after neoadjuvant CRT and surgery. ypCR does not get nivolumab by this indication.
Definitive esophageal CRT	FOLFOX or cisplatin/5-FU; carboplatin/paclitaxel is common with CROSS-style pre-op CRT.	Do not escalate definitive esophagus dose reflexively above 50.4 Gy outside selected protocols.
Pancreas adjuvant / neoadjuvant systemic backbone	mFOLFIRINOX if fit; gemcitabine/nab-paclitaxel or gemcitabine-based options if less fit.	RT is selective after systemic therapy response/stability; metastatic progression usually stops local intensification.
Pancreas with germline BRCA and metastatic platinum response	Olaparib maintenance is the POLO memory hook.	PARP inhibitor is biomarker-selected systemic therapy; it does not replace local palliation or SBRT when focal symptoms dominate.
Rectal dMMR / MSI-H stage II-III	PD-1 blockade, especially dostarlimab in the landmark dMMR rectal strategy.	Potential nonoperative management if sustained cCR in expert surveillance. Always test MMR/MSI before committing to routine TNT.
Rectal TNT	FOLFOX/CAPOX are the common consolidation/induction backbones; FOLFIRINOX is for selected fit high-risk patients.	Consolidation after CRT is the OPRA-style organ-preservation favorite.
Anal SCC	5-FU/mitomycin or capecitabine/mitomycin with RT.	Cisplatin is not the routine substitute; mitomycin-based CRT remains the clean board answer.
Advanced HCC	Atezolizumab/bevacizumab or durvalumab/tremelimumab; TKIs include sorafenib/lenvatinib and later-line agents.	SBRT can be definitive/bridging/consolidative, but systemic therapy is central for macrovascular invasion or disseminated disease.

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.

SYSTEMIC THERAPY QUICK HITS — Genitourinary

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Unfavorable intermediate prostate	ADT 4-6 months with definitive RT.	No routine ADT for favorable intermediate risk; ADT is a major risk-group discriminator.
High-risk localized prostate	Long-course ADT, usually 18-36 months, with definitive RT.	Brachy boost or DIL boost may escalate local dose; systemic intensification depends on very-high-risk/cN1 biology.
Very-high-risk or cN1 M0 prostate	Abiraterone/prednisone + ADT is the STAMPEDE systemic intensification memory hook.	Do not add enzalutamide to abiraterone routinely; added toxicity without clear extra benefit in STAMPEDE-style data.
mHSPC	ADT plus an ARPI such as abiraterone, enzalutamide, apalutamide, or darolutamide; docetaxel for selected high-volume/fit patients.	Primary prostate RT improves OS mainly in low-volume de novo mHSPC; systemic intensification remains the backbone.
mCRPC biomarker therapy	PARP inhibitors for BRCA/HRR-altered disease; Lu-PSMA for PSMA-positive mCRPC in appropriate sequence.	Keep ADT going in mCRPC. Coordinate marrow reserve before radiopharma, chemo, and pelvic/bone RT.
MIBC, cystectomy candidate	Neoadjuvant cisplatin-based chemotherapy, typically gemcitabine/cisplatin or dose-dense MVAC.	Carboplatin is not equivalent neoadjuvant therapy for cure-intent cisplatin-eligible MIBC.
MIBC bladder preservation	Radiosensitizers: 5-FU/mitomycin, gemcitabine, cisplatin, or cisplatin/5-FU depending fitness and protocol.	RT alone is inferior for trimodality candidates; maximal TURBT + concurrent radiosensitizer is the board answer.
Metastatic urothelial carcinoma	Enfortumab vedotin + pembrolizumab is the major first-line advanced/metastatic standard; avelumab maintenance follows platinum response when platinum is used.	Systemic control first; RT is for bleeding, pain, obstruction, oligoprogression, or durable local control in selected sites.
RCC systemic era	IO/TKI combinations such as pembrolizumab/axitinib or nivolumab/cabozantinib; ipilimumab/nivolumab for selected intermediate/poor-risk disease; adjuvant pembrolizumab after high-risk nephrectomy.	RCC is not "radioresistant" to ablative SBRT. SBRT can treat primary, oligometastatic, or oligoprogressive sites around systemic therapy.
Seminoma systemic anchors	Stage I: surveillance preferred, carboplatin alternative; metastatic/advanced: BEP or EP depending risk/bleomycin fitness.	RT is now selective for low-volume stage II or unusual cases; avoid outdated routine RT for all stage I seminoma.

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.

SYSTEMIC THERAPY QUICK HITS — Gynecologic

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Definitive cervical CRT	Weekly cisplatin 40 mg/m2 is the classic radiosensitizer.	Brachytherapy is mandatory for cure-intent intact cervix treatment; chemo does not compensate for omitted brachy.
High-risk locally advanced cervix, FIGO 2014 III-IVA	Pembrolizumab with CRT then maintenance is a KEYNOTE-A18 trigger.	Approved/high-yield subset is FIGO 2014 stage III-IVA. RT dose and brachy goals remain unchanged.
Cervix induction option	Weekly carboplatin/paclitaxel induction before CRT is the INTERLACE memory hook.	Positive strategy, but do not stack induction chemo and pembrolizumab automatically without protocol-level rationale.
Metastatic/recurrent cervical cancer	Pembrolizumab + platinum/taxane +/- bevacizumab for PD-L1-positive disease; cemiplimab or tisotumab vedotin are later-line concepts.	RT remains important for bleeding, pain, obstruction, oligoprogression, and durable pelvic control.
Advanced/recurrent endometrial cancer	Carboplatin/paclitaxel + pembrolizumab for primary advanced/recurrent disease; dostarlimab/chemo and durvalumab/chemo are important IO options, especially dMMR.	Molecular class matters. p53abn/serous disease is systemic-risk heavy; dMMR is immunotherapy-sensitive.
Recurrent pMMR endometrial cancer after platinum	Lenvatinib + pembrolizumab.	Different from first-line chemo-IO. Toxicity can be substantial; RT still useful for isolated vaginal/pelvic relapse if RT-naive.
HER2-positive uterine serous carcinoma	Trastuzumab added to carboplatin/paclitaxel.	Board trap: HER2 testing is not just a breast/gastric issue.
Advanced epithelial ovarian cancer	Carboplatin/paclitaxel backbone; bevacizumab and PARP maintenance depend on stage, response, BRCA/HRD, and bev exposure.	RT is not maintenance for ovarian cancer. It is focal palliation or selected oligometastatic/oligoprogressive local control.
Platinum-resistant ovarian cancer, FR-alpha positive	Mirvetuximab soravtansine.	Useful board recognition as an antibody-drug conjugate; not an RT substitute for focal symptoms.
Vulvar/vaginal definitive CRT	Concurrent cisplatin is common; 5-FU/mitomycin or 5-FU/cisplatin may appear in protocols.	Systemic therapy is radiosensitizing; nodal/gross-dose coverage still drives control.

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.

SYSTEMIC THERAPY QUICK HITS — Pediatric

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Wilms tumor	Favorable histology often uses vincristine/dactinomycin +/- doxorubicin; higher-risk/anaplastic disease intensifies chemo.	RT dose is stage/histology driven and time-sensitive; do not biopsy classic upfront-nephrectomy presentations unless diagnosis is unclear.
High-risk neuroblastoma	Induction multi-agent chemo, surgery, high-dose chemo/ASCT, RT, then anti-GD2 immunotherapy with isotretinoin-based maintenance.	RT usually follows transplant and targets primary site plus selected persistent metastatic sites.
Rhabdomyosarcoma	VAC backbone; vincristine/irinotecan and other risk-adapted additions by protocol. FOXO1 fusion is a major risk feature.	RT timing/dose is group-, site-, nodal-, and FOXO1-driven. Local control is integrated, not optional.
Ewing sarcoma	VDC/IE systemic backbone.	Surgery and/or RT are local therapy; systemic therapy is essential even for apparently localized disease.
Medulloblastoma	Cisplatin/vincristine/cyclophosphamide or lomustine-containing regimens by protocol/risk group.	Chemo enables risk-adapted CSI dose, but CSI is not omitted for standard patients age ≥3 outside protocol-defined situations.
Pediatric low-grade glioma	Targetable alterations matter: BRAF V600E inhibitors, MEK inhibitors, and other MAPK-pathway strategies.	RT is often delayed in young children when systemic/targeted options can preserve development.
Pediatric B-ALL relapse / refractory disease	CAR-T and blinatumomab/inotuzumab are key modern systemic concepts.	RT may appear as CNS/testicular/local palliation or transplant conditioning, but systemic immunotherapy dominates relapse memory questions.

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.

SYSTEMIC THERAPY QUICK HITS — Lymphoma

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Early favorable classical Hodgkin lymphoma	ABVD x2 then ISRT is the classic combined-modality anchor.	PET-adapted chemo-alone may reduce RT use but trades some PFS; combined modality remains board-clean.
Advanced classical Hodgkin lymphoma	N-AVD is a modern frontline reference; BV-AVD is another major non-bleomycin option.	Routine consolidative RT is not used after complete metabolic response; RT is selective for residual/bulky/threatening sites.
Relapsed/refractory Hodgkin lymphoma	Salvage systemic therapy, often checkpoint inhibitor or brentuximab-containing strategies, then ASCT when eligible.	RT is valuable for localized relapse, peri-transplant consolidation, bulky residual, or palliation.
DLBCL standard backbone	R-CHOP; pola-R-CHP is an important modern option for selected higher-risk patients.	RT is response- and risk-adapted: bulky, osseous, residual PET-positive, extranodal sanctuary, or abbreviated chemo settings.
PMBCL	DA-EPOCH-R is commonly used to avoid mediastinal RT in complete responders.	If Deauville 1-3 after DA-EPOCH-R, omit RT; Deauville 4-5 needs biopsy/individualization.
Primary testicular DLBCL	R-CHOP-based chemo + CNS prophylaxis + contralateral testis RT.	Board trap: contralateral testis RT is part of the management memory hook.
Indolent lymphoma	Rituximab-based systemic therapy when disseminated/symptomatic; localized FL/MZL can be cured with RT alone.	For localized indolent NHL, 24 Gy ISRT is not "palliative"; it is definitive-intent.
CAR-T eligible aggressive B-cell lymphoma	Axicabtagene, lisocabtagene, tisagenlecleucel and other cellular therapies by disease/line.	RT can bridge after apheresis, consolidate residual disease, or palliate relapse; avoid jeopardizing T-cell collection when possible.

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

MEDICAL THERAPY QUICK HITS — Benign Disease

Board Trigger	Medical / Non-RT Option To Recognize	RT Integration / Trap
Osteoarthritis / enthesopathy LDRT	NSAIDs, physical therapy, injections, bracing, weight loss, and surgery remain standard conservative/orthopedic options.	Benign LDRT is most defensible after conservative failure in older patients with mild/moderate inflammatory-pain phenotype.
Keloids	Surgery, steroid injections, pressure therapy, silicone, cryotherapy, laser, and 5-FU injections.	RT works best post-excision and early; unresected keloid RT is less definitive.
Dupuytren / Ledderhose	Observation, splinting, collagenase injection, needle aponeurotomy, fasciectomy, orthotics, steroid injections.	RT is for early active nodular/cord disease, not fixed severe contracture.
Endocrine orbitopathy	Steroids, selenium in mild disease, teprotumumab, decompression surgery, smoking cessation.	RT is best for active inflammatory orbitopathy, especially motility/diplopia; less effective for inactive fibrotic proptosis.
Heterotopic ossification prophylaxis	NSAIDs such as indomethacin are the classic alternative.	RT is attractive when NSAIDs are contraindicated; mature HO needs surgery, not RT alone.
Gynecomastia from antiandrogens	Tamoxifen is often more effective than prophylactic breast RT.	RT can prevent/treat symptoms but is no longer the only memory hook.

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

SYSTEMIC THERAPY QUICK HITS — Radiopharmaceuticals

Board Trigger	Drug / Regimen To Recognize	RT Integration / Trap
Ra-223 in mCRPC	Use in bone-predominant/symptomatic mCRPC without known visceral metastases; combine carefully with androgen-axis agents.	ERA-223 trap: abiraterone + Ra-223 increased fractures. Bone-protective agents are essential when combining with AR pathway therapy.
Lu-PSMA sequencing	PSMA-positive mCRPC after ARPI, before or after taxane depending indication and patient factors.	Coordinate marrow reserve with prior docetaxel/cabazitaxel, pelvic RT, extensive bone disease, and radium exposure.
Lu-DOTATATE	Continue somatostatin analog strategy around PRRT; use amino acid renal protection.	High-yield trap: PRRT requires SSTR-positive well-differentiated disease; poorly differentiated NEC is a chemo disease, not a PRRT disease.
Y-90 radioembolization	May integrate with systemic HCC therapy or colorectal liver-metastasis therapy depending setting.	Mapping angiography, lung shunt, liver reserve, and dosimetry drive safety. It is locoregional internal RT, not external beam SBRT.
I-131 thyroid / MIBG	I-131 for iodine-avid differentiated thyroid cancer; I-131 MIBG for MIBG-avid pheochromocytoma/paraganglioma.	Theranostic principle: diagnostic uptake predicts therapeutic targeting; radiation-safety counseling is part of the treatment.