Southwestern Medical Center at Dallas
Radiation Oncology
• Residency Training Program •

Most rotations will be for three consecutive months, although the schedule may be modified if sufficient exposure to all disease sites is achieved.

RESIDENT CLINICAL ROTATIONS AND LECTURES

Competency requirements for all clinical rotations•   On all clinical rotations the resident is expected to demonstrate competence in six main areas as specified by the ACGME: patient care, medical knowledge, practice based learning, interpersonal skills, professionalism, and systems based practice. Additional learning objectives for each individual clinical rotation are noted below.

Required rotations in the Department of Radiation Oncology  •   Residents rotate through each attending physician’s service at MROC for a period of time, usually three months.  During this time, the resident is expected to learn the presentation, work-up, and treatment for the malignancies covered by the attending physician.  Residents are expected to learn the following topics during each rotation:

1. Epidemiology and etiology
2. Presentation and natural history, including prognostic factors, patterns of spread and relapse
3. Anatomy
4. Pathology & implications of histologic subtype
5. Staging workup
6. Staging systems
7. Prognostic factors  
8. Treatment options (surgery, radiation therapy, chemotherapy)
9. Indication for, and types of, systemic therapy
10. Roles for radiation therapy in malignancies of each site
11. Radiation doses, fractionation, and techniques for various clinical settings   
12. Radiation complications; incidence, presentation, treatment

Site-specific goals are delineated below:

GOALS OF SPECIFIC ROTATIONS IN RADIATION ONCOLOGY

Breast  •   Goals of the rotation:

• To develop an understanding of the natural history of breast cancer.  This includes familiarity with breast and lymphatic anatomy, the natural history of non-invasive and invasive disease, the histologic subtypes of breast cancer, the patterns of spread, probability of spread, and AJCC staging.
• To develop expertise in the management of the breast cancer patient.  This includes experience with patient evaluation, interpretation of diagnostic imaging, proficiency in physical examination, participation in multidisciplinary conferences, and determining treatment options for in situ and invasive disease, including surgery and chemotherapy/hormonal therapy.
• To develop competency in radiotherapy techniques used in breast cancer.  This will include an understanding of standard fields and individual adaptation of these fields, experience in treatment planning and dosimetry with photons, electrons and implants, and managing side effects and complications of treatment.

Bone Marrow Transplant  •  Goals of the rotation:

• Learn the role of bone marrow transplant in adult and childhood malignancies, particularly leukemia. This includes the rationale and techniques of total body irradiation (TBI), the acute side effects and the late effects of TBI, particularly with regard to its integration with high-dose chemotherapy.
• Learn the sources of donor stem cells and marrow.

Central Nervous System  • Goals of the rotation:

• Understand the natural history of disease for both benign and malignant central nervous system tumors.
• Understand the neurologic examination and correlation of the examination with the patient’s disease and response to treatment.
• Become familiar with standard management decisions in the treatment of central nervous system tumors including the roles of surgery, chemotherapy, and radiotherapy, including stereotactic radiosurgery.
• Understand central nervous system response to therapy; acute and late toxicities in relationship to the nature of treatment; and physical, neuropsychologic, and imaging responses.
• Gain knowledge of the advantages and disadvantages of different    radiation treatment techniques including external beam, 3-D conformal, IMRT and stereotactic radiotherapy and radiosurgery.

Gastrointestinal  • Goals of the rotation:

• Understand the natural history and staging of various gastrointestinal malignancies.
• Develop physical examinations skills, particularly those pertaining to carcinoma of the rectum or anal canal.
• Develop competency in interpreting diagnostic studies, making treatment decisions, and using radiotherapy techniques.

Genitourinary  •  This rotation covers tumors arising in the male and female genitourinary tracts. Goals of the rotation:

• Become proficient in the diagnosis and management of patients with genitourinary tumors, including tumors of the testicle, penis, urethra, prostate, bladder, kidney, and ureter.
• Learn to perform a comprehensive and accurate genitourinary physical examination.
• Understand the surgical and chemotherapeutic options to treat these malignancies
• Become proficient in the radiotherapeutic techniques necessary to treat tumors arising in these anatomic regions, including external beam, and intracavitary/interstitial implants.
• Develop an understanding of possible consequences of radiation therapy, surgery, and chemotherapy in terms of treatment-related complications, as well as probabilities for survival and control.

Gynecologic • 

Cancer of the Uterine Corpus
Knowledge base
1. Epidemiology: incidence, death rate, risk factors
2. Natural history: estrogen-associated presentations
3. Staging: FIGO surgical staging and clinical staging criteria
4. Prognostic factors: patient related, tumor related
5. Chemotherapy indications and results
6. Ongoing GOG, RTOG clinical trials
7. Specific understanding of current treatment results

General management
1. Diagnostic evaluation of abnormal bleeding
2. Evaluation of the uterine cancer patient
3. Management of the medically inoperable patient
4. Indications for brachytherapy
5. Management of abdominal disease
6. Management of complications of treatment

Treatment techniques
1. External beam planning and delivery
2. Use of intracavitary brachytherapy (preoperative patient and medically inoperable patient)
3. Techniques for the treatment of the vaginal cuff.

Cancer of the Uterine Cervix
Knowledge base
1. Epidemiology: incidence, death rate, risk factors
2. Natural history
3. Staging: FIGO
4. Prognostic factors: patient related, tumor related, treatment related
5. Chemotherapy indications and results
6. Ongoing GOG, RTOG clinical trials
7. Specific understanding of current treatment results

General management
1. Management of abnormal bleeding
2. Management of complications of treatment

Treatment techniques
1. External beam planning and delivery
2. Use of intracavitary brachytherapy
3. Use of interstitial brachytherapy

Cancer of the Vagina or Female Urethra
Knowledge base
1. Natural history and modes of spread for carcinomas of the vagina or periurethral tissues
2. Diagnostic evaluation, disease work-up, and indications for radiation treatment
3. Current FIGO staging

General management
1. Role for surgery in the treatment of carcinoma of the vagina and in the salvage of recurrent disease.
2. Knowledge of the incidence and management of radiation complications.

Treatment techniques
1. Planning and coordination of external beam therapy with brachytherapy.
2. Use of intravaginal as well as interstitial brachytherapy devices.  Residents are expected to know the physical characteristics and the associated isodose distributions for template treatment, vaginal cylinders, and HDR vaginal applicators.
3. Planning and construction of planar implants using the Paterson-Parker system for planning.

Vulvar Cancer
Knowledge base
1. Epidemiology: incidence, death rate, risk factors for disease, associated diseases
2. Natural history: patterns of spread and common presentations with attention to the incidence and significance of lymphadenopathy
3. Anatomy of the female pelvis
4. Staging: current AJCC & FIGO staging criteria
5. Prognostic factors: patient related, tumor related (including the significance of clinically or pathologically positive inguinal lymph nodes)
6. Indication for and the choice of specific surgical procedures, including vulvar conservation
7. Chemotherapy indication and results
8. On-going GOG, RTOG clinical trials
9. Specific understanding of current treatment results

General management
1. Management of preinvasive disease
2. Invasive disease management: use of combined irradiation and radical vulvectomy, inguinal lymphadenectomy, or vulvar conservation.
3. Locally advanced disease: use of preoperative radiotherapy or radiotherapy alone

Treatment techniques
1. External beam planning and delivery
2. Use of intracavitary brachytherapy
3. Use of interstitial brachytherapy

Head and Neck  •   This rotation includes malignant and benign tumors of the head and neck, and their treatment with radiotherapy, surgery, and/ or chemotherapy. Goals of this rotation:

• Learn the natural history of the disease process.
• Develop competency in interpreting diagnostic studies such as CT scans, PET scans and MRI.
• Develop competency in head and neck physical examination skills.
• Develop competency in management decisions.
• Develop competency in radiotherapy techniques.

Lymphomas  •   This rotation includes Hodgkin’s disease, non-Hodgkin’s lymphomas and other reticuloendothelial tumors. Goals of the rotation:

• Develop an understanding of the natural history of lymphomas and Hodgkin’s disease, the patterns of distribution and spread, the staging system, and pathologic classification.
• Develop competence in management decisions.  This includes familiarity with all treatment options in any given clinical situation, proficiency in physical exam, reading pertinent diagnostic examinations, experience in patient evaluation, and multidisciplinary conference participation.
• Develop proficiency in the radiotherapy techniques used for lymphomas and Hodgkin’s disease.

The following should be learned during this rotation:

Lymphomas
1. Histologic classification schemes
2. Non-histologic classification methods (immunophenotyping, kinetics, markers and analyses, genetics.
3. Natural history 
4. Staging workup and system
5. Patterns of spread and recurrence
6. Treatment approaches
7. Role of radiation
8. Radiation dose, volume, technique 

Hodgkin's disease
1. Histologic subtypes
2. Presentation, radiographic findings, etc.
3. Workup
4. Staging system
5. Prognosis
6. Treatment options
7. Role of radiation, doses, volumes, techniques
8. Radiation complications
9. Late effects
10. Differences in pediatric and adult HD

Other reticuloendothelial diseases

Pediatrics  •  Goals of the rotation:

• Learn the natural history (including the genetics) and workup of patients with childhood leukemia, brain tumors, lymphomas, Wilm’s tumor, neuroblastoma, bone and soft tissue sarcomas, and retinoblastoma.
• Learn physical exam techniques used in children.
• Learn the radiation treatment techniques for the above tumors.
• Learn the unique late effects that are particular to children after treatment with radiotherapy, particularly those of the musculoskeletal, endocrine, and central nervous systems.
• Learn the role of surgery and chemotherapy in childhood malignancies.
• Become knowledgeable about the chemotherapy drugs in the treatment of these tumors, as well as the acute and late effects of the chemotherapy. 
• Become familiar with the role and advantages of fractionated stereotactic radiotherapy (and radiosurgery) in the treatment of pediatric brain tumors.

Pulmonary •   Goals of the rotation: By the end of this rotation, the resident physician should have a full understanding of the following topics as they relate to the management of primary lung cancer.

• Epidemiology and etiology
• Clinical manifestations
• Histopathology
• Chromosomes, genes, and lung cancer
• Staging of lung cancer
  • International Staging System using TNM categories for non-small-cell lung cancer.
  • Limited vs. extensive for small cell lung cancer
  • Staging procedures and tests
  • Performance status determination
• Treatment recommendation
  • Non-small-cell lung cancers
  • Small cell lung cancers
  • By tumor stage
  • By patient performance status
  • Curative intent
  • Palliative
  • Treatment modality
    • Surgery
    • Chemotherapy
    • Radiotherapy
    • Sequential vs. Concurrent modalities
• Results of treatment
  • Local control
  • Absolute survival
  • Cause-specific survival
  • Acute and long-term morbidity of treatment
• Specifics of radiation treatment
  • Evaluation and treatment planning
  • Dosimetry issues
  • Target volumes, margins, and limits (tumor and normal tissues)
    • Beam arrangements, energies, weighting, compensators, and shielding
    • Irradiation dose to tumor and regional lymphatics
    • Tolerance limits of critical normal tissues (spinal cord, lung, heart)
• Review of relevant and appropriate literature

Sarcomas • This rotation covers malignant and benign tumors arising from musculoskeletal tissues. Goals of this rotation:

• Learn the natural history, workup, and evaluation of lesions arising from connective tissue, including bone, cartilage, muscle, fat, and blood vessels.
• Become proficient in physical examination techniques that apply to tumors arising from these structures.
• Understand the anatomy involved in treating these tumors.
• Understand the surgical and chemotherapeutic options involved in treating these tumors.
• Become proficient in the radiotherapeutic techniques necessary to treat these tumors, particularly for soft tissue sarcomas where complicated, extended SSD techniques are required.
• Understand the late consequences of surgical and radiotherapeutic treatment to these tissues.