Table Of ContentAinaz Sourati · Ahmad Ameri
Mona Malekzadeh
Acute Side Effects of
Radiation Therapy
A Guide to Management
123
Acute Side Effects of Radiation Therapy
Ainaz Sourati • Ahmad Ameri
Mona Malekzadeh
Acute Side Effects of
Radiation Therapy
A Guide to Management
Ainaz Sourati Ahmad Ameri
Department of Clinical Oncology Department of Clinical Oncology
Imam Hossein Educational Hospital, Shahid Imam Hossein Educational Hospital, Shahid
Beheshti University of Medical Sciences Beheshti University of Medical Sciences
(SBMU), Shahid Madani Street (SBMU), Shahid Madani Street
Tehran Tehran
Iran Iran
Mona Malekzadeh
Department of Radiotherapy and Oncology
Shohadaye Tajrish Educational Hospital
Shahid Beheshti University of Medical
Sciences (SBMU)
Tehran
Iran
ISBN 978-3-319-55949-0 ISBN 978-3-319-55950-6 (eBook)
DOI 10.1007/978-3-319-55950-6
Library of Congress Control Number: 2017944188
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To my dear mother who I will forever be
beholden to her.
To my loving husband, Arash, who I really
appreciate his support and endurance
through my most trying times.
Ainaz Sourati
To my love Zhila.
Ahmad Ameri
To my dear parents and my beloved son,
Hooman.
Mona Malekzadeh
Foreword
Dichotomies in medicine are common, but it is nowhere more clearly demonstrated
than in radiation exposure either used in diagnoses or in treatment as compared to
excessive or unwanted radiation exposure either locally or systematically. Other
dichotomies demonstrated in radiation injury include the separation between acute
and late radiation damage, locally applied as contrasted to systemic or total body
exposure, one or few radiation exposures vs. fractionated radiation exposures, and
use of preventive or ameliorating agents applied before exposure in contrast to post-
exposure treatments. All of these are important to our understanding of the effective,
appropriate use of radiation as a treatment modality. This can only be ameliorated
by accurate information about the causes, frequency, severity, and prevention or
treatment of these radiation-associated conditions.
In the clinic, observed reactions to radiotherapy range from minor to serious and
from temporary to permanent. Physician concern for these potential debilitating
effects permeates the clinical practice of radiation and influences the selection of
treatments on a day-to-day basis. Optimal utilization of radiation as a cancer ther-
apy requires a clear understanding of the range of the major tissue sequela that can
occur, including the risk of occurrence, natural history, and their management. This
understanding leads to better clinical practice: greater confidence in recommending
aggressive radiation treatment programs when appropriate or selection of other
therapies when they are safer and equally effective.
Acute reactions of radiation therapy, the inflammatory reactions that occur as
part of normal tissue reaction to radiotherapy, are often considered as an expected
part of therapy, but they also may become debilitating to the patient during the treat-
ment course. Understanding of the mechanism, timing of occurrence, preventable
measures, and management of these side effects warrant discussion of their success-
ful management, including ways to facilitate more comfortable therapy course for
the patient.
In the era of multimodality therapy, it’s also important to understand the risk fac-
tors of radiation therapy when combined with other modalities, i.e., systemic che-
motherapy or biological agents. It is also important to realize the impact of other
modalities as sole cause of side effect or as a co-positive impact along with radia-
tion. Therefore, clinicians must be aware of these alternative possibilities and the
method diagonals and modify them.
vii
viii Foreword
In this volume, the clinician-scientists of Shahid Beheshti University and Dr.
Sourati and her associates have successfully provided to the readers the plethora of
these concerns in a comprehensive yet relatively straightforward and simple text for
day-to-day use of clinicians. Organ-specific effects are detailed as appropriate to
understanding, minimizing, and managing radiation injuries. I congratulate them in
their successful effort, and I am certain that many clinicians and their patients would
significantly benefit from the information provided by these authors.
Maywood, IL, USA Bahman Emami, MD, FACR, FASTRO, FACRO
Introduction
Cancer is one of the leading causes of death worldwide [1]. Currently, cancer
patients survive longer than they did more than two decades ago, and the population
living with cancer is increasing. Understanding more about cancer radiobiology and
major developments in radiation therapy technology play a critical role in increas-
ing the life expectancy of these patients. Radiation therapies are used with three
different concepts in cancer that are definitive, adjuvant, or palliative. It has been
estimated that more than 50% of all cancer patients receive radiation therapy
throughout the course of their disease [2]. With new technological advancements in
imaging and radiation delivery, radiation therapy has been possible for more com-
plicated cases, increasing the rate of radiation therapy in cancer treatments.
In addition to the tumor sterility and tumoricidal effects of radiation therapy,
radiation has the potential to affect normal tissues, which includes tissue damage in
radiation therapy fields or systemic side effects (e.g., hematologic side effects,
fatigue). Physicians try to lower radiation therapy side effects by defining smaller
targets and using more dedicated machines, but side effects continue to occur and
their spectrum and severity are changing. As these patients live longer, more atten-
tion is directed on their quality of life.
Radiation therapy side effects are divided into acute and late. Late side effects
occur 3 months after treatment completion, and acute side effects occur during
treatment or within 3 months after treatment.
Late side effects can develop without dose thresholds, which include stochastic
side effects, or with distinctive thresholds, which include deterministic side effects
(e.g., neurologic effects, cardiac effects). Deterministic late side effects are dose-
limiting and can be the result of the healing process following severe acute side
effects. This kind of late side effects could be predictable, and efforts should be
made to protect normal tissues [3].
Acute side effects are a type of deterministic effects, which have distinctive
thresholds, and there is a direct relation with delivered dose and severity of resultant
damage. These effects usually cause no limit in treatment dose because they occur
in rapidly dividing cells, which have rapid cell repopulation; as a result, they are
reversible. The main point in acute side effects is necessary actions for prevention
and proper treatment in accordance with their severity to prevent radiation therapy
disruption because treatment disruption can affect treatment results, particularly in
tumors with rapid cell growth, which intensify cell growth inversely. Severe acute
ix
x Introduction
side effects can also result in consecutive late effects. Using new techniques in radi-
ation therapy (e.g., 3D-conformal radiation therapy, intensified modulated radiation
therapy, image-guided radiation therapy) reduces normal tissue dose and conse-
quently reduces treatment complications. However, the percentage of acute side
effects is still noticeable because the dose threshold in these side effects’ occurrence
is less than late side effects. Furthermore, in some treatments, it is necessary to
increase radiation dose to reach a definite complication (e.g., in locally advanced
breast cancer after radical mastectomy, enough radiation must be delivered to reach
dermatitis). We have to know the proper actions in approaching the complications
in order to inhibit unwanted treatment disruption. Acute side effects may increase
risk of late side effects, and prevention of these effects should be considered.
With respect to all points, acute side effects of radiation therapy are one of the
most important issues in the treatment of cancer patients. Approach and manage-
ment of these side effects are substantial to improve treatment results and increase
patient compliance with treatment. We attempt to assemble the most common of
these acute side effects in this book. In each part, we describe a summary of inci-
dence, mechanism, symptoms, grading, and management of distinct acute side
effects based on available evidence. Our main goal is gathering articles about each
acute side effect for convenient and practical use for all involved in the radiation
therapy process.
References
1. Stewart BW, Wild C (2014) World Cancer Report 2014. International Agency for Research on
Cancer. World Health Organization. 505
2. Slotman BJ, Cottier B, Bentzen SM, Heeren G, Lievens Y, Van den Bogaert W (2005) Overview
of national guidelines for infrastructure and staffing of radiotherapy. ESTRO-QUARTS: work
package 1. Radiother Oncol 75(3):349. E1–E6
3. ICRP (1977) Recommendations of the International Commission on Radiological Protection.
Ann ICRP. Sect. ICRP Publication 26
Contents
1 Radiation Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Sign and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 Scoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5.1 Treatment-Related Factors Including . . . . . . . . . . . . . . . . . . . . 4
1.5.2 Patient-Related Factors Include . . . . . . . . . . . . . . . . . . . . . . . . 5
1.6 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.7 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.7.1 General Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.7.2 Intensity-Modulated Radiation Therapy (IMRT) . . . . . . . . . . . 8
1.7.3 Low-Level Laser Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.7.4 Amifostine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.7.5 Ascorbic Acid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.7.6 Oral Zinc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.7.7 Silver Leaf Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7.8 MAS065D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7.9 Soft Dressing or Barrier Film . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7.10 Hyaluronic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7.11 Trolamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.7.12 Topical Sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.13 Theta Cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.14 Dexpanthenol (Provitamin B5) . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.15 Calendula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.16 Pentoxifylline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.17 Aloe Vera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.7.18 Deodorant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.7.19 Laughter Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.8 Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.8.1 Grade 1 Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.8.2 Grade 2–3 Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.8.3 Grade 4 Dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
xi
