List Of Contributors

Bendell, MD, Assistant Professor, Division of Oncology and Transplantation, Duke University Medical Center, Durham, NC Angel I. Blanco, MD, Assistant Professor, Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX Jeffrey Bradley, MD, Assistant Professor, Department of Radiation Oncology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO Linda Casey, MS, ARNP, AOCN, James A. Haley VA Medical Center,...

References

Emami, B, J Lyman, A Brown, L Coia, M Goitein, JE Munzenrider, B Shank, LJ Solin, and M Wesson. 1991. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys 21 109 122. 2. Groover, TA, AC Christie, and EA Merritt. 1922. Observations on the use of a copper filter in the roentgen treatment of deep-seated malignancies. South Med J 15 440. 3. Evans, WA and T Leucutia. 1925. Intrathoracic changes induced by heavy radiation. AmJ Radiol 13 203. 4. Gross, NJ. 1977....

Lung Toxicity

The lungs are particularly sensitive to irradiation. Lung injury by irradiation is related to both dose and volume effects. The TD5 5 for one-third, two-thirds, and three-thirds lung is 45, 30, and 17.5 Gy, respectively.1 The acute complication of lung injury by irradiation is radiation pneumonitis. The late effect of lung injury is lung fibrosis. Both can be severely debilitating or even fatal. This section reviews our present understanding of the biology of lung injury by irradiation, updates...

B5 Kidney

The original paper describing radiation toxicity to the kidneys was from Luxton and Kunkler and Farr and Luxton in the early 1950s. They followed the outcomes of seminoma patients who were treated with abdominal bath radiotherapy.80'81 They described an initial acute radiation nephritis, appearing 6 12 months after radiation treatment, including headache, vomiting, hypertension, fatigue, and edema. Patients could be found to have proteinuria and microscopic hematuria. These acute effects...

B2 Augmented or Reconstructed Breast Appearance

Breast cancer patients who receive radiation to an augmented breast following lumpec-tomy or a reconstructed breast following mastectomy have a higher risk of cosmetic failure. Breast augmentation preceding the diagnosis and treatment of a breast cancer can create a clinical conundrum. The appearance of the breasts is, typically, particularly important in this patient group yet, their risk for cosmetic failure following breast conservation therapy is higher in some studies. Table 9 lists the...

A4 Liver

Radiation-induced liver disease (RILD) is seen in 5 10 of patients when the whole liver radiation dose reaches 3000 3500 cGy.21'22 The pathologic lesion in RILD is central vein thrombosis at the lobular level, or venoocclusive disease, which results in marked retrograde congestion leading to hemorrhage and secondary alterations in the surrounding hepatocytes.23 Fibrin deposition in the central veins is thought to be the cause of the venoocclusive injury. It is unknown what stimulates the fibrin...

Info

In stature, which was more pronounced in larger (e.g., abdominopelvic) fields, and in children who received higher doses (Table 8). Younger children were especially sensitive to radiation irradiation doses of 10 Gy or more resulted in greater stature deficits than seen in older children who received significantly greater dose. Children irradiated during puberty were not at increased risk of radiation-induced stature loss when compared to children irradiated at other ages. The effects of...

Long Bone Fracture

Long bone fracture as a complication following radiotherapy is most commonly seen following the higher doses used in the management of extremity sarcoma. Contemporary publications on limb-sparing treatment of soft tissue sarcoma of the extremities report a post-radiotherapy fracture incidence ranging from 4 23 to 8.6 .24 The most consistently important risk factor for fracture is periosteal excision (Table 5). Table 5. Risk factors for long bone fracture Periosteal excision (especially...

B7 Lymphedema Shoulder Immobility and Brachial Plexopathy

These three toxicities are discussed together as they are all primarily consequences of supraclavicular and or axillary irradiation in the treatment of breast cancer. Arm edema or lymphedema in breast cancer patients is caused by an interruption ofthe normal filtration process that occurs between capillaries, interstitial tissue, and lymphatic vessels in the arm. Under normal circumstances, capillary pressures force fluid into the interstitium and reabsorption pressures pull most ofthe fluid...

Rib Fractures

Rib fractures are a long recognized late complication ofbreast and chest wall irradiation. In a review of the literature, Pierce et al. found that the incidence of rib fractures following breast irradiation ranged from 0 to almost 20 ,39 though when restricting the review to studies using modern techniques, the incidence was 1 3 . In other contemporary series, the incidence of rib fracture following breast-conserving therapy is well below 1 .40 Risk factors for post-irradiation rib fracture...

B9 Radiation Pneumonitis

Symptomatic radiation pneumonitis is uncommon when only the breast is irradiated following breast conserving therapy. It typically onsets 2-3 months after completing treatment with a clinical syndrome of cough, fever, shortness of breath, and radiologic changes confined to the radiation therapy field.161 Symptoms can persist for several weeks and in general are self-limiting. Pulmonary fibrosis typically follows in the effected portion of the lung. Lingos et al. reported a 1 incidence of...

Clinical Aspects Of Cns Radiation Tolerance

The radiation tolerance of the CNS is dependent on a number of factors, including total dose, dose per fraction, total time, volume, host factors, radiation quality (linear energy transfer), and adjunctive therapies. Table 2 defines the role of these factors in radiation tolerance and injury to the brain, as well as ways they might be modified to increase tolerance (i.e., reduce injury).54'55 Table 3 shows partial and whole organ tolerance doses for the brain and spinal cord, and includes doses...

Conclusion

Three-dimensional conformal radiation therapy has greatly enhanced our understanding of partial organ tolerances of lung and esophagus to radiotherapy. Concurrent chemotherapy appears to shift the TCP and NTCP dose response curves to the left for both lung and esophagus. Much additional work remains to be performed before biological modifiers, either radiosensitizers or radioprotectors, become a more integral part of therapy. Summaries of clinical data indicate that both patient-related and...

B5 Skin Telangiectasia and Atrophy

Telangiectasia or dilatations of the dermal vasculature that lie within a few millimeter of the epidermis can occur following radiation for breast cancer. Several studies examining post-mastectomy radiation have demonstrated that the incidence of telangiectasia is affected by total radiation dose,84'85'87 larger fraction size,81'84 and the occurrence of moist desquamation.85-87 The Gothenburg fractionation trials conducted during post-mastectomy radiation in Sweden in the 1970s examined the...

Introduction

Without regard to normal tissue complications, most tumors could likely be eradicated by irradiation through escalating the dose. However, normal tissue complications limit our ability to administer the dose necessary for tumor control. Tumor control probability (TCP) for a given tumor is represented by a sigmoid curve in which an increase in dose results in greater tumor cell kill. Likewise, the normal tissue complication probability (NTCP) is represented by a second sigmoid curve sitting to...

Normal Skin Response To Radiation

The skin-sparing capabilities of megavoltage, high-energy equipment, and increasingly sophisticated treatment planning methods have reduced the incidence of severe skin complications. However, certain acute and late side effects of radiation occur and, in some instances, are expected and unavoidable as the radiation must enter, exit, or be deposited near the skin to reach the target volume. Skin cells, because they originate from a rapidly reproducing differentiated stem cell, are relatively...

A3 Small Intestine

Histologic damage to the small intestine is seen within hours after the radiation. The most sensitive cells to radiation therapy in the small intestine are the crypts of Langerhans.12 The epithelial lining ofthe small intestine constantly undergoes shedding and replenishment, and damage to the actively proliferating cells results in an inability to replace cells that are naturally shed, causing a generalized mucosal sloughing.13 With the sloughing, the villi shorten, and the area of absorption...

Etiology And Pathogenesis

Elimination of preexisting dental periapical, periodontal, and mucosal infections, institution of comprehensive oral hygiene protocols during therapy, and reduction of other factors that may compromise oral mucosal integrity (e.g., physical trauma to oral tissues) can help reduce the frequency and severity of oral complications in cancer patients. Such complications can be acute (developing during therapy) or chronic (developing months to years after therapy). Radiation is not only associated...

B10 Secondary Malignancy

The overall survival of early stage breast cancer is good so that there are increasing numbers oflong-term breast cancer survivors that need to be followed for the occurrence of secondary malignancies. It is well established that patients treated for one breast cancer have a higher risk of subsequent contralateral breast cancer (CBC).168-172 The risk for CBC averages between 1.1 and 1.5 per year. On the basis of the evidence from both randomized trials and population-based studies, it does not...

Mandibular Osteoradionecrosis

Mandibular osteoradionecrosis is a hypocellular, hypovascular dissolution of bone following irradiation. The most vulnerable part of the mandible is the buccal cortex of the premolar, molar, and retromolar regions.1 The molar and premolar regions are the most common sites of necrosis.2'3 There are three distinct types ofMORN (Table 14), but all begin similarly as erythema of overlying mucosa, which subsequently ulcerates to reveal the underlying necrotic bone.5 The diagnosis ofMORN includes an...

Portal Film

Acute Mild Tanning Breast Radiation

Chest x-ray and portal film correlating classic radiation pneumonitis. Figure 2. Chest x-ray and portal film correlating classic radiation pneumonitis. Table 2. NCI CTC (version 3) acute pneumonitis pulmonary infiltrates 1 Asymptomatic, radiographic findings only 2 Symptomatic, not interfering with activities of daily living 3 Symptomatic, interfering with activities of daily living O2 indicated 4 Life-threatening ventilatory support indicated Table 3. RTOG EORTC late lung morbidity...

Skin Changes

Lee Moffitt Cancer Center, Tampa, FL James A. Haley VA Medical Center, Tampa, FL H. Lee Moffitt Cancer Center, Tampa, FL Radiation therapy has a direct effect on the skin. The effects of radiation can be dramatic. Providers are challenged to classify and minimize both acute and late effects and to manage the complications of treatment. Strategies to manage radiation skin reactions are ongoing topics of research and have led to a variety of clinical management models. Managing skin reactions...