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radiation therapy (XRT)

Tolerance of normal tissues for radiation: organ radiation pathology brain 6000 cGy necrosis spinal cord 4500 cGy myelitis heart 4500 cGy pericarditis, myocardial injury intestine 4500 cGy stenosis, perforation liver 3000 cGy hepatitis, hepatic vein thrombosis lung 2000 cGy pneumonitis, fibrosis kidney 2000 cGy nephropathy, renal failure bone marrow 250 cGy aplasia ovary 200 cGy sterilization testes 100 cGy sterilization Indications: - prostate cancer* - breast cancer* - lymphoma - Hodgkin's lymphoma - non-Hodgkin's lymphoma - germ cell tumor - lung cancer* - small cell lung cancer - non-small cell lung cancer - skin cancer - not melanoma - head and neck cancer - cervical cancer - anal cancer - brain tumor * prophylactic radiation to asymptomatic, high-risk bone metastases reduces pathologic fractures, spinal cord compression, orthopedic surgery, or palliative radiation therapy & hospitalizations in patients with lung cancer, breast cancer, prostate cancer & other cancers [21] Procedure: - intensity-modulated radiation therapy (IMRT) Complications: 1) general - thoracic radiation damages all cells including those of - pericardium, myocardium, cardiac valves, coronary arteries, coronary veins, & cardiac conduction system - most effects are delayed 2-3 decades after irradiation 2) immediate effects a) nausea, vomiting, diarrhea b) enteritis (rare) c) esophagitis d) dermatitis e) cystitis f) mucositis 3) delayed effects a) radiation dermatitis b) radiation necrosis b) radiation-induced heart disease (mediastinal radiation) [1] - occurs months to years after radiation therapy - generally 2-3 decades after treatment [1] - pericarditis or pericardial effusion - after 5 months average (2%) - pericardial fibrosis & constriction (constrictive pericarditis) - after 1.5- > 10 years, risk persists for > 25 years - coronary artery disease (CAD) [1,9,19] - after 7 years average - fibrous nature of radiation induced coronary artery lesions makes them poor candidates for PCI [1,11] - bare metal stenting has restenosis rate of 80% [1] - predilection for ostia or proximal segments of coronary arteries - may occur in the absence of other risk factors for CAD, but occurs more frequently in those with other risk factors - may present as myocardial infarction or rarely sudden death - CABG associated with complications due to mediastinal fibrosis [1] - valvular heart disease - after 10 to 25 years or more - valvular fibrosis & regurgitation - aortic valve regurgitation [1] (>= 25%) - anthracycline in combination with radiation increases risk - myocardial fibrosis - after years - diastolic dysfunction & restrictive cardiomyopathy - anthracycline in combination with radiation increases risk of diastolic heart failure - fibrosis of cardiac conduction system results in - heart block - other cardiac arrhythmias [1] - fibrosis of conduction system - after years or decades - bradyarrhythmias, heart block [1] d) radiation-induced pulmonary disease - interstitial fibrosis (6-12 months) - acute radiation pneumonitis (6 weeks-4 months) e) neurologic - transverse myelitis (very rare) - shingles is common - Lhermitte's sign - hypopituitarism if sella turcica irradiated [1,10] f) hypothyroidism (head & neck radiation, check thyroid function) g) xerostomia h) phantosomia (olfactory hallucinations) [18] i) secondary malignancies - myelodysplasia - acute leukemia - malignant lymphoma - angiosarcoma (latency generally 5-7 years) - breast cancer (mantle radiation) - especially women treated with chest irradiation during adolescence or young adulthood - lifetime risk may be > 30% [1] - both screening breast MRI & mammography beginning 8 years after completion of radiation therapy (not before age 25 years) [1] - lung cancer (mantle radiation) - esophageal cancer (mantle radiation) - colon cancer (abdominal irradiation) [8] - rectal cancer (prostate irradiation) - excess 10-year risk ~ one case per 100 men [7] j) chronic bladder fibrosis 4) prevention of complications - radioprotective agent(s) - CBLB502 [5] {investigational, animal models} Management: - follow-up - aggressive management of cardiovascular risk for patients with chest radiation [1]

Related

electromagnetic radiation radiation necrosis radiation oncology radiation pneumonitis radiation-induced heart disease radiology

Specific

brachytherapy chemoradiation (CRT) hyperfractionated radiotherapy intensity-modulated radiation therapy (IMRT) proton therapy radiation & hormonal therapy for prostate cancer radiation therapy after mastectomy radiation therapy for prostate cancer sterotactic radiation therapy for cranial lesion targeted alpha therapy

General

interventional radiology

References

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  17. Wikipedia: Radiation therapy http://en.wikipedia.org/wiki/Radiation_therapy
  18. Brooks M 'Phantom Odors' a Common but Under-Reported Toxicity of Radiation Therapy. Medscape. November 01, 2021 https://www.medscape.com/viewarticle/961865?
  19. Wendling P Left-Breast Radiation Tied to Doubling of CAD Risk in Young Women. Medscape. September 23, 2021 https://www.medscape.com/viewarticle/959342 - Carlson LE, Watt GP, Tonorezos ES et al Coronary Artery Disease in Young Women After Radiation Therapy for Breast Cancer: The WECARE Study. JACC CardioOncol. 2021 Sep 21;3(3):381-392 PMID: 34604798 PMCID: PMC8463731 Free PMC article
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  22. National Cancer Institute: Radiation Therapy to Treat Cancer http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation