radiation therapy (XRT)
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Introduction
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
- germ cell tumor
- 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
Complications
- 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
- thoracic radiation damages all cells including those of
- immediate effects
- delayed effects
- radiation dermatitis
- radiation necrosis
- 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
- fibrosis of conduction system
- after years or decades
- bradyarrhythmias, heart block[1]
- occurs months to years after radiation therapy
- radiation-induced pulmonary disease
- interstitial fibrosis (6-12 months)
- acute radiation pneumonitis (6 weeks-4 months)
- neurologic
- transverse myelitis (very rare)
- shingles is common
- Lhermitte's sign
- hypopituitarism if sella turcica irradiated[1][10]
- hypothyroidism (head & neck radiation, check thyroid function)
- xerostomia
- phantosomia (olfactory hallucinations)[18]
- 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]
- chronic bladder fibrosis
- prevention of complications
Management
- follow-up
- aggressive management of cardiovascular risk for patients with chest radiation[1]
More general terms
More specific terms
- 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
Additional terms
- electromagnetic radiation
- radiation necrosis
- radiation oncology
- radiation pneumonitis
- radiation-induced heart disease
- radiology
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012. 2015, 2018, 2021.
- ↑ Principles of Ambulatory Medicine, 4th edition, Barker et al (eds), Williams & Wilkins, Baltimore, 1995, pg 104
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 526
- ↑ Journal Watch 25(11):87, 2005 Baxter NN, Tepper JE, Durham SB, Rothenberger DA, Virnig BA. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology. 2005 Apr;128(4):819-24. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15825064
- ↑ 5.0 5.1 Burdelya LG et al, An agonist of toll-like receptor 5 has radioprotective activity in mouse and primate models. Science 2008, 320:226 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18403709
- ↑ PRACTICE GUIDELINE FOR THE PERFORMANCE OF TOTAL BODY IRRADIATION (American College of Radiology) http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/RadiationOncology/ACRPracticeGuidelineforthePerformanceofTotalBodyIrradiationDoc10.aspx
- ↑ 7.0 7.1 Margel D et al. Radiation therapy for prostate cancer increases the risk of subsequent rectal cancer. Ann Surg 2011 Dec; 254:947 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22107741
- ↑ 8.0 8.1 Henderson TO et al Secondary Gastrointestinal Cancer in Childhood Cancer Survivors: A Cohort Study Annals of Internal Medicine, 2012. 156(11):757-766 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22665813 PMCID: PMC3554254 Free PMC article <Internet> http://www.annals.org/content/156/11/757.abstract
- ↑ 9.0 9.1 Darby SC et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med 2013 Mar 14; 368:987. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23484825 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1209825
Moslehi J The Cardiovascular Perils of Cancer Survivorship. N Engl J Med 2013; 368:1055-1056 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23484833 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1215300 - ↑ 10.0 10.1 Darzy KH, Shalet SM. Hypopituitarism following radiotherapy. Pituitary. 2009;12(1):40-50 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18270844
- ↑ 11.0 11.1 Darby SC, Cutter DJ, Boerma M et al Radiation-related heart disease: current knowledge and future prospects. Int J Radiat Oncol Biol Phys. 2010 Mar 1;76(3):656-65. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20159360
- ↑ Demirci S, Nam J, Hubbs JL, Nguyen T, Marks LB. Radiation-induced cardiac toxicity after therapy for breast cancer: interaction between treatment era and follow-up duration. Int J Radiat Oncol Biol Phys. 2009 Mar 15;73(4):980-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19251085
- ↑ Heidenreich PA, Kapoor JR. Radiation induced heart disease: systemic disorders in heart disease. Heart. 2009 Mar;95(3):252-8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19144884
Heidenreich PA, Schnittger I, Strauss HW et al Screening for coronary artery disease after mediastinal irradiation for Hodgkin's disease. J Clin Oncol. 2007 Jan 1;25(1):43-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17194904 - ↑ Myrehaug S, Pintilie M, Tsang R et al Cardiac morbidity following modern treatment for Hodgkin lymphoma: supra-additive cardiotoxicity of doxorubicin and radiation therapy. Leuk Lymphoma. 2008 Aug;49(8):1486-93. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18608873
- ↑ Fogh S, Yom SS. Symptom management during the radiation oncology treatment course: a practical guide for the oncology clinician. Semin Oncol. 2014 Dec;41(6):764-75. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25499635
- ↑ Jaworski C, Mariani JA, Wheeler G, Kaye DM. Cardiac complications of thoracic irradiation. J Am Coll Cardiol. 2013 Jun 11;61(23):2319-28. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23583253 Free Article
- ↑ Wikipedia: Radiation therapy http://en.wikipedia.org/wiki/Radiation_therapy
- ↑ 18.0 18.1 Brooks M 'Phantom Odors' a Common but Under-Reported Toxicity of Radiation Therapy. Medscape. November 01, 2021 https://www.medscape.com/viewarticle/961865?
- ↑ 19.0 19.1 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: https://www.ncbi.nlm.nih.gov/pubmed/34604798 PMCID: PMC8463731 Free PMC article - ↑ NEJM Knowledge+ Question of the Week. Sept 12, 2023 https://knowledgeplus.nejm.org/question-of-week/1000/
Bonito FJP, de Almeida Cerejeira D, Dahlstedt-Ferreira C et al Radiation-induced angiosarcoma of the breast: A review. Breast J. 2020 Mar;26(3):458-463. Epub 2019 Aug 25. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31448482 Review.
Dufresne A, Meeus P, Sunyach MP. Treatment of radiation-associated angiosarcoma. Curr Opin Oncol. 2023 Jul 1;35(4):296-300. Epub 2023 May 12. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37222197 Review. - ↑ 21.0 21.1 Gillespie EF et al. Prophylactic radiation therapy versus standard of care for patients with high-risk asymptomatic bone metastases: A multicenter, randomized phase ii clinical trial. J Clin Oncol 2024 Jan 1; 42:38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37748124 PMCID: PMC10730067 (available on 2025-01-01) https://ascopubs.org/doi/10.1200/JCO.23.00753
- ↑ National Cancer Institute: Radiation Therapy to Treat Cancer http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation