Radiation Side Effects and Syndromes: Difference between revisions

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'''Original Editors '''-Alicia Dupilka &amp; Kristin Gramling&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''-[[User:Alicia Dupilka|Alicia Dupilka]] & [[User:Kristin Gramling|Kristin Gramling]]&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


'''Lead Editors''' &nbsp;
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
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== Definition/Description  ==
== Definition/Description&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; ==
[[File:Radiation therapy prep.jpg|right|frameless]]
Radiation therapy, or radiotherapy, is a common [[Oncology|oncologic]] treatment modality utilising ionising radiation to control or eliminate malignant cells.  Radiotherapy may be used alone, or synergistically with [[Chemotherapy Side Effects and Syndromes|chemotherapy]] or immunotherapy. The type of radiation therapy employed depends on the disease and the specific type of cancer being treated.


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Fotolia 3929119 XS.jpg|198x148px]]<ref>Picture: http://photos2.demandstudios.com/DM-Resize/photos.demandstudios.com/60/210/fotolia_3929119_XS.jpg?h=10000&amp;w=400&amp;keep_ratio=1</ref>  
Radiotherapy plays a part in:
# Primary curative treatment (eg. head and neck cancer),
# Adjuvant therapy (e.g. reducing recurrence rate after local [[Breast Cancer|breast cance]]<nowiki/>r surgery)
# Palliation of cancer symptoms (e.g. reducing pain from bone metastases).
# Treating non-malignant disease, e.g. [[Graves' Disease|Graves]] thyroiditis, keloid scarring.<ref name=":0">Radiopedia [https://radiopaedia.org/articles/radiation-therapy Radiation Therapy] Available from:https://radiopaedia.org/articles/radiation-therapy (last accessed 25.8.2020)</ref>
* Nearly two-thirds of all cancer patients will receive radiation therapy <ref name="Goodman">Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis. Missouri: Saunders, 2009.</ref>
* There are no good estimates of how many of these patients will develop complications due to the radiation therapy <ref name="Stubblefield">Stubblefield MD. Radiation Fibrosis Syndrome: Neuromuscular and Musculoskeletal Complications in Cancer Survivors. PM R. 2011;3:1041-1054.</ref>  


Radiation therapy is when radiation is delivered to a specific area of the body to try and treat a disease, usually cancer.&nbsp; The goal of the radiation is to kill rapidly dividing cancer cells while sparing slower dividing somatic cells.&nbsp; Radiation is usually used in conjunction with surgery or chemotherapy, so this makes it difficult to separate the effects resulting from each of these treatments. <ref name="Stubblefield">Stubblefield MD. Radiation Fibrosis Syndrome: Neuromuscular and Musculoskeletal Complications in Cancer Survivors. PM R. 2011;3:1041-1054.</ref><br>
== Techniques ==
 
Radiotherapy is customarily divided into three main categories:
The radiation may be delivered by a machine outside the body (external-beam radiation therapy) or it may come from radioactive material placed in the body (internal radiation therapy, also called brachytherapy).<ref name="NCI Radiation Therapy">National Cancer Institute. Radiation Therapy for Cancer. National Institutes of Health. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation. Reviewed May 30, 2010. Accessed April 3, 2013.</ref>  
# External beam radiotherapy (EBRT) where a medical linear accelerator (linac) directs ionising radiation at the tumour from outside the body eg
 
#* Conventional Radiation Therapy. This refers to the old techniques of radiation therapy where treatments would be planned by defining a limited number of beams with the boundaries delineated on orthogonal x-rays of the patient. It has been largely replaced by other highly conformal external beam radiation therapies, which use CT images to plan the treatment.<ref>Radiopedia [https://radiopaedia.org/articles/conventional-radiation-therapy?lang=gb CRT] Available from:https://radiopaedia.org/articles/conventional-radiation-therapy?lang=gb (last accessed 25.8.2020)</ref> Examples of these newer techniques include: three-dimensional conformal radiation therapy (3D-CRT); intensity-modulated radiation therapy (IMRT); stereotactic radiosurgery; electron therapy; particle (hadronic) therapy.<ref name=":0" />
Type of radiation used depends on:<br>&nbsp;&nbsp;&nbsp;&nbsp; • Type of cancer<br>&nbsp;&nbsp;&nbsp;&nbsp; • Size<br>&nbsp;&nbsp;&nbsp;&nbsp; • Location<br>&nbsp;&nbsp;&nbsp;&nbsp; • How close the cancer is to normal tissues<br>&nbsp;&nbsp;&nbsp;&nbsp; • How far the radiation needs to travel<br>&nbsp;&nbsp;&nbsp;&nbsp; • General health and medical history<br>&nbsp;&nbsp;&nbsp;&nbsp; • Other types of treatment<br>&nbsp;&nbsp;&nbsp;&nbsp; • Age and other medical conditions
#Sealed source radiotherapy (brachytherapy) where a radiation source(s) is placed, under the guidance of imaging, within or next to the area requiring treatment.
 
#Unsealed source radiotherapy (systemic radioisotope therapy) where a radioisotope is delivered through: infusion e.g. for neuroendocrine tumours ; ingestion e.g for thyroid cancer.<ref name=":0" />
<br>'''External-beam radiation therapy''': most often delivered in the form of photon beams (x-rays or gamma rays) <ref name="NCI Radiation Therapy" />
== Characteristics/Clinical Presentation   ==
 
[[File:Radiation Sickness.png|right|frameless|510x510px]]
3-Dimensional Conformal Radiation Therapy (3D-CRT): most common type
'''Side Effects'''
 
Intensity-Modulated Radiation Therapy (IMRT)  
 
&nbsp;&nbsp;&nbsp;&nbsp; • Dosage is chosen for different areas of the tumor and surrounding tissues<br>&nbsp;&nbsp;&nbsp;&nbsp; • High-powered computer program calculates the required number of beams and angles<br>&nbsp;&nbsp;&nbsp;&nbsp; • Goal: increase the dose to areas that need it and reduce exposure to sensitive areas<br>&nbsp;&nbsp;&nbsp;&nbsp; • Can reduce the risk of some side effects<br>&nbsp;&nbsp;&nbsp;&nbsp; • Larger volume of normal tissue overall is exposed
 
Image-Guided Radiation Therapy (IGRT)
 
&nbsp;&nbsp;&nbsp;&nbsp; • Repeated imaging scans performed during treatment<br>&nbsp;&nbsp;&nbsp;&nbsp; • Can increase the accuracy and may allow reduction in planned volume of tissue to be treated<br>&nbsp;&nbsp;&nbsp;&nbsp; • Decreasing total radiation dose to normal tissue
 
Tomotherapy
 
&nbsp;&nbsp;&nbsp;&nbsp; • Type of image-guided IMRT<br>&nbsp;&nbsp;&nbsp;&nbsp; • Hybrid between a CT and an external-beam radiation therapy machine<br>&nbsp;&nbsp;&nbsp;&nbsp; • Sparing normal tissue from high radiation doses
 
Stereotactic Radiosurgery
 
&nbsp;&nbsp;&nbsp;&nbsp; • Can deliver one or more high doses of radiation to a small tumor<br>&nbsp;&nbsp;&nbsp;&nbsp; • Extremely accurate image-guided tumor targeting and positioning<br>&nbsp;&nbsp;&nbsp;&nbsp; • High dose of radiation can be delivered without excess damage to normal tissue
 
Stereotactic Body Radiation Therapy
 
&nbsp;&nbsp;&nbsp;&nbsp; • Radiation therapy in fewer sessions<br>&nbsp;&nbsp;&nbsp;&nbsp; • Uses smaller radiation fields and higher<br>&nbsp;&nbsp;&nbsp;&nbsp; • Treats tumors that lie outside the brain and spinal cord<br>&nbsp;&nbsp;&nbsp;&nbsp; • Usually given more than one dose<br>&nbsp;&nbsp;&nbsp;&nbsp; • Can treat only small, isolated tumors; including cancers in the lung and liver
 
Proton Therapy
 
&nbsp;&nbsp;&nbsp;&nbsp; • Deposit much of their energy at the end of their path (Bragg peak) and deposit less energy along the way<br>&nbsp;&nbsp;&nbsp;&nbsp; • Should reduce the exposure of normal tissue
 
'''Internal-beam radiation therapy (Brachytherapy):''' <ref name="NCI Radiation Therapy" />  
 
Interstitial: uses radiation source placed within tumor tissue
 
Intracavitary: uses a source placed within a surgical cavity or a body cavity
 
Episcleral: used to treat melanoma inside the eye, uses a source that is attached to the eye
 
Low-dose: receive continuous low-dose radiation over a period of several days
 
High-dose: robotic machine attached to delivery tubes placed inside the body, can be given in one or more treatment session, cause less damage to normal tissue
 
Placement is either permanent or temporary
 
Permanent
 
&nbsp;&nbsp;&nbsp;&nbsp; •Surgically sealed within the body and left<br>&nbsp;&nbsp;&nbsp;&nbsp; • Remaining material does not cause any discomfort or harm<br>&nbsp;&nbsp;&nbsp;&nbsp; • Low-dose rate&nbsp;
 
Temporary<br>
 
&nbsp;&nbsp;&nbsp; • Carrier and the radiation sources are removed after treatment<br>&nbsp;&nbsp;&nbsp; • Can be either low-dose or high-dose
 
[[Image:Internal-and-External-Radiation-Therapy.png|222x166px]]<ref>Picture: http://www.asbestos.net/diseases/cancer/asbestos-cancer-treatment</ref>
 
'''Systemic Radiation Therapy''' <ref name="NCI Radiation Therapy" />
 
Swallows or receives an injection of a radioactive substance or a radioactive substance bound to a monoclonal antibody
 
Examples: radioactive iodine, ibritumomab tiuxetan (Zevalin®), combined tositumomab and iodine I 131 tositumomab (Bexxar®), samarium-153-lexidronam (Quadramet®), and strontium-89 chloride (Metastron®)
 
== Prevalence  ==
 
- Nearly two-thirds of all cancer patients will recieve radiation therapy <ref name="Goodman">Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis. Missouri: Saunders, 2009.</ref>
 
- There are no good estimates of how many of these patients will develop complications due to the radiation therapy <ref name="Stubblefield" />  
 
== Characteristics/Clinical Presentation<br>  ==
 
'''Side Effects'''<ref name="NCI Radiation Therapy" />


Depend on the area of the body being treated, dose given per day, total dosage, general medical condition and other treatments being given.  
Depend on the area of the body being treated, dose given per day, total dosage, general medical condition and other treatments being given.  
# Acute radiation injury
#* Nausea, malaise, dysphagia, vomiting immediately following irradiation
#* Erythema
#* Mucosal inflammation (stomatitis, esophagitis, enteritis, etc.)
#* [[Bone Marrow|Bone marrow]] damage: [[Anaemia]], thrombocytopenia, and/or leukocytopenia (pancytopenia)
#* Infection due to immunocompromise
#* Early radiation-induced lung injury (radiation pneumonitis): Dyspnea, dry cough, hemoptysis, and fever may occur several weeks following radiation.
#* Partial respiratory insufficiency is an early sign.
#Chronic radiation damage
#*Radiation Fibrosis Syndrome
#*Late radiation-induced lung injury (radiation fibrosis)
#* Bone: fractures
#* Bone marrow damage: anemia, thrombocytopenia, and/or leukocytopenia (pancytopenia); Infection due to immunocompromise
#* Heart: increased risk of myocardial infarction
#* Gastrointestinal: impaired function
#* Thyroid: impaired function (hypothyroidism)
#* Impaired fertility: Fibrosis in ovaries involving amenorrhea; Azoospermia
#* Radiation of the head: Leukoencephalopathy; Hormone imbalances and their outcomes, such as stunted growth due to low growth hormone levels
#* Xerostomia
#* Malignancies: especially [[Leukemia|leukemias]], MDS, [[lymphoma]], thyroid cancer<ref name="NCI Radiation Therapy">National Cancer Institute. Radiation Therapy for Cancer. National Institutes of Health. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation. Reviewed May 30, 2010. Accessed April 3, 2013.</ref>


Acute (Early)<br>&nbsp;&nbsp;&nbsp;&nbsp; • Skin irritation<br>&nbsp;&nbsp;&nbsp;&nbsp; • Damage at regions exposed (salivary glands or hair loss if head or neck treated)<br>&nbsp;&nbsp;&nbsp;&nbsp; • Urinary problems (lower abdomen treated)<br>&nbsp;&nbsp;&nbsp;&nbsp; • Fatigue<br>&nbsp;&nbsp;&nbsp;&nbsp; • Nausea with or without vomiting <br>&nbsp;&nbsp;&nbsp;&nbsp; • Most disappear after treatment ends (some may be permanent)
== Common general side effects of radiation therapy ==
 
[[File:Fatigue.jpg|right|frameless]]
Chronic (Late)<br>&nbsp;&nbsp;&nbsp;&nbsp; • May or may not occur<br>&nbsp;&nbsp;&nbsp;&nbsp; • Fibrosis (replacement of normal tissue with scar tissue)<br>&nbsp;&nbsp;&nbsp;&nbsp; • Damage to the bowels<br>&nbsp;&nbsp;&nbsp;&nbsp; • Memory loss<br>&nbsp;&nbsp;&nbsp;&nbsp; • Infertility<br>&nbsp;&nbsp;&nbsp;&nbsp; • Second cancer (rare); highest in those treated for cancer as a child or adolescent<br>&nbsp;&nbsp;&nbsp;&nbsp; • Some chemotherapy drugs, genetic risk factors, and lifestyle factors can also increase risk of late side effects<br>
'''Fatigue''': Is different from the fatigue of everyday life, and it might not get better with rest. It can last a long time and can get in the way of usual activities. It will usually go away gradually after treatment ends. It’s very common for people with cancer and with radiation therapy. Usually starts after a few weeks of radiation therapy as a result of radiation treatments which destroys some healthy cells as well as the cancer cells. Fatigue usually gets worse as treatment goes on. Stress from being sick and daily trips for treatment can make fatigue worse. Managing fatigue is an important part of care<ref name=":1">ACS [https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/effects-on-different-parts-of-body.html Radiation Therapy] Available from:https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/effects-on-different-parts-of-body.html (last accessed 26.8.2020)</ref>.
 
[[Image:Radiation Therapy Side Effects During Cancer Treatment L.jpg|764x554px]]<ref>Picture: http://wc1.smartdraw.com/examples/content/examples/10_healthcare/cancer_illustrations/radiation_therapy_side_effects_during_cancer_treatment_l.jpg</ref>
 
'''Lymphedema'''<ref name="Lymphedema">National Cancer Institute. Lymphedema. National Institutes of Health. http://www.cancer.gov/cancertopics/pdq/supportivecare/lymphedema/healthprofessional/page1. Reviewed May 30, 2011. Accessed April 3, 2013.</ref><br>
 
• Swelling that occurs when protein-rich lymph fluid accumulates in the interstitial tissue<br>• May contain plasma proteins, extravascular blood cells, excess water, and parenchymal products<br>• Often insidious<br>• Characteristics<br>&nbsp;&nbsp;&nbsp;&nbsp; o Non-pitting swelling of either the arm or leg and usually involves the digits<br>&nbsp;&nbsp;&nbsp;&nbsp; o Early stages: manifest pitting edema until fibrosis develops<br>&nbsp;&nbsp;&nbsp;&nbsp; o May predispose to recurrent skin infections<br>• Complaints<br>&nbsp;&nbsp;&nbsp;&nbsp; o Heaviness or fullness of the limb<br>&nbsp;&nbsp;&nbsp;&nbsp; o Tight sensation of the skin<br>&nbsp;&nbsp;&nbsp;&nbsp; o Decreased flexibility<br>&nbsp;&nbsp;&nbsp;&nbsp; o Ambulation may be affected <br>• Risk factors<br>&nbsp;&nbsp;&nbsp;&nbsp; o Undergoing axillary surgery/radiation therapy<br>&nbsp;&nbsp;&nbsp;&nbsp; o Extent of local surgery<br>&nbsp;&nbsp;&nbsp;&nbsp; o Local radiation<br>&nbsp;&nbsp;&nbsp;&nbsp; o Delayed wound healing<br>&nbsp;&nbsp;&nbsp;&nbsp; o Tumor causing lymphatic obstruction<br>&nbsp;&nbsp;&nbsp;&nbsp; o Scarring of the left or right subclavian lymphatic ducts<br>• Grades<br>&nbsp;&nbsp;&nbsp;&nbsp; o Grade 1: 5-10% interlimb discrepancy in volume or circumference, pitting edema<br>&nbsp;&nbsp;&nbsp;&nbsp; o Grade 2: &gt;10-30% interlimb discrepancy in volume or circumference, obliteration of skin folds, readily apparent deviation from normal contour<br>&nbsp;&nbsp;&nbsp;&nbsp; o Grade 3: &gt;30% interlimb discrepancy in volume; lymphorrhea; gross deviation from normal contour interfering with activities of daily living<br>&nbsp;&nbsp;&nbsp;&nbsp; o Grade 4: progression to malignancy, amputation indicated, disabling
 
'''Radiation Fibrosis Syndrome<ref name="Stubblefield" />'''
 
- Progressive fibrotic tissue sclerosis resulting from radiation treatment
 
- It affects many different types of tissue including skin, muscle, ligaments, tendons, nerves, heart, lung, gastrointestinal and genitourinary tract, and bone; in order for a structure to be considered affected by this syndrome, it must be within the radiation field or have tendons, neurovascular innervation or lymphatic flow that travels in the field.
 
- The pathophysiology behind the sclerosis, fibrosis and atrophy is not well understood.&nbsp; Some believe there is a link between vascular endothelial damage and the progression of the fibrosis.&nbsp; When endothelial cells are damaged by radiation they can no longer get rid of the surrounding thrombin causing a profibrogenic effect on smooth muscle cells, fibroblasts, myofibroblasts and other cells.  
 
- Problems may not present for several months or years after treatment  
 
- Usually has a slow, insidious onset and is not reversible
 
&nbsp; &nbsp; &nbsp;'''Risk Factors''':
 
&nbsp;&nbsp;&nbsp;&nbsp; - Hodgkin lymphoma
 
&nbsp;&nbsp;&nbsp;&nbsp; - Age
 
&nbsp;&nbsp;&nbsp;&nbsp; - Overall health
 
&nbsp;&nbsp;&nbsp;&nbsp; - Degenerative spine disease
 
&nbsp;&nbsp;&nbsp;&nbsp; - Exposure to chemotherapy treatment
 
&nbsp;&nbsp;&nbsp;&nbsp; - Location of radiation
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Head and neck cancer, because high doses are needed and there are many vital tissues in that radiation field
 
&nbsp;&nbsp;&nbsp;&nbsp; - Size of radiation field
 
&nbsp;&nbsp;&nbsp;&nbsp; - Type of radiation and time since radiation was administered<br>
 
&nbsp;&nbsp;&nbsp; - Neuropathic pain due to RFS is more likely to occur in those with pre-existing medical disorders involving the nervous system such as &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; diabetes, spinal degeneration and cervical radiculopathy
 
'''&nbsp; &nbsp; &nbsp;Structures Affected:'''
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Nerve'''
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Peripheral Nervous System (PNS): Pain, sensory loss and weakness caused by external compressive fibrosis of soft tissue and &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; ischemia from fibrosis.
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Central Nervous System (CNS): Autonomic Nervous System can be affect resulting in orthostatic hypotension, bowel and bladder &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; changes, and sexual dysfunction
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Neuropathic pain involving both the PNS and CNS is common.&nbsp; It is due to damage of neural structures within the field of radiation.<br>
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Sensory loss is also common including loss of light touch, pain, temperature, vibration and position sensation
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Weakness due to damage of neural structures, including plexopathy and mononeuropathies.
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Muscle'''
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Painful spasms are common due to myopathies, weakened and fatigability of muscles and ectopic activity of the motor nerve
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Localized muscle pain due to sensitization of local pain neurons
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Tendon and Ligaments'''
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Progressive fibrosis and sclerosis causing decreased elasticity, shortening and contractures
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Effects do not always have to be direct.&nbsp; Radiation to the upper leg can cause ankle contractures because the muscles, tendons and vascular structures of the ankle run of the length of the leg.  
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Bone'''
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Decreased bone density
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Osteoradionecrosis of the mandible and fractures of the pelvis, hip, long bones and ribs are common
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; - Radiation in children may cause long bones and the spine to mature abnormally if the growth plate is affected
 
'''&nbsp; &nbsp; &nbsp;Common Clinical Syndromes Associated with RFS:'''
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Neck Extensor Weakness''' - sever atrophy of the cervicothoracic paraspinal and shoulder girdle musculature resulting from damage to the motor nerve and/or the muscle itself
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Shoulder Pain and Dysfunction '''- damage to the cervical nerve roots, brachial plexus, rotator cuff (RTC) muscles, rhomboids and peripheral nerves innervating these muscles all contributes to this dysfunction.&nbsp; May result in RTC tendonitis and adhesive capsulitis
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Cervical Dystonia '''- usually involving the SCM, scalenes, and trapezius.&nbsp; If severe it can affect swallowing, phonation and activities of daily living.
 
&nbsp;&nbsp;&nbsp;&nbsp; '''Trismus '''- impaired mouth opening can result from the invasion of the tumor into the masseter and pterygois muscles, the innervation of these muscles, or the TMJ.&nbsp; It can affect chewing, swallowing, oral hygiene and pulmonary function.
 
== Associated Co-morbidities  ==
 
'''Lymphedema<ref name="livestrong">Zuther, J. (2010, June 3). Complications of Lympedema. Retrieved April 22, 2012, from Livestrong website: http://www.livestrong.com/article/138346-complications-lymphedema/</ref>'''
 
-Cardiac insufficiency
 
-Venous insufficiency
 
-Arthritis
 
-Fungal infection
 
-Cellulitis
 
-Psychosocial complications
 
-Lymphatic cysts
 
'''Other Co-morbidities '''<ref name="Cancer Forward">Stubblefield MD. Radiation Fibrosis Syndrome: What It Is And How To Treat It [Internet]. Houston, Texas: Cancer Forward The Foundation for Cancer Survivors; 2010. Available from: http://www.cancerforward.org/survivor-resources/experts-speak/Michael-D-Stubblefield-MD/radiation-fibrosis-syndrome-what-it-is-and-how-to-treat-it.</ref>  
 
These co-morbidities can have an effect on how radiation is tolerated:
 
- Diabetes
 
- Heart Disease
 
- Arthritis
 
== Medications  ==


Radioactive iodine
'''Radiation Dermatitis/ Erythema''': Skin in the radiation treatment area might look red, irritated, swollen, blistered, sunburned, or tanned. After a few weeks, the skin might become dry, flaky, or itchy, or it may peel.


Ibritumomab tiuxetan (Zevalin®)  
'''Hair loss''': Radiation therapy can cause hair to be thinned or lost in the area being treated. Eg radiation to the head may cause hair loss on your head (even eyebrows and lashes). Most people find that their hair grows back after treatment ends. When it does grow back, the hair may be thinner or a different texture than it was before.


Combined tositumomab and iodine I 131 tositumomab (Bexxar®)  
'''Low blood count''': Rarely, radiation therapy can cause changes in blood count levels, making clients more vulnerable to bleeding and infections. If blood tests show low blood counts, treatment might be stopped for a week or so to allow blood counts to return to normal (this side effect is more likely if you’re also getting chemotherapy)<ref name=":1" />.


Samarium-153-lexidronam (Quadramet®)  
== Specific side effects of radiation therapy<sup></sup> ==
[[File:Radiation therapy for cancer.jpg|right|frameless]]'''Gastrointestinal'''
* Radiation Esophagitis: often involved in radiation treatment for lung cancer especially when a chemosensitizer is also used. Symptoms usually resolve in 1 to 3 weeks after radiation is finished. Symptoms: abnormal peristalsis, odynophagia (pain with swallowing) and dysphagia
* Radiation Enterocolitis: often results in fibrosis leading to strictures in the intestines, bowel obstruction, fistulas with abscess formation, ulceration with bleeding and malabsorption
* Acute or Chronic Radiation Enteritis<ref name="Goodman" />.
'''Pulmonary'''
* see [[Pulmonary Complications of Cancer]]<u></u>
'''Cardiovascular'''
* Radiation Heart Disease - may result in pericarditis, [[Coronary Artery Disease (CAD)|Coronary artery disease]], [[Myocardial Infarction|myocardial]] disease and aortic-valve disease
'''Musculoskeletal'''


Strontium-89 chloride (Metastron®)<br>
Connective Tissue Involvement&nbsp;- late changes such as fibrosis, atrophy and contraction is common especially in [[collagen]]
* In [[Bone|bones]] and limbs it can cause weakness, [[Leg Length Discrepancy|limb-length discrepancies]] and [[scoliosis]]
* It can result in edema and decreased range of motion&nbsp;
* It can cause [[Pelvic Floor Anatomy|pelvic]] adhesions that result in painful motion and sometimes plexopathy (a disorder affecting a network of nerves in the [[Brachial Plexus|brachial]] or [[Lumbar Plexus|lumbosacral]] plexus, resulting in pain and loss of motor control).
* In the circulatory and [[Lymphatic System|lymphatic system]] it can cause loss of elasticity on contractility of vessels. Even though the actual lymph vessels may maintain their shape, fibrosis in the surrounding tissue can inhibit growth of the vessels into tissues that need to be healed.
'''Nervous System''' &nbsp; &nbsp; &nbsp;
* Acute symptoms: occur during treatment and include debilitating fatigue; cranial radiation may result in short-term memory loss, changes in behavior and cognition, decreased appetite, dry skin, hearing loss, hair loss and decreased salivation
* Subacute symptoms: occur 1 to 4 months after treatment and are not as common. &nbsp;Radiation to the cervical spine may result in subacute [[myelopathy]] (Lhermitte's sign). &nbsp;Radiation to the [[brainstem]] may result in [[ataxia]], nystagmus and dysarthria
* Chronic symptoms: occur months to years after therapy and can include damage to the cerebral vasculature leading to coronary artery disease, [[Transient Ischaemic Attack (TIA)|transient ischemic attacks]], [[stroke]] or [[Myocardial Infarction|myocardial]] infarction.
* Radionecrosis - results from whole-brain radiotherapy. &nbsp;Secondary tumors may develop and the hypothalamic system may be affected. Symptoms: headache, changes in cognition and personality, focal neurological deficits and seizures.&nbsp;
* Myelopathy - results from radiation of the spinal cord. &nbsp;May present as Brown-Sequard syndrome or motor neuron syndrome.
* Plexopathy - results from damage to the brachial and lumbar plexuses. &nbsp;Symptoms may include paresthesias, motor deficits, lymphedema and pain.
'''Radiation Fibrosis Syndrome (RFS)'''


Amifostine is the only drug approved by the FDA to protect normal tissues (radioprotector)<ref name="NCI Radiation Therapy" /><br>
Radiation affects healthy cells within the treatment field, and can cause an increased production of fibrin (a protein found in the body that accumulates and causes damage in radiated tissue over time). Radiation fibrosis can affect any tissues in the radiation field. This damage can cause shortening of tissues, contracture and atrophy of muscle, cause bones to become weak and brittle, cause heart, lung and nerve damage (neuropathy) and lymphedema.


&nbsp; &nbsp; &nbsp;- It can be used to reduce the frequency and/or severity of radiation induced esophagitis<ref name="Goodman" />
Patients may notice signs and symptoms of RFS anywhere from a few weeks to years after treatment has ended. These symptoms will progress over time.


== Diagnostic Tests/Lab Tests/Lab Values  ==
Patients being treated with radiation for head and neck cancer are at a higher risk of developing radiation fibrosis syndrome (RFS) due to the high doses of radiation to parts of the body with structures crucial to activities of daily living eg eating, moving head. Some examples of the problems encountered include:
* Decreased ability to fully open the mouth (trismus)
* [[Neck Pain Tool-kit: Step 1|Neck pain]] and tightness (cervical dystonia)
* Lymphedema (swelling)
* Difficulty with speech and swallowing
The treatment for RFS depends upon the symptoms and side effects the patient is having. Physical therapy, occupational therapy, speech and swallow therapy, and surgery may all play a part in treatment for RFS.<ref>Oncolink [https://www.oncolink.org/cancers/head-and-neck/side-effect-management-support-resources/radiation-fibrosis-syndrome RFS] Available from:https://www.oncolink.org/cancers/head-and-neck/side-effect-management-support-resources/radiation-fibrosis-syndrome (last accessed 26.8.2020)</ref>


'''Lymphedema'''<ref name="Lymphedema" /><br>  
== Medical Management ==
* Clinical trials to learn how to use radiation therapy more safely and effectively are being conducted by doctors and scientists. <ref name="NCI Radiation Therapy" />
* Working on improving image-guided radiation. <ref name="NCI Radiation Therapy" />
* Research is also being done on radiosensitizers and radioprotectors. <ref name="NCI Radiation Therapy" />
* The use of carbon ion beams is still being investigated and remain experimental. This type of therapy are not currently available in the US. <ref name="NCI Radiation Therapy" />


• Clinical assessment<br>• Lymphoscintigraphy: imaging of the lymphatic system<br>• Magnetic Resonance Imaging: complement lymphoscintigraphy, provide detail about anatomy and nodes<br>• Circumferential upper-extremity measurement: most widely used to diagnose upper extremity lymphedema<br>
== Physical Therapy Management  ==
[[File:Breast Cancer Exercise Classes.jpg|right|frameless]]
Cancer and treatment can cause physical problems including, but not limited to, [[Pain Behaviours|pain]], fatigue and muscle weakness. These often interfere with life in physical, emotional and practical ways.


'''Radiation Fibrosis Syndrome'''  
Physiotherapy rehabilitation services can work on: improving strength and stamina; pain resolution; site specific problems eg contractures, [[Lymphatic Obstruction (Lymphedema)|lymphedema]], RFS; education re skin care, importance of remaining [[Physical Activity|physically active]] and good [[Nutrition|nutrition.]]
* Physical therapists should always wash their hands before treating a patient who has undergone radiation therapy to protect that client from possible infection.<ref name="Goodman" />
'''Skin Care<ref name="Goodman" />'''
* Avoid use of alcohol/drying agents, lotion, gel, or oil. Creams and gels can increase the dosage received on the skin and increase the likelihood of side effects
* Do not wash away markings of the targeted area
* Position the patient so they are not lying on the targeted area
* Avoid exposing the patient to sources of heat, including direct sunlight and modalities
* Monitor wound healing
'''Musculoskeletal&nbsp;<ref name="Goodman" />'''
* If adhesions are present in the hip after radiation of the pelvis, be sure to incorporate range of motion activities; early intervention is important to prevent contractures and restrictive scarring.
* Post-radiated tissue can tear when stretching so it is important to observe for blanching of the skin during stretching and not to stretch beyond that point. &nbsp;Stretching should be continued 18 to 24 months after radiation therapy has been discontinued.
'''Nervous System'''&nbsp;<ref name="Goodman" />
* Anyone with neurological signs or symptoms of an unknown cause should be asked about a previous history or cancer and radiation therapy
'''Infection<ref name="Goodman" />'''
* Therapists should observe carefully for signs of infection in patients who have undergone radiation treatment. &nbsp;The first and only sign may be a fever because the patient may be immunosuppressed and their body cannot create a normal inflammatory response. 
'''[[Therapeutic Exercise|Exercise]]&nbsp;<ref name="Goodman" />'''
* A successful protocol should include patient education, exercise evaluation and an individualized exercise prescription. - Therapists must monitor vital signs in patients who have undergone radiation treatment because radiation and chemotherapy can leave the lungs and heart tissue permanently scarred. Patients should be taught to monitor their own vitals including heart rate, respiration rate and rate of perceived exertion (should not exceed 15 to 17) and taught to detect signs of complications such as dyspnea, pallor, excessive perspiration, or fatigue while exercising. &nbsp;Patients should be told not to exercise within 2 hours of chemotherapy or radiation therapy because it increases the circulation and may increase the effects of the treatment.
* Studies have shown low to moderate intensity aerobic exercise during the same weeks of radiation treatment can help improve physical function and lower subjective levels of fatigue, anxiety, depression and sleep disturbances.
'''Management of Syndromes Associated with Radiation Fibrosis Syndrome'''<ref name="Stubblefield" />


Diagnostic criteria is dependent on area of radiation and what structures are affected.  
&nbsp;&nbsp;Physical Therapy is usually the first line of treatment for the dysfunctions listed below.
* '''Neck Extensor Weakness''' - emphasize postural retraining through core strengthening, flexibility of the shoulder musculature, and strengthening the cervicothoracic and rotator cuff muscles.&nbsp; This will help reduce energy demands and pain.&nbsp; It is also important to develop a long-term home exercise program
* '''Shoulder Pain and Dystonia''' - treated through conservative measures because shoulder surgery should be avoided in patients with RFS because damage of the neruomuscular structures often results in poor surgical outcomes.&nbsp; Work on core strength and posture, neck extensor and rotator cuff strength and stretching of pectoral girdle musculature in order to try to restore normal anatomical alignment of the shoulders. There is a potential long-term benefit if the patient consistently follows a home exercise program.
* '''Cervical Dystonia''' - the goal is to restore and maintain neck range of motion and a long-term home exercise program should be utilized.
* '''[[Trismus]]''' - Literature is limited but a variety of jaw-opening devices are available to help treat trismus.
== Resources    ==
Radiation Side Effects Worksheet http://www.cancer.org/acs/groups/content/@nho/documents/document/acsq-009503.pdf<br>


== Etiology/Cause<ref name="Goodman" /><sup></sup>  ==
Risk Factors:<br>
Dependent on organ radiated, individual tolerance, tumor type, volume radiated and fraction size/dosage.
'''Neurotoxicity'''
- High total dose and fractionation dose
- Large volume radiated
- Increased edema
- Age &lt;12 or &gt;60 years
- Concurrent chemotherapy
- Underlying diseases affecting the vascular structures (Diabetes, HTN)
- Stereotactic radiation surgery and brachytherapy (internal radiation)
'''Dermatitis'''
- Total dose/volume and fractionation dose
- Surface area exposed
'''Acute Enterocolitis'''
- Large volume
- High total dose and fractionation dose
- Concurrent chemotherapy
'''Chronic Entercolitis'''
- Older age
- Postoperative radiation
- Presence of collagen vascular disease
- Concurrent chemotherapy
- Poor radiation technique
'''Pulmonary'''
- Older age
- Lower performance status
- Lower pulmonary baseline function
- Large volume treated
== Systemic Involvement <ref name="Goodman" />  ==
'''Gastrointestinal''' <br>
<u>Radiation Esophagitis</u>: often involved in radiation treatment for lung cancer especially when a chemosensitizer is also used. Symptoms usually resolve in 1 to 3 weeks after radiation is finished.
Symptoms: abnormal peristalsis, odynophagia (pain with swallowing) and dysphagia<br>
<u>Radiation Enterocolitis</u>: often results in fibrosis leading to strictures in the intestines, bowel obstruction, fistulas with abscess formation, ulceration with bleeding and malabsorption
Acute Radiation Enteritis - decreases the surface area of absorption leading to decreased nutritional uptake and possible dehydration and malnutrition.&nbsp;Symptoms: diarrhea, abdominal cramping, and nausea
Chronic Radiation Enteritis - symptoms don't occur for 6 months to 25 years after treatment and usually require more serious treatment
Other symptoms may include dry mouth, anorexia, and stomatitis (inflammation of mouth mucosa)
<br>
'''Pulmonary'''
<u>Radiation Lung Disease</u>&nbsp;
<u></u>Radiation Pneumonitis (acute): interstitial inflammation creating a decrease in the amount of gas exchanged in the lungs. &nbsp;It can occur 1 to 6 months after radiation and usually resolves in 6 to 12 months. &nbsp;Symptoms: dry cough with dyspnea on exertion or can turn into a severe cough with dyspnea at rest
Radiation fibrosis (chronic): progressive and occurs months after radiation treatment
Other problems may include bronchopleural fistulas, pneumothorax, hemoptysis and bronchial stenosis
'''Cardiovascular'''
<u>Radiation Heart Disease</u> - may result in pericarditis, coronary heart disease, myocardial disease and aortic-valve disease
'''Musculoskeletal'''
<u>Connective Tissue Involvement</u>&nbsp;- late changes such as fibrosis, atrophy and contraction is common especially in collagen
- In bones and limbs it can cause weakness, limb-length discrepancies and scoliosis
- It can result in edema and decreased range of motion&nbsp;
- It can cause pelvic adhesions that result in painful motion and sometimes plexopathy
- In the circulatory and lymphatic system it can cause loss of elasticity on contractility of vessels. Even though the actual lymph vessels may maintain their shape, fibrosis in the surrounding tissue can inhibit growth of the vessels into tissues that need to be healed.
'''Nervous System''' &nbsp; &nbsp; &nbsp;
Acute symptoms: occur during treatment and include debilitating fatigue; cranial radiation may result in short-term memory loss, changes in behavior and cognition, decreased appetite, dry skin, hearing loss, hair loss and decreased salivation
Subacute symptoms: occur 1 to 4 months after treatment and are not as common. &nbsp;Radiation to the cervical spine may result in subacute myelopathy (Lhermitte's sign). &nbsp;Radiation to the brainstem may result in ataxia, nystagmus and dysarthria
Chronic symptoms: occur months to years after therapy and can include damage to the cerebral vasculature leading to coronary artery disease, transient ischemic attacks, stroke or myocardial infarction.
<u>Radionecrosis</u> - results from whole-brain radiotherapy. &nbsp;Secondary tumors may develop and the hypothalamic system may be affected. Symptoms: headache, changes in cognition and personality, focal neurological deficits and seizures.&nbsp;
<u>Myelopathy</u> - results from radiation of the spinal cord. &nbsp;May present as Brown-Sequard syndrome or motor neuron syndrome.
<u>Plexopathy</u> - results from damage to the brachial and lumbar plexuses. &nbsp;Symptoms may include paresthesias, motor deficits, lymphedema and pain.
'''Integumentary'''
<u>Radiation Dermatitis</u> - common since it is involved in most radiation therapy<br>
Acute
&nbsp; &nbsp; &nbsp;Grade 1: resembles a sunburn. Hair follicles and sebaceous glands are damaged and may result in hair loss, pruritis, desquamation, dyspigmentation and scaling due to damage of the hair follicles
&nbsp; &nbsp; &nbsp;Grade 2: persistent erythema or patchy moist desquamation in creases of the skin that is usually painful with some edema
&nbsp; &nbsp; &nbsp;Grade 3: moist desquamation with pitting edema not confined to skin creases
&nbsp; &nbsp; &nbsp;Grade 4: skin necrosis or ulceration of dermis with bleeding
Consequential-late: acute changes that are persistent
Chronic: develop months to years after radiation treatment; may include skin scarring, contractures (atrophic skin susceptible to tearing and ulceration), and secondary malignancies<br>
Other problems may include destruction of nails, delayed wound healing and epidermolysis (loose skin)
== Medical Management (current best evidence)  ==
Clinical trials to learn how to use radiation therapy more safely and effectively are being conducted by doctors and scientists. <ref name="NCI Radiation Therapy" />
Working on improving image-guided radiation. <ref name="NCI Radiation Therapy" />
Research is also being done on radiosensitizers and radioprotectors. <ref name="NCI Radiation Therapy" />
The use of carbon ion beams is still being investigated and remain experimental. This type of therapy are not currently available in the US. <ref name="NCI Radiation Therapy" />
'''Treatment of Common Clinical Syndromes associated with RFS'''<ref name="Stubblefield" />
&nbsp;&nbsp;&nbsp;&nbsp; These treatments are usually used in conjunction with physical therapy or after conservative/rehabilitative treatments have failed
'''&nbsp;&nbsp;&nbsp;&nbsp; Neck Extensor Weakness''' - cervical orthotics, nerve stabilizing medications such as pregabalin, gabapentin or duloxetine, and local anesthetic injection into tender points
'''&nbsp;&nbsp;&nbsp;&nbsp; Shoulder Pain and Dystonia''' - anti-inflammatory and/or nerve stabilizing medications and subacromial injection with steroids and anesthetic
'''&nbsp;&nbsp;&nbsp;&nbsp; Cervical Dystonia''' - nerve stabilizing medications, opiods and botulinum toxin injections
'''&nbsp;&nbsp;&nbsp;&nbsp; Trismus''' - forced mouth opening under general anesthetic for short-term effects, surgical coronoidectomy, botulinum toxin injection and jaw opening devices
== Physical Therapy Management (current best evidence)  ==
Physical therapists should always wash their hands before treating a patient who has undergone radiation therapy to protect that client from possible infection.<ref name="Goodman" />
'''Skin Care<ref name="Goodman" />''' - Avoid use of alcohol/drying agents, lotion, gel, or oil. Creams and gels can increase the dosage received on the skin and increase the likelihood of side effects
- Do not wash away markings of the targeted area
- Position the patient so they are not lying on the targeted area
- Avoid exposing the patient to sources of heat, including direct sunlight and modalities
- Monitor wound healing
'''Musculoskeletal&nbsp;<ref name="Goodman" />'''
- If adhesions are present in the hip after radiation of the pelvis, be sure to incorporate range of motion activities; early intervention is important to prevent contractures and restrictive scarring.
- Post-radiated tissue can tear when stretching so it is important to observe for blanching of the skin during stretching and not to stretch beyond that point. &nbsp;Stretching should be continued 18 to 24 months after radiation therapy has been discontinued.
'''Nervous System'''&nbsp;<ref name="Goodman" /><br>- Anyone with neurological signs or symptoms of an unknown cause should be asked about a previous history or cancer and radiation therapy
'''Infection<ref name="Goodman" />''' - Therapists should observe carefully for signs of infection in patients who have undergone radiation treatment. &nbsp;The first and only sign may be a fever because the patient may be immunosuppressed and their body cannot create a normal inflammatory response. '''Exercise&nbsp;<ref name="Goodman" />''' - A successful protocol should include patient education, exercise evaluation and an individualized exercise prescription. - Therapists must monitor vital signs in patients who have undergone radiation treatment because radiation and chemotherapy can leave the lungs and heart tissue permanently scarred.
- Patients should be taught to monitor their own vitals including heart rate, respiration rate and rate of perceived exertion (should not exceed 15 to 17) and taught to detect signs of complications such as dyspnea, pallor, excessive perspiration, or fatigue while exercising. &nbsp;Patients should be told not to exercise within 2 hours of chemotherapy or radiation therapy because it increases the circulation and may increase the effects of the treatment.
- Studies have shown low to moderate intensity aerobic exercise during the same weeks of radiation treatment can help improve physical function and lower subjective levels of fatigue, anxiety, depression and sleep disturbances.
'''Lymphedema&nbsp;<ref name="Lymphedema" />'''
• Exercise has a different effect on the body at lower doses than it does at higher doses<br>• Extreme exercise would promote inflammation and injury and should be avoided<br>• Slowly, progressive, carefully controlled increases in stress on a limb may actually provide protection'''<br>'''• Individuals at risk and with lymphedema should be evaluated by a certified lymphedema therapist
'''Management of Syndromes Associated with Radiation Fibrosis Syndrome'''<ref name="Stubblefield" />
&nbsp;&nbsp;&nbsp;&nbsp; Physical Therapy is usually the first line of treatment for the dysfunctions listed below.
&nbsp;&nbsp;&nbsp;&nbsp; '''Neck Extensor Weakness''' - emphasize postural retraining through core strengthening, flexibility of the shoulder musculature, and strengthening the cervicothoracic and rotator cuff muscles.&nbsp; This will help reduce energy demands and pain.&nbsp; It is also important to develop a long-term home exercise program.
&nbsp;&nbsp;&nbsp;&nbsp; '''Shoulder Pain and Dystonia''' - treated through conservative measures because shoulder surgery should be avoided in patients with RFS because damage of the neruomuscular structures often results in poor surgical outcomes.&nbsp; Work on core strength and posture, neck extensor and rotator cuff strength and stretching of pectoral girdle musculature in order to try to restore normal anatomical alignment of the shoulders. There is a potential long-term benefit if the patient consistently follows a home exercise program.<br>
'''&nbsp;&nbsp;&nbsp;&nbsp; Cervical Dystonia''' - the goal is to restore and maintain neck range of motion and a long-term home exercise program should be utilized.
'''&nbsp;&nbsp;&nbsp;&nbsp; Trismus''' - Literature is limited but a variety of jaw-opening devices are available to help treat trismus.<br>
== Differential Diagnosis  ==
'''Lymphedema'''<br>
{| width="787" cellspacing="1" cellpadding="1" border="1"
|-
| Disorder<br>
| Definition<br>
| Signs and Symptoms<br>
|-
| Deep Vein Thrombosis<ref name="Differential">Goodman C and Snyder T. Differential Diagnosis for Physical Therapy: SCREENING FOR REFERRAL. 5th edition. Missouri: Elsevier Saunders; 2013.</ref><br>
| -Blood clot in the leg.<br>
| -Tenderness<br>-Leg pain<br>-Swelling (Difference of 1.4 cm in men and 1.2 cm in women)<br>-Warmth<br>-Subcutaneous venous distension<br>-Discoloration<br>
|-
| Hypoalbuminemia<ref>Shifko R. Livestrong (Internet). Demand Media, Inc; 2010, September 24 (Cited 2013, April 22). Available from: http://www.livestrong.com/article/257967-side-effects-of-hypoalbuminemia/</ref><ref>Peralta R and Rubery B. Medscape Reference (Internet). WebMD LLC; Update 2012, July 30 (Cited 2013, April 22). Available from: http://emedicine.medscape.com/article/166724-clinical#a0217</ref><br>
| -Low level of albumin (serum-binding protein).<br>-Common problem among persons with acute and chronic medical conditions<br>
| -Swelling<br>-Loss of appetite<br>-Muscle weakness, fatigue, cramps<br>-Pleural effusion<br>-Ascites<br>
|-
| Renal Failure<ref>Mayo Clinic. Mayo Foundation for Medical Education and Research (Internet); 1998 (Updated 2012, August 10; Cited 2013 April 22). Available from: http://www.mayoclinic.com/health/kidney-failure/DS00280/DSECTION=symptoms</ref><br>
| -Failing of the kidneys.<br>
| -Decreased urine output<br>-Fluid retention, swelling<br>-Fatigue<br>-Confusion<br>-Nausea<br>
|-
| Lipedema<ref name="Goodman" /><br>
| -Symmetrical swelling of both legs, extending from the hips to the ankles caused by deposits of subcutaneous adipose tissue.<br>
| -Fatty bulges in the medial proximal thigh and the medial distal thigh just above the knee<br>-Feet not affected<br>-Pitting edema relieved by prolonged elevation<br>
|-
| Baker Cyst<ref name="Goodman" /><br>
| -Subtype of ganglion that often communicates with a joint space. -Most often palpated behind the knee.<br>
| -Rupture of the cyst or hemorrhage from the joint into the cyst causes severe pain<br>-Swelling below the lesion.<br>
|-
| Idiopathic Edema<ref>Cunha J. MedicineNet (Internet). 1996 (Cited 2013, April 22). Available from: http://www.medicinenet.com/edema/page6.htm</ref> <br>
| -Syndrome of real or perceived excessive weight gain.<br>
| -Bloating and swelling<br>-Decreased blood volume<br>-Edema around the eyes<br>
|-
| Congestive Heart Failure<ref name="Differential" /><br>
|
-Physiologic state in which the heart is unable to pump enough blood to meet the metabolic needs of the body at rest or during exercise. <br>
-Also called cardiac decompensation or cardiac insufficiency.
|
'''Left Ventricular Failure'''<br>-Dyspnea<br>-Paroxysmal nocturnal dyspnea<br>-Orthopnea<br>-Cough<br>-Pulmonary edema<br>-Cerebral hypoxia<br>-Fatigue and muscular cramping or weakness<br>-Nocturia<br>
<br>'''Right Ventricular Heart Failure'''<br>-Dependent edema<br>-Cyanosis<br>-Diastolic heart failure<br>
<br>'''Diastolic Heart Failure'''<br>-Left ventricle stiffens and hypertrophies<br>-Fatigue and dyspnea after mild physical exertion<br>
-Orthopnea<br>-Edema<br>-Jugular vein distension<br>
|-
| Neurofibromatosis<ref name="Goodman" /><br>
| -Involves the nervous system, muscles, bones, and skin.<br>
| -Characterized by multiple soft tumors over the entire body associated with areas of pigmentation.<br>
|-
| Erysipelas<ref name="Goodman" /> <br>
| -Type of cellulitis that may cause an acute infection of the skin with sharply defined borders.<br>
| -Accompanied by fever and chills<br>-Very red skin<br>-Shiny skin<br>-Swelling<br>-Warmth<br>-Red streaks extending from the patch indicate lymph vessels involved<br>-Develops over a few hours<br>-Blisters may form after 2-3 days<br>
|-
| Filariasis<ref name="Goodman" /> <br>
| -Parasitic infection carried by mosquitoes. Most damaged occurs after the larva injected has died (approximately 5-10 years later). <br>
| -Severe local inflammatory reactions leading to severe fibrosis and scarring<br>-Massive swelling response<br>
|-
| Thrombophlebitis<ref>Mayo Clinic. Mayo Foundation for Medical Education and Research (Internet); 1998 (Cited 2013 April 22). Available from: http://www.mayoclinic.com/health/thrombophlebitis/DS00223/DSECTION=symptoms</ref> <br>
| Blood clot causing swelling in one or more veins, typically in legs.<br>
| -Warmth<br>-Tenderness<br>-Swelling<br>-Pain<br>-Redness<br>
|}
<br>'''Radiation Fibrosis Syndrome'''<ref name="Stubblefield" />
When it involves localized muscle pain patients can be misdiagnosed with fibromyalgia or a rheumatic disorder.
'''Radiation Pneumonitis<ref name="Goodman" />'''
Can resemble an underlying lung disease such as COPD.
'''Radiation-Induced Brachial Plexopathy'''<ref name="Stephenson Medscape">Stephenson RO. Radiation-Induced Brachial Plexopathy Differential Diagnosis [Internet]. Medscape; Updated Mar 26, 2013. Available from: http://emedicine.medscape.com/article/316497-differential.</ref>
Can resemble other neurological problems and must be differentiated from brachial neuritis, carpal tunnel syndrome, cervical disc disease, cervical myofascial pain, and brachial plexopathy caused by trauma or a secondary tumor.
== Case Reports/ Case Studies  ==
'''Nozu T, Yoshida Y, Ohira M, Okumura T. Severe hyponatremia in association with I(131) therapy in a patient with metastatic thyroid cancer. ''Intern Med''. 2011;50(19):2169-74. DOI: 10.2169/internalmedicine.50.5740'''<br>
Abstract
Hyponatremia is a common clinical problem that results from various causes. Hypothyroidism is known to be one of the causes of this disorder. We report a case of metastatic thyroid cancer presenting with severe hyponatremia in association with hypothyroidism induced by pretreatment of I(131) therapy, such as a low-iodine diet and withdrawal of thyroid hormone. Serum arginine vasopressin (AVP) was elevated and urine osmolality was higher than that of serum. Saline infusion and thyroid hormone replacement normalized serum sodium and AVP. Inappropriate secretion of AVP in hypothyroid state was thought to be one of the causes of this hyponatremia.<br>
<br>
'''Sonawane S, Gadgil N, Margam S. Therapy related myelodysplastic syndrome: a case report and review of literature. ''Indian J&nbsp;Pathol Microbiol''. 2011 Apr-Jun;54(2):371-3. doi: 10.4103/0377-4929.81643.''' <br>
Abstract
Therapy related myeloid neoplasm is directly related to previous cytotoxic chemotherapy or radiation therapy. We present a 47-year-old lady who developed therapy related myelodysplastic syndrome (MDS) 2.5 years after she received four cycles of chemotherapy and local radiation therapy for carcinoma breast. She presented with bicytopenia with trilineage dyspoiesis in the peripheral blood, bone marrow aspirate and biopsy. Fluorescent in-situ hybridization studies did not reveal any of the common abnormalities associated with MDS. A diagnosis of therapy related MDS was rendered. Different studies have shown that patients treated with alkylating agents and ionizing radiation present as MDS with a latent period of 3-10 years. Our patient developed MDS within 2.5 years of starting chemotherapy and radiotherapy and did not reveal any of the conventional cytogenetic abnormalities. It highlights the importance of simple tests like a complete blood count and peripheral blood smear examination in follow-up of the patients treated with chemotherapy.<br>
<br>
'''Fibrosis After Proton Beam Therapy for Non-small Cell Lung Cancer.''' '''''Jpn J Clin Oncol.'''''<b>2012 Oct;42(10):965-9. Accessed April 10, 2013.</b><br>
Abstract
There have been no reports describing acute exacerbations of idiopathic pulmonary fibrosis after particle radiotherapy for non-small cell lung cancer. The present study describes the case of a 76-year-old Japanese man with squamous cell carcinoma of the lung that relapsed in the left upper lobe 1 year after right upper lobectomy. He had been treated with oral prednisolone 20 mg/day every 2 days for idiopathic pulmonary fibrosis, and the relapsed lung cancer was treated by proton beam therapy, which was expected to cause the least adverse effects on the idiopathic pulmonary fibrosis. Fifteen days after the initiation of proton beam therapy, the idiopathic pulmonary fibrosis exacerbated, centered on the left upper lobe, for which intensive steroid therapy was given. About 3 months later, the acute exacerbation of idiopathic pulmonary fibrosis had improved, and the relapsed lung cancer became undetectable. Clinicians should be aware that an acute exacerbation of idiopathic pulmonary fibrosis may occur even in proton beam therapy, although proton beam therapy appears to be an effective treatment option for patients with idiopathic pulmonary fibrosis.<br>
== Resources <br>  ==
Radiation Therapy and You: Support for People with Cancer
http://www.cancer.gov/cancertopics/coping/radiation-therapy-and-you/page1<br>
American Cancer Society<br>
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/radiationtherapyeffects/index<br>
Radiation Side Effects Worksheet<br>
http://www.cancer.org/acs/groups/content/@nho/documents/document/acsq-009503.pdf<br>
<br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1FOSZGBm2W2xub-1cPJ8CZcHUlM65rTt0obuyYn1uKvqZOXkPu|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==


<references />&nbsp;  
<references />&nbsp;  


[[Category:Bellarmine_Student_Project]] [[Category:Oncology]]
[[Category:Bellarmine_Student_Project]]  
[[Category:Oncology]]

Latest revision as of 18:59, 8 March 2024

Original Editors -Alicia Dupilka & Kristin Gramling from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Kristin Gramling, Alicia Dupilka, Lucinda hampton, Vidya Acharya, Kim Jackson, Admin, Elaine Lonnemann, WikiSysop, 127.0.0.1 and Wendy Walker

Definition/Description                                                   [edit | edit source]

Radiation therapy prep.jpg

Radiation therapy, or radiotherapy, is a common oncologic treatment modality utilising ionising radiation to control or eliminate malignant cells. Radiotherapy may be used alone, or synergistically with chemotherapy or immunotherapy. The type of radiation therapy employed depends on the disease and the specific type of cancer being treated.

Radiotherapy plays a part in:

  1. Primary curative treatment (eg. head and neck cancer),
  2. Adjuvant therapy (e.g. reducing recurrence rate after local breast cancer surgery)
  3. Palliation of cancer symptoms (e.g. reducing pain from bone metastases).
  4. Treating non-malignant disease, e.g. Graves thyroiditis, keloid scarring.[1]
  • Nearly two-thirds of all cancer patients will receive radiation therapy [2]
  • There are no good estimates of how many of these patients will develop complications due to the radiation therapy [3]

Techniques[edit | edit source]

Radiotherapy is customarily divided into three main categories:

  1. External beam radiotherapy (EBRT) where a medical linear accelerator (linac) directs ionising radiation at the tumour from outside the body eg
    • Conventional Radiation Therapy. This refers to the old techniques of radiation therapy where treatments would be planned by defining a limited number of beams with the boundaries delineated on orthogonal x-rays of the patient. It has been largely replaced by other highly conformal external beam radiation therapies, which use CT images to plan the treatment.[4] Examples of these newer techniques include: three-dimensional conformal radiation therapy (3D-CRT); intensity-modulated radiation therapy (IMRT); stereotactic radiosurgery; electron therapy; particle (hadronic) therapy.[1]
  2. Sealed source radiotherapy (brachytherapy) where a radiation source(s) is placed, under the guidance of imaging, within or next to the area requiring treatment.
  3. Unsealed source radiotherapy (systemic radioisotope therapy) where a radioisotope is delivered through: infusion e.g. for neuroendocrine tumours ; ingestion e.g for thyroid cancer.[1]

Characteristics/Clinical Presentation[edit | edit source]

Radiation Sickness.png

Side Effects

Depend on the area of the body being treated, dose given per day, total dosage, general medical condition and other treatments being given.

  1. Acute radiation injury
    • Nausea, malaise, dysphagia, vomiting immediately following irradiation
    • Erythema
    • Mucosal inflammation (stomatitis, esophagitis, enteritis, etc.)
    • Bone marrow damage: Anaemia, thrombocytopenia, and/or leukocytopenia (pancytopenia)
    • Infection due to immunocompromise
    • Early radiation-induced lung injury (radiation pneumonitis): Dyspnea, dry cough, hemoptysis, and fever may occur several weeks following radiation.
    • Partial respiratory insufficiency is an early sign.
  2. Chronic radiation damage
    • Radiation Fibrosis Syndrome
    • Late radiation-induced lung injury (radiation fibrosis)
    • Bone: fractures
    • Bone marrow damage: anemia, thrombocytopenia, and/or leukocytopenia (pancytopenia); Infection due to immunocompromise
    • Heart: increased risk of myocardial infarction
    • Gastrointestinal: impaired function
    • Thyroid: impaired function (hypothyroidism)
    • Impaired fertility: Fibrosis in ovaries involving amenorrhea; Azoospermia
    • Radiation of the head: Leukoencephalopathy; Hormone imbalances and their outcomes, such as stunted growth due to low growth hormone levels
    • Xerostomia
    • Malignancies: especially leukemias, MDS, lymphoma, thyroid cancer[5]

Common general side effects of radiation therapy[edit | edit source]

Fatigue.jpg

Fatigue: Is different from the fatigue of everyday life, and it might not get better with rest. It can last a long time and can get in the way of usual activities. It will usually go away gradually after treatment ends. It’s very common for people with cancer and with radiation therapy. Usually starts after a few weeks of radiation therapy as a result of radiation treatments which destroys some healthy cells as well as the cancer cells. Fatigue usually gets worse as treatment goes on. Stress from being sick and daily trips for treatment can make fatigue worse. Managing fatigue is an important part of care[6].

Radiation Dermatitis/ Erythema: Skin in the radiation treatment area might look red, irritated, swollen, blistered, sunburned, or tanned. After a few weeks, the skin might become dry, flaky, or itchy, or it may peel.

Hair loss: Radiation therapy can cause hair to be thinned or lost in the area being treated. Eg radiation to the head may cause hair loss on your head (even eyebrows and lashes). Most people find that their hair grows back after treatment ends. When it does grow back, the hair may be thinner or a different texture than it was before.

Low blood count: Rarely, radiation therapy can cause changes in blood count levels, making clients more vulnerable to bleeding and infections. If blood tests show low blood counts, treatment might be stopped for a week or so to allow blood counts to return to normal (this side effect is more likely if you’re also getting chemotherapy)[6].

Specific side effects of radiation therapy[edit | edit source]

Radiation therapy for cancer.jpg

Gastrointestinal

  • Radiation Esophagitis: often involved in radiation treatment for lung cancer especially when a chemosensitizer is also used. Symptoms usually resolve in 1 to 3 weeks after radiation is finished. Symptoms: abnormal peristalsis, odynophagia (pain with swallowing) and dysphagia
  • Radiation Enterocolitis: often results in fibrosis leading to strictures in the intestines, bowel obstruction, fistulas with abscess formation, ulceration with bleeding and malabsorption
  • Acute or Chronic Radiation Enteritis[2].

Pulmonary

Cardiovascular

Musculoskeletal

Connective Tissue Involvement - late changes such as fibrosis, atrophy and contraction is common especially in collagen

  • In bones and limbs it can cause weakness, limb-length discrepancies and scoliosis
  • It can result in edema and decreased range of motion 
  • It can cause pelvic adhesions that result in painful motion and sometimes plexopathy (a disorder affecting a network of nerves in the brachial or lumbosacral plexus, resulting in pain and loss of motor control).
  • In the circulatory and lymphatic system it can cause loss of elasticity on contractility of vessels. Even though the actual lymph vessels may maintain their shape, fibrosis in the surrounding tissue can inhibit growth of the vessels into tissues that need to be healed.

Nervous System      

  • Acute symptoms: occur during treatment and include debilitating fatigue; cranial radiation may result in short-term memory loss, changes in behavior and cognition, decreased appetite, dry skin, hearing loss, hair loss and decreased salivation
  • Subacute symptoms: occur 1 to 4 months after treatment and are not as common.  Radiation to the cervical spine may result in subacute myelopathy (Lhermitte's sign).  Radiation to the brainstem may result in ataxia, nystagmus and dysarthria
  • Chronic symptoms: occur months to years after therapy and can include damage to the cerebral vasculature leading to coronary artery disease, transient ischemic attacks, stroke or myocardial infarction.
  • Radionecrosis - results from whole-brain radiotherapy.  Secondary tumors may develop and the hypothalamic system may be affected. Symptoms: headache, changes in cognition and personality, focal neurological deficits and seizures. 
  • Myelopathy - results from radiation of the spinal cord.  May present as Brown-Sequard syndrome or motor neuron syndrome.
  • Plexopathy - results from damage to the brachial and lumbar plexuses.  Symptoms may include paresthesias, motor deficits, lymphedema and pain.

Radiation Fibrosis Syndrome (RFS)

Radiation affects healthy cells within the treatment field, and can cause an increased production of fibrin (a protein found in the body that accumulates and causes damage in radiated tissue over time). Radiation fibrosis can affect any tissues in the radiation field. This damage can cause shortening of tissues, contracture and atrophy of muscle, cause bones to become weak and brittle, cause heart, lung and nerve damage (neuropathy) and lymphedema.

Patients may notice signs and symptoms of RFS anywhere from a few weeks to years after treatment has ended. These symptoms will progress over time.

Patients being treated with radiation for head and neck cancer are at a higher risk of developing radiation fibrosis syndrome (RFS) due to the high doses of radiation to parts of the body with structures crucial to activities of daily living eg eating, moving head. Some examples of the problems encountered include:

  • Decreased ability to fully open the mouth (trismus)
  • Neck pain and tightness (cervical dystonia)
  • Lymphedema (swelling)
  • Difficulty with speech and swallowing

The treatment for RFS depends upon the symptoms and side effects the patient is having. Physical therapy, occupational therapy, speech and swallow therapy, and surgery may all play a part in treatment for RFS.[7]

Medical Management[edit | edit source]

  • Clinical trials to learn how to use radiation therapy more safely and effectively are being conducted by doctors and scientists. [5]
  • Working on improving image-guided radiation. [5]
  • Research is also being done on radiosensitizers and radioprotectors. [5]
  • The use of carbon ion beams is still being investigated and remain experimental. This type of therapy are not currently available in the US. [5]

Physical Therapy Management[edit | edit source]

Breast Cancer Exercise Classes.jpg

Cancer and treatment can cause physical problems including, but not limited to, pain, fatigue and muscle weakness. These often interfere with life in physical, emotional and practical ways.

Physiotherapy rehabilitation services can work on: improving strength and stamina; pain resolution; site specific problems eg contractures, lymphedema, RFS; education re skin care, importance of remaining physically active and good nutrition.

  • Physical therapists should always wash their hands before treating a patient who has undergone radiation therapy to protect that client from possible infection.[2]

Skin Care[2]

  • Avoid use of alcohol/drying agents, lotion, gel, or oil. Creams and gels can increase the dosage received on the skin and increase the likelihood of side effects
  • Do not wash away markings of the targeted area
  • Position the patient so they are not lying on the targeted area
  • Avoid exposing the patient to sources of heat, including direct sunlight and modalities
  • Monitor wound healing

Musculoskeletal [2]

  • If adhesions are present in the hip after radiation of the pelvis, be sure to incorporate range of motion activities; early intervention is important to prevent contractures and restrictive scarring.
  • Post-radiated tissue can tear when stretching so it is important to observe for blanching of the skin during stretching and not to stretch beyond that point.  Stretching should be continued 18 to 24 months after radiation therapy has been discontinued.

Nervous System [2]

  • Anyone with neurological signs or symptoms of an unknown cause should be asked about a previous history or cancer and radiation therapy

Infection[2]

  • Therapists should observe carefully for signs of infection in patients who have undergone radiation treatment.  The first and only sign may be a fever because the patient may be immunosuppressed and their body cannot create a normal inflammatory response.

Exercise [2]

  • A successful protocol should include patient education, exercise evaluation and an individualized exercise prescription. - Therapists must monitor vital signs in patients who have undergone radiation treatment because radiation and chemotherapy can leave the lungs and heart tissue permanently scarred. Patients should be taught to monitor their own vitals including heart rate, respiration rate and rate of perceived exertion (should not exceed 15 to 17) and taught to detect signs of complications such as dyspnea, pallor, excessive perspiration, or fatigue while exercising.  Patients should be told not to exercise within 2 hours of chemotherapy or radiation therapy because it increases the circulation and may increase the effects of the treatment.
  • Studies have shown low to moderate intensity aerobic exercise during the same weeks of radiation treatment can help improve physical function and lower subjective levels of fatigue, anxiety, depression and sleep disturbances.

Management of Syndromes Associated with Radiation Fibrosis Syndrome[3]

  Physical Therapy is usually the first line of treatment for the dysfunctions listed below.

  • Neck Extensor Weakness - emphasize postural retraining through core strengthening, flexibility of the shoulder musculature, and strengthening the cervicothoracic and rotator cuff muscles.  This will help reduce energy demands and pain.  It is also important to develop a long-term home exercise program
  • Shoulder Pain and Dystonia - treated through conservative measures because shoulder surgery should be avoided in patients with RFS because damage of the neruomuscular structures often results in poor surgical outcomes.  Work on core strength and posture, neck extensor and rotator cuff strength and stretching of pectoral girdle musculature in order to try to restore normal anatomical alignment of the shoulders. There is a potential long-term benefit if the patient consistently follows a home exercise program.
  • Cervical Dystonia - the goal is to restore and maintain neck range of motion and a long-term home exercise program should be utilized.
  • Trismus - Literature is limited but a variety of jaw-opening devices are available to help treat trismus.

Resources[edit | edit source]

Radiation Side Effects Worksheet http://www.cancer.org/acs/groups/content/@nho/documents/document/acsq-009503.pdf

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Radiopedia Radiation Therapy Available from:https://radiopaedia.org/articles/radiation-therapy (last accessed 25.8.2020)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. 3rd ed. St. Louis. Missouri: Saunders, 2009.
  3. ↑ 3.0 3.1 Stubblefield MD. Radiation Fibrosis Syndrome: Neuromuscular and Musculoskeletal Complications in Cancer Survivors. PM R. 2011;3:1041-1054.
  4. ↑ Radiopedia CRT Available from:https://radiopaedia.org/articles/conventional-radiation-therapy?lang=gb (last accessed 25.8.2020)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 National Cancer Institute. Radiation Therapy for Cancer. National Institutes of Health. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation. Reviewed May 30, 2010. Accessed April 3, 2013.
  6. ↑ 6.0 6.1 ACS Radiation Therapy Available from:https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/effects-on-different-parts-of-body.html (last accessed 26.8.2020)
  7. ↑ Oncolink RFS Available from:https://www.oncolink.org/cancers/head-and-neck/side-effect-management-support-resources/radiation-fibrosis-syndrome (last accessed 26.8.2020)

 

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