Fatigue

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Cancer-related Symptoms

Radiotherapy Side-effects
Sakpisid Nawasiri,M.D. 16 March 2006
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Radiation Effect on Cell
Ionizing radiation?? tissue(? cell) ? DNA
Damage to DNA may results.

• Immediate cell death.
• Apoptosis at the next mitosis.
• Fully repaired.
• Permanent change in genotype.

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Cellular effects
Acute

• On high mitotic activity eg. BM , GI
• Renewal of the cell stopped.
• Damage to vascular lining (Endothelium)

Late

• Vascular endothelial cell loss.
• Platelet adherence Thrombus formation.
• Intimal lining of vessel wall proliferates.
• (Endarteritis obliterans)
• Chronic vascular insufficiency Atrophy /
  Fibrosis.

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Fatigue

• Symptoms Fatigue is common among most
  individuals during radiotherapy and for varying
  periods afterwards.
• Management Patients should be encouraged to
  rest frequency and alter their schedule.

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Anorexia

• Symptoms Anorexia occurs frequently regardless
  of the treatment site. It is related to the
  presence in the persons system of waste products
  of tissue destruction.
• Management Utilize all the techniques known to
  encourage adequate intake

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Alopecia

• Symptoms Alopecia will occur with treatment to
  the scalp area , as with a primary brain
  tumor.Hair loss typically occurs gradually a 2 or
  3 week peroid followed by a sudden loss of all
  hair. Hair loss may also occur regionally or in
  patches.

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Alopecia

• Management
• ? The patient can prepare by procuring
• a wig, attractive scarf, or cap..
• ? Gentle hair and scalp care is important,
• and harsh chemicals should be avoided.
• ? The top of the head should be protected
• from sunburn with a cap.

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Radiation Effect on Skin

• Desquamation.
• Hair loss
• Hyper/ Hypopigmentation
• Telangiectasia.
• Radionecrosis.

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Skin reactions

• Symptoms The response of normal skin to
  radiation varies from mild erythema to moist
  desquamation that leaves a raw surface similar to
  second degree burn. Healing and cosmesis are
  usually satisfactory. Some patient may have
  permanent tanning. Others will have
  fibrosclerotic change in subcutaneous structures
  and their skin will be smooth, taut and shiny.
  Telangiectasia may also be present.

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Skin reactions

• Management
• ? The skin should be kept as possible.
• ? Cornstarch or A and D ointment
• followed by a Telfa dressing may be
• applied to specific skin reactions.
• ? Exposure to sun should be minimized
• for treated areas.

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Management of skin reaction

• Explanation to patient
• propable effects.
• normal reaction, not Burn
• Leave it alone to normal healing process (2-3 wk)
• Prevention of infection.
• Avoid talcum powder (Zinc, Bismuth)
• Advise Natural powder Simple baby powder.
• Caution all forms of irritation.

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Radiation Dermatitis (1)

• Acute reaction by time
• At 2nd wk ? Hair loss
• 3rd wk ? Erythema(warm, red, edema)
• ? Dusky pigmentation
• (itching ,discomfort)
• 4th-5th wk ? Dry desquamation
• ? Moist desquamation

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Radiation Dermatitis (2)

• Recovery time
• At 1st wk ? Regenerate of new skin
• 2nd wk ? Sweat gland function
• 3rd wk ? Completely regrowth of skin
• 2-3 Mo ? Regrow of hair

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Radiation Dermatitis (3)

• Chronic reaction
• ?Ischemia destruction narrowing of
  blood
• vessel ? fibrosis
• ?Pigmentation Irradiated field.
• ?Thickening fibrosis of dermis, loss of
  elasticity.
• ?Telangiectasia dilatation of thin-walled
• blood vessel.
• ?Ulceration late necrosis , breakdown.

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Oropharyngeal Mucosal Reaction.

• Early reaction due to mucosa rapidly proliferate.
• Destruction of stem cells in the basal layer
  ?degenerate necrosis
• Dilatation of capillaries and swelling of
  endothelial cell lining ? Erythema.
• Mucosal reaction is maximal in the 3rd wk
• (Depend an Energy, Dose, Fractionation)

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Treatment of mucosal reactions.

• Dental prophylactic treatment.
• Light diet during RT.
• More oral fluid.
• Mucaine / Xylocaine Viscous.
• Avoid hot or spicy food , smoking, alcohol.

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Mucositis

• Symptoms mucositis is a patchy, white membrane
  that becomes confluent and may bleed is
  disturbed. The reaction is most visible when
  radiation is given to the mouth and oropharynx.

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Mucositis

• Management
• ? The patients should be encouraged
• to avoid alcohol and other oral
• irritants.
• ? One ounce of Benadryl elixir
• diluted in 1 quart of water provides.
• ? Mouth care should be done.
• ? Maalox and lidocaine may be used
• to coat or soothe the mucosa.

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Nausea and vomiting

• Symptoms Although nausea and vomiting are not
  common, the fear that they will occur causes
  great stress in many individuals.
• Management Nausea can be controlled by
  antiemetics administered on a regular schedule
  and by adjusting the eating pattern so that
  treatment is given when the stomach is relatively
  empty.

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Salivary Gland Effects

• Parotid gland is the main source of saliva.
• Minor salivary glands locate in tongue , cheek,
  lip, tonsil palate.
• Loss of secretory acini ? xerostomia.
• Low probability effect in dose less than 26 Gy.
• Dose 40-60 Gy ?permanent effect in 80 of
  patient.
• Dosegt60Gy ? total Xerostomia in all.
• Loss of taste, Dental caries.

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Xerostomia

• Symptoms Xerostomia is the dry mouth that
  results from radiation to the salivary glands.
• Management Frequent mouth care, saliva
  substitutes and frequent sips of water are most
  of useful.

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Radiation caries

• Symptoms Absence and decrease in saliva and
  alter Ph produced by treatment promote decay.

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Radiation caries

• Management Proper preventive oral care before,
  during and after treatment should include
  Benadryl mouth sprays, followed by a 5-minute
  application of fluoride gel, and brushing with a
  soft-bristled brush several times daily.
• If extensive decay and general poor dentition
  exist, full mouth extraction is usually the
  treatment of choice.

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Radiation Effects on Thorax RT

• Nausea , Anorexia ? Fluid Nutrition,
• NG
  tube feeding.
• Radiation Esophagitis ?Soft diet, Mucaine.
• High
  calorie fluid ,
• Fungal Esophagitis.
• Perforation, Fistula.
• Infective mediastinitis.
• Pneumonia / Pneumonitis.

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Esophagitis and dysphagia

• Symptoms Treatment to the mediastinum may
  produce symptoms of transient esophagitis. It may
  interfere with the patients swallowing and cause
  a decrease in intake of foods and fluids.
• Management for a mixture that gives temporary
  relief. The diet should consist of high-calorie,
  high-protein, high-carbohydrate liquids and soft
  bland foods.

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General Care of Breast RT. (1)
During treatment

• Avoid washing the treated area.
• Advise loose clothes, bra.
• Use baby powder to keep irradiated area dry.
• Shoulder exercises.

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General Care of Breast RT. (2)
After treatment

• Apply hydrocortisone cream to dry desquamation.
• Apply Flamazine to moist desquamation.
• Continue shoulder exercise.
• Lymphedema prevention.

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Gastrointestinal Effects

• Loss of protective ad absorptive function.
• Diarrhea, Infection, Nausea ,Vomiting ,
  Dyspepsia.
• Stricture of bowel ,Obstruction.
• Esophageal soreness, dysphagia , odynophagia ,
  painful spasm.

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Lower GI track effects

• Diarrhea , dehydration and Elyte imbalance.
• Irritation proctitis.
• Tenesmus.
• Mucous / Bloody stool.
• Malabsorption, Fibrosis , Stenosis.
• Fistula.

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Diarrhea

• Symptoms Diarrhea occurs if the areas of the
  abdomen and pelvis are treated after about 2000
  cGy have been given.
• Management For most individuals, a low-residue
  diet,and prescription of loperamide hydrochloride
  are usually sufficient.

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Tenesmus, cystitis, and urethritis

• Symptoms These symptoms occur in some
  individuals receiving pelvic irradiation.

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Tenesmus, cystitis, and urethritis

• Management
• ? Relief can sometimes be obtained from
• gastrointestinal and urinary spasmodics and
• anticholinergic preparations.
• ? Antibiotics may be used for cystitis and
• urethritis if infection is found by culture.
• ? High-fluid intake is encouraged.
• ? Sitz baths are contraindicated if the perineal
• area is being irradiated.

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Bone marrow depression

• Symptoms When large volumes of active bone
  marrow are irradiated (especially the pelvis or
  spine in the adult), the effect on the marrow can
  be quite significant.

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Bone marrow depression

• Management
• Weekly blood counts should be done, 2 to 3
• times weekly for patients also receiving
• chemotherapy.(eg.for Hodgkins disease), and
  
• more offen for patients receiving total body
  
• irradiation or splenic irradiation.
• ? For significant effects, a laminar flow unit
  and
• transfusions may be needed.
• Nurses, patients, and family should look for
• signs of bleeding, anemia, and infection.

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THANK YOU
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