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Complications of radiation therapy and factors in their prevention

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Abstract

Radiation therapy of most malignant tumors requires dose-fractionation regimens near the tolerance of the surrounding normal tissues. With the exception of the bone marrow and the lung in which the morbidity may be minimized by reducing the volume irradiated, other structures require limitations of total doses to minimize adverse effects. In thoracic irradiation, the most sensitive normal structure is the lung, while the heart and esophagus do not frequently have serious late effects. Pelvic irradiation carries a much greater risk of morbidity, primarily to the fixed segments of small bowel and less frequently to the large bowel and bladder. Irradiation of the upper aerodigestive tract may be complicated by necrosis of soft tissues and bone, especially the mandible. Dental management greatly affects the risk of complications. Bones and soft tissues elsewhere in the body are rarely affected except in the growing child. The normal pituitary may be irradiated when tumors near the base of the skull are treated. The production of growth hormone may especially be compromised in children. Acute, subacute, and late effects of irradiation of the brain are well recognized. While transient radiation myelopathy is frequent and not serious, progressive radiation myelopathy is rare but extremely grave. Host factors, other diseases, and technical aspects of radiation therapy affect the risks and severity of adverse effects on normal tissues. Surgical procedures may be important in preventing complications as well as in managing them.

Résumé

L'irradiation de la majorité des tumeurs malignes implique le fractionnement des doses susceptibles d'Être tolérées par les tissus normaux voisins. A l'exception de la moelle osseuse et du poumon dont la morbidité après irradiation peut Être diminuée en réduisant le volume irradié, les autres structures anatomiques imposent de limiter les doses de manière à réduire les effets secondaires. Au niveau du thorax, le poumon est particulièrement sensible à l'irradiation alors que l'oesophage et le coeur le sont moins. L'irradiation pelvienne comporte de plus grands risques de morbidité en particulier en ce qui concerne l'intestin grÊle et moins souvent en ce qui concerne le colon et la vessie. L'irradiation de la partie supérieure de l'appareil aéro-digestif peut Être suivie de la nécrose des parties molles et du squelette spécialement du maxillaire. Le traitement des affections dentaires implique un risque indubitable de complications. En revanche les os et les parties molles des autres parties du corps sont moins sensibles, sauf chez l'enfant. L'hypophyse peut Être irradiée lors du traitement des tumeurs situées au niveau de la base du crane. La production de l'hormone de croissance peut Être compromise quand l'irradiation est pratiquée chez l'enfant. Les effets immédiats secondaires et tardifs de l'irradiation du cerveau sont bien connus. Alors que la myélopathie fugace secondaire à l'irradiation est fréquente et peu grave, la forme progressive est rare mais extrÊmement sévère. Les facteurs propres au malade, les autres maladies, les conditions techniques de l'irradiation ne sont pas sans affecter les risques et la gravité des effets secondaires sur les tissus normaux. Les méthodes chirurgicales pour prévenir ces complications ou les traiter revÊtent une grande importance.

Resumen

La terapia de irradiación para la mayoría de los tumores malignos requiere regimenes de fraccionamiento de la dosis cercanos a la tolerancia de los tejidos vecinos normales. Con excepción de la medula ósea y del pulmón, donde la morbilidad puede ser minimizada reduciendo el volumen irradiado, otras estructuras exigen la limitación de la dosis total para minimizar los efectos adversos. En la irradiación torácica la estructura más sensible es el pulmón, en tanto que el corazón y el esófago frecuentemente exhiben efectos tardíos. La irradiación pélvica conlleva un riesgo mucho más alto de morbilidad, primordialmente a cargo de los segmentos fijos de intestino, y con menos frecuencia a cargo del intestino grueso y de la vejiga. La irradiación del tracto aerodigestivo superior puede complicarse por necrosis de los tejidos blandos y del hueso, especialmente de la mandíbula. El manejo dental afecta en forma importante el riesgo de complicaciones. Los huesos y los tejidos blandos en otras regiones del cuerpo rara vez se ven afectados, excepto en los niños en crecimiento. La pituitaria puede resultar irradiada en el curso del tratamiento de tumores cerca de la base del cráneo. La producción de hormona del crecimiento puede verse especialmente comprometida en los niños. Los efectos agudos, subagudos y tardios de la irradiación del cerebro son bien conocidos. En tanto que la mielopatía transitoria de irradiación es frecuente y no grave, la mielopatía progresiva de irradiación es rara pero extremadamente grave. Factores relativos al huésped, otras enfermedades, los aspectos técnicos de la radioterapia, son factores que afectan los riesgos y la severidad de los efectos adversos sobre los tejidos normales. Los procedimientos quirÚrgicos pueden ser importantes en la prevención de las complicaciones así como en el manejo de ellas.

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  1. Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

    James D. Cox M.D. (Professor and Chairman), Roger W. Byhardt M.D., J. Frank Wilson M.D., Judith S. Haas M.D., Ritsuko Komaki M.D. & Laird E. Olson M.D.

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  1. James D. Cox M.D.
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  2. Roger W. Byhardt M.D.
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  3. J. Frank Wilson M.D.
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Cox, J.D., Byhardt, R.W., Wilson, J.F. et al. Complications of radiation therapy and factors in their prevention. World J. Surg. 10, 171–188 (1986). https://doi.org/10.1007/BF01658134

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