Mais conteúdo relacionado

Similar a Acute and Late Radiation Related Side Effects and their Management in Pelvic Malignancies.pptx(20)


Acute and Late Radiation Related Side Effects and their Management in Pelvic Malignancies.pptx

  1. Acute and Late Radiation Related Side Effects and their Management in Pelvic Malignancies Dr. Kartik Kadia Moderator : Prof Dr Rajeev K Seam MMIMSR, Ambala
  2. Introduction • Radiation therapy affects both – tumour cells and uninvolved normal cells • With the goal of achieving uncomplicated locoregional control of cancer, balancing between the two is very important
  3. Normal Tissue damage • Most of the effects of radiation therapy on normal tissues can be attributed to cell killing, but there are some that cannot. • Examples include the following: ■ Nausea or vomiting that may occur a few hours after irradiation of the abdomen. ■ Fatigue felt by patients receiving irradiation to a large volume.
  4. • Somnolence that may develop several hours after cranial irradiation. • Acute edema or erythema that results from radiation-induced acute inflammation and associated vascular leakage.
  5. Cont. • The response to damage is governed by (1) the inherent cellular radiosensitivity, (2) the kinetics of the tissue, and (3) the way cells are organized in that tissue. • The threshold dose below which no effect is seen and the delay between irradiation and the time at which the damage becomes observable vary greatly among different tissues.
  6. Radiation Response • Response of all normal tissues to radiation is not same • Depending on their response tissues are either –  Early responding – constitute fast proliferating cells such as skin, mucosa, intestinal epithelium, colon, testis etc.  Late responding – have large no. of cells in the resting phase e.g. spinal cord, bladder, lung, kidneys etc.
  7. Normal Tissue Reactions • Radiation effects are commonly divided into two categories, early and late, which show quite different patterns of response to fractionation : • Early (acute) side-effects are observed during or shortly after a course of radiotherapy. • Late (chronic) side-effects become clinically manifest after latent times of months to many years.
  8. • The cut-off time to distinguish early from late effects has arbitrarily been set to 90 days after the onset of radiotherapy. • Their dose-response relations are characterized by different α/β ratios. • Late effects are more sensitive to changes in fractionation than early effects.
  9. Early Effects Late Effects Cell turnover rate High Low Progression Can repair Cant be repaired – Persistent and progressive Time of Manifestation 2-3 weeks Months to years Dose per Fraction Important Very Important a/b ratio High Low Overall treatment time Important Not very important Mechanism Cell depletion Combination of vascular damage and parenchymal changes
  10. Consequential Late Effect • If there is depletion of the stem cell population below levels needed for tissue restoration, an early reaction in a rapidly proliferating tissue may persist as a chronic injury • This has been termed a consequential late effect, that is, a late effect consequent to, or evolving out of a persistent severe early effect —for example, fibrosis or necrosis of skin consequent to desquamation and acute ulceration.
  11. History of “TOLERANCE OF NORMAL TISSUE TO THERAPEUTIC IRRADIATION” • Mendelsohn had discussed the lack of time-dose data related to patterns of radiation damage in normal tissue and had noted that “some tissues are dealt effectively, but the bulk of tissues are seldom discussed, poorly documented and have data which are sparse and meaningless.” Mendelsohn, M. L. The biology of dose-limiting tissues. Conference on Time and Dose Relationships in Radiation Biology as Applied to Radiotherapy supported by the National Cancer Institute, National Institutes of Health; 1969: 154-160.
  12. Cont. • The monumental work of Rubin and Cassarett was a major step in this direction. • TD 5/5 (the probability of 5% complication within five years from treatment) and • TD 50/5 (the probability of 50% complication within five years), were introduced Rubin, P.; Cassarett, G. A direction for clinical radiation pathology. In: Vaeth, J. M., et al., eds. Frontiers of radiation therapy and oncology VI. Baltimore: University Park Press; 1972:1-16.
  13. Tissue tolerance and sensitivity • Concept of TD5/5, TD 50/5
  14. Emami et al - 1991
  15. QUANTEC • With the development of more sophisticated three-dimensional treatment planning systems, numerous studies in the literature have reported associations between dosimetric parameters and normal tissue outcomes • The Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) article, which appeared in the International Journal of Radiation Oncology, Biology, and Physics in 2010 summarized the available data in a clinically useful format.
  16. Studies • Perez et al. described the incidence of major sequelae in 1211 patients treated at Mallinkrodt between 1959 and 1986. • Those patients who received a dose of less than or equal to 80 Gy had a 2% to 3% incidence of major rectal complications as compared with a rate of 6% to 13% at doses greater than 80 Gy.
  17. • Lanciano and colleagues in the Patterns of Care Study reported a crude complication rate of 9.8% with 3- and 5-year actuarial rates of 10% and 14%, respectively, in 1558 patients treated only with radiation for all stages of disease at a large number of institutions in the United States. • Of all complications, - 61% occurred in the large and small bowel, 21% in the bladder, and 10% in the vagina. • Of these complications, 64% required surgical correction,and 9% were fatal (total of 0.8% fatal complication rate).
  18. Classification systems • The absence of a uniform classification system for reporting treatment morbidity had resulted in a considerable inconsistency in the reporting of treatment complications in cervical cancer patients. Nowadays the classifications most used are the: • RTOG/EORTC • LENT/SOMA • European • WHO • French/Italian • AADK • Common Toxicity Criteria (CTC).
  19. Tissue Tolerance Tissue Tolerance – The ability of tissue/organs to endure the effect of radiation without adverse effect Tolerance Doses : • Uterus - 300 Gy • Cervix - 250 Gy • Upper third of the vagina - 120 Gy to 140 Gy, • The lower two thirds - 80 Gy to 85 Gy. Most institutions do not exceed:- • 75 Gy to 80 Gy (combined EBRT and LDR intracavitary dose)
  20. Acute Reactions
  21. Acute Toxicity • In cervical cancers, the use of concurrent CRT has clearly shown to increase in acute toxicities • Especially with respect to – hematologic and gastrointestinal function as compared with RT alone
  22. Radiation Complications • Acute complications : (cell loss in rapidly dividing tissue) • Acute radiation enteritis • Acute radiation proctitis • Skin reaction • Nausea • Anorexia • Fatigue,Weakness • Acute Genito-urinary symptoms: Dysuria, frequency
  23. Late Reactions
  24. • Chronic complications : • GI: ulceration ,hemorrhage ,stricture ,small bowel obstruction, malabsorption • Bladder: Mucosal thinning, telangiectasia and fibrotic contracture in bladder. • Skin: thinning ,loss of appendage, telangiectasia,subcut fibrosis. • Cervix and vagina: obliteration of os, shortening of vagina ,fistula • Ovary: early menopause
  25. Late Toxicities • The incidence of major late sequelae of radiation therapy for –  stage I and IIA carcinomas of the cervix ranges from 3% to 5%  stages IIB and III between 10% and 15% • The severe complications occur in the first 3 years to 5 years after completion of radiotherapy, but there still remains a small but continuous added risk thereafter
  26. • Injury –  gastrointestinal tract usually appears within the first 2 years after radiation therapy  urinary tract are seen more frequently 3 to 5 years after treatment Late Toxicities
  27. • Smoking during RT has been associated with a significantly higher risk of late complications. • Most reports of late morbidity have focused on severe gastrointestinal and genitourinary toxicities; only recently have rigorous efforts been made to monitor for less severe sequelae. Late Toxicities
  28. Late toxicities Late effects, which are now recognized as important consequences- • Pelvic insufficiency fracture • Vaginal stenosis • Lymphedema • Neuropathy
  29. Contin. • Perez et al. quantitated the effect of total doses of irradiation dose rate ratio of doses to bladder and rectum and point A on sequelae in 1,456 patients. (EBRT plus two LDR 70 to 90 Gy to point A; Median follow-up was 11 years)
  30. Cont. The most frequent grade 2 urinary/rectal sequelae were I. cystitis and II. proctitis (0.7% to 3%) The most common grade 3 sequelae were- I. vesicovaginal fistula (0.6% to 2% in patients with stage I to III tumors) II. rectovaginal fistula (0.8% to 3%), and III. intestinal obstruction (0.8% to 4%).
  31. Late toxicities (cont.) • In the bladder, doses <80 Gy correlated with a <3% incidence of morbidity, which was 5% with higher doses (P = .31). • In the rectosigmoid, the incidence of significant morbidity was <4% with doses <75 Gy and increased to 9% with higher doses. • For the small intestine, the incidence of morbidity was I. <1% with 50 Gy or less, II. 2% with 50 to 60 Gy, and III. 5% with higher doses to the lateral pelvic wall
  32. Skin Reactions
  33. Patient-related and treatment-related factors for Dermatologic toxicity • Risk of skin toxicity as well as its onset, severity, and duration are strongly affected by clinical and treatment related factors: • Vascular disease, smoking, and poor nutrition may impair acute and long-term recovery of the dermis and subcutaneous tissues. • Radiation-induced skin reaction may occur in a patient with a high body mass index because of the presence of skin folds and may be compounded by parallel fungal or bacterial infection.
  34. Acute skin reactions • Grade 1 and 2 skin reactions are most common in Radiotherapy, with an incidence of 10%. • At a dose of 40 Gy, grade 2 reactions are typically observed
  35. • Grade 3 skin reactions are associated with exceed 50 to 60 Gy with bolus placement. • Grade 4 skin reactions are associated with even more higher doses. Acute skin reactions
  36. Acute skin reactions • Severe skin reactions are rare (range, 1%-5%) in the treatment of cervical cancer • Acute skin reactions typically peak within 1 or 2 weeks after treatment, with a relatively rapid healing time of 3 to 4 weeks
  37. Treatment of acute skin toxicity • An acute skin reaction is generally apparent after 2 or 3 weeks of pelvic EBRT with conventional dose fractionation • Mild skin reactions, such as erythema, may be treated with topical moisturizers without added perfumes or metals like zinc or silver, which can irritate the skin or enhance the reaction.
  38. Late Dermatologic Effects • May include – • hyperpigmentation or hypopigmentation, • Telangiectasia • textural changes (xerosis and hyperkeratosis), • thinning of the skin because of atrophy xerosis telangiectasia hyperkeratosis
  39. Cont. • In the months after RT, folliculitis is common because of regrowth of occluded hair follicles, sweat glands, and sebaceous glands and may be relieved with warm compresses or occasionally may require antibiotics • Subcutaneous fibrosis with associated woody thickening of the skin may also be observed Folliculities
  40. • Physicians use –  Kojic Acid cream for hyperpigmentation  Laser therapies  Sclerotherapy  Surgical excisions for treatment of chronic skin reactions like xerosis and telangiectasia
  41. Gastro-intestinal System
  42. Patient-related and treatment-related factors associated with GI toxicity • Prior abdominal or pelvic surgery has increased risk of developing small bowel obstructions in patients who receive > 50 Gy of RT to the pelvis and can lead to adhesions, which limit intestinal displacement.
  43. Cont. coexisting comorbidities including – prior pelvic inflammatory disease, vascular disease because of diabetes or arteriosclerosis, collagen vascular disease, smoking history inflammatory bowel disease may be at greater risk for developing acute and long-term radiation induced GI side effects.
  44. Contin.. • Overall, for patients treated with radiation for carcinoma of the uterine cervix, the crude incidence of small bowel obstruction was – 2% to 3% in the Perez report 4% in the Patterns of Care Study 4% in the pelvic radiation therapy–alone arm of the RTOG para-aortic study • Incidence increases to 17% in patients treated who had a prior history of abdominal surgery. • Studies that have pushed the dose to 60 Gy have resulted in severe GI complication rates of as high as 57%.
  45. Mechanism of GI injury • Both early and late complications are observed in the gastrointestinal tract. • Acute mucositis frequently occurs, with symptoms such as - diarrhea or gastritis • depending on the treatment field.
  46. Acute GI injury mechanism • In the small intestine, stem cells are located toward the bottom of the crypts of Lieberkühn • Atrophy of the villus occurs about 2 to 4 days postirradiation.
  47. • Epithelial denudation is responsible for the acute gut reactions. • A regenerative response appears rapidly, and within 2 to 4 days, microcolonies and macrocolonies are detectable. • The surviving crypts have at least the same radiosensitivity to reirradiation as the unirradiated crypts Acute GI injury mechanism
  48. Late GI mechanism • Long-term late sequelae, which may develop either from persistent severe early reactions (consequential late effects) or independently of acute damage in the submucosal, muscular, or serosal layers. • Late bowel reactions involve all tissue layers and are caused by atrophy of the mucosa caused by vascular injury, with subsequent breakdown resulting from mechanical irritation and bacterial infection, which leads to an acute inflammatory response.
  49. • In addition, overgrowth of the fibromuscular tissue with stenosis and serosal breakdown and adhesion formation may occur, which may be predisposed to by previous surgery and is related to inflammatory mediators. • Fibrosis and ischemia are typical late effects. Late GI mechanism
  50. Tolerance Dose • Tolerance dose is about 50 Gy for the small intestine and slightly higher for the large intestine. • Rectal tolerance dose is about 70 Gy.
  51. Acute Radiation Enteritis • Enteritis is inflammation of the small intestine • Symptoms:  diarrhea  nausea and vomiting  loss of appetite  abdominal cramps and pain
  52. • The management of acute radiation enteritis is mainly supportive • Patients may be treated with fiber products and probiotics • Frequent use of antidiarrheal agents, such as loperamide or diphenoxylate and atropine, starting with 1 tablet a day before the development of diarrhea and increasing as needed, may be indicated. Acute Radiation Enteritis
  53. • Fluid status and electrolytes also should be monitored carefully • Intravenous hydration may also be required if patients are unable to adequately maintain fluid intake. • Aggressive management during treatment is important to reduce the risk of chronic enteropathy. Acute Radiation Enteritis
  54. Acute Radiation Proctitis • Proctitis is a condition in which the lining tissue of the inner rectum becomes inflamed • Symptoms : A frequent or continuous feeling that patient needs to have a bowel movement Pain on the left side abdomen. A feeling of fullness in the rectum. Pain with bowel movements. Rectal pain Rectal bleeding
  55. • Numerous anti-inflammatory agents, intestinal protectants, intestinal antimotility agents, and probiotics have been studied as preventative strategies • However till date, none of these agents have demonstrated the ability to definitively mitigate radiation toxicity. Acute Radiation Proctitis
  56. • The treatment of acute radiation proctitis can mainly be considered supportive and includes antidiarrheal agents and intravenous hydration as needed. • Several studies have also suggested a potential benefit with short-chain fatty acid butyrate enemas, which may aid in accelerating the healing process of acute radiation damage Acute Radiation Proctitis
  57. Chronic Radiation Enteritis • Symptoms –  diarrhea.  nausea and vomiting.  loss of appetite.  abdominal cramps and pain.  pain, bleeding, or mucus-like discharge from the rectum.  fever  Malabsorption
  58. • Cholestyramine may be useful in treating bile salt malabsorption. • Surgical resection may be required in up to 30% of patients because of persistent ileus, intestinal fistulization, or adhesions Chronic Radiation Enteritis
  59. Late Radiation Proctitis • Proctitis is inflammation of the lining of the rectum • Symptoms: Tenesmus (A feeling of fullness in rectum) Rectal bleeding. Rectal pain. Diarrhea. Pain with bowel movements.
  60. • If rectal bleeding does not cause symptoms, then treatment is not always necessary, because most cases will resolve spontaneously. • Stool softeners may aid in minimizing damage to friable rectal tissue with the passage of stool. • Treatment with a 4-week course of metronidazole also has been effective, possibly because of the treatment of anaerobic bacteria, which may contribute to hypoxia or immunomodulatory effects Late Radiation Proctitis
  61. Contin.. • Severe Rectal bleeding that is refractory to medical management, patients may be referred for consideration of endoscopic therapy with argon-plasma coagulation • In cases of chronic rectal bleeding, hyperbaric oxygen has been effective in reducing chronic pelvic radiation toxicities
  62. Genito-Urinary System
  63. Patient-related and treatment-related risk factors for Genito-Urinary toxicity • Treatment-related factors that influence the risk of GU toxicity include – cumulative radiation dose treatment volume radiation modality (EBRT, brachytherapy, or both), prior pelvic surgery.
  64. Cont. • Patients who undergo radical hysterectomy, adjuvant radiation may cause higher rates of –  bladder dysfunction  hydroureteronephrosis  stress incontinence  radiation cystitis.
  65. Mechanism of Bladder injury • Cell renewal rate of Bladder is low, the superficial cells having a life span of several months. • Because of this long life span, proliferation following irradiation does not begin for months. • Senescence of the differentiated functional cells then reveals latent damage in the basal layer.
  66. • Frequency of urination increases in parallel with bladder damage and loss of surface cells. • The absence of these surface cells explains the irritation by urine of the deeper cellular layers, leading to stimulation of cellular proliferation. • Subsequent late effects are related to fibrosis and reduction in bladder capacity. Mechanism of Bladder injury
  67. Cont. • Acute side effects (Focal) from incidental bladder irradiation are common and include urinary frequency, urgency, and dysuria (symptoms that may also reflect acute urethral toxicity). • Late effects (Global) include dysuria, frequency, urgency, contracture, spasm, reduced flow, and incontinence. • In contrast, late effects arising from focal injury include hematuria, fistula, obstruction, ulceration, and necrosis.
  68. Acute Genito-Urinary toxicity • Pelvic radiation for gynaecologic malignancies may result in both upper and lower tract genitourinary (GU) complications, which are dose-dependent and related to RT modalities
  69. • Low-grade (grade 1-2) acute GU toxicity is relatively common during EBRT, with an incidence of 17% to 40% in the definitive treatment of cervical cancer with concurrent chemoradiotherapy • Severe urinary tract toxicity is relatively rare during treatment (range, 2%- 5%). Acute Genito-Urinary toxicity
  70. Cystitis • Cystitis is an inflammation of the bladder • Symptoms: pain, burning or stinging while micturition Increased urgency for micturition than normal. urine that's dark, cloudy or strong-smelling. pain in lower abdomen feeling generally unwell, sick and tired.
  71. Cystitis Treatment • Antibiotics if infectious source; • Pyridium/NSAID’s if non-infectious; • Urinary urgency is effectively managed with anticholinergics like oxybutynin. • Tolderodine, Trospium have similar efficacy but lower rates of confusion, dry eyes, dry mouth, and constipation compared with oxybutynin.
  72. Late Genito-Urinary effects • The reported rates of major urologic complications (grades 3-4) after RT for cervical cancer range from - 1.3% to 14.5% at 3 years and most commonly include ureteral stricture and hemorrhagic cystitis • Hemorrhagic cystitis may be treated with laser fulguration of ectatic vessels, intravesical alum or formalin, or hyperbaric oxygen
  73. Ureteral Strictures • Ureteral strictures – Narrowing of Ureter. • Symptoms – oSide or back pain. oFeeling of fullness. oBlood in the urine. oUrinary tract infections. oPain that worse with increased fluids
  74. have been noted in –  5% of patients after preoperative RT and  2.5% of patients after definitive RT alone for cervical cancer Ureteral Strictures
  75. • Strictures of the ureter may be managed by endoscopic procedures, such as – dilation or stent placement, but they often require ureteral reimplantation or ileal ureteral substitution • Ureteral strictures may represent recurrent cancer until proven otherwise Ureteral Strictures
  76. Vaginal Complications
  77. Vaginal stenosis • Risk factors include – higher radiation dose age older than 50 years, lack of compliance to treatment • Radiation doses >80 Gy have been associated with a 10% to 15% increased risk of grade 2 vaginal toxicities, including Vaginal Stenosis
  78. Vaginal adhesions • Vaginal adhesions is shortening of vagina – leading to labial adhesions, and potentially total agglutination of the vagina. • Small adhesions form quickly in the irradiated patient, which can make coitus and pelvic examinations quite painful. • May be prevented by use of Vaginal Dilators
  79. Vaginal dryness • Dryness of the irradiated vagina is a common side effect, because of a combination of direct radiation effect. • Vaginal lubricants and topical estrogen creams are beneficial in partially relieving these symptoms.
  80. Vaginal Complications • Other effects of irradiation of the vagina includes – Erythema moist desquamation confluent mucositis - leading to the loss of vaginal epithelium that may persist for 3 to 6 months.
  81. • Gross abnormalities in the vagina may include pale color, a thin atrophic mucosa, inflammation, and tissue necrosis with ulceration leading to a fistula. • Tolerance doses, however, are high – 90 Gy for ulceration and 100 Gy for the development of a fistula Vaginal Complications
  82. Vaginal necrosis • Vaginal necrosis may result from high doses of radiation, especially in patients who have undergone reirradiation • Patients who receive HDR, may be at greater risk for vaginal necrosis • Hydrogen peroxide douching with a dilution of at least 1:10 with saline, oral metronidazole, and hyperbaric oxygen may be considered.
  83. Vesicovaginal Fistula • Patients who have bladder involvement at diagnosis are at risk of developing a vesicovaginal fistula after definitive RT. • Fistulae should first undergo biopsy to rule out recurrence of malignancy.
  84. Fistula • Small vesicovaginal fistulae may be managed with –  simple fulguration and catheter drainage  but they may require open surgical repair and, occasionally  urinary diversion • Uretero-arterial fistulae are rarely encountered and have a acute mortality rate. • They should be treated with endovascular stent placement or, if this fails, open surgical repair.
  85. Other Complications • Most common gynecologic complications of pelvic radiation are ovarian failure in premenopausal patients and vaginal stenosis (VS) in any female patient who receive pelvic radiation (Incidence ranges from 20% to 88% of patients)
  86. Contin.. • Patients who receive radiation to the pelvis for locally advanced cervical cancer will have their ovaries irradiated and, thus, may undergo menopause, typically within the first 6 months after treatment. • Vaginal Stenosis is most likely to occur within the first year of treatment but has been observed in as short a time as 26 days and as far out as 5.5 years from definitive therapy. • The distal vaginal mucosa has less radiation tolerance than the mucosa in the upper region, and vaginal shortening may begin during the course of RT.
  87. Haematological
  88. Hematological toxicity • Includes - Anemia, Neutropenia, Thrombocytopenia • Large prospective studies have demonstrated that the rate of grade 3 hematologic toxicity with cisplatin- based pelvic chemoradiotherapy is approximately 20% to 25%. • Extended-field RT leads to the irradiation of a larger proportion of the total Bone Marrow and a correspondingly higher rate of hematologic toxicity.
  89. Haematological toxicities • Weekly blood counts should be routinely taken into consideration • Chemotherapy is typically held when the neutrophil count decreases below 1500/mcL • Radiotherapy is typically held when the neutrophil count approaches 500/mcL to 1000/mcL
  90. Osteogenic Toxicities
  91. Bone Complications • Important sequelae of radiation to bone, such as pathologic fractures osteoradionecrosis second malignancies are associated with a decrease in quality of life and increase in mortality.
  92. • Factors that influence bone toxicity include – • radiation dose (>50 Gy) • as well as patient factors, such as  age,  menopausal status,  presence of underlying bone weakness (such as osteopenia or osteoporosis),  cigarette smoking,  vascular integrity. Bone Complications
  93. • Fractures of the humeral and femoral head are observed if the dose - in conventional fractions is high  TD5/5 is 52 Gy and  TD50/5 is 65 Gy. Bone Complications
  94. • The 5-year cumulative rate of PIF (pelvic insufficiency fracture) ranges from 5.1 to 45%. • A 4-level instability classification system is followed Bone Complications
  95. • The classification recommends – • nonoperative treatment for stable type I fractures, • nonoperative or minimally invasive surgical fixation for type 2 fractures • surgical stabilization for type 3 and 4 fracture patterns. Bone Complications
  96. • Nonoperative treatment measures usually consist of a combination of –  nonsteroidal antiinflammatory and  pain medication • And slow progression from bed rest to full mobilization with full weight- bearing on the affected side. Bone Complications
  97. Neurologic Toxicity • Extremely rare, lumbosacral plexopathy has been occasionally reported in patients treated for pelvic tumors with doses of 60 to 67.5 Gy. • Lower extremity paralysis secondary to lumbosacral plexopathy • The neurologic deficit is irreversible, and no effective therapy other than supportive care has been found.
  98. Second Malignancy • The risk of second malignancies rises over time after radiation for carcinoma of the cervix, although the exact increase over the rate expected in the general population is difficult to assess.
  99. • The Risk rate of developing a second tumor after pelvic irradiation is greater than 2.5 for the development of –  vulva or vagina carcinoma (5.6)  anal carcinoma (4.6)  Laryngeal carcinoma (3.3)  lung cancer(3.0)  bladder carcinoma (2.7)  bone cancer(2.7) Second Malignancy *Perez & Brady’s Principles of Radiation Oncology – 7th Edition
  100. • However, the presence of shared causal factors, such as –  HPV in anal, vulvar, and cervical malignancies, or  excess smoking in the population of cervical carcinoma patients makes it unclear that the treatment contributes to this excess risk of second malignancy Second Malignancy
  101. Thank You

Notas do Editor

  1. ; the former to the benefit and the later to the detriment of patients.
  2. Somnolence- drowsy, sleepiness Edema- as a part of radiation induced dermatitis
  3. Radiosensitivity – blood cells producing organs, most sensitive…nerve, muscles least sensitive Cell kinetics – based on 4 r’s. rapidly cycling cells redistribute around cell cycle when cells in sensitive phase are destroyed.. So experience less mitotic delay as compared to slow cycling cells
  4. Prolonging overall treatment time can reduce acute reactions without sparing late damage
  5. Inflamation of small intestine
  6. Rule out infective causes
  7. Assess for uti
  8. Stricture – narrowing of ureter
  9. VS is defined as narrowing or shortening of the vaginal canal that may interfere with physical examination or sexual function.