This document discusses the management of acute and chronic pelvic radiation toxicity. It begins with an introduction and overview of risk factors and organs at risk from pelvic radiation. It then provides detailed information on the symptoms, investigations, dose constraints, timelines, and management approaches for toxicities affecting specific organs, including the rectum, bowel, bladder, and vagina. Conservative approaches are generally recommended for acute toxicities while both medical and surgical interventions may be needed for chronic complications such as strictures or fistulas.
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pelvic toxicities management (2).pptx
1. Management of acute and
chronic pelvic radiation toxicity
Presentor – Dr.G.Sai Sunayana
DNB 1 st year resident
Radiation oncology
Moderator- Dr . Premitha . R
2. Flow of presentation
• Introduction
• Risk factors
• Organs at risk
• Management of toxicities of each organ
• Summary
• References
3. PELVIC RADIATION TOXICITY
• Acute – less than 3 months
• Subacute- 3-6 months
• Chronic – greater than 6 months
• Gastrointestinal manifestations are the most common
• Genitourinary symptoms are 2nd most common
4. Pelvic radiation toxicity
• Although symptoms can be similar in acute and late stages, the treatment approach
differs because the underlying insult differs.
Acute injury Late injury
Epithelial damage
Inflammatory response
Small vessel endothelial damage
Ischemia
Fibrosis
Necrosis
Self limiting
Conservative management
Cessation of radiation
Symptomatic after latent period
Need intervention
Mostly surgical management
5. RISK FACTORS FOR PELVIC RADIATION
TOXICITY
• diabetes mellitus
• inflammatory bowel disease
• concurrent chemotherapy
• prior abdominal surgery
• collagen vascular disease
• HIV
• lower body mass index (18.5 kg/m2)
• chronic tobacco use
• have an increased risk for developing pelvic radiation toxicities
6. Organ at risk in Pelvic Irradiation
• Rectum
• Small and large bowel
• Bladder
• Bone
• Vagina
• Gonads
• Skin
7. Rectum – radiation proctitis
• Diarrhea
• Tenesmus
• Abdominal discomfort (including rectal/perineal areas)
• Fecal urgency
• Fecal incontinence
• Mucus in the stool
• Rectal bleeding (secondary to radiation-induced formation of telangiectasias and
neovascularization)
8. Radiation proctitis
Acute proctitis Chronic proctitis
Time within 3 months of
treatment
Either continue acute phase
or begins after atleast 90
days of treatment
Pathophysiology Tissue hypoplasia
Loss of epithelial barrier
integrity
Exposure of lamina propria
to luminal microbes
Acute inflammatory
response triggered
Progressive vasculitis –
thrombosis of small vessels
Ischemia , necrosis,
ulceration and fistula
Arteritis and submucosal
fibrosis lead to stricture and
obstruction
Symptoms Diarrhoea
Urgency
Tenesmus
Rectal bleeding
Stricture
Sepsis
Intestinal obstruction
10. RTOG ACUTE Radiation Morbidity
Grade I Grade II Grade III Grade IV
Lower GI / Pelvis Increased frequency
or change in quality
of bowel habits not
requiring
medication
rectal discomfort
not requiring
analgesics
Diarrhea requiring
parasympatholytic
drugs (e.g. Lomotil)
mucous discharge
not necessitating
sanitary pads
rectal or abdominal
pain requiring
analgesics
Diarrhea requiring
parenteral support
Severe mucous or
blood discharge
necessitating
sanitary pads
abdominal
distention (flat plate
radiograph
demonstrates
distended bowel
loops)
Acute or subacute
obstruction, fistula
or perforation; GI
bleeding requiring
transfusion
abdominal pain or
tenesmus requiring
tube decompression
or bowel diversion
11. RTOG/EORTC LATE Radiation Morbidity
Grade I Grade II Grade III Grade IV
Lower GI / Pelvis Mild diarrhea; mild
cramping
bowel movement 5
times daily
slight rectal
discharge or
bleeding
Moderate diarrhea
and colic
bowel movement
> 5 times daily
excessive rectal
mucus or
intermittent
bleeding
Obstruction or
bleeding, requiring
surgery
Necrosis /
perforation fistula
17. Investigations
• sigmoidoscopy or colonoscopy
• Direct visualization of mucosa often
shows pale friable tissue. In patients
with severe rectal bleeding, endoscopy
typically reveals multiple
telangiectasias
• biopsies(suspectedmalignancy) tissue
is obtained from the posterior and
lateral rectal walls.
18. Management of acute radiation proctitis
• Self limiting
• Hydration
• Supportive management (sitz bath , stool softners)
• Anti inflammatory agents (sulfasalazine , rectal sucralfate , steroid enema)
• Anti diarrhoeals (loperamide)
• Probiotics
• Cessation of therapy is definitive treatment
• Surgical intervention rarely required
19. • Dietary interventions should be considered
• If the symptoms persist, medication should be considered, such as anti-inflammatory
agents.
• Medical treatment is the first-line approach
Management of Chronic Radiation Proctitis
20. Treatment Administration Mechanism of action
Sucralfate Topical administration stimulate mucosal healing by its
angiogenic action
Corticosteroids As enema is effective for rectal
bleeding
inhibiting the inflammation by
blocking cytokine release and
production, inhibiting histamine
release and activation of
macrophages
Sulfasalazine/mesalazine 5ASA - inhibits pro
inflammatory mediators
inhibit the acute inflammatory
and immune response
21. Treatment Administration Mechanism of action
metronidazole bactericidal agent and
immunomodulator effect
effective in treating chronic
rectal bleeding and diarrhea
formalin highly irritant and direct
application to radiation-
damaged tissues leads to local
chemical cauterization
Hyperbaric oxygen treatment hypoxia decreasing properties inducing angiogenesis in
patients whose bowel was
affected by radiotherapy and
promotes healing
22. Management of Chronic
Radiation Proctitis
• Endoscopic coagulation has become the
preferred approach in the management of
rectal bleeding from chronic radiation
proctitis.
• most common method utilizes argon plasma
coagulation, which delivers high-frequency,
non- contact thermal therapy to control
bleeding in the gastro-intestinal tract
23. Surgical intervention
• more severe complications which are associated with radiation proctitis, including
strictures that may lead to large bowel obstruction, fistulas, or even perforation.
• Fecal diversion either colostomy or ileostomy is commonly done
26. INVESTIGATIONS
• In chronic radiation enteritis, direct visualization through standard endoscopy,
enteroscopy, or capsule endoscopy may show telangiectasias, strictures, adhesions,
mucosal ulceration, or, rarely, necrotic changes
Symptoms Investigations
nausea/vomiting, abdominal
pain, dyspepsia, bloating
upper endoscopy or small
bowel fluoroscopic studies.
Nonspecific symptoms CT or MR enterography
Bleeding Enteroscopy or capsule
endoscopy
27.
28. Management of acute radiation enteritis
• Self resolving within weeks
• Supportive treatment with antimotility agents and good water intake
• Oral antibiotics - suspected of bacterial overgrowth
• Vitamins and electrolytes replacement if needed
• Surgery is rarely needed
29. Management of Chronic Radiation Enteritis
• Dietary modifications - first-line treatment
• Antidiarrheal agents can be effective in symptomatic management.
• loperamide slow intestinal transit and even increase the absorption of bile acids.
• Bile acid sequestrants - diarrhea secondary to bile salt malabsorption
• Argon plasma coagulation has been successful in radiation- induced enteritis caused
by telangiectasias in the large and small bowel
• Hyperbaric oxygen remains an option for the treatment of chronic radiation enteritis,
especially as a result of its ability to target multiple portions of noncontiguous small
bowel
30.
31. RADIATION STRICTURES
• submucosa of the affected bowel becomes injured as endarteritis obliterans
• ischemia — fibrosis —— strictures and obstruction
• Symptoms
• postprandial nausea
• Vomiting
• abdominal pain and distension
32. Small Bowel Radiation Strictures
• Endoscopic therapy for small bowel strictures is often limited, because the location can be
difficult to access with standard endoscopes
• Endoscopic dilation of benign small bowel strictures using double-balloon enteroscopy
• Surgery is often avoided unless absolutely necessary
• Complete small bowel obstructions from radiation strictures may require surgical
intervention
• The affected segment can be resected with a primary anastomosis or bypassed. Intestinal
bypass has a lower operative mortality and a decreased incidence of anastomotic dehiscence.
• Patients who are not surgical candidates can obtain a decompressive gastrostomy and
parental nutrition
34. Large Bowel Radiation Strictures
• Pelvic radiation strictures can also occur in the sigmoid colon and rectum.
• Constipation, abdominal pain, distension, nausea, and vomiting.
• Important to maintain a broad differential for colonic strictures, because malignant,
nonsteroidal anti-inflammatory drug–induced, and inflammatory bowel disease
strictures can have similar presentations
• Dilations can be performed with a push-type bougie dilator, which has a fixed
diameter, or radial expanding balloon dilators.
• Balloon dilators are typically used for shorter, more focal strictures.
• Major adverse events (perforation, bleeding, abscess, fistula, sepsis) for dilation
35. • Partial colonic obstruction - endoscopic therapy can be performed to decrease
the need for surgical intervention.
• Complete colonic obstruction, surgical management is indicated with a
diverting colostomy or a resection with anastomosis.
• Self-expanding metal stents have been used for malignant colonic strictures for
palliative intent or as a bridge to surgery.
36. Bladder – radiation cystitis
Acute cystitis Chronic cystitis
Time Within 3 months of
treatment
Months to years later
treatment
Symptoms Frequency
Urgency
Dysuria
hematuria
Fibrosis
Urinary incontinence
Hydronephrosis
Mucosal ulceration
Fistula formation
39. RTOG – acute toxicity
Grade I Grade II Grade III Grade IV
Genitourinary Frequency of
urination or
nocturia twice
pretreatment habit
/ dysuria, urgency
not requiring
medication
Frequency of
urination or
nocturia that is
less frequent than
every hour.
Dysuria, urgency,
bladder spasm
requiring local
anesthetic (e.g.
Pyridium)
Frequency with
urgency and
nocturia hourly or
more frequenty /
dysuria, pelvis
pain or bladder
spasm requiring
regular, frequent
narcotic / gross
hematuriawith/with
out clot passage
Hematuria
requiring
transfusion / acute
bladder
obstruction not
secondary to clot
passage,
ulceration, or
necrosis
40. RTOG – late toxicity
Grade I Grade II Grade III Grade IV
bladder Slight epithelial
atrophy; minor
telangiectasia
(microscopic
hematuria)
Moderate
frequency;
generalized
telangiectasia;
intermittent
macroscopic
hematuria
Severe frequency
& dysuria; severe
telangiectasia
(often with
petechiae);
frequent
hematuria;
reduction in
bladder capacity
(<150 cc)
Necrosis/contracte
d bladder
(capacity < 100
cc); severe
hemorrhagic
cystitis
51. • Patients who have bladder involvement at diagnosis are at risk of
developing a vesicovaginal fistula after definitive RT.
• Small vesicovaginal fistulae may be managed with simple fulguration and
catheter drainage, but they may require open surgical repair and,
occasionally, urinary diversion.
52.
53. Ureteral strictures
• Ureteral strictures have been noted
• 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.
• The classical teaching is that a ureteral stricture represents recurrent cancer until
proven otherwise; imaging with CT or MRI is recommended.
• Ureteroarterial fistulae are rarely encountered and have a 10% acute mortality rate
• They should be treated with endovascular stent placement or, if this fails, open
surgical repair
54. Vagina
• Changes in the microvasculature, with loss of capillaries and impaired
microcirculation, result in secondary mucosal atrophy.
• Pathological dilation of capillaries results in telangiectasias, which are prone to
bleeding.
• In addition, increased collagen production within the fibroconnective tissue can
lead to shortening and tightening of the vagina.
• Eventually, ulceration, necrosis, and fistulae can develop
60. Dose constraints
• Upper vagina – 120 Gy
• Middle vagina – 80-90 Gy
• Lower vagina – 60-70 Gy
• Radiation dose >70 Gy was significantly related to development of
vaginal toxicity
• Tolerance doses are high – 90Gy for ulceration and 100Gy for fistula
61. Management
• Vaginal dilator therapy
• VDT four weeks after completing RT treatment, perform VDT 2–3 times
per week for 1–3 min and to continue VDT for 9 to 12 months.
• Hyaluronic acid therapy
• Vaginal estrogen therapy
• Intravaginal laser treatment
62. Bone effects
• After pelvic radiotherapy, bones of the pelvic region can undergo changes
secondary to decreased osteoblast proliferation and decreased bone blood flow as
a result of blood vessel fibrosis combined with bone resorption from osteoclast
activity that can result in fracture or necrosis
• The sites of fracture were sacroiliac joints, pubic rami, iliac bones, and femoral neck.
• The significant risk factors of PIF were old age, body mass index <23, bone mineral
density <−3.5 SD
63. Pelvic
insufficiency
fractures
• Insufficiency fracture (IF)
is a type of stress fracture,
which occurs when normal
or physiological stress
applied to weakened bone
with demineralization and
decreased elastic
resistance.
64. Dose constraints
• Femoral head – Dmean<30Gy
• Median time to development of PIF was 12.5 months (range 5–30
months).
65.
66. Management
• Most symptomatic patients were fully resolved after conservative treatment
using analgesics and rest
• some patients needs narcotics or hospitalization because of severe pain and
disability those who generally have multiple sites of fracture or larger lesions
• Pentoxifylline may be effective in recovering symptoms
• CT-guided sacroplasty for sacral IF was reported to be helpful in patients with
pain resistant to conservative treatment
69. Bone marrow suppression
• Bone marrow is one of the most radiosensitive organs in the pelvis.
• Approximately 40% of the total body bone marrow reserve lies within the pelvic
bones
• Neutropenia occurs in 2–3 weeks
• Followed by thrombocytopenia
• Anemia in 2–3 months.
• Growth factor administration is now a common supportive measure in patients
with white cell deficiencies.
• Erythropoietin is now approved for use in patients with depressed hemoglobin
levels. Transfusion is typically reserved for patients with hemoglobin levels below
8 g/dL
73. Gonads – Ovarian dysfunction
• Oocytes are extremely radiosensitive, with 50% destruction at doses less than
2 Gy.
• Premature menopause and the ensuing hormonal changes can lead to hot
flashes, mood changes, and vaginal dryness.
• ASCO guidelines for patients receiving pelvic radiotherapy include embryo or
unfertilized oocyte cryopreservation, ovarian transposition, and ovarian tissue
cryopreservation and transplantation.
• In addition, the uterus in an irradiated pelvis will not function to carry a fetus
to term, resulting in miscarriage, preterm labor, low birth weight, and placental
abnormalities
74. Radiation dermatitis
• At a dose of 40 Gy, grade 2 reactions are typically observed, defined as tender and
edematous erythema with patchy, moist desquamation in skin folds and associated
pain.
• Grade 1 and 2 skin reactions are common in gynecologic RT, with an incidence
of 10% to 50% in cervical and endometrial cancerand 85% to 100% in the
treatment of vulvar cancer.
• Grade 3 skin reactions are associated with confluent moist desquamation when
doses exceed 50 to 60 Gy with bolus placement.
• Grade 4 skin reactions include skin ulceration, hemorrhage, and necrosis.
75. Acute Radiation dermatitis
• Mild erythema is most commonly observed in the vulva, perineum, and the inguinal
and gluteal folds.
• Mild skin reactions, such as erythema topical moisturizers without added perfumes
or metals like zinc or silver, which can irritate the skin or enhance the reaction.
• Daily use of a sitz bath with the addition of sodium bicarbonate, Epsom salts, or
Domeboro soaks may provide symptomatic relief.
• Gentle cleaning with a mild, unperfumed soap is advised for folliculitis.
• Wearing loose fitting clothes, avoiding sun exposure and metallic topical products,
and using water-based lipid-free moisturizers.
• Topical corticosteroids have been used to prevent radiodermatitis as well as itching
due to inflammation
77. Late radiation dermatitis
• 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, although tissue retraction and pain are less common.
• Twice daily use of a 1:10 diluted hydrogen peroxide douche can prevent the
formation of necrotic tissue, particularly in previously irradiated patients.
78. Second malignancy
• Risk of smoking related lung cancer squamous cell carcinoma
• Second malignancy of colon, soft tissue , melanoma and non hodgkins
lymphoma adenocarcinoma
• HPV related cancers pharynx,genital and anal cancers
• Secondary leukaemia 5-10 yrs after treatment
• Uterine sarcomas
79. References
• Perez and bradys principles and practice of radiation oncology
• Radiation ProctitisDavid G. McKeown; Scott Goldstein.Last
Update: January 27, 2023.
• Radiation EnteritisBeenish S. Bhutta; Rawish Fatima; Muhammad Aziz.
Last Update: February 22, 2023.
• Strategies to Minimize Late Effects From Pelvic Radiotherapy
• Insufficiency fracture after radiation therapy
• Radiation-induced femoral head necrosisAbdulkareem, IH
