Radiation Toxicity

Matthew Everett

Radiation pneumonitis

  • 6 weeks to 6 months after RT to chest.
  • Radiation pneumonitis is more progressive, low-grade, no fever, nonproductive cough, and SOB.
  • Rule out PNA.
  • Imaging: CXR or CT.
  • Treatment: prednisone 0.5 mg/kg/day or a fixed dose of 40 mg/day for 2 weeks, followed by gradual tapering over 4–6 weeks. In patients with good PS, could consider high-dose inhaled budesonide to avoid systemic exposure.

Radiation dermatitis 

  • Onset during or shortly after treatment
  • Variable: redness, dry desquamation (peeling, dry skin), or wet desquamation (blistering and oozing)
  • Treatment
    • Aquaphor or Aquaphor + lidocaine. Lidocaine can sometimes burn over wet desquamation. For wet desquamation (especially if looks potentially infected), start on Silvadene until it dries up. Then add non-adhesive barrier dressings.
    • Topical corticosteroids (e.g. OTC hydrocortisone, inpatient betamethasone valerate 0.1% cream BID) applied to intact skin for prophylaxis and symptomatic treatment (e.g., irritation/itching).
    • Sitz baths and peri bottles useful for perineal skin reaction after RT to chest.

Mucositis

  • Treatment
    • Salt water and baking soda rinses to help clear debris out of mouth.
    • Magic mouthwash, swish and spit if mouth only (as many times a day as they want) or swish and swallow up to every 4h. Can give viscous lidocaine if pt prefers.
    • Seen more commonly in H/N Ca and Esophageal Ca: weight loss >15lbs during treatments - >consider G-tube but want to avoid if possible since slows swallowing function recovery. Early SLP involvement. Can try soft or liquid diet, protein drinks.
    • For esophagitis, can order carafate liquid formulation (to coat esophagus). May require prior auth, indication is radiation esophagitis. Consider PPI.

Secretions and mouth dryness

  • Glycopyrrolate or Mucinex can help with thick secretions but can be drying.
  • Baking soda and salt, sugarless gum.
  • Can try Levsin, scopolamine patches.

Nausea 

  • Evaluate for and treat constipation, secretions, and acid reflux.
  • See “Nausea/Vomiting” Section.

Pain flairs 

  • Present with treatment of bony mets in up to 40% of pts. Spikes in pain usually occur either toward the end of treatment or a few days after due to inflammation.
  • Treat with steroid taper per Rad-Onc.

Radiation-associated dysuria 

  • Presents with UTI-like symptoms during treatment.
  • Rule out UTI, UA more likely to be sterile.
  • Treatment: Hydration. Can try NSAIDs and phenazopyridine (note urine color change). Consider short steroid course next.

Bowel toxicity 

  • Upper: nausea/vomiting, loose/watery stools.
  • Lower: loose/watery stools, cramping, tenesmus, urgency.
  • Treatment: Try low residue diet, anti-diarrheal agents (Imodium, Lomotil), sucralfate, protozoa/5-ASA enemas.
  • Consider cessation or break of RT.
Last updated on