MODULE IV: SITE SPECIFIC MANAGEMENT

 

SITE-SPECIFIC MANAGEMENT

Radiation therapy or radiotherapy is the use of various forms of radiation to safely and effectively treat cancer. It controls the growth of the cancer or relieves pain. Radiation therapy for cancer aims to get enough radiation into the body to kill cancer cells while preventing damage to healthy tissue. There are different radiotherapy types.

Depending on the location, size, and cancer type, high-energy particles or waves (such as X-rays, gamma rays, electron beams, or protons) destroy or damage cancer cells. Radiation therapy works by damaging cancerous cells.

BRAIN AND CNS RADIATION:

Radiation therapy usually is a critical part of treatment for brain and spine tumors. For patients with benign tumors, radiation is an alternative to surgery. Radiation also can be used to treat large areas of the brain in patients with malignant tumors that arise in the brain. Radiation therapy has long been a critical modality of the treatment of patients with central nervous system tumors, including primary brain tumors, brain metastases, and meningiomas. Advances in radiation technology and delivery have allowed for more precise treatment to optimize patient outcomes and minimize toxicities. Improved understanding of the molecular underpinnings of brain tumors and normal brain tissue response to radiation will allow for continued refinement of radiation treatment approaches to improve clinical outcomes for brain tumor patients. With continued advances in precision and delivery, radiation therapy will continue to be an important modality to achieve optimal outcomes for brain tumor patients.

BRAIN AND CNS RADIATION TREATMENTS:

Radiation oncologists use the following types of radiation therapy to treat brain and spine tumors.

Stereotactic body radiation therapy (SBRT) – This radiation technology delivers very high doses of focused radiation to a small area. It is used for brain and spine tumors that are very confined. Patients complete treatment within just one to five days.

Intensity-modulated radiation therapy (IMRT) – IMRT delivers targeted radiation doses to the tumor site, patterned to match the shape of the tumor by modulating the intensity of the radiation beams. For benign and malignant tumors that have spread to the normal areas of the brain or spine, IMRT is used to deliver targeted radiation beams in real-time. For tumors that started in the brain or spine, IMRT is used to carefully treat the tumor as well as a large portion of the normal brain or spine tissue over about six weeks.

Proton Therapy – Proton therapy is a form of targeted radiation treatment that uses energy from positively charged particles called protons. Protons very precisely zero in on tumors, delivering most of their cancer-fighting energy directly to cancer cells while minimizing radiation exposure and damage to neighboring healthy tissue and organs. The therapy reduces the risk of late effects after treatment.

Three-dimensional conformal radiation therapy (3D-CRT)- 3D-CRT uses the results of imaging tests such as MRI and special computers to map the location of the tumor precisely. Several radiation beams are then shaped and aimed at the tumor from different directions. Each beam alone is fairly weak, which makes it less likely to damage normal tissues, but the beams converge at the tumor to give a higher dose of radiation there.

Volumetric modulated arc therapy (VMAT)- This newer technique is similar to IMRT. For this treatment, the patient lies on a table, which passes through the machine delivering the radiation. The source of the radiation (the linear accelerator) rotates around the table in an arc, delivering the beams from different angles. A computer controls the intensity of the beams to help keep the radiation focused on the tumor. It’s not yet clear if this approach results in better outcomes than IMRT, although it does allow the radiation to be given over less time in each treatment session.

Stereotactic radiosurgery (SRS)/stereotactic radiotherapy (SRT): This type of treatment delivers a large, precise radiation dose to the tumor area in a single session (SRS) or in a few sessions (SRT). (There is no actual surgery in this treatment.) It may be used for some tumors in parts of the brain or spinal cord that can’t be treated with surgery or when a patient isn’t healthy enough for surgery.

A head frame might be attached to the skull to help aim the radiation beams. (Sometimes a face mask is used to hold the head in place instead.) Once the exact location of the tumor is known from CT or MRI scans, radiation is focused on the tumor from many different angles. This can be done in 2 ways:

In one approach, thin radiation beams are focused on the tumor from hundreds of different angles for a short period. Each beam alone is weak, but they all converge at the tumor to give a higher dose r An example of a machine that uses this technique is the Gamma Knife. Another approach uses a movable linear accelerator (a machine that creates radiation) that is controlled by a computer. Instead of delivering many beams at once, this machine moves around the head to deliver radiation to the tumor from many different angles. Several machines with names such as X-Knife, Cyber-knife, and Linac deliver stereotactic radiosurgery in this way.

Brachytherapy – Radioactive implants are placed as close to the cancer as possible. Since implant placement is invasive, brachytherapy is rarely used for brain and spine tumors. Brachytherapy may be used when SBRT hasn’t proven successful.

BRAIN AND CNS RADIOTHERAPY SIDE EFFECTS:

Radiation used to destroy cancer cells can also damage normal cells that are in the treatment area or the beam path. Side effects from radiation treatment can vary, depending on the area of the body being treated. Side effects are caused by the cumulative effect of radiation on the cells.

Acute (Short-Term) Side Effects:

The following list includes some of the most common side effects of radiation therapy for brain tumors, treatment can affect each patient differently, and may not experience these particular side effects. Side effects can also be different depending on the dose and treatment schedule.

💽Fatigue is very common with radiation treatment and tends to begin a few weeks into therapy. Fatigue typically goes away slowly over the weeks and months following treatment.

💽Hair loss may occur where you received radiation. Hair typically starts to regrow a few months after treatment. However,  hair might not grow back exactly as it was before treatment and for some, the hair loss becomes permanent.

💽Muffled hearing: Hearing may become muffled during treatment. This typically resolves in 2-4 weeks after finishing treatment.

💽Skin irritation: The skin in the treatment area may become red, irritated, dry, or sensitive. It may start to look like a sunburn. The patient must treat the skin gently to avoid further irritation, and bath carefully, using only warm water and mild soap. Instruct the patient to avoid scented lotions and soaps, as these may cause more irritation. and to avoid sun exposure, which can worsen the irritation.

💽Short-term memory loss and difficulty thinking can occur if the patient is treated with whole-brain radiation therapy.

💽Brain tissue swelling can develop during treatment. Patients may get a headache or feel pressure in their head if this occurs. The health care team watches for signs of this problem and may prescribe medications to decrease swelling. 

Chronic (Long-Term) Side Effects:

The side effects mentioned above tend to occur during or shortly after treatment. Long-term effects can happen months to years after treatment has ended. The risks of long-term effects vary depending on the treatment area, the total dose that is given, and the radiation techniques that were used, as these continue to develop and improve

💽There is a low risk of developing second cancer in or near the radiation field. These are called secondary cancers, and they develop as a result of the exposure of healthy tissue to radiation. Modern radiation techniques are designed to limit this exposure, but it is not always possible to prevent all exposure and still achieve the desired outcomes.

💽Radiation necrosis: Rarely, a mass of dead (necrotic) tissue forms at the site of the tumor. If this occurs, it usually develops months to years after radiation is given. Surgery may be needed to remove the necrotic tissue.

💽Damage to healthy brain tissue: Although rare, this side effect can cause headaches, seizures, or even death.

💽Harm to the pituitary gland and other areas of the brain can happen, which can affect hormone levels in the body, including thyroid and sex hormones. Damage to the pituitary gland can affect future fertility for women and cause sexuality concerns for men. Healthcare providers may prescribe synthetic hormones to manage these changes.

💽Loss of some brain function can occur if large areas of the brain receive radiation. There may also be other symptoms that develop as a result of damage to healthy brain tissue. These symptoms depend on what the treated area of the brain controls and how much radiation was given. These risks must be weighed against the risks of not using radiation and having less impact on the tumor.

Stereotactic Radiosurgery (SRS) Side Effects:

Side effects of radiosurgery are usually related to sending high doses of radiation to particular areas of the brain. For instance, if a patient is treated for an acoustic neuroma (a tumor involving the nerve that controls hearing), they might lose hearing. Treatment for trigeminal neuralgia can lead to tingling or numbness of the face. 

After treatment, the patient will receive a survivorship care plan, which can help to manage the transition to survivorship and learn about life after cancer. 

Managing Side Effects of Brain Radiation Therapy:

Headaches: Administer steroid medication during the treatment. 

                          

Nausea & Vomiting:

💉Anti-nausea medications are taken an hour before the radiation treatments.

💉Instruct the patient to eat smaller meals more often, instead of a big meal, and to avoid foods that are spicy, fatty, overly sweet, or that have a strong smell.

💉Sip on cool liquids, such as water, juice, or other caffeine-free liquids throughout the day. Sucking on ice chips and popsicles can also help in preventing dehydration. 

Hair Loss:

1-2 weeks after your first radiation treatment, the patient may experience hair loss in the area that has been treated. The hair loss may occur as a gradual thinning of the hair, but can also come out more quickly. The amount of hair loss depends on the amount of radiation received. It may take several months for the hair to start growing back, and when it does, the texture and color of it can be different

than before. For some patients, the hair never fully returns.

While it is not possible to prevent hair loss, here are some

tips to help you cope: Instruct the patient to 

- Be gentle with the hair and avoid brushing hair too much. Use a mild shampoo.

- Find a good hair cover that feel comfortable with, such as a turban, hat, wig, or scar.

Skin Reaction :

⌛ Instruct the patient to be gentle with skin when washing & to avoid scrubbing or scratching the area.

⌛Instruct the patient to use unscented, lanolin-free cream in the area of treatment, make sure that the cream is absorbed before the treatment. Stop using the cream if there is any skin peel or is moist-looking.

⌛Things to avoid: Extreme hot or cold temperatures on the skin in the treatment area (i.e. ice packs and heating pads Hot tubs, saunas, and chlorinated pools, Swimming in lakes,  All perfumes, lotions, creams, sprays, colognes, etc. in the treatment area.

Fatigue 

Fatigue is a general feeling of tiredness. Fatigue is a common side effect of cancer treatment. Not everyone will have fatigue, but for those who do, it is usually mild to moderate.

Fatigue can be caused by:

👓The cancer

👓Treatments including radiation, chemotherapy, and medications

👓 The travel involved in coming for treatments

👓The change in your daily schedule

👓The amount of sleep that you get

👓Less food and/or fluid intake

👓 Lack of physical activity and exercise

👓 Pain, depression, or anxiety

Things that  can do for fatigue:

 ☝Light exercise, such as walking

 ☝Take frequent rests during the day

 ☝Try a relaxing activity to reduce stress

 ☝Drink more fluids daily to keep your body hydrated.

 ☝ Ask family/friends for help with daily activities or chores

HEAD AND NECK RADIATION:

Radiation therapy (RT) is an important and potentially curative modality for head and neck cancers. For many primary sites within the head and neck, RT yields better functional outcomes than surgery and, thus, is often preferred for localized disease. For locoregionally advanced lesions, RT is often used in combination with chemotherapy as a definitive organ function-preserving approach, or after surgery as an adjuvant. Radiation oncologists treat head and neck cancers using a personalized, results-driven approach that minimizes pain and damage to nearby body structures.

HEAD & NECK RADIATION TREATMENTS:

Proton Therapy: Proton therapy is extremely helpful for many people. At present, it is most commonly used for head and neck cancer that has come back after prior treatment. A limited number of centers only offer proton therapy.

Intensity-modulated radiation therapy (IMRT): Intensity-modulated radiation therapy (IMRT) represents a major evolution in the treatment of head-and-neck cancer, enhancing the therapeutic ratio by increasing the dose delivered to the tumor volume while reducing that to healthy organs

Tomotherapy: uses detailed, three-dimensional maps of a tumor’s size and location. Then the machine delivers small beamlets of radiation from various angles, providing exceptional accuracy when targeting tumors. 

Stereotactic radiosurgery: minimizes the amount of radiation to healthy tissue. Although stereotactic radiosurgery is often completed in a one-day session, physicians sometimes recommend multiple treatments, especially for tumors larger than one inch in diameter. The radiation beams are silent and invisible.

For small tumors, particularly those that have recurred following radiation, this type of treatment may be performed. This treatment typically involves fewer treatments than IMRT delivered every other day to small areas.

Benefits include:

💲Noninvasive

💲Does not require anesthesia

💲Does not require incisions

💲Minimizes radiation damage to surrounding healthy tissue/organs.

Doctors generally reserve SRS/SBRT for people with recurrent head and neck cancers

HEAD & NECK RADIOTHERAPY SIDE EFFECTS:

Radiation treatment damages cancer cells but can also affect normal tissues in the treatment area. Damage to normal tissues may cause side effects.

These side effects will vary depending on:

• The amount of radiation prescribed

• The area of the body being treated.

• The size of the treatment area.

• Whether the patient is having chemotherapy or not.

Short-term side effects can include:

👉Fatigue

👉Mouth sores

👉Taste changes

👉Loss of appetite

👉Dry mouth and thick saliva

👉Swallowing difficulties

👉Skin redness, burning, and pain in the area treated

breathing difficulties

👉Weight loss.

Long-term side effects may include:

👉Dry mouth

👉Thick saliva

👉Difficulties with swallowing and speech

👉Changes in taste

👉Fatigue

👉Muscle stiffness

👉Neck swelling

👉Appetite and weight loss

👉Mouth infection (oral thrush)

👉Hoarseness

👉Dental problems such as tooth decay

👉Difficulty opening the mouth

👉Hair loss.

Aspiration

Some people develop a temporary or ongoing problem where fluid or food enters the windpipe while swallowing. This is called aspiration and it can cause coughing, lung infections such as pneumonia, and, sometimes, difficulty breathing.

Thyroid damage

If the treatment damages the thyroid, it can cause an underactive thyroid (hypothyroidism). This can be managed with thyroid hormone replacement tablets.

Osteoradionecrosis of the jaw

Radiation therapy can damage blood vessels, reducing the blood supply to the area treated. Occasionally, the bone starts to die, leading to pain, infection, and fractures. This is known as osteoradionecrosis or ORN. About 5–7% of people who have radiation therapy to the head and neck develop ORN of the jaw. It can occur months or years later, most commonly after having dental work such as the removal of teeth, when the bone is unable to heal itself.

Swallowing problems

 Radiation can cause scar tissue in the throat or esophagus months to years after treatment. This can lead to swallowing problems. Report any changes in your swallowing to your provider. It may help to see a speech and swallowing specialist.

Radiation fibrosis

This is the scarring of muscles that can make the muscles feel stiff or tough. These muscles can have spasms, stiffness, pain, and/or become weak. Scarring of muscles in the neck can cause the patient's head to be turned and tilted to the side or make it difficult to hold up their head. Physical therapy, cancer rehabilitation, supportive devices, and certain medications can help manage these problems.

Nerve Issues

Nerves in the radiation area can be damaged or pinched by scar tissue, causing weakness or pain in the area.

Lymphedema

Swelling of the face, chin, and neck area can happen.  Physical therapy can be used to treat and manage lymphedema.

Trismus

This is an ongoing contraction of the muscle that opens and closes your mouth (TMJ). Trismus makes the patient unable to open their mouth normally. This can make it difficult to eat, speak, or perform dental care.  oncology team can give jaw exercises to prevent or help improve trismus. For some patients, jaw manipulation by a dentist or treatment by a cancer rehabilitation provider can be helpful.

Managing Side Effects of Head & Neck Radiation Therapy

Skincare:

💡Keep  skin moist and flexible 

💡Stop using lotions/ointments 4 hours before radiation treatment. 

💡Prevent additional irritation in the area being treated

💡Be very gentle with the skin in the treated area

💡Wear loose, comfortable clothing

Mouth and Throat Care:

❤Instruct the patient to rinse their mouth several times a day with non-alcohol-based mouthwash and to use a soft brush for brushing their teeth.

❤The patient can sip water regularly and always carry a bottle of water.

❤ Instruct the patient to eat soft, moist foods with gravy and sauces instead of dry or chewy foods.

❤Use a humidifier to make the atmosphere in the patient's room to make it less dry.

❤ Use artificial saliva which your doctor can prescribe – it is available as sprays, gels, lozenges, and pastilles.

❤Using a sodium bicarbonate mouthwash may help clear thick saliva. 

❤Bad breath can be treated with antibiotics or antifungal medicine.

Other symptoms can be managed as mentioned in general symptom management. 

BREAST RADIOTHERAPY

Radiation therapy for breast cancer uses high-energy X-rays, protons, or other particles to kill cancer cells. Rapidly growing cells, such as cancer cells, are more susceptible to the effects of radiation therapy than normal cells.

The X-rays or particles are painless and invisible. You are not radioactive after treatment, so it is safe to be around other people, including children.

Radiation therapy for breast cancer may be delivered through:

External Beam Breast Cancer Radiation:

External beam radiation (also known as traditional or whole breast radiation therapy) uses external beam radiation, like that of a regular X-ray, but the beam is highly focused and targets the cancerous area for two to three minutes. This form of treatment usually involves multiple appointments in an outpatient radiation center — as many as five days a week for five or six weeks. Certain situations may require a slightly higher dose of radiation over a shorter course of treatment, usually three to four weeks (called accelerated radiation.)

External breast cancer radiation used to be the most common type used for breast cancer. However, in more recent years internal radiation clinical trials have enabled more women to opt for this method if their cancer was caught early enough.  Internal radiation typically offers fewer noticeable side effects.

Types and schedules of external beam radiation

Whole breast radiation:

Radiation to the entire affected breast is called whole breast radiation. The standard schedule for getting whole breast radiation is 5 days a week (Monday through Friday) for about 6 to 7 weeks.

Another option is 

Hypofractionated radiation therapy where the radiation is also given to the whole breast, but in larger daily doses (Monday through Friday) using fewer treatments (typically for only 3 to 4 weeks). For women who have had breast-conserving surgery (BCS) and whose cancer has not spread to underarm lymph nodes, this schedule is just as good at keeping cancer from coming back in the same breast as giving the radiation over longer periods. It might also lead to fewer short-term side effects.

Accelerated partial breast irradiation: After whole breast radiation or even after surgery alone, most breast cancers tend to come back very close to the area where the tumor was removed (tumor bed). For this reason, some doctors are using accelerated partial breast irradiation (APBI) in selected women to give larger doses over a shorter time to only one part of the breast (the tumor bed) compared to the entire breast (whole breast radiation). 

There are several different types of accelerated partial breast irradiation:

Intraoperative radiation therapy (IORT): In this approach, a single large dose of radiation is given to the area where the tumor was removed (tumor bed) in the operating room right after BCS (before the breast incision is closed). IORT requires special equipment and is not widely available.

3D-conformal radiotherapy (3D-CRT): In this technique, the radiation is given with special machines to better aim at the tumor bed. This spares more of the surrounding normal breast tissue. Treatments are given twice a day for 5 days or daily for 2 weeks.

Intensity-modulated radiotherapy (IMRT): IMRT is like 3D-CRT, but it also changes the strength of some of the beams in certain areas. This gets stronger doses to certain parts of the tumor bed and helps lessen damage to nearby normal body tissues.

Internal Breast Cancer Radiation:

Internal radiation is a form of partial breast radiation. During the treatment, the physician or surgeon inserts a radioactive liquid using needles, wires, or a catheter to target the area where cancer originally began to grow and the tissue closest to the tumor site to kill any possible remaining cancer cells. Internal radiation is rarely used today, with many doctors opting for short-term radiation therapy instead.

 

Brachytherapy:

Brachytherapy, also known as internal radiation, is another way to deliver radiation therapy. Instead of aiming radiation beams from outside the body, a device containing radioactive seeds or pellets is placed into the breast tissue for a short time in the area where the cancer had been removed (tumor bed).

For certain women who had breast-conserving surgery (BCS), brachytherapy can be used by itself (instead of radiation to the whole breast) as a form of accelerated partial breast irradiation. Tumor size, location, and other factors may limit who can get brachytherapy.

Types of brachytherapy:

Intracavitary brachytherapy:

This is the most common type of brachytherapy for women with breast cancer. A device is put into the space left from BCS and is left there until treatment is complete. 

There are several different devices available, most of which require surgical training for proper placement. They all go into the breast as a small catheter (tube). The end of the device inside the breast is then expanded like a balloon so that it stays securely in place for the entire treatment. The other end of the catheter sticks out of the breast.

 For each treatment, one or more sources of radiation (often pellets) are placed down through the tube and into the device for a short time and then removed. Treatments are typically given twice a day for 5 days in an outpatient setting. After the last treatment, the device is deflated and removed.

Interstitial brachytherapy:

In this approach, several small, hollow tubes called catheters are inserted into the breast around the area where the cancer was removed and are left in place for several days. 

Radioactive pellets are inserted into the catheters for short periods each day and then removed. This method of brachytherapy has been around longer (and has more evidence to support it), but it is not used as much.

Early studies of intracavitary brachytherapy as the only radiation after Breast Conserving surgery  have had promising results as far as having at least equal cancer control compared with standard whole breast radiation, but may have more complications including poor cosmetic results. Studies of this treatment are being done and more follow-up is needed.   

Possible side effects of intracavitary brachytherapy:

As with external beam radiation, intracavitary brachytherapy can have side effects, including:

🎀Redness and/or bruising at the treatment site

🎀Breast pain

🎀Infection

🎀Damage to fatty tissue in the breast

🎀Weakness and fracture of the ribs in rare cases

🎀Fluid collecting in the breast (seroma)

BREAST RADIOTHERAPY SIDE EFFECTS:

Short-term side effects:

1. Skin Changes:

About 2 or 3 weeks after the first treatment, begin to notice changes in the skin of the radiated treatment area. Skin changes that can happen with external beam radiation (and sometimes with internal radiation such as brachytherapy) can include:

👉Dryness

👉Irritation

👉Flakiness

👉Bruising (mainly with brachytherapy)

👉Sensitivity to sunlight

👉Skin color changes

2. Fatigue: an overall lack of energy. Fatigue isn’t just physical tiredness; it’s also mental and emotional tiredness that can leave you feeling wiped out.

Fatigue doesn’t happen for everyone undergoing radiation treatment. If it does happen, it usually starts a few weeks after beginning radiation therapy. As treatment continues, symptoms can increase, and resting doesn’t always bring relief.

3. Swelling & Soreness:

Radiation therapy can cause fluid to temporarily build up in or around the breast. Radiation can also cause your breast, shoulder, or arm to feel sore or stiff and inflexible.

4. Nausea: Post-radiation patients are prone to have nausea, the radiation team can provide antiemetic drugs.

Long-term side effects:

Some side effects of radiation therapy to the breast don’t show up until months or years later. 

1. Scar tissue:

Radiation fibrosis, or scar tissue, can sometimes develop years after radiation therapy. This can happen if radiation damages blood vessels in healthy tissue, cutting off blood supply to the tissue and causing it to harden. Symptoms can include tenderness and firmness. If radiation fibrosis is not treated, for some people, it can lead to muscle pain, tightness, or pain from nerve damage (neuropathy).

There are ways to reduce the effects of radiation fibrosis, including:

✏Physical therapy to improve range of motion

✏Massage to break down scar tissue

✏Pain-relieving medication

2. Spider Veins:

Telangiectasia or “spider veins” on the radiated skin may happen months or years after treatment. While this change can be permanent, it may fade with time.

3. Lung Inflammation:              

Lung inflammation (radiation pneumonitis) can sometimes happen with breast radiation, although it doesn’t happen often. Symptoms may not start until 3-6 months after radiation therapy is finished. Symptoms can include:

✏Shortness of breath

✏Cough

✏Chest pain that feels worse when taking a deep breath

✏Low-grade fever

Sometimes, there are no symptoms, and lung inflammation is found on a chest x-ray.

4. Lymphedema: A condition that causes fluid buildup and swelling in the breast, chest, shoulder, or arm — can sometimes happen after radiation therapy to the lymph nodes. For some people, lymphedema can develop months or years after radiation therapy. There are ways to manage lymphedema if it’s caught early.

Rare side effects:

Some long-term breast radiation side effects are very rare but can happen.

Heart damage can be a rare long-term side effect of radiation therapy. This is more of a risk if the left side (closer to the heart) is being treated. Deep inspiration breath hold (DIBH) has been shown to effectively reduce radiation exposure to the heart.

Other rare side effects include rib weakening that can lead to fractures, and nerve damage in the arm that can lead to arm tingling or weakness.

Also very rarely, radiation therapy can lead to another cancer, such as certain carcinomas and lung cancer. The risk is very small and doctors generally find the benefits of radiation are much greater than the risk of it causing another cancer.

Managing Side Effects of Breast Radiation Therapy:

💠Wear loose-fitting cotton clothes to avoid skin soreness.

💠Take advice from the doctors before using any deodorants, lotions, or creams on the treated area.

💠Extra rest and making good nutrition a priority.

💠Routine exercise, such as walking for 30 minutes a day, has been proven to reduce the degree of fatigue patients experience from radiation therapy.

💠Moisturize before and during Radiation Therapy,

💠Good nutrition, Avoiding extreme temperatures, balanced weight, Hand hygiene for avoiding infection.

RADIATION THERAPY FOR LUNG CANCER

Lung cancer radiation therapy uses powerful, high-energy X-rays to kill cancer cells or keep them from growing. Radiation may come from outside the body (external) or from radioactive materials placed directly inside the lung cancer tumor (internal/implant). External radiation is used most often. The radiation is aimed at the lung cancer tumor and kills the cancer cells only in that area of the lungs.

Radiation Techniques for Lung Cancer:

A variety of radiation therapy options may be available depending on the patient's diagnosis, so the radiation oncology team will work with the patient to develop a customized treatment plan based on the type of lung cancer and the tumor's location.

External beam radiation therapy (EBRT):

Advanced EBRT helps to lower the risk of side effects typically associated with radiation treatment for lung cancer, such as difficulty breathing or heart damage. 

Some additional advantages of EBRT may include:

📏The procedure itself is painless.

📏EBRT poses no risk of radioactivity to patients or to others who are in contact with them, allowing lung cancer patients to continue normal activities with family and friends.

Types of EBRT to treat lung cancer include:

Intensity-modulated radiation therapy (IMRT)

Three-dimensional planning with IMRT allows the radiation oncologist to simultaneously treat lung cancer tumors with different doses of radiation while sparing healthy tissue in the lungs and elsewhere. A computer-controlled device called a linear accelerator delivers radiation in doses that match the 3-D geometrical shape of the target, including concave and complex shapes.

RapidArc:

The care team may use RapidArc technology to deliver IMRT with greater speed and precision. RapidArc radiation therapy is designed to shorten treatment times.

 In a single 360-degree rotation, a linear accelerator revolves around the patient, delivering a sculpted, tightly focused beam of radiation directly to a tumor in less than two minutes. This results in better tumor targeting and less damage to surrounding healthy tissue. It also helps reduce the amount of time a patient spends in radiation treatment.

Respiratory gating:

Tumors, such as those near the lungs, often move as a result of breathing and other involuntary movements in the body. Respiratory gating enables the radiation therapy team to provide concentrated doses of radiation to tumors with greater accuracy. The system tracks tumor motion as a result of breathing, helping the care team target the tumor and protect healthy tissue from receiving unnecessary radiation during radiation therapy.

Stereotactic body radiation therapy (SBRT)

Preserving healthy tissue is important for many lung cancer patients, who may be struggling with other conditions, such as emphysema. 

With SBRT, the procedure:

💿May be used instead of surgery in early-stage lung cancer or for patients for whom surgery is not an option.

💿Delivers higher radiation doses to tumors, which would not be possible with other radiation therapies causes less damage to healthy lung tissue.

💿Requires fewer treatments than conventional radiation therapy

SBRT, a sub-type of external beam radiation, uses advanced technologies such as:

TrueBeam and CyberKnife:

The software and respiratory tracking systems in these advanced technologies are designed to confirm the location of a lung tumor and continually track its movement in real-time, which allows for the delivery of a more precise dose of radiation without damaging surrounding healthy tissue.

TomoTherapy: 

This technology is designed to deliver precise radiation doses to match complex lung tumor shapes while avoiding sensitive structures. This may help limit side effects, such as shortness of breath or heart damage.

LUNG RADIOTHERAPY SIDE EFFECTS:

Short-term side effects :

📍Damage to the lungs, which may cause side effects, such as coughing and feeling short of breath

📍Nausea and vomiting

📍Fatigue

📍Hair loss at the site of radiation

📍Changes to the skin in the area of radiation, such as Blistering or peeling

📍Loss of appetite

Possible long-term side effects: 

💳Heart complications, such as a hardening of the arteries, which can lead to heart attack

💳Lung complications, such as lung inflammation called radiation pneumonitis

💳Nerve damage in the arm and shoulders — called brachial plexopathy — which can cause pain, numbness, and tingling

💳Rib fractures, as radiation may weaken the ribs to the point of breakage.

Managing the side effects of lung radiation therapy:

Radiation therapy itself is painless, but the radiation may affect some tissues of the body and cause various side effects. These side effects vary depending on the dose of radiation, the number of treatments, and the part of the chest treated. Most are temporary and disappear a few weeks or months after treatment.

Discomfort when swallowing and heartburn:

 

If the cancer is in the centre of the chest and near the esophagus, the patient may have some discomfort when swallowing, and heartburn during the treatment period and up to 4 weeks after treatment ends. Until these side effects improve, the patient may need to eat soft foods and avoid hot drinks.

Fatigue: 

Feeling tired is common after radiation therapy. Plan daily activities so the patient can rest regularly. Educating the patient to do gentle physical exercise helps to reduce fatigue.

Skin changes: 

The skin on the chest and back may become red or dry, like sunburn. It is important to avoid getting direct sunlight in these areas. Applying a moisturizing cream daily can help protect the skin. 

Shortness of breath and cough: 

Radiation therapy may cause inflammation of the lungs. Called radiation pneumonitis, this may cause shortness of breath and/or a cough. This may happen during treatment, but it is more likely to appear 1–6 months after treatment ends. Radiation pneumonitis is usually temporary and can be treated. 

Nausea: 

A person may feel nauseous for a while after radiation therapy. It may help to avoid eating before treatment or eating only a bland snack, such as crackers or dry toast.

Hair loss: 

Hair lost from radiation therapy usually grows back in the following months. A person should protect the area of hair loss from the sun.

Side effects can change from one treatment session to the next and may build up over time.

GASTROINTESTINAL CANCERS RADIATION THERAPY:

Radiation therapy, also called radiotherapy, works by directing high-energy X-rays at a tumor in the gastrointestinal tract. Examples of tumors in the gastrointestinal tract include esophageal cancers, pancreatic cancer, cholangiocarcinoma, liver cancers, stomach cancers, and colon and rectal cancers.

Radiation therapy options for gastrointestinal cancers include:

Image-Driven Planning: Accurately defining the gross tumor for radiation delivery is the key to successful radiation treatment. PET CT has promising results over traditional CT imaging to identify the gross tumor in the intestinal tract.

Radiation Therapy for Esophageal Cancer:

There are several ways radiation therapy can be used to treat esophageal cancer. 3D conformal external beam radiation is a technique that utilizes three-dimensional imaging to more accurately target the lesion and to reduce normal tissue damage. The second type is brachytherapy, which incorporates an active source within a catheter to allow the delivery of a high dose of radiation to a small volume of tissue. The main side effects of treatment are painful swallowing, fatigue, weight loss, and loss of appetite.

Radiation Therapy for Gastric Cancer:

The radiation treatment typically lasts five weeks with chemotherapy given before, during, and after the radiation therapy. We can accurately target the stomach by using contrast agents as well as 3D conformal techniques. Improved targeting is very important in maximizing the dose to the stomach while limiting the toxicity to normal structures. 

Side effects can include fatigue, nausea, loss of appetite, and weight loss.

Radiation Therapy for Pancreatic Cancer:

The pancreas is located deep in the abdomen and surrounded by many organs including the kidneys, small bowel, liver, stomach, spleen, and spinal cord. Due to these intimate relationships with other organs, treatment planning/targeting for pancreatic cancer is a very important way to reduce potential side effects. therefore employ 3D conformal radiation to accomplish this task.

A new planning and delivering technique called Intensity Modulated Radiation Therapy or IMRT is being used to treat various cancers including pancreatic cancer. By using computer-generated images, we can plan and deliver a very exquisitely shaped beam that points to the cancerous tissue with a tighter margin while sparing the normal cells to a much higher degree. This precise technique allows us to increase the cancer-killing dose while simultaneously decreasing the side effects of the treatment.

Radiation Therapy for Rectal Cancer:

Various techniques are used to reduce toxicity including positioning, contrast, and multiple field arrangements. The radiation therapy lasts approximately 5-6.5 weeks with chemotherapy. 

Side effects may include skin irritation, diarrhea, fatigue, and low blood counts.

Radiation Therapy for Anal Cancer:

With modern radiation techniques and the addition of chemotherapy, we can prevent the vast majority of colostomies without sacrificing cure rates. Radiation is given over 4-6 weeks with concurrent chemotherapy. Surgery is reserved for salvage treatment only. 

Side effects include skin irritation, diarrhea, fatigue, and low blood counts.

Managing the side effects of GI radiation therapy:

Radiation enteritis is inflammation of the intestines that occurs after radiation therapy. Radiation enteritis causes diarrhea, nausea, vomiting, and stomach cramps in people receiving radiation aimed at the abdomen, pelvis, or rectum. It's most common in people receiving radiation therapy for cancer in the abdomen and pelvic areas.

Radiation enteritis is temporary, with inflammation usually subsiding several weeks after treatment ends. But for some, radiation enteritis may continue long after radiation therapy ends or may develop months or years after treatment.

Chronic radiation enteritis can cause complications such as anemia, diarrhea, or bowel obstruction.

Treatment focuses on relieving symptoms until the inflammation heals. In severe cases, tube feeding or surgery to remove sections of the intestine may be necessary.

Esophageal Irritation: Patients may experience irritation or inflammation that makes swallowing difficult. Sometimes this occurs following radiation to the upper part of the spine to treat a tumor there. The problem usually diminishes within a week or two of the completion of radiation treatment. Patients may be given a medication that numbs the area to make swallowing easier and less painful.

Nausea: Patients may experience nausea shortly after receiving radiation in this area. Throughout treatment, they may develop a decreased appetite. Nutritionists often work with patients on a dietary strategy that involves small meals spread over time, often including high-calorie snacks.

Bowel Discomfort & Pain: Patients receiving radiation to the lower digestive tract may have cramping and abdominal pain. This is thought to be because radiation can cause the bowel to become swollen, pushing undigested food further into the digestive tract, where bacteria produce more intestinal gas. Treatment may include anti-gas agents or a change in diet to reduce fruits and vegetables and increase simple starches like toast and pasta. 

Diarrhea: Diarrhea is the most common short-term side effect of radiation to this area. Radiation-associated irritation to the large intestine may prevent it from absorbing water properly, causing food waste to pass through faster than normal. The problem can usually be managed with anti-diarrheal medications and dietary changes that sometimes include more fiber. Some patients experience pain with bowel movements because of skin irritation, which generally diminishes over time. Pain medication is a common remedy.

GENITO URINARY RADIATION

Radiation therapy plays a crucial role in the management of genitourinary malignancies, with technological advancements that have led to improvements in outcomes and a decrease in treatment toxicities.

Technological advances in imaging, treatment planning, and treatment delivery have allowed physicians to deliver higher radiation dose to tumor or tumor bed while minimizing doses to surrounding normal tissue. Other advances in screening and other treatment options have translated to improvements in clinical outcomes for patients with genitourinary malignancies.

Radiation therapy can be used along with chemotherapy to preserve the patient’s bladder in bladder cancers. It can also be used to destroy any cancer cells left behind in the pelvis after bladder cancer surgery. For kidney cancer, radiation can be used to destroy tumors that are too difficult to treat with surgery. 

 Radiation Treatments:

To treat bladder cancer:

Intensity-modulated radiation therapy (IMRT) delivers targeted radiation doses to the tumor site, patterned to match the shape of the tumor through modulating the intensity of the radiation beams) or 

Three-dimensional (3-D) conformal radiation therapy: For this technique, imaging scans are used to create a three-dimensional model of the exact shape and size of the tumor. Then multiple radiation beams are aimed at the tumor shape, sparing nearby healthy tissue.

Side effects of radiation therapy:

Radiation therapy for bladder cancer can cause temporary side effects, including increased urgency to urinate, burning while passing urine, fatigue, loss of appetite, diarrhea, and soreness around the anus. Symptoms tend to build diarrhea during treatment and usually start improving over a few weeks after treatment ends.

Less commonly, radiation therapy may permanently affect the bowel or bladder. Bowel motions may be more frequent and looser, and damage to the bladder lining (radiation cystitis) can cause blood in the urine.

Radiation therapy for males may cause poor erections and make ejaculation uncomfortable for some months after treatment. For females, radiation therapy can cause the vagina to become drier, narrower, and shorter.

Late Effects After Radiation for Bladder Cancer

Bladder Problems:

✌Developing scar tissue

✌Hemorrhagic cystitis

✌Urinary tract infections

Bowel Problems:

✌Scarring and strictures

✌Ulceration and bleeding

✌Chronic diarrhea

✌Fistula formation

✌Colon cancer

To treat kidney cancer:

The direct removal of the kidney tumor or cryoablation therapy (freezing) are more likely to be used than radiation. When radiation is appropriate, our radiation experts use 

IMRT or stereotactic radiosurgery, is a nonsurgical radiation therapy that can be used as an alternative to invasive surgery. The technology delivers multiple radiation beams from different angles and planes. Three-dimensional images are used to determine the exact location of the tumor.

Proton Therapy is a form of targeted radiation treatment that uses energy from positively charged particles called protons. Protons very precisely zero in on tumors, delivering most of their cancer-fighting energy directly to cancer cells while minimizing radiation exposure and damage to neighboring healthy tissue and organs. The therapy reduces the risk of late effects after treatment.

Short-Term Side Effects:

Some of the most common short-term side effects of radiation therapy for kidney cancer are:

Skin irritation: The skin in the treatment area may become red, irritated, dry, or sensitive. This may start to look like a sunburn. Treat the skin gently to avoid further irritation, and bathe carefully, using only warm water and mild soap. Do not use perfumed or scented lotions or soaps, and avoid sun exposure, as these may worsen irritation.

Fatigue: Fatigue is feeling very tired or exhausted. This is very common and tends to begin a few weeks into treatment. Fatigue often gets better slowly over the weeks and months after treatment.

Alopecia (Hair Loss): This can happen in the area that received radiation. Hair often starts to regrow a month or so after treatment, hair might not grow back exactly as it was before treatment, and for some, the hair loss is permanent.

Nausea and/or vomiting: This is common and may start during or right after treatment and last for several weeks after treatment ends. 

Long-Term Side Effects:

Long-term effects can happen months to many years after cancer treatment and the risks depend on the area of the body being treated. They can also depend on the radiation techniques that are used. Some of the long-term side effects of radiation to the kidney are:

• Damage to the kidney.
• Bowel problems.
• Liver damage.
• Damage to the spleen.
• Skin changes.
• Secondary Cancer.

To treat prostate cancer:

Radiation therapy uses high-energy rays or particles to kill cancer cells. Depending on the stage of the prostate cancer and other factors, radiation therapy might be used:

• As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
• As part of the first treatment (along with hormone therapy) for cancers that have grown outside the prostate gland and into nearby tissues.
• If the cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery.
• If the cancer is advanced, help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

The main types of radiation therapy used for prostate cancer are:

📍External beam radiation

📍Brachytherapy (internal radiation)

📍Radiopharmaceuticals (medicines containing radiation that are injected into the body)

External beam radiation therapy:

In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier-stage cancers or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.

Three-dimensional conformal radiation therapy (3D-CRT):

3D-CRT uses special computers to precisely map the location of the prostate. Radiation beams are then shaped and aimed at the prostate from several directions, which makes it less likely to damage surrounding normal tissues and organs.

Intensity-modulated radiation therapy (IMRT):

IMRT, an advanced form of 3D-CRT therapy, is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to limit the doses of radiation reaching nearby normal tissues. This lets doctors deliver an even higher radiation dose to the cancer.

Stereotactic body radiation therapy (SBRT):

This technique uses advanced image-guided techniques to deliver large doses of radiation to a precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.

SBRT is often known by the names of the machines that deliver the radiation, such as Gamma Knife, X-Knife, CyberKnife, and Clinac.

MRI-guided radiation therapy:

This approach combines some features of IMRT, IGRT, and SBRT therapies into one. It is done with a machine known as an MRI-linac, which combines an MRI scanner with a linear accelerator (linac, the machine that delivers the radiation). 

As with other types of IGRT, MRI pictures can be taken before each treatment, so the aim of the radiation can be adjusted to account for any change in the position of the prostate (and the tumor) since the last treatment. 

MRI images can also be taken while the radiation is given. If body functions (like breathing or digestion) cause the tumor to move out of the path of the radiation, the radiation stops until it is aimed correctly again. This can help reduce the amount of radiation to healthy tissues and organs around the tumor.

Proton beam radiation therapy:

Proton beam therapy focuses beams of protons instead of x-rays on the cancer. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and release their energy only after traveling a certain distance. This means that proton beam radiation can, in theory, deliver more radiation to the prostate while doing less damage to nearby normal tissues. Proton beam radiation can be aimed with techniques similar to 3D-CRT and IMRT.

Short-term side effects:

👉Tiredness and weakness

👉Sore skin in the treatment area

👉Loss of pubic hair

👉Cystitis

👉Burning pain while urination.

👉Difficulty in passing urine

👉A weak flow of urine

Long-term side effects:

Problems in passing urine and leakage of urine:

Almost 50 out of every 100 men (almost 50%) who have radical radiotherapy have some problem with leaking urine after 6 years. A  small number of men find they can’t pass urine at all. This is due to the treatment causing a narrowing of the tube from the bladder to the penis (the urethra). The narrowing is called a urethral stricture.

Difficulty getting an erection (impotence):

Radiotherapy can damage the nerves that control getting an erection.

Bowel Problems: Rectal inflammation, Proctitis, Diarrhea, bleeding per rectum, and slimy mucus discharge.

Lymphedema: Swelling of legs and scrotum.It happens when the lymph channels that drain fluid from the legs are damaged by radiotherapy. The swelling can be uncomfortable.

Second cancer: A small number of men develop bladder cancer or cancer of the lower bowel (rectum) after radiotherapy for prostate cancer. This can happen many years after treatment.

Avascular necrosis: Radiotherapy can damage the pelvic area's bone cells and lower the blood supply to the bones. The bones can become weaker.  Damage to the bones can cause pain and sometimes make walking or climbing stairs hard.

Malabsorption: Radiation therapy can stop the functioning of the digestive system which will cause  Vitamin B12 deficiency and results in anemia. 

All the side-effects should be intimated to the medical team and adequate management should be done.

To treat testicular cancer:

Radiation therapy is mainly used for patients with seminoma, which is very sensitive to radiation. Sometimes it’s used after orchiectomy (the operation to remove the testicle) and is directed at the lymph nodes at the back of the abdomen (the retroperitoneal lymph nodes). This is to kill any tiny bits of cancer in those lymph nodes that can’t be seen. It can also be used to treat small amounts of seminoma that have spread to the nodes (based on changes seen on CT and PET scans).

Radiation is also sometimes used to treat testicular cancer (both seminoma and non-seminoma) that has spread to distant organs.

Side effects of radiotherapy for testicular cancer:

Tiredness/ Weakness: Tiredness starts during treatment, usually lasts for one week after treatment, and then gradually becomes better. Patients may feel weak and lack energy.

Management: Adequate rest and stay active

Sore skin: The skin in the treatment area gets red and sore like a mild sunburn, changes should go away once treatment finishes, and the medical team can prescribe creams that prevent the reoccurrence of the soreness.

This is not usually too bad with radiotherapy for testicular cancer, particularly if radiotherapy for 2 weeks.

Nausea or vomiting: This is common and can usually be easily treated with medicine.

Diarrhea: Instruct the patient to drink plenty of water, to decrease high-fiber foods

Hair loss in the treated area, may be permanent.

RADIATION TREATMENT FOR GYNECOLOGIC CANCERS

Gynecologic cancers include malignancies of the female genital tract involving the vulva, vagina, cervix, uterus, fallopian tubes, or ovaries. According to the American Cancer Society, 109,000 women diagnosed with some form of gynecologic cancer this year. Cancers of the uterus and cervix are the most common gynecologic cancers treated with radiation and account for 75,050 new cases each year. Widespread screening with the PAP test allows doctors to find pre-cancerous changes in the cervix and vagina early. 

Vaginal Cancer:

Radiation therapy is the treatment most often used for vaginal cancer. Vaginal cancer is most often treated with a combination of both external and internal radiation.

External beam radiation therapy:

With this type of treatment, radiation is delivered from outside the body in a procedure that's a lot like getting an X-ray. It's sometimes used along with chemotherapy to treat more advanced cancers. It can shrink tumors so they can be easier to remove with surgery. Radiation alone might be used to treat lymph nodes in the groin and pelvis.

Intracavitary brachytherapy:

Another way to deliver radiation is to place radioactive material inside the vagina. There are 2 main types of intracavitary brachytherapy:

💡Low Dose Rate brachytherapy: The radioactive material is inside a cylinder-shaped container that's put in the vagina. It stays in place for a day or 2. Gauze packing is used to help hold the cylinder in place, but you have to stay in bed in the hospital during the treatment.

💡High Dose Rate brachytherapy: The radiation source is in a cylinder, but it doesn’t need to stay in place for long. This means it can be given in an outpatient setting. Typically, 3 or 4 treatments are given 1 or 2 weeks apart.

When given this way, the radiation mainly affects the tissue in contact with the cylinder. This means the radiation is less likely to cause bladder and bowel side effects.

Another type of brachytherapy, called interstitial radiation, uses radioactive material inside needles that are put right into the tumor and nearby tissues.

Short-term side effects: 

• Tiredness: It may get worse about 2 weeks after treatment begins and get better over time after treatment ends
• Nausea and vomiting: more common if radiation is given to the belly or pelvis
• Diarrhea 
• Skin changes:  in the area where the radiation is given, which can range from mild redness to blistering and peeling. The skin may become raw and tender.
• Low blood counts

The diarrhea caused by radiation can usually be controlled with over-the-counter medicines. Nausea and vomiting can be treated with medicines Skin needs to be kept clean and protected to prevent infection.

Side effects tend to be worse when chemotherapy is given with radiation.

Long-term side effects: 

Many of the side effects are caused by radiation damage to nearby organs.

Early menopause: pelvic radiation can damage the ovaries, leading to early menopause. It can also weaken bones, making them more likely to break from a fall or other trauma.

Radiation colitis: Radiation to the pelvis can also severely irritate the intestines and rectum called radiation colitis, leading to diarrhea and bloody stool. If severe, radiation colitis can cause holes or tears to form in the intestines called perforations.

Radiation cystitis:  Pelvic radiation can cause problems with the bladder, leading to discomfort and an urge to urinate often. In rare cases, radiation can cause abnormal connections (called fistulas) to form between the vagina and the bladder, rectum, or uterus.

Skin Irritation: If the skin was irritated by radiation, when it heals it may be darker and not as soft. The hair may not grow back.

Radiation can cause the normal tissue of the vagina to become irritated and sore.

Cervical Cancer:

Depending on the stage of the cervical cancer, radiation therapy may be used:

• For some stages of cervical cancer, the preferred treatment is radiation alone or surgery followed by radiation. For other stages, radiation and chemo given together (called concurrent chemoradiation) is the preferred treatment as the chemo helps the radiation work better.
• Radiation therapy may be used to treat cervical cancers that have spread to other organs and tissues.

The types of radiation therapy most often used to treat cervical cancer are:

• External beam radiation
• Brachytherapy

External beam radiation therapy:

When EBRT is used as the main treatment for cervical cancer, it is usually combined with chemotherapy (called concurrent chemoradiation). Often, a low dose of the chemo drug called cisplatin is used. Other chemo drugs can be used as well. The radiation treatments are given 5 days a week for about 5 weeks. The chemotherapy is given at scheduled times during the radiation. The schedule is determined by which drug is used.

Short-term side effects of external beam radiation therapy for cervical cancer can include:

📱Fatigue 

📱Bowel discomfort

📱Diarrhea or loose stools 

📱Nausea and vomiting

📱Skin changes (mild redness to peeling or flaking)

📱Radiation cystitis: Radiation to the pelvis can irritate the bladder (radiation cystitis), causing discomfort, an urge to urinate often, and sometimes blood in the urine.

📱Vaginal pain: Radiation can make the vulva and vagina more sensitive and sore, and sometimes causes a discharge.

📱Menstrual changes: Pelvic radiation can affect the ovaries, leading to menstrual changes and even early menopause

📱Low blood counts: Anemia, Neutropenia (increase the risks of serious infection ),  and Thrombocytopenia increases the risk of bleeding. 

When chemotherapy is given with radiation, the blood counts tend to be lower and fatigue and nausea tend to be worse. These side effects typically improve in the weeks after treatment is stopped.

Brachytherapy:

The types are the same as   Vaginal cancer. 

• To treat cervical cancer in women who have had a hysterectomy, the radioactive material is placed in a tube in the vagina.

• To treat a woman who still has a uterus, the radioactive material can be placed in a small metal tube (called a tandem) that goes in the uterus, along with small round metal holders (ovoids) placed near the cervix. This is sometimes called tandem and ovoid treatment.

• Another option is called tandem and ring. For this, a round holder (like a disc) is placed close to the uterus. The choice of which one to use depends on what type of brachytherapy is planned.

Possible short-term side effects of brachytherapy:

Since the radiation only travels a short distance with brachytherapy, the main effects of the radiation are on the cervix and the walls of the vagina. The most common side effect is irritation of the vagina. It may become red and sore, and there may be a discharge. The vulva may become irritated as well.

Brachytherapy can also cause many of the same side effects as EBRT, such as fatigue, diarrhea, nausea, irritation of the bladder, and low blood counts.

Long-term side effects of  cervical radiation therapy:

📙Vaginal stenosis

📙Vaginal dryness

📙Rectal bleeding/rectal stenosis

📙Urinary problems

📙 Bone weakness

📙Lymphedema

Ovarian Cancer:

Radiation therapy is rarely used in frontline ovarian cancer treatment

External beam radiation therapy:

External beam radiation therapy is the type of radiation therapy that is most commonly used to treat ovarian cancer, and is administered by a machine that focuses photon, particle, or electron radiation beams on cancer cells in the affected area. This treatment is painless, and the patient experience is much like getting an x-ray, but with stronger radiation. 

Side effects:

Common side effects of radiation therapy include skin changes (“sunburn” feelings, or blistering); fatigue; nausea or vomiting; diarrhea; and vaginal irritation or discharge. Most side effects improve after treatment is finished, though side effects involving the skin may improve more gradually, generally clearing up within 6 to 12 months.

Brachytherapy:

Brachytherapy  is rarely used to treat ovarian cancer.

When is radiation used for ovarian cancer?

Most commonly, radiation treatment for ovarian cancer is used if the cancer has spread to other organs that are more easily targeted by external radiation. If cancer spreads, radiation therapy can help alleviate symptoms, as well as help stop or slow the cancer cells from spreading further. 

Endometrial(Uterine) Cancer:

Modern radiation therapy for uterine cancers is given via machines called linear accelerators, which produce high-energy external radiation beams that penetrate the tissues and deliver the radiation dose deep into the areas where the cancer resides. 

These modern machines and other state-of-the-art techniques have enabled radiation oncologists to significantly reduce side effects while improving the ability to deliver a maximum radiation dose to cancer-containing areas and minimizing the radiation dose to normal tissue

Simulation:

After an initial consultation with a radiation oncologist, the next session is usually a planning session, which is called a simulation. 

During simulation, patients lie on a table somewhat similar to that used for a CT scan. The table can be raised and lowered and rotated around a central axis. 

The “simulator” machine is a machine whose dimensions and movements closely match that of an actual linear accelerator. Rather than delivering radiation treatment, the simulator lets the radiation oncologist and technologists see the area to be treated. The simulation is usually guided by fluoroscopy, so that a patient’s internal anatomy can be observed

Treatment Schedules:

A typical course of radiation for uterine cancer would entail daily radiation treatments, Monday through Friday, for 3 to 5 weeks. The actual treatment with radiation generally lasts no more than a few minutes, during which time the patient is unlikely to feel any discomfort.

There are two main ways to get radiation therapy for endometrial cancer:

External radiation: The radiation comes from a machine called a linear accelerator (linac). The beams of energy are aimed at the tumor through your skin. The treatment is a lot like getting an X-ray.

Internal radiation (brachytherapy): This is a common type of radiation therapy used for endometrial cancer. A tube is placed in the vagina, up against the location of the tumor. The tube has an opening in the center that allows a radioactive seed to travel into the tube when the tube is connected to a radiation machine. This allows the radiation to be delivered. This is usually done after surgery to remove the uterus. It treats the upper part of the vagina that was near the uterus.

Some people need both an external radiation treatment ( 4 to 6 weeks) followed by internal radiation (often 2 to 3 sessions).

Common side effects of radiation therapy for endometrial cancer include:

💠Skin irritation in the treated area (with external radiation)

💠Irritation, dryness, or redness of the vaginal lining (the most common side effect of brachytherapy)

💠Vaginal pain and discharge

💠Hair loss in the area being treated (including pubic hair)

💠Feeling very tired or weak

💠Nausea

💠Bladder irritation and/or blood in your urine

💠Bowel irritation and diarrhea or rectal bleeding

💠Early menopause

Side effects depend on the type of radiation therapy used. For instance, brachytherapy mainly affects the lining of the vagina that's in contact with the cylinder, not the skin.

Side effects tend to be worse if the patient gets chemotherapy along with radiation. Patients need to report the side effects to the physician and seek medical advice to manage and prevent the side effects.

Vulvar Cancer:

Radiation for vulvar cancer is most often given from a machine outside the body. This is called external beam radiation therapy (EBRT). It may be aimed at the vulva and could also include the areas in the groin if vulvar cancer has spread. Radiation is one of the most common treatments for vulvar cancer.

When is radiation used in vulvar cancer:

Radiation is most often used along with chemotherapy. This can make the radiation work better. This is called chemoradiation. 

It is used:

Before surgery: Treatment is used to shrink locally advanced tumors that have spread to nearby structures, such as the vagina, anus, or urethra. The goal is for the radiation to shrink the tumor so it's easier to remove.

After surgery: If cancer is found in or near the edges of the removed tumor (called positive or close margins), the removed tumor has aggressive features when looked at under the microscope, or the cancer cells are found in lymph nodes, radiation can help kill any cancer cells left in the body.

Cancer in the lymph nodes: Radiation alone could be used instead of surgery if it has spread to the lymph nodes in the groin and pelvis.

As the main treatment: Radiation alone or chemoradiation can be used if a woman isn't healthy enough to go through surgery.

Side effects can include:

Short term side effects:

👦Skin irritation, redness, blistering, and peeling (like a bad sunburn), especially around the vulva or groin area

👦Skin sores or infection

👦Severe tiredness (fatigue)

👦Diarrhea

👦Nausea and vomiting

👦Problems with urination, including burning with urination

👦Premature menopause & infertility due to ovary damage

👦Sexual changes,

👦lymphedema

👦Low blood counts

Management:

💁Most of these side effects go away over time after treatment ends, and some can be prevented. 

💁Instruct the patent to report any side effects they have. This way it can be managed easily or can be prevented. 

Long-term side effects

Some long-term side effects of radiation may not show up for many years after treatment ends. These depend on the dose and location of the radiation. 

 👦Infertility,

 👦Chronic lymphedema,

 👦Bowel or bladder control problems

 👦 Sexual dysfunction 

Management:

💁Educate the patient about possible long-term side effects that can occur.

💁Instruct the patient to monitor for any of the signs & symptoms of long-term side effects.

💁Educate the patient regarding fertility options before treatment.

Fallopian tube cancer:

Radiation therapy usually is not used to treat Fallopian tube cancer. Sometimes it is given after surgery and chemotherapy.

Treatment Modalities used:

👉Brachytherapy 

👉Conformal Radiation Therapy 

👉Image-guided Radiation Therapy (IGRT)

👉Intensity-modulated Radiation Therapy (IMRT) 

BONE METASTASES:

Bone metastases represent an important complication of malignant tumours. The primary goal of radiation therapy is to provide pain relief, preserving patients' quality of life. A  vast majority of patients with bone metastases require active treatment, due to pain, difficulty with ambulation, pathologic fractures, spinal cord compression, hypercalcemia, and neurologic deficits.

Indications and Aims of Radiation Therapy for Bone Metastases:

• The important role of RT in the palliation of bone metastases is well recognized. RT is performed primarily to relieve pain, definitely control a bone affected by metastases and prevent pathologic fractures as well as spinal cord compression. Radioisotopes can be administered for more diffuse bone pain that is not eligible for palliative RT.
• The goals of RT are to improve QoL, reduce analgesic requirements, and maintain or improve skeletal function. Beneficial effects on pain may necessitate several days to a few weeks, so analgesic medication must be optimized during that interval.

Effects  of Radiation Therapy on  Bone Metastases:

• The beneficial effects of RT on bone pain are mainly related to its capability to produce ossification.
• Ionizing radiations can diminish osteoclasts activation and kill tumor cells. 
• Reduction in tumor volume, preserving discomfort to adjacent nerves.
• The reported evidence of symptom relief within 24 hours after initial RT suggests that reduction of both inflammatory cells and chemical pain mediators is involved in this rapid reaction.

Radiation Therapy Techniques:

Three-dimensional conformal radiation therapy (3-DCRT):  is considered as the standard of practice to treat bone metastases. 3-DCRT allows conforming dose distribution to the target volume, reducing the dose to the surrounding normal tissues. Before treatment, a computed tomography (CT) scan of the affected anatomic site is obtained. The patient should be positioned in a comfortable position. The goal is to deliver the maximum dose to the target volume and spare the normal tissues.

Stereotactic body radiation:

Stereotactic body radiation (SBRT) is a modern treatment modality that delivers high doses to the metastatic bone with great accuracy, minimizing the dose to the adjacent critical structures, primarily the spinal cord and cauda equine, but the lung, esophagus, kidney, bowel and contiguous vertebral bodies.

Side effects:

👤Fatigue

👤Red and itchy skin

👤Flare up of pain for 1 or 2 days, needs pain management 

👤 Nausea and vomiting, anti-emetics to be administered

👤Diarrhea, require medications to stop diarrhea and adequate hydration.

REIRRADIATION:

Re-irradiation to the same bone site should be considered after initial palliative RT in the following scenario: 

1) No response in the previously irradiated area; 

2) Partial response and the hope of additional benefit from repeat treatment;

3) Pain relapse after an initial satisfactory response.

RADIOISOTOPE THERAPY:

Radioisotopes are radioactive substances. They may be given as a drink, capsules or an injection into a vein. Cancer cells absorb radioisotopes more than normal cells and get a higher dose of radiation.

All the bones affected by cancer will be treated.

👉Radium-223 can be used to treat secondary cancer in the bone from prostate cancer that is no longer responding to hormonal therapy.

👉Strontium-89 can be used to treat secondaries in the bone from prostate cancer and breast cancer.

👉Iodine-131 can be used to treat secondaries in the bone from thyroid cancer.

Side effects:

👤Reduced number of RBC and WBCs

👤Infection, requires antibiotics

👤Swelling around the treatment area called tumour flare flare with temporary pain which requires pain management.

REFERENCES:

1.https://www.cancer.org/cancer/types/brain-spinal-cord-tumors-adults/treating/radiation-therapy.html.

2.https://www.hopkinsmedicine.org/radiation_oncology/conditions_we_treat/brain_spine_tumors_cns.html.

3.https://www.oncolink.org/cancers/braintumors/treatments/possible-side-effects-of-radiation-treatment-for-brain-tumors

4. Radiation therapy side effects. National Cancer Institute. (2018, May 1). Retrieved November 16, 2021, from https://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/side-effects.

5. Side effects of radiation therapy. Cancer.Net. (2020, September 23). Retrieved November 16, 2021, from https://www.cancer.net/navigating-cancer-care/how-cancer-treated/radiation-therapy/side-effects-radiation-therapy.

6.https://www.rvh.on.ca/wpcontent/uploads/2021/05/Managing-Side-Effects-of-Brain-Radiation-Therapy.pdf

7.https://hillman.upmc.com/cancer-care/head-neck/treatment/radiation

8.https://www.cancercouncil.com.au/head-and-neck cancer/treatment/radiotherapy/side-effects-of-radiation-therapy/

9.https://www.cancercenter.com/cancer-types/lung cancer/ treatments/radiation-therapy.

10.https://www.mygenesishealth.com/treatment-options/radiation-oncology/radiation-therapy-for-gastrointestinal-cancers.html.

https://ocrahope.org/patients/diagnosis-and treatment/treatment-options/radiation/