RADIATION THERAPY PRESENTER- DR.

SANGAY

IN HEAD AND NECK CHODEN LEPCHA

MODERATOR- DR

CANCER SOURABHA K. PATRO

INTRODUCTION
TYPES
RADIATION PLANNING
SITE SPECIFIC RADIATION DOSAGE
SIDE EFFECTS
INTRODUCTION
BRIEF HISTORY

1895- discovery of x-ray by Wilhelm Conrad Roentgen

1987- demonstrated disapperance of a hairy mole with use of x-ray Wilhelm
Alexander Feud
1898: Discovery of radium by Marie and Pierre Curie.
Early 1900s: First use of radiation in cancer treatment.
1950s: Development of megavoltage radiation therapy.
1990s-Present: Advances in IMRT, IGRT, proton therapy, and AI-driven
treatment planning.
DNA Damage Mechanisms:

Direct Action: Radiation directly damages DNA, causing strand breaks.

Indirect Action: Radiation interacts with water molecules, producing reactive oxygen species (ROS)
that damage DNA.

Repair and Radiosensitivity:

Single-strand breaks are often repaired successfully.

Double-strand breaks are more lethal and lead to mitotic catastrophe when the cell tries to divide.

Tumor cells generally have weaker repair mechanisms, making radiation more effective against
them.
 TYPES OF RADIOTHERAPHY

External Beam Radiation Therapy (EBRT) / Teletherapy

•Conventional EBRT
•3D Conformal Radiation Therapy (3D-CRT)
•Intensity-Modulated Radiation Therapy (IMRT Image-Guided Radiation Therapy (IGRT).
•Stereotactic Radiosurgery (SRS) / Stereotactic Body Radiation Therapy (SBRT)
•Proton Beam Therapy
•Neutron and Heavy Ion Therapy
2. Brachytherapy (Internal Radiation Therapy)
Radiation sources are placed inside or very close to the tumor.
•Interstitial Brachytherapy
•Intracavitary Brachytherapy
•Surface Brachytherapy
•High-Dose Rate (HDR) Brachytherapy
•Low-Dose Rate (LDR) Brachytherapy

3. Systemic Radiation Therapy

•Radioactive Iodine Therapy (I-131)
•Radium-223 (Xofigo)
EXTERNAL BEAM
RADIOTHERAPHY
(1) electromagnetic radiation (photons) in the form of x-rays and gamma rays

(2) particulate radiation in the form of electrons, neutrons, and protons.

Ionizing radiation deposits energy at a constant rate as it travels through matter,

defined as linear energy transfer (LET).
Each unit of absorbed radiation is called one gray (Gy), which is equivalent to one
joule per kilogram of tissue. One Gy = 100 centi-Gy (cGy).
Linear Energy Transfer (LET):

Low-LET Radiation (Sparsely Ionizing): X-rays, gamma rays

Deposits energy less densely along its path.
Causes indirect DNA damage (via free radical formation).

High-LET Radiation (Densely Ionizing): Neutrons, alpha particles, heavy ions

Deposits energy more densely, leading to more lethal DNA damage (double-strand breaks).
More effective at cell killing due to higher biological impact.

Relative Biological Effectiveness (RBE):

Measures how effective a type of radiation is at producing a biological effect.

Higher RBE means higher damage potential at lower doses.
Penetration Depth and Clinical Use:

Superficial X-rays (40–100 kV): Treat surface lesions (e.g., skin cancers).

Orthovoltage X-rays (250 kV): Limited penetration, used for shallow tumors.

Super voltage Gamma Rays (Cobalt-60, 1.25 MV): Moderate penetration.

Megavoltage X-rays (4–25 MV, LINAC): Deep penetration, used for deep-seated
tumors (e.g., lung, prostate).
CONVENTIONAL
RADIOTHERAPHY
Used for all sites except parotid ,thyroid and nasal cavity tumors
1.5 – 2cm of margin around the tumor should be included in the radiation
portal
Total dose delivered- 70 Gy/35 fraction or 60 Gy/30 fraction
Delivered by shrinking field technique( spinal cord is excluded from the field)
Radiotheraphy portals
Upper border- line joining tragus of ear to maxillary/zygomatic prominence
for all non parotid tumors, non nasopharyngeal cancer and unknown primary
with secondary neck
Lower border-immediately below clavicle except for thyroid and post cricoid
cancer with esophageal extension
Anterior border- air for oral cavity and those tumours with
submandibular lymph nodes , those without submandibular lymph
nodes anterior cortex of mandible with aim to exclude lip
Posterior border- tip of c2 vertebrae or 1- 1.5cm posterior to
maximum extent of neck lymph node
3D CONFORMAL
RADIOTHERAPHY
Relatively newer technique
Good for tumours of parotid and thyroid
(1) the target volumes are defined in three dimensions using contours drawn on many slices
from a computed tomography (CT) (or other) imaging study
(2) multiple beam directions are used to cross fire on the targets
(3) the individual beams are shaped or intensity modulated to create a dose distribution that
conforms (in shape and dose) to the target volume shape(s) and desired dose levels, and
(4) appropriate use is made of image guidance, accurate patient setup and immobilization,
and management of motion and other changes to ensure accurate delivery of the planned
dose distributions to the patient
IMRT
Advanced form of three-dimensional conformal radiotherapy.

particular value for target volumes with concave or complex shapes with close
proximity to radiosensitive normal structures

It has two key additional features compared to conformal radiotherapy:

1.Non-uniform intensity of the radiation beams.

2.Computerised inverse planning.

PROTON BEAM THERAPHY
Protons are charged particles due to which they have minimal entry and exit dose in
the tissue.
slightly more effective in killing tumor cells than photons or X-rays.
unique physical & biological properties of proton beams along with the complex
delivery system allows highly precise delivery of radiation to the tumour with minimal
dose to the surrounding normal structures, thereby allowing optimal radiation dose
delivery with minimal side effects.
Primary tumuors are in periocular in location and or invade the skull base ,
cavernous sinus
Tumour extend intracranially or exhibit extensive perineural invasion
Patients being treated with curative intent and have long life expectencies.
 SOURCES OF TELETHERAPHY
•Teletherapy sources include photons, electrons, neutrons, protons, α particles, and
heavy charged ions (carbon, neon, silicon, argon).

•6-MV photons are the most commonly used for shallow tumors in head and neck cancer.

•Brachytherapy is an option for recurrent tumors, using sources like cesium-137,

iridium-192, iodine-125, gold-198, and others.

•The standard electromagnetic radiation energy for head and neck cancer treatment is 6
MV.
•Electrons (6–20 MeV) are commonly used for skin cancers and tumors near the spinal cord,
offering controlled penetration and minimal damage to deeper tissues.

•Neutrons (up to 50 MeV) have a higher biological effectiveness (RBE) than photons but
also increase the risk of normal tissue damage. Used for unresectable salivary gland
tumors, though their use is limited due to availability.

•Proton therapy has become more accessible due to technological advancements. depth
control, reducing normal tissue toxicity and the risk of secondary cancers. beneficial for
skull base tumors, unilateral head and neck treatments, and previously irradiated cases.
 KEY FACTORS AFFECTING
RADIATION SENSITIVITY
•Type of Radiation: Low LET (e.g., X-rays) vs. high LET (e.g., protons, neutrons).

•Dose Size & Radiosensitizers: Higher doses and radiosensitizing drugs increase cell kill.

•Cell Cycle Phase: Cells are most sensitive in G2 and M phases, while G1 and S phases
are more resistant.

•Tumor Oxygenation: Well-oxygenated cells are 3x more radiosensitive than hypoxic cells.
Bulky tumors have hypoxic centers, making them radioresistant, but reoxygenation occurs
as the tumor shrinks.
Cellular Response to Radiation
•G2 Arrest: Surviving cells after radiation accumulate in the radiosensitive G2
phase, making them more vulnerable to subsequent doses.

•Reoxygenation: With each radiation fraction, peripheral (oxygenated) cells die

first, improving oxygen supply to inner hypoxic cells over hours to days. F-MISO PET
imaging is being studied to track hypoxia changes during treatment.

•Cancer cells repair DNA less efficiently than normal cells, making them more
susceptible to radiation.

•Tumor characteristics (size, histology, cell cycle dynamics) influence treatment

design.

•These principles guide hyperfractionated and hypofractionated radiation

schedules to optimize tumor control while sparing normal tissues.
 FRACTIONATION
Fractionated radiation therapy -1927 -deliver a high total dose while sparing
normal tissues. The treatment plan depends on tumor type and normal tissue
tolerance.
Key Factors in Fractionation:
Tissue Response – Fast-proliferating tissues (e.g., most tumors, skin, mucosa) are
affected by treatment duration. Slow-proliferating tissues (e.g., brain, bone, spinal
cord) are affected by fraction size and number.

Treatment Duration – Shorter durations impact rapidly dividing tumors more.

Fraction Size & Number – Smaller fractions protect late-responding tissues while
still effectively targeting tumors.
Conventional fractionation -180 to 200 cGy per fraction, one fraction per day, 5 days per
week for 6 to 7 weeks for a total dosage of 6500 to 7000 cGy

Altered fractionation aims to maximize tumor kill while minimizing toxicity using low-LET
radiation. There are two main types:

1.Hyperfractionation (for slow-proliferating tumors) – Uses smaller, more frequent doses to:
1. Redistribute tumor cells into more radiosensitive phases.
2. Spare late-responding normal tissues by reducing per-fraction dose.

2.Accelerated fractionation (for rapidly proliferating tumors) – Shortens treatment duration

to limit tumor repopulation.
Both strategies improve the therapeutic ratio, balancing tumor control with normal tissue
protection.
RTOG 90-03 TRIAL
CHAART
Continuous fractionated accelerated radiation therapy
Delivery of more than one fraction per day over shorter interval of time within
fractionated interval of 6 hours
Improves over all survival and local control
RADIOSENSITZERS
Agents that sensitize the tumor cells to radiation.
promote fixation of the free radicals produced by radiation damage at the molecular
level.
The mechanism of action is similar to the oxygen effect, in which biochemical
reactions in the damaged molecules prevent repair of the cellular radiation damage.
Free radicals such as OH+ are captured by the electron affinity of the
radiosensitizers, rendering the molecules incapable of repair .
RADIOPROTECTORS
Compounds that are designed to reduce the damage in normal tissues caused by radiation.
These compounds are often antioxidants and must be present before or at the time of radiation
for effectiveness.
Other agents, termed mitigators, may be used to minimize toxicity even after radiation has been
delivered.
RADIATION MITIGATORS
Radiation-induced late normal tissue toxicity is increasingly being appreciated as a
phenomenon of ongoing changes in tissue after radiation but prior to the
manifestation of toxicity.
Include ongoing mitotic cell death and perpetually active cytokine cascades that can
lead to vascular damage, tissue hypoxia, and excessive extracellular matrix
deposition.
Radiation mitigators aim to interrupt these cascades or intervene to prevent the
perpetuation of damage and thus reduce the expression of toxicity.
HYPERTHERMIA AS AN
ADJUCT IN RADIOTHERAPHY
Hyperthermia alone or in combination with ionizing radiation has been used in the treatment of
radioresistant tumors. Enhance cell killing.
Cells with higher radioresistance such as chronically hypoxic cells with a low intracellular Ph, and
those in S-phase of cell cycle are more susceptible to thermal killing and radiosensitization.
MECHANISM:
• Elevated temperatures increase the fluidity of membranes and this critically determines
survival after thermal insult
• Inhibition of energy metabolism
 • Inhibition of macromolecular (DNA, RNA, and protein) synthesis
• Inhibition of DNA repair as well as the repair of sublethal,[46] and potentially lethal cellular
damage.
THERAPHY PLANING
DELINEATION OF
RADIOTHERAPHY TARGETS
Gross Tumor Volume (GTV) is the visible or clinical demonstrable location and
extent of the tumor.
Clinical Target Volume (CTV) is the tissue volume that contains the GTV and/or
subclinical malignant disease.
Planning Target Volume (PTV) is a geometric volume generated by adding a margin
to the CTV to account for treatment-related uncertainties such as set up errors and
organ motion.
Portals and Fields:
The direction of radiation beam entry into the body is essential for treatment planning.

Port Films: Used for verifying the treatment field, ensuring proper alignment before and during
treatment.
Beam Shaping and Modifying:
Shielding Blocks (Cerrobend lead): Used to shape the beam to match the tumor's
configuration.

Bolus: Materials like petroleum jelly-impregnated gauze are used to ensure superficial tumors
receive the correct dose, preventing underdosage.

Compensators (Filters): These adjust dose distributions, particularly in areas where the
anatomy causes irregularities.

Junction Blocks: Used when multiple treatment fields overlap, ensuring an even distribution of
radiation and avoiding excessive doses, especially near sensitive areas like the spinal cord.

Wedges: These adjust the shape of the isodose curve to provide a more uniform dose at
different depths.
BRACHYTHERAPHY
Uses radioactive sources placed directly at or within the tumor to deliver a high
radiation dose to a localized area.
Types of Brachytherapy:

 Permanent Implantation: Involves the placement of radioactive seeds (e.g., iodine-125,

125I) that remain in the body, delivering radiation over time.

 Temporary Exposure: temporarily inserted into the tumor or tumor bed and removed
after a specified time. used for localized cancers like recurrent nasopharyngeal
carcinoma or neck masses.
o Intracavitary Insertion: Radioactive sources like 125I are placed inside cavities,
such as the nasopharyngeal region.
o Interstitial Implantation: Catheters are inserted into the tumor or tumor bed, which
are then "afterloaded" with radioactive sources (e.g., iridium-192, 192Ir).
Dose Distribution:
Radiation travels only a short distance- allows for the delivery of high doses to the tumor with
minimal radiation exposure to surrounding healthy tissues. Follows inverse square law (i.e., as
distance from the source increases, the dose decreases significantly).

Dose Rates in Brachytherapy:

 Low-Dose-Rate (LDR) Brachytherapy: Delivers radiation continuously at rates of 40–200

cGy per hour. Increases radiosensitivity and improve tumor control.

 High-Dose-Rate (HDR) Brachytherapy: Delivers radiation at rates higher than 1200 cGy per
hour. It requires careful fractionation (delivering only one to three fractions per week) to avoid
complications in normal tissues.
Clinical Considerations:

 Site Selection: Common areas for brachytherapy in head and neck cancers include the lip,
floor of mouth, oral tongue, base of tongue, buccal mucosa, tonsillar region, nasopharynx,
skull base, and neck.

 Patient Evaluation: Factors such as tumor size, volume, anatomical location, proximity to
vital organs, prior treatments, and the patient's overall health are critical in deciding whether
brachytherapy is a viable option.

 Combination Therapy: For certain lesions (e.g., T1 and T2 in the oral tongue and floor of
the mouth), brachytherapy can be used alone or in combination with external beam
radiation therapy. The goal is to deliver precise radiation while minimizing harm to
surrounding tissues.
 Late-Responding Tissues: HDR brachytherapy, with its higher radiation dose in a short time,
poses a higher risk of complications in late-responding tissues (e.g., soft tissue or bone
necrosis).

 Risk of Necrosis: When radioactive sources are placed near the gums or bones, there is an
increased risk of soft tissue or bone necrosis.
PRETREATMENT REQUISITES
Dental Evaluation:
 A dental assessment is critical if the radiation treatment fields involve the major salivary glands
or oral cavity.

 Extraction of Salvageable Teeth

 Timing of Extractions: Avoiding extraction near the tumor site before surgery is crucial to
prevent the risk of tumor implantation.

 Dental Care During Radiation Therapy: For patients with dental fillings, customized mouth
guards with lead shields help minimize mucositis (inflammation of the mucous membranes) from
scatter radiation.

 Fluoride Prophylaxis

 Ongoing Dental Monitoring

Thyroid Function:Radiation to the neck can increase the risk of hypothyroidism

Anemia:negatively impact the efficacy of radiation therapy. hematocrit level of patients

receiving treatment with curative intent be maintained above 30%.

Ophthalmologic Evaluation

Nutritional Status: crucial, especially for patients experiencing weight loss, dysphagia
(difficulty swallowing), odynophagia (painful swallowing), or trismus (restricted mouth
opening).
Dietary consultation -For patients with anticipated severe swallowing difficulties (e.g.,
those with hypopharyngeal or cervical esophageal tumors), the placement of a
percutaneous endoscopic gastrostomy (PEG) tube may be considered.

Speech and swallow specialists should be consulted early on to address potential

swallowing issues during treatment.

Patients who smoke or abuse alcohol should receive counseling and more intense
supportive care because they are at higher risk for adverse effects from radiation therapy.
 STIMULATION
Process of creating a detailed plan to ensure radiation is delivered precisely to the tumor while
minimizing exposure to healthy tissues.
The process includes the following steps:
1. Radiographic Imaging:
o Two-Dimensional Treatment Planning:
 A plain radiograph or fluoroscopy is used to visualize the tumor and surrounding
structures.
 The radiation oncologist uses these images to determine the treatment fields, which
include the primary tumor site, lymph nodes, and nearby tissues at risk of cancer spread.
o Three-Dimensional Treatment Planning (CT-Assisted):
 computed tomography (CT) is used to create 3D models of the patient’s anatomy.
 more precise information about the tumor’s location, size, and relationship to critical
structures, improving the accuracy of radiation delivery.
Simulation Films:

Simulation films are specialized radiographs used to define the treatment area.
includes:

Cross-hair wires to mark the isocenter (the center of the radiation field).

Delineator wires to mark the portal margins (the boundaries of the treatment field).

Graticule marks: A grid of dots placed 2 cm apart, creating a reference for the field's
dimensions. These dots help the radiation oncologist plan the precise placement of the
radiation.
Gold Seed Implantation (for Oral Cavity/Oropharynx Lesions):

visible, palpable tumors in the oral cavity or oropharynx - gold seeds are
implanted to help visualize the tumor on the simulation films.

involves spraying a topical anesthetic on the tumor site, then using a seed injector
to place gold seeds at key locations along the tumor perimeter to a depth of about 1
cm. Help with accurate tumor localization.
Marking and Outlining:

Block positions are drawn on the films using a wax pencil.

Used to shield critical structures (e.g., the larynx, spinal cord) from unnecessary
radiation exposure.

Custom Blocks for Shielding:

Cerrobend blocks (made from lead) are custom-fabricated to match the tumor shape
and anatomical features. Mounted on the treatment unit's head to block radiation from
non-target areas.
Tattooing and Patient Setup:

After the simulation, Polaroid photographs are taken to record the patient’s setup
for treatment.

Tattoos are discreetly placed on the patient’s skin at reference points to ensure
accurate positioning during treatment. Act as markers for precise alignment during
each treatment session.

Beam Films and Treatment Initiation:

After the simulation process is completed and the setup is verified, beam films are
obtained to confirm that the radiation beam is aligned correctly.

Once everything is set, radiation therapy is initiated, following the planned treatment
fields and shielding protocols
TREATMENT INTENT
Curative:

Radiosensitive tumors like squamous cell carcinomas of the nasopharynx and oropharynx,
early-stage laryngeal carcinomas, and certain skin cancers (basal cell and superficial
squamous cell carcinomas).

The choice depends on tumor and patient factors.

Radiation is also used adjuvant theraphy after surgery in high-risk cases, typically with doses
over 6000 cGy, sometimes exceeding 7000 cGy.

Palliative: Radiation therapy is used to alleviate symptoms in patients with incurable head and
neck cancers, such as pain relief, tumor shrinkage, airway obstruction, and bleeding control.

Palliative radiation uses lower doses compared to curative treatments.

PALLIATIVE RADIOTHERAPHY
DOSES
50 gy in 20 fractions
37.5 gy in 15 fractions
30gy in 10 fractions
30 gy in 5 fractions, give 2 fraction per week with more than equal to 3 days
between two treatments
44.4 gy in 12 fractions
TREATMENT SELECTION
Preoperative radiotheraphy
Definative radiotheraphy
Postoperative radiotheraphy
 PREOPERATIVE
RADIOTHERAPHY
Theory behind preoperative radiation therapy:
Tumor cells are maximally oxygenated and more radioresponsive.

Radiation dose and schedule:

Approximate dose: 5000 cGy.
Conventional fractionation: 180-200 cGy per fraction.
Delivered 5 days a week for up to 5 weeks.

Recovery period:
A 4- to 6-week period is required for the acute inflammatory reaction to subside before surgery
DEFINITIVE RADIOTHERAPHY
Special considerations apply to oropharyngeal and nasopharyngeal carcinomas.

Oropharyngeal Carcinoma (OPC):

Increased incidence due to HPV infection.

HPV-positive OPC has better survival and response to treatment than HPV-negative cases (5-
year survival: 80-90% for HPV-positive vs. 50-70% for HPV-negative).

Treatment: Locally advanced OPC is definitive chemoradiation with concurrent high-dose

bolus cisplatin (100 mg/m2 every 3 weeks). Areas of gross disease are treated with 7000 Gy
while surrounding areas at risk and elective volumes in the neck are treated to a lower dose of
3000 to 6000 cGy, .High locoregional control rates (>90%).

Ongoing research aims to de-escalate therapy, reducing toxicity while maintaining cure rates
(e.g., reducing radiation, eliminating systemic therapy, or using cisplatin alternatives).
Follow-up: PET scans for surveillance; neck dissection is no longer routine, only for persistent
or progressive disease.
Nasopharyngeal Carcinomas:

Radiation is the definitive treatment, especially for EBV-associated tumors, which are highly
radiosensitive.

Treatment: For locally advanced NPC - Concurrent chemotherapy with radiation therapy. High
dose Cisplatin is given on days 1, 22, and 43. Adjuvant cisplatin and 5-fluorouracil is given after
CRT. Surgery - considered for persistent disease after 3 months.
RT dose 7000 cGy to the primary tumor, 5940 cGy to high-risk subclinical areas
Five-year survival rates: 60-75% for early-stage, 40-50% for advanced stages.

Lymph node metastases are common (75-90%), with the most at-risk nodes being levels V, II,
and retropharyngeal nodes. B/L nodes as well as retropharyngeal nodes included in the radiation
field

Control rates are >90% in T3/T4 tumors.

 POSTOPERATIVE
RADIOTHERAPHY(PORT)
Indicated when the estimated risk of locoregional recurrence of disease is at least 20%.
Started within 6 weeks of surgery to maximize benefits of combined approach

A delay in initiating PORT does not affect local recurrence at the primary tumor site however
strongly correlated with a higher failure rate in the cervical lymph nodes.

PORT can still be beneficial even when started up to 3 months after surgery.
Optimal radiation dose for the primary tumor site and neck regions:180-200 cGy per fraction, 5
days per week.Total dose: 6000-6600 cGy for high-risk areas, 5000-5400 cGy for elective
nodal irradiation.
Studies (EORTC 22931 and RTOG 95-01) show that adding concurrent chemotherapy with
PORT improves locoregional control in patients with positive surgical margins or extra-nodal
extension.
 RERADIATION
Reirradiation is considered when surgical resection is not feasible or if concerns exist about
margins after salvage surgery.

Factors influencing reirradiation feasibility include:

Previous dose, volume, and tumor response.

Tolerance of normal tissues to additional radiation.
Radiation dose to vital structures.
Feasibility of delivering a tumoricidal dose of radiation.
The need for vascularized tissue to protect vital structures.
Techniques for Reirradiation:
Brachytherapy: Recurrent metastatic disease in the neck, particularly with tumor invasion of the
carotid sheath. Afterloading catheters with iridium-192 - deliver high-dose radiation precisely to the
target area, minimizing damage to surrounding tissues.

IMRT or Proton Therapy: May be considered with complex treatment planning, especially when
brachytherapy isn't suitable.

Intraoperative Radiation Therapy (IORT)

proximity to vital structures like the carotid artery.

CT scan done - assess the extent of residual disease and determine whether IORT is appropriate.

An applicator with afterloading catheters is used to deliver IORT, typically 1500 cGy (range: 1250-
1750 cGy) in a single fraction.

IORT protects previously radiated skin from further exposure, avoiding the need for excision and
replacement by a flap.
SITE SPECIFIC
RADIOTHERAPHY DOSAGE
NASOPHARYNX
HYPOPHARYNGEAL CANCER
DOSE CONTRAINTS TO OAR
 CARE DURING
RADIOTHERAPHY
•Weekly Status Checks: assessing symptoms like sore mouth, dysphagia, hoarseness, altered taste, dry mouth,
skin reactions, and ear issues.

•Physical Examination: tumor status, skin and mucous membranes, and tracking overall health (weight, blood
count).

•Skin and Mouth Care:

•Use moisturizers and RadiaCare Gel for skin burns.
•Mouth sores: rinse with salt and baking soda solution; use lidocaine for pain.
•Use a humidifier to prevent dryness in the upper airway.

•Pain Management:
•Gabapentin and opiates for pain relief.
•Gabapentin can reduce mucositis pain and opiate use.
•Acute Parotitis: Inflammation of the parotid gland, self-limiting, treated with NSAIDs.

•Weight Loss & Dehydration: May require outpatient IV hydration or a PEG tube for more severe cases.
•Mucositis & Infections:
•Pain: Acetaminophen with codeine, morphine, or fentanyl may be needed.
•Oral Candida infections: Treat with antifungal medications.
 ACUTE SEQUALAE
Skin Toxicity: range from erythema (redness) to dry and wet desquamation (peeling), which
could lead to severe cases where the epidermis sloughs off. Skin care, such as using
moisturizers and antiseptic creams, can help alleviate these effects.

.
Mucositis: Mucous membranes are sensitive to radiation and can develop erythema,
followed by mucositis, which could progress to ulceration.

Areas like the soft palate, tonsillar pillars, and buccal mucosa are particularly
vulnerable. Metal dental restorations may intensify these effects
Otitis Media: Radiation to the base of the skull may cause acute serous otitis media,
which can lead to hearing loss or pain. This may require medical intervention such as
a myringotomy.

Salivary Gland Effects: Radiation can lead to a decrease in saliva production,

resulting in dry mouth, increased viscosity, and changes in taste. This can impair
eating and require modifications in diet or even tube feeding in severe cases
 LATE SEQUALAE

Mechanisms - Caused by vascular endothelial damage, fibrosis, muscle atrophy, and cell death, leading to
long-term complications.

Skin Effects:
Atrophy, telangiectasias (common after electron therapy), fibrosis, and subdermal contracture.
Risk of skin carcinomas developing years after treatment.
Delayed healing and necrosis in irradiated fields if surgery is required.

Xerostomia (Dry Mouth):

Leads to difficulty swallowing, dental caries, and affects quality of life.
No effective treatment but salivary substitutes and oral irrigation can provide relief.
Preventive treatments like amifostine show limited benefit.
Thyroid Dysfunction:

Subclinical hypothyroidism is common, with possible hormone replacement if TSH levels rise.
Full endocrine screening is necessary if the hypothalamic-pituitary axis is affected.

Fibrosis and Muscle Atrophy:

Can lead to motor dysfunction, dysphagia, contractures, and strictures.

Dysphagia can be treated with repeated dilations; trismus (jaw stiffness) can be prevented with
early jaw exercises. Shoulder movement may be limited, requiring daily range-of-motion
exercises.

Dental Care:
Lifelong fluoride prophylaxis is crucial to prevent caries and osteoradionecrosis.
Dental procedures like extractions may trigger radiation necrosis, requiring careful management
Hyperbaric oxygen therapy can prevent necrosis but not reverse it once it occurs.
Osteoradionecrosis
Direct osteocytic damage or injury to the small vasculature of the haversian systems and the
periosteum
Pathologic fractures may occur
Pain, fistula, infection, and complete or partial sensational loss
Typically involves the mandible
occurs within the first 3 years after diagnosis of head and neck cancer
Management –
includes the maintenance of meticulous oral hygiene, maintenance of adequate nutritional
intake, and discontinuation of alcohol and tobacco consumption
if attempts to preserve teeth are unsuccessful, postradiotherapy dental extractions should be
performed cautiously due to the risk of initiating osteonecrosis.
Local resection of loose bony spicules may be possible.
Hyperbaric oxygen treatment may be recommended if conservative treatment has failed
Site-Specific Late Effects:

Chronic Serous Otitis Media

Lhermitte Syndrome: Symmetric shooting pain after cervical radiation, typically self-
limiting but can last several months.

Radiation Myelitis: Serious, if symptoms appear 9–12 months post-radiation.

Growth and Bone Effects:

In children, radiation can impair growth, cause atrophy, or lead to
chondritis/osteonecrosis.

Cancer Risk:
Radiation can increase the risk of second cancers in the irradiated field, usually
squamous cell carcinoma or high-grade sarcomas.
Risk increases with time, especially in younger patients
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