Clinical Course of Radiation Therapy

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The patient undergoing radiation therapy will need to be seen for routine status evaluation at least once a week. At that time, a pertinent interval history is obtained with special attention paid to the development of a sore mouth or throat, dysphagia, hoarseness, taste problems, xerostomia, skin symptomol-ogy, and even ear symtoms when the portal includes the external auditory canal and/or eustachian tube. A directed examination will evaluate the tumor status with measurements and an estimation of the mobility and texture when appropriate. Failure of head and neck cancers to achieve a complete response at or shortly after completion of radiation is associated with an increased risk of local failure. Therefore close monitoring and weekly documentation of the tumor is necessary. The patient should be checked for mucositis, oral Candida and dermal reactions. The general condition, weight status and complete blood count will need to be monitored.

An occasional patient will develop acute parotitis which can occur within the first 12 hours after initiation of irradiation to portals including the parotid gland. This is due to an acute inflammatory reaction within the parotid gland due to radiation. These patients will complain of parotid area swelling, localized pain and perhaps even a low-grade temperature. This is a self-limited problem that will usually resolve spontaneously after several hours. However, we generally prescribe a nonsteroidal anti-inflammatory drug and reassure the patient.

During the second week of treatment at around the 2,000 cGy dosage, the patient should be checked for development of tumoritis, a mucosal inflammation which indicates the true extent of tumor and thus may necessitate a modification of the portal.24 If tumors do not show reasonable regression or if they actually progress during radiation therapy, immediate reevaluation by all of the physicians on the case is mandatory, as this may be an indication that surgery is necessary. However, we have seen an occasional patient in whom their lymphadenopathy had actually increased in size during treatment and while preparing to undergo surgery, it had regressed to its baseline dimensions. We elected to complete the initially planned radiation therapy and had very good results. These unusual situations may be related to a transitory inflammatory response in the lymph nodes from an undetermined cause.

Patients can develop progressive weight loss and dehydration by the fourth to fifth week of treatment.

Xerostomia After Radiation
Figure 21-16. Radiation-induced acute mucositis of the lateral aspect of the oral tongue. Note the erythema and the more pale area of fibrinous exudate.

This is particularly prominent in patients undergoing concurrent chemotherapy and radiation therapy. They initially may require intravenous hydration as outpatients but often will ultimately need to have a percutaneous endoscopic gastrostomy tube placed for more intensive daily hydration and caloric administration.

Patients will develop mucositis (Figures 21-16 and 17) which can become quite severe by the fourth to fifth week of treatment, particularly in patients who are receiving concurrent chemotherapy and radiation therapy. Acetaminophen with codeine either in tablet or liquid form can be palliative initially. However, not infrequently, we have needed to advance the medication to a long-acting morphine sulfate or fentanyl patch with immediate-release morphine sulfate for rescue.

A fair number of patients will develop an oral Candida infection (Figure 21-18). Some may be asymptomatic at presentation while others may complain of an acute development or exacerbation of their sore mouth or throat. Immediate initiation of antifungal medication will usually resolve the problem in short order.

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