Treatmentrelated Toxicities

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Toxicities of radiotherapy may limit the dose that can be delivered. These toxicities range from mild and temporary to more serious and potentially permanent and debilitating. Side effects are divided into acute and delayed toxicities. Acute toxicities, which generally are temporary, include hair loss, skin reaction, sore throat, dysphagia, Eustachian tube dysfunction with "plugged ears", nausea and vomiting, and fatigue. In patients with leptomeningeal spread of their primary cancer, acute toxicities often are more concerning because the patient may not live long enough to experience long-term problems. Certain patients, however, attain longer survival and maybe at risk for delayed toxicities.

Radiation therapy may contribute to both acute and chronic bone marrow suppression, especially when large fields, such as craniospinal irradiation, are treated. Decreases in blood counts are heightened in patients who have previously received myelosuppressive chemotherapy. Because of this, more limited involved field radiation ports are used to treat the bulk of disease rather than the entire craniospinal axis. If further chemotherapy is contemplated, care should be taken to encompass the bulky disease only in order to spare bone marrow reserve.

Damage to the CNS is another serious potential toxicity of radiation treatment for leptomeningeal cancer. CNS damage is multifactorial and is dependent on total dose, dose per fraction, treatment volume and patient-related factors such as other medical co-morbidities. CNS toxicities can occur at any time, but certain problems have typical time appearances. Acute toxicities occur within the first few weeks, early-delayed toxicity from four weeks to four months, and late-delayed toxicity from four months to years after radiation.25 Important examples include acute radiation encephalopathy, early-delayed cerebral necrosis, and late-delayed cranial nerve damage. The spinal cord also is at risk with toxicities including acute Lhermitte's sign, late-delayed radiation myelopathy, and late-delayed motor neuron syndrome. As with bone marrow toxicity, all of these complications may be potentiated with chemotherapy, particularly with intrathecal chemotherapy. These complications can confound the oncologist as they may be mistaken for disease progression.

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