Laryngeal Complications Head and Neck

necessary depending on the underlying cause of the edema and the severity. ENT evaluation and hospitalization may be required for more com- plicated cases. Adolescent patients should be advised against smoking during and after RT as it has been reported to lead to persistent hoarse- ness in adults with glottic tumors Chopra and Bogart 2009 .

13.6 Gastrointestinal

Complications The stomach and small bowel are often inciden- tally irradiated when treating upper GI tract, infe- rior lung, retroperitoneal, and pelvic tumors. Acute gastrointestinal RT-induced side effects include nausea, vomiting, and anorexia immedi- ately after treatment as well as dysphagia, esopha- gitis, dyspepsia, ulceration, bleeding, enteritis GI mucositis manifesting as cramping, diarrhea, and malabsorption, and proctitis within the fi rst few weeks of therapy Kavanagh et al. 2010 ; Michalski et al. 2010 . Late small bowel obstruction due to RT-induced fi brosis and secondary adhesions as well as chronic dyspepsia, ulceration, diarrhea, fi stula, perforation, bleeding, strictures, and chronic radiation proctitis must be considered but are beyond the scope of this chapter. RT dose- volume constraints for the stomach and small bowel are diffi cult to determine as partial volume irradiation is usually undertaken; ≥45 Gy for the whole stomach and for partial small bowel 195 mL are thresholds that have been published for adult patients Kavanagh et al. 2010 .

13.6.1 Dysphagia and Esophagitis

Radiation to the oropharynx can lead to pharyn- geal edema as well as dysphagia while RT to the thorax can lead to esophagitis. Adult patients receiving chemoradiation or hyperfractionated RT have been noted to have a 15–25 risk of severe acute esophagitis with symptoms peaking 4–8 weeks after the commencement of RT Werner-Wasik et al. 2010 . Of note, esophageal infections such as oroesophageal OE candidiasis or herpes simplex esophagitis can lead to similar symptoms and must be ruled out; additionally, preexisting gastroesophageal refl ux GER can worsen esophagitis and should be treated Werner- Wasik et al. 2010 . If infection is a concern, patients should undergo diagnostic endoscopy unless the level of symptoms contradicts such a procedure; in such cases empiric therapy e.g., fl u- conazole for OE candidiasis may be required. Radiation doses 40–50 Gy in adults have been shown to correlate with increased risk of acute esophagitis Werner-Wasik et al. 2010 . Data in the pediatric population are lacking. Amifostine has shown some potential benefi t in non-small cell lung cancer patients, but the reports are inconsistent, and recommendation for its use is also not uniform Keefe et al. 2007 ; Hensley et al. 2009 ; Peterson et al. 2011 . No other agent has been well studied; oral sucralfate has been utilized, but data are confl icting, and it is not recommended in consensus guidelines for RT-induced esophagitis Bradley and Movsas 2004 . General treatment strategies include treat- ment of underlying GER with an H 2 blocker or proton pump inhibitor, ruling out and treating infectious etiologies for esophagitis, and prescrib- ing viscous lidocaine and analgesics for pain. Promotility agents such as metoclopramide can also be tried. Patients should be advised to avoid acidic and spicy foods as well as alcohol and cof- fee. Nutritional status should be closely moni- tored, and patients at risk for malnutrition should receive oral supplementation, nasogastric feeds, PEG placement if with a head and neck tumor, or TPN, depending on the underlying clinical sit- uation; see Chap. 12 for more details. Pediatric patients with a history of chemoradiation- induced esophagitis are at risk for esophageal stricture and should be monitored for this potential late compli- cation Mahboubi and Silber 1997 .

13.6.2 Nausea, Vomiting and Anorexia

Radiation-induced nausea and vomiting RINV has been reported to occur in 50–80 of adult patients dependent on the radiation fi eld, RT dose, and use of concurrent chemotherapy Feyer et al. 2011 . MASCCISOO and ASCO have created clinical practice guidelines for antiemetics with RINV and have devised an RT emetogenic risk stratifi cation, with high risk in those receiving TBI, moderate risk with RT to the upper abdo- men, low risk for cranial, craniospinal, head and neck, lower thorax, and pelvic RT, and minimal risk with extremity and breast RT Basch et al. 2011 ; Feyer et al. 2011 . Emetic prophylaxis should be per the chemotherapy- related anti- emetic schedule unless the risk of emesis is higher with RT Basch et al. 2011 ; Feyer et al. 2011 . Pediatric guidelines for RINV are lacking. Chap. 10 has a more extensive discussion of antiemetics in relation to chemotherapy- induced nausea and vomiting in children. MASCCISOO and ASCO guidelines both recommend prophylaxis with a 5-HT 3 receptor antagonist in the high- and moderate-risk groups with prophylactic dexamethasone in the high- risk group and optional dexamethasone in the moderate-risk group. MASCCISOO guidelines recommend prophylaxis or rescue with a 5-HT 3 receptor antagonist in the low-risk group while ASCO guidelines recommend no prophylaxis in this cohort. Finally, both guidelines advise res- cue only with either a 5-HT 3 receptor antagonist or dopamine antagonist in the minimal-risk group Basch et al. 2011 ; Feyer et al. 2011 . ASCO guidelines recommend a 5-HT 3 receptor antagonist prior to each fraction with 5 days of dexamethasone; MASCCISOO guidelines make no particular recommendation in regard to duration of prophylaxis Basch et al. 2011 ; Feyer et al. 2011 . Gastric protection should be consid- ered with repeated or prolonged dexamethasone therapy.

13.6.3 Enteritis

Abdominopelvic radiation can cause acute injury to the small bowel mucosa leading to enteritis GI mucositis with cramping, diarrhea, and malabsorptive symptoms, potentially exacer- bated by concomitant chemotherapy administra- tion Chopra and Bogart 2009 . Basic bowel care is recommended including maintenance of ade- quate hydration and consideration for possible lactose intolerance and bacterial pathogens Keefe et al. 2007 ; Peterson et al. 2011 . Symptoms of radiation-induced enteritis have traditionally been managed with moderate bowel rest, such as institution of a low-residue, low-fat and low-lactose diet. For severe diarrhea, anti- motility agents such as loperamide or atropine may be utilized. Due to the risk of bacterial pathogens, treatable causes such as Clostridium diffi cile should be ruled out. A recent systematic review by MASCCISOO suggests the prophy- lactic use of probiotics with Lactobacillus spp. and sulfasalazine, 500 mg twice daily, to prevent RT-induced enteritis for adult patients with pel- vic tumors Gibson et al. 2013 . The recommen- dation for sulfasalazine is specifi cally for patients receiving pelvic EBRT. Additionally the guidelines recommend octreotide in patients after HSCT with chemotherapy conditioning that fail loperamide for control of diarrhea Gibson et al. 2013 . Patients undergoing RT are not included in this recommendation. Agents that have not shown benefi t and should not be utilized include amifostine, 5-ASA and related compounds, and sucralfate Peterson et al. 2011 ; Gibson et al. 2013 . Pediatric data are lacking.

13.6.4 Proctitis

Adult patients receiving radiation for anal cancer are at risk for the development of radiation proc- titis which is usually self-limited and leads to softer or diarrhea-like stools, pain, a sense of rec- tal distension with cramping, urgency, increased frequency, and rarely bleeding Chopra and Bogart 2009 ; Michalski et al. 2010 . A potential example in pediatric patients could be perineal sarcoma; evidence is lacking. RT doses to the rectum 45 Gy increase the risk for proctitis Michalski et al. 2010 . Recent guidelines by MASCCISOO and ESMO suggest the use of IV intrarectal amifostine prior to RT as well as HBO and sucralfate enemas for the treatment of procti- tis and recommend against misoprostol supposi- tories Peterson et al. 2011 ; Gibson et al. 2013 .