Erosive esophagitis secondary to radiotherapy: Case report / Esofagitis erosiva secundaria a radioterapia: reporte de un caso

Abstract Introduction: Erosive esophagitis secondary to radiotherapy is an unusual complication in the oncological treatment of thoracic tumors. This pathological entity is associated with multiple complications, which is a clinical challenge for health workers unfamiliar with the clinical manifestations. Clinical case: A 64-year-old woman with a 3-day clinical picture of chest pain radiating to the epigastrium with 10/10 intensity. On physical examination, she was tachycardic, hypotensive, and with intense pain in the upper hemiabdomen region; she had no signs of peritoneal irritation on deep palpation. Paraclinical tests showed no signs of local or disseminated infection, but endoscopy of the digestive tract reported post-radiation esophagitis. Discussion: Erosive esophagitis after radiotherapy occurs in less than 1 % of cases, and clinical manifestations such as dysphagia, odynophagia, and abdominal pain are common. Initial symptomatic management is preserved, with supportive measures such as intravenous hydration and proton pump inhibitors (PPIs). In case of intolerance to the oral route, therapy with nutritional support is indicated via nasogastric tube or gastrostomy in the most severe cases.

Resumen Introducción: la esofagitis erosiva secundaria a la radioterapia es una complicación inusual del tratamiento oncológico de los tumores torácicos. Esta entidad patológica está asociada con múltiples complicaciones, lo que resulta un reto clínico para los profesionales en salud que están poco familiarizados con las manifestaciones clínicas. Caso clínico: mujer de 64 años con cuadro clínico de 3 días de dolor torácico irradiado al epigastrio con intensidad 10/10. En el examen físico se encontró taquicárdica, hipotensa, con dolor intenso en la región hemiabdominal superior; a la palpación profunda no tenía signos de irritación peritoneal. Los paraclínicos no mostraron signos de infección local o diseminada, pero la endoscopia de vías digestivas reportó esofagitis posirradiación. Discusión: la esofagitis erosiva posterior a la radioterapia se presenta en menos del 1 % de los casos, las manifestaciones clínicas como disfagia, odinofagia y dolor abdominal son frecuentes; el manejo sintomático inicial es conservado, con medidas de soporte como hidratación intravenosa e inhibidores de la bomba de protones (IBP). En caso de intolerancia a la vía oral se indica terapia con soporte nutricional por sonda nasogástrica o gastrostomía en los casos más graves.

Aumento da hiperdensidade da cortical óssea línguo-basal após radioterapia em região de cabeça e pescoço: relato de caso / Hyperdensity of the lingual-basal bone cortex incresead after radiotherapy in the head and neck region: case report

Objetivo: relatar um caso de aumento da hiperdensidade da cortical óssea línguo-basal pós-radioterapia em região de cabeça e pescoço por meio de avaliação imaginológica. Relato de caso: paciente do sexo feminino, 80 anos, procurou tratamento odontológico com a finalidade de reabilitação oral com implantes dentários. Na anamnese, relatou histórico de carcinoma espinocelular em regiões distintas da cavidade oral. No exame clínico, notou-se que a paciente era edêntula total e foi solicitado um exame de tomografia computadorizada de feixe cônico. Foi observado, na região anterior inferior, aumento da hiperdensidade da cortical óssea línguo-basal, com osso compacto mais espesso, achado incomum na literatura após radioterapia. Considerações finais: os efeitos da radioterapia em mandíbula estão relatados na literatura. No caso clínico em questão, detectou-se uma alteração pouco notada em pacientes submetidos à radioterapia, fazendo surgir novos questionamentos, sendo eles sobre o diagnóstico dessa modificação na estrutura óssea e suas repercussões. (AU)

Objective: to report a case of increased hyperdensity of the lingual-basal bone cortex after radiotherapy in the head and neck region by means of imaging evaluation. Case report: female patient, 80 years old, sought dental treatment for the purpose of oral rehabilitation with dental implants. In the anamnesis, she reported a history of squamous cell carcinoma in different regions of the oral cavity. Upon clinical examination, it was noted that the patient was total edentulous and a cone beam computed tomography examination was requested. An increase in the hyperdensity of the lingual-basal bone cortex was observed in the lower anterior region, with thicker compact bone, an unusual finding in the literature after radiotherapy. Final considerations: the effects of radiotherapy on the mandible are reported in the literature. In the clinical case in question, a little-noticed change was detected in patients undergoing radiotherapy, leading to new questions, concerning the diagnosis of this change in bone structure and its repercussions.(AU)

Proctitis crónica hemorrágica por radioterapia en el Instituto Nacional de Enfermedades Neoplásicas del Perú, 2011-2013 / Radiotherapy associated chronic hemorrhagic proctitis at the National Institute of Neoplastic Diseases of Peru, 2011-2013

Objetivo: Estudiar las características clínicas y endoscópicas de la proctitis crónica hemorrágica por radioterapia en el Instituto Nacional de Enfermedades Neoplásicas del Perú. Materiales y métodos: Estudio descriptivo, retrospectivo y longitudinal, con una población de 588 pacientes con esta patología, en el periodo 2011-2013, de donde se seleccionaron 114 pacientes por muestreo probabilístico aleatorizado. Se usó la estadística descriptiva e inferencial para el análisis de las variables cualitativas y cuantitativas. Resultados: La investigación encontró como principales resultados, un periodo de latencia de 439,96 días; la severidad de rectorragia clínica fue grado II y III en el 86,84%, la hemoglobina media fue de 11,63 gr/dl, los hallazgos endoscópicos fueron severidad moderada en el 58,77%, extensión solo rectal en el 92,11%, friabilidad leve del 43,86%, compromiso menor del 33% de la superficie rectal en el 71,93% y una longitud media de 7,28 cm. Los hallazgos inflamatorios fueron de cicatrices en el 0,88%, erosiones del 0,88%, de úlceras del 7%, de fístula del 0,88% y del 3,51% de estenosis rectales, el tratamiento de argón plasma coagulación (APC) único o combinado se ofreció en el 96% de los casos. Conclusiones: La proctitis crónica hemorrágica por radioterapia fue una complicación importante de la radioterapia pélvica, con hallazgos clínicos y endoscópicos característicos.

Objective: To study the clinical and endoscopic features of chronic hemorrhagic proctitis by radiotherapy in the National Institute of Neoplastic Diseases of Peru. Materials and methods: The study was descriptive, retrospective and longitudinal, with a population of 588 patients with this pathology, in the period 2011-2013, from which 114 patients were selected by randomized probabilistic sampling. Descriptive and inferential statistics were used for the analysis of qualitative and quantitative variables. Results: The main results were a latency period of 439.96 days; the severity of clinical rectal bleeding was grade 2 and 3 in 86.84%, the mean hemoglobin in chronic hemorrhagic proctitis by radiotherapy was 11.63 g / dl, the endoscopic findings were moderate severity in 58.77%, extension rectal only in 92.11%, slight friability of 43.86%, compromise less than 33% of the rectal surface in 71.93% and an average length of 7.28 cm. The inflammatory findings were 0.88% scars, erosions of 0.88%, ulcers of 7%, fistula of 0.88% and 3.51% of rectal stenosis, single or combined argon plasma coagulation (APC) treatment was offered in 96% of cases. Conclusion: Chronic hemorrhagic proctitis is an important complication of pelvic radiotherapy, with characteristic clinical and endoscopic findings.

Pathological fracture after radiotherapy: systematic review of literature

SUMMARY OBJECTIVE: To evaluate the epidemiological data and available treatments for fractures secondary to radiotherapy treatment. METHODS: Identification of publications on pathological skeletal fractures previously exposed to ionizing radiation. RESULTS: The incidence of fractures after irradiation varies from 1.2% to 25% with a consolidation rate of 33% to 75%, being more frequent in the ribs, pelvis, and femur. The time elapsed between irradiation and fracture occurs years after radiotherapy. Risk factors include age above 50 years, female gender, extensive periosteal detachment, circumferential irradiation, tumor size, and anterior thigh location. The etiology is still uncertain, but cellular disappearance, reduction of bone turnover and activity were observed hematopoietic as possible causes of failure of consolidation. CONCLUSION: There is no consensus in the literature on the factors related to the development of fractures, with radiation dose, previous tumor size and periosteal detachment being suggested as potential factors.

RESUMO OBJETIVO: Avaliar dados epidemiológicos e tratamentos disponíveis para fraturas secundárias ao tratamento radioterápico. MÉTODOS: Identificação de publicações sobre as fraturas patológicas ocorridas em esqueleto previamente exposto à radiação ionizante. RESULTADOS: A incidência de fraturas após irradiação varia de 1,2% a 25% com taxa de consolidação de 33% a 75%, sendo mais frequente em costelas, pelve e fêmur. O tempo decorrido entre a irradiação e a fratura ocorre anos após a radioterapia. Os fatores de risco incluem idade acima de 50 anos, sexo feminino, descolamento periosteal extenso, irradiação circunferencial, tamanho do tumor e localização anterior na coxa. A etiologia ainda é incerta, mas foram observados desaparecimento celular, redução do turnover ósseo e da atividade hematopoiética como possíveis causas da falha de consolidação. CONCLUSÃO: Não há consenso na literatura avaliada sobre os fatores relacionados ao desenvolvimento de fraturas, sendo a dose de radiação, o tamanho prévio do tumor e o descolamento periosteal sugeridos como fatores potenciais.

Hyberbaric oxygen as sole treatment for severe radiation - induced haemorrhagic cystitis

ABSTRACT Purpose To examine the safety and efficacy of hyperbaric oxygen as the primary and sole treatment for severe radiation-induced haemorrhagic cystitis. Materials and methods Hyperbaric oxygen was prospectively applied as primary treatment in 38 patients with severe radiation cystitis. Our primary endpoint was the incidence of complete and partial response to treatment, while the secondary endpoints included the duration of response, the correlation of treatment success-rate to the interval between the onset of haematuria and initiation of therapy, blood transfusion need and total radiation dose, the number of sessions to success, the avoidance of surgery and the overall survival. Results All patients completed therapy without complications with a mean follow-up of 29.33 months. Median number of sessions needed was 33. Complete and partial response rate was 86.8% and 13.2%, respectively. All 33 patients with complete response received therapy within 6 months of the haematuria onset. One patient needed cystectomy, while 33 patients were alive at the end of follow-up. Conclusions Our study suggests the early primary use of hyperbaric oxygen for radiation-induced severe cystitis as an effective and safe treatment option.

Impact of late radiation effects on cancer survivor children: an integrative review / Impacto dos efeitos tardios da radiação em crianças sobreviventes de câncer: revisão integrativa

We aimed to identify the late effects of radiation exposure in pediatric cancer survivors. An integrated literature review was performed in the databases MEDLINE and LILACS and SciELO. Included were articles in Portuguese and English, published over the past 10 years, using the following keywords: “neoplasias/neoplasms” AND “radioterapia/radiotherapy” AND “radiação/radiation”. After analysis, 14 articles - published in nine well-known journals - met the inclusion criteria. The publications were divided into two categories: “Late endocrine effects” and “Late non-endocrine effects”. Considering the increased survival rates in children who had cancer, the impact of late effects of exposure to radiation during radiological examinations for diagnosis and treatment was analyzed. Childhood cancer survivors were exposed to several late effects and should be early and regularly followed up, even when exposed to low radiation doses.

Objetivamos identificar os efeitos tardios da exposição à radiação em crianças sobreviventes do câncer. Foi realizada uma revisão integrativa de literatura, nas bases de dados MEDLINE e LILACS, e no suporte eletrônico SciELO. Foram incluídos artigos nos idiomas português e inglês, publicados nos últimos 10 anos, utilizando os descritores “neoplasias/neoplasms” AND “radioterapia/radiotherapy” AND “radiação/radiation”. Após análise, 14 artigos, publicados em nove revistas conceituadas, atenderam os critérios de inclusão. As publicações foram divididas em duas categorias: “Efeitos tardios endócrinos” e “Efeitos tardios não endócrinos”. Com o aumento nas taxas de sobrevida em crianças sobreviventes do câncer, foi observado o impacto dos efeitos tardios referentes à exposição da radiação, e decorrentes do tratamento e de exames radiodiagnósticos. Sobreviventes de câncer na infância estiveram expostos a diversos efeitos tardios e devem ter um seguimento precoce e regular, ainda que expostos a doses baixas de radiação.

A Comparison of Gastrointestinal Toxicities between Intensity-Modulated Radiotherapy and Three-Dimensional Conformal Radiotherapy for Pancreatic Cancer

BACKGROUND/AIMS: Concurrent chemoradiotherapy (CCRT) is considered the treatment option for locally advanced pancreatic cancer, but accompanying gastrointestinal toxicities are the most common complication. With the introduction of three-dimensional conformal radiotherapy (3-D CRT) and intensity-modulated radiotherapy (IMRT), CCRT-related adverse events are expected to diminish. Here, we evaluated the benefits of radiation modalities by comparing gastrointestinal toxicities between 3-D CRT and IMRT. METHODS: Patients who received CCRT between July 2010 and June 2012 in Severance Hospital, Yonsei University College of Medicine, were enrolled prospectively. The patients underwent upper endoscopy before and 1 month after CCRT. RESULTS: A total of 84 patients were enrolled during the study period. The radiotherapy modalities delivered included 3D-CRT (n=40) and IMRT (n=44). The median follow-up period from the start of CCRT was 10.6 months (range, 3.8 to 29.9 months). The symptoms of dyspepsia, nausea/vomiting, and diarrhea did not differ between the groups. Upper endoscopy revealed significantly more gastroduodenal ulcers in the 3-D CRT group (p=0.003). The modality of radiotherapy (3D-CRT; odds ratio [OR], 11.67; p=0.011) and tumor location (body of pancreas; OR, 11.06; p=0.009) were risk factors for gastrointestinal toxicities. CONCLUSIONS: IMRT is associated with significantly fewer gastroduodenal injuries among patients treated with CCRT for pancreatic cancer.

Is there a role for hyberbaric oxygen as primary treatment for grade IV radiation-induced haemorrhagic cystitis? a prospective pilot-feasibility study and review of literature

Purpose To examine the safety and efficacy of hyperbaric oxygen as the primary treatment for Grade IV radiation-induced haemorrhagic cystitis. Materials and Methods Hyperbaric oxygen was prospectively applied as a primary treatment option in 11 patients with Grade IV radiation cystitis. Primary endpoint was the incidence of complete and partial response to treatment. Secondary endpoints included the duration of response, the correlation of treatment success-rate to the interval between the onset of haematuria and initiation of therapy, blood transfusion need and total radiation dose, the number of sessions to success, the avoidance of surgery and the overall survival. Results All patients completed therapy without complications for a mean follow-up of 17.82 months (range 3 to 34). Mean number of sessions needed was 32.8 (range 27 to 44). Complete and partial response rate was 81.8% and 18.2%, respectively. However, in three patients the first treatment session was not either sufficient or durable giving a 72.7% rate of durable effect. Interestingly, all 9 patients with complete response received therapy within 6 months of the haematuria onset compared to the two patients with partial response who received therapy at 8 and 10 months from the haematuria onset, respectively (p = 0.018). The need for blood transfusion (p = 0.491) and the total radiation dose (p = 0.259) were not correlated to success-rate. One patient needed cystectomy, while all patients were alive at the end of follow-up. Conclusions Early primary use of hyperbaric oxygen to treat radiation-induced grade IV cystitis is an effective and safe treatment option. .

Riscos da Radiação X e a Importância da Proteção Radiológica na Cardiologia Intervencionista: Uma Revisão Sistemática / Radiation Risks and the Importance of Radiological Protection in Interventional Cardiology: A Systematic Review

Discutimos aqui aspectos vinculados ao enquadramento legal, a recomendações internacionais e a programas de formação em proteção radiológica; ao angiógrafo e à qualidade da imagem; aos efeitos biológicos e aos riscos das radiações ionizantes; às lesões em operadores e pacientes; aos níveis de referência do paciente; ao limite de dose ocupacional e a suas medidas de prevenção. O uso das radiações ionizantes acarreta riscos, que, contudo, justificam-se em procedimentos diagnósticos e terapêuticos. A consciência e o conhecimento desses riscos minimizam o dano, otimizando a qualidade da imagens e o uso seguro das radiações ionizantes. Tem-se demonstrado a ocorrência de cataratas radioinduzidas em trabalhadores de laboratórios de cateterismo. Diversos estudos sugerem que pode haver um risco significativo de opacidade do cristalino, caso não se utilizem adequadamente os dispositivos de proteção radiológica. Adicionalmente, esses tipos de procedimentos intervencionistas são realizados na América Latina, geralmente por médicos especialistas, com a colaboração de enfermeiros, tecnólogos e técnicos, que, muitas vezes, não têm formação adequada em proteção radiológica.

We discuss some aspects related to the legal framework, international recommendations and training programs on radiological protection; image quality and equipment; the biological effects and risks of ionizing radiation; lesions in patients and operators; patient's reference levels; occupational dose limit and preventive actions. The use of ionizing radiation involves risks that are justified in diagnostic and therapeutic procedures. The awareness and knowledge of these risks minimizes the damage, optimizing the quality of images and safe use of ionizing radiation. There is evidence of radiation-induced cataracts in individuals who work in catheterization laboratories. Several studies suggest there may be a significant risk of lens opacity, if radiological protection devices are not properly used. Additionally, these interventional procedures are performed in Latin America, usually by medical specialists in collaboration with nurses, technologists and technicians, who often do not have adequate training in radiological protection.

Growing Heterotopic Calcification in the Prevertebral Space of a Cervical Spine as a Late Complication of Irradiation: Case Report

Heterotopic calcification following head and neck irradiation has rarely been reported. It usually develops as a late complication of radiotherapy in patients with malignancies, including breast cancer, lymphoma, and genitourinary malignancies. The occurrence of heterotopic calcification in the prevertebral space of the cervical spine has not been described as a late complication of irradiation. Here, we report a case of prevertebral heterotopic calcification in a patient with history of chemotherapy and radiotherapy for tonsil cancer 21 years ago.

Phacoemulsification and foldable acrylic IOL implantation in children with treated retinoblastoma / Facoemulsificação e implante de lente intraocular acrílica dobrável em crianças com retinoblastoma

PURPOSE: To study the results of cataract surgery in children with radiation-induced cataract after treatment for retinoblastoma. METHODS: Retrospective interventional case series. Six consecutive patients diagnosed with secondary cataracts due to radiation therapy for retinoblastoma. Intervention: Phacoemulsification and foldable acrylic intraocular lens implantation. Outcomes measu- red: Visual acuity, binocular indirect ophthalmoscopy and slit-lamp biomicroscopy. Aspirated lens material and aqueous humor samples were collected during surgery. RESULTS: Six uniocular children between 3 to 5 years of age at time of surgery were studied. The mean time interval between radiotherapy and cataract diagnosis was 22.3 months. The mean follow-up after surgery was 17.2 months (range: 12 to 23 months). All eyes achieved a clear visual axis after surgery allowing monitoring of the tumor status. None developed recurrence or retinoblastoma dissemination. Histopathological analysis of the aspired material showed no tumoral cells in all samples. All patients improved vision after cataract surgery. CONCLUSIONS: Phacoemulsification with acrylic intraocular lens implantation seems to be a safe, feasible, and effective method for the removal of radiation-induced cataracts in patients with treated retinoblastoma.

OBJETIVOS: Estudar os resultados da cirurgia da catarata induzida pela radioterapia para o tratamento do retinoblastoma em crianças. MÉTODOS: Estudo retrospectivo intervencional em série de casos onde seis pacientes consecutivos apresentaram catarata secundária à terapia por radiação para o retinoblastoma. Intervenção: Facoemulsificação e implante de lente intraocular acrílica dobrável. Foram avaliadas: acuidade visual, oftalmoscopia binocular indireta e biomicroscopia. Material para análise histológica do cristalino e do humor aquoso foi coletado durante as cirurgias. RESULTADOS: Seis crianças, entre 3 e 5 anos de idade, com catarata secundária à radiação para tratamento de retinoblastoma foram submetidas à cirurgia de facoemulsificação com implante de lente intraocular. A média do intervalo de tempo decorrido entre a radioterapia e o diagnóstico da catarata foi 22,3 meses. O período médio de seguimento após a cirurgia foi de 17,2 meses (intervalo: 12 a 23 meses). Todos os olhos melhoraram a visão e mantiveram eixo visual livre permitindo a fundoscopia para monitorar o tumor. Nenhum paciente evoluiu com recorrência ou disseminação do retinoblastoma. A análise histopatológica do material colhido resultou em ausência de células tumorais nas amostras. CONCLUSÕES: A cirurgia de facoemulsificação com implante de lente intraocular acrílica dobrável mostrou ser um procedimento seguro e efetivo para o tratamento da catarata induzida pela radioterapia em pacientes portadores de retinoblastoma.

Obstrução de vias lacrimais associada ao tratamento radioiodoterápico de carcinoma de tireoide / Lacrimal drainage system obstruction associated to radioactive iodine therapy for thyroid carcinoma

OBJETIVO: Descrever uma série de pacientes portadores de obstrução do sistema lacrimal associado à radioiodoterapia para tratamento de carcinoma de tireoide, revisar os dados clínicos e a resposta ao tratamento cirúrgico desta rara complicação. MÉTODOS: Foi realizada uma análise retrospectiva dos achados oftalmológicos de pacientes com histórico de carcinoma de tireoide previamente submetidos à tireoidectomia e à RIT que foram encaminhados para cirurgia de vias lacrimais. RESULTADOS: Dezessete pacientes com carcinoma de tireoide tratados com tireoidectomia e RIT apresentaram obstrução do ducto nasolacrimal sintomática após período médio de 13,2 meses do tratamento do câncer. Onze pacientes tiveram epífora bilateral, 8 com mucocele de saco lacrimal. A idade dos pacientes variou entre 30 e 80 anos, sendo 10 com idade menor ou igual a 49 anos. A dose cumulativa média de radioiodo administrada foi de 571 mCi (variação entre 200-1200 mCi). Sintomas de obstrução nasal e aumento de glândulas salivares ocorreram em 53% dos pacientes. Todos os pacientes foram submetidos à dacriocistorrinostomia. Observou-se ainda que nos 3 pacientes mais jovens houve maior sangramento intraoperatótio e dilatação de saco lacrimal. A resolução completa da epífora e da dacriocistite ocorreu em 82,4%, e foi parcial em 17,6% (3 pacientes mantiveram queixa unilateral após a correção da obstrução bilateralmente). O seguimento médio foi de 6 meses (intervalo: 2-24 meses). CONCLUSÕES: Alta dose cumulativa de radioiodo, disfunção nasal e de glândulas salivares estão associadas à obstrução das vias lacrimais. Observa-se uma maior porcentagem de pacientes mais jovens apresentando quadro de dacriocistite quando comparado à dacrioestenose idiopática. A absorção de iodo radioativo pela mucosa do ducto nasolacrimal com subsequente inflamação, edema e fibrose parece ter relação direta com a obstrução do ducto nasolacrimal. O conhecimento desta complicação é importante para o estudo e abordagem correta desses pacientes.

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with radio iodine therapy and to review clinical data and the surgical treatment outcome of this rare complication. METHODS: We retrospectively analyzed ophthalmological data of patients with history of thyroid carcinoma that underwent radioactive iodine I-131 therapy and were referred to lacrimal surgery. RESULTS: 17 patients with thyroid cancer treated with thyroidectomy and radioactive iodine I-131 therapy presented symptomatic nasolacrimal duct obstruction after 13.2 months following cancer treatment. 11 patients presented bilateral epiphora, 8 had lacrimal sac mucocele. Age range was 30 to 80 years, 10 patients had less than or equal to 49 years. The mean cumulative dose of radioiodine was 571mCi (range: 200-1200 mCi). Nasal obstruction symptoms and increased salivary glands were also present in 53% of patients. All subjects underwent dacryocystorhinostomy. Dilation of the lacrimal sac and increased intraoperative bleeding was also observed in 3 younger patients. Complete epiphora and dacryocystitis resolution after surgery occurred in 82.4%, and partial in 17.6% (3 patients that still presented unilateral relapse after correction of bilateral obstruction). Mean follow-up was 6 months (range: 2-24 months). CONCLUSIONS: Cumulative high dose of radioidine, nasal and salivary gland dysfunction are associated with lacrimal drainage obstruction. We observed a great percentage of younger patients presenting dacryocystitis when compared to the idiopathic dacryostenosis. Radioactive iodine uptake by nasolacrimal duct mucosa with subsequent inflammation, edema and fibrosis seems to have a relationship to lacrimal duct obstruction. The knowledge of this complication is important for the study and proper management of these patients.

Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients

Radiotherapy, alone or associated with surgery or chemotherapy, produces a significant increase in cure rates for many malignancies of the head and neck region. However, high doses of radiation in large areas, including the oral mucosa, may result in several undesired reactions that manifest during or after the completion of therapy. The multidisciplinary management is the best alternative to minimize or even prevent such reactions, and the dentist has a fundamental role in this context. This paper reviews the literature related to the main oral sequelae from head and neck radiotherapy and establishes clinical oral management protocol for these irradiated patients.

Tratamento de lesão de tronco da artéria coronária esquerda após radioterapia do tórax / Treatment of left main coronary artery lesion after late thoracic radiotherapy

A prevenção de complicações cardiovasculares tardias após radioterapia (RT) para tratamento de um tumor maligno é um desafio. Relatamos o caso de um jovem paciente com linfoma de Hodgkin submetido a tratamento com RT que desenvolveu doença cardíaca isquêmica no seguimento, embora não apresentasse fatores de risco cardiovasculares. Concluímos que pacientes submetidos a RT que apresentam dor torácica deveriam ser criteriosamente avaliados em relação à doença arterial coronariana.

Prevention of late cardiovascular complications after radiation therapy (RT) for treatment of a malignant tumor is challenging. We report the case of a young male patient with Hodgkin's lymphoma treated with RT, who developed ischemic heart disease during follow-up, although he had no cardiovascular risk factors. We conclude that patients undergoing RT who experience chest pain should be fully investigated for coronary artery disease.

Alterações tireoidianas associadas à radiação externa em crianças e adolescentes / Thyroid disorders associated with external radiation in children and adolescents

O efeito da radiação ionizante sobre a tireoide vem sendo estudado há várias décadas, e os acidentes nucleares têm sido a maior fonte de informação. Existe associação de hipotireoidismo, hipertireoidismo, nódulos e câncer de tireoide com a radiação, mas os limiares de dose, mecanismos de lesão e alguns fatores de risco ainda não estão bem estabelecidos. Crianças são mais suscetíveis à lesão tireoidiana por radiação e necessitam de seguimento prolongado após a exposição. Esse tema adquire maior relevância atualmente, pois um grande número de pessoas tratadas com radioterapia para câncer na infância sobrevive e poderá apresentar sequelas. Exames radiodiagnósticos também representam fonte de exposição à radiação na população pediátrica. Nesta revisão, analisamos as diferentes alterações clínico-patológicas e os mecanismos de lesões tireoidianas provocadas por tratamento radioterápico e tomografia computadorizada em crianças e adolescentes. É importante conhecer esses dados para prevenção, detecção precoce e tratamento da disfunção tireoidiana.

The effects of ionizing radiation on the thyroid have been studied for several decades, and nuclear accidents are the major source of information about the subject. There is an association of hypothyroidism, hyperthyroidism, thyroid nodules and cancer with radiation, but the threshold dose, mechanism of injury, and some risk factors have not been fully established. Children are more susceptible to thyroid injury caused by radiation and require prolonged follow-up after exposure. This issue is especially relevant nowadays, since a large number of people treated with radiation for childhood cancer survive and may have sequelae. Diagnostic radiology tests also represent a source of exposure to radiation in the pediatric population. In this review, we analyze different clinical and pathological changes, and the mechanisms of thyroid lesions caused by radiotherapy and computed tomography in children and adolescents. It is important to understand these data for prevention, early detection, and treatment of thyroid dysfunction.

Carotid artery rupture following radioiodine therapy for differentiated thyroid carcinoma / Ruptura de carótida pós-iodoterapia em carcinoma diferenciado de tireoide

INTRODUCTION: Radioiodine therapy for patients with differentiated thyroid cancer aims at reducing tumor recurrence by eradicating residual macro- and microscopic foci. Side effects are generally rare, tenuous and transient, with little clinical significance. OBJECTIVE: To report a rare case of differentiated thyroid carcinoma presenting a large expansive solid mass at the base of the skull, with invasion of the left masticatory muscle and adjacent subcutaneous tissue, and without invasion of the carotid space, which evolved to carotid artery rupture following radioiodine therapy. DISCUSSION: Side effects are uncommon after radioiodine therapy and when present, have mild intensity. Serious adverse events are very rare, especially those arising from structures not directly invaded by metastatic tissue with radioiodine uptake, as occurred in this case. This occurrence serves to raise awareness of the need for increased care when using radioiodine therapy on high-avidity masses located close to important structures.

INTRODUÇÃO: Iodoterapia em pacientes com carcinoma diferenciado da tireoide tem o objetivo de reduzir a recorrência tumoral erradicando focos residuais macro e microscópicos. Os efeitos colaterais, em geral, são raros, tênues e transitórios, com pouca repercussão clínica. OBJETIVO: Relatar um caso raro de carcinoma diferenciado da tireoide apresentando grande massa sólida expansiva na base do crânio, com invasão da musculatura mastigatória esquerda e do tecido subcutâneo adjacente, sem invasão do espaço carotídeo que evoluiu com ruptura de carótida pós-iodoterapia. DISCUSSÃO: Os efeitos colaterais pós-iodoterapia são pouco frequentes e, quando presentes, de intensidade discreta. Os eventos adversos graves são muito raros, em especial, aqueles decorrentes de estruturas não invadidas diretamente pelo tecido metastático iodocaptante, como nesse caso, alertando também para a necessidade do aumento dos cuidados na terapia de grandes massas ávidas pelo radioiodo próximas às estruturas nobres.

Tratamiento de la rectitis actínica hemorrágica con aplicación tópica de formalina al 4 por ciento / Treatment of hemorrhagic radiation rectitis with topical application of 4percent formaldehyde

Background: Hemorrhagic radiation rectitis occurs in 15 percent of patients subjected to pelvic irradiation. One of the treatment alternatives is the topical application of 4 percent formaldehyde. Aim: To report the results of the use of topical formaldehyde in radiation rectitis. Material and Methods: Twenty patients aged 36 to 80 years (13 women) with hemorrhagic radiation rectitis were prospectively recruited. Fistula or stenosis was discarded endoscopically. Formaldehyde was applied in the operating room or at the outpatient clinic. Results: Fifteen patients required repeated transfusions. The application was performed in the operating room in five patients. Bleeding stopped in three patients with one application, in 12 patients with two applications and in four, with three applications. In one patient, bleeding did not stop after the first application and had a sigmoid perforation; therefore no further application was attempted. One patient had a severe proctitis after the procedure, which subsided with symptomatic treatment after 15 days. Conclusions: Topical formaldehyde application for hemorrhagic rectitis is effective to stop bleeding but has complications in 10 percent of patients.

Introducción: La rectitis actínica hemorrágica es una complicación que se presenta en el 15 por ciento de los pacientes sometidos a radioterapia por una neoplasia pélvica. Existen distintas alternativas para su tratamiento, entre las que se cuenta la aplicación de formalina al 4 por ciento. Presentamos los resultados del tratamiento de esta complicación en una serie prospectiva no aleatoria. Material y Método: Desde marzo de 2004 a mayo de 2007 se reclutaron en forma prospectiva todos los pacientes tratados por una rectitis actínica hemorrágica en nuestro servicio. En todos los pacientes se descartó una estenosis o fístula por endoscopia flexible. Los pacientes fueron sometidos a aplicación de formalina en pabellón o ambulatoria según la evaluación del tratante. Resultados: La serie corresponde a 20 pacientes, 13 mujeres, con un promedio de edad de 61 años (36-80), 15 requerían transfusiones a repetición. La indicación de radioterapia fue por un cáncer cérvico uterino en 9 casos, de próstata en 7 casos y endometrio en 4. El promedio de sesiones necesarias para controlar el sangrado fue de 2 (1-3); en 5 pacientes la aplicación se realizó en pabellón. Tres pacientes mejoraron con una aplicación, 12 pacientes con 2 aplicaciones y 4 con 3 procedimientos. Un paciente continúa sangrado después de un procedimiento, pero presenta una perforación de sigmoides en terreno neoplásico y no se intentó una segunda sesión, por lo que se considera un fracaso del procedimiento. Además un paciente presentó una proctitis intensa que cedió con tratamiento sintomático en 15 días, con lo que la morbilidad del procedimiento alcanza a un 10 por ciento. El éxito acumulado es de un 95 por ciento de los casos, con detención del sangrado, sin necesidad de transfusiones. Conclusión: Estimamos que el tratamiento con formalina al 4 por ciento es un procedimiento seguro para el tratamiento de la rectitis actínica hemorrágica, con buenos resultados en la gran mayoría de los pacientes ...

Achados audiológicos em pacientes tratados com radioterapia para tumores de cabeça e pescoço / Audiological findings in pacients treated with radiotherapy for head and neck tumors

A radioterapia é uma modalidade terapêutica muito utilizada, uma vez que o aumento de resultados satisfatórios e a cura de algumas neoplasias através deste tipo de tratamento estão sendo observados. OBJETIVO: Avaliar a funcionalidade do sistema auditivo em pacientes submetidos ao tratamento radioterápico em região de cabeça e pescoço. MATERIAL E MÉTODO: Estudo realizado no período de maio de 2007 a maio de 2008. Foram realizadas avaliações otorrinolaringológicas e audiológicas como audiometria tonal limiar por via aérea e óssea, audiometria vocal, timpanometria, pesquisa do reflexo do estapédio e Emissões Otoacústicas Evocadas por Produto de Distorção em 19 pacientes com diagnóstico de neoplasia em região de cabeça e pescoço e indicação do tratamento radioterápico. Estudo de série prospectivo. RESULTADOS: 10,5 por cento orelhas esquerdas e 26,3 por cento orelhas direitas apresentaram diminuição dos limares auditivos tonais logo após o término do tratamento radioterápico, segundo os critérios da ASHA. CONCLUSÃO: O tratamento radioterápico apresentou efeitos ototóxicos quando realizado em região de cabeça e pescoço. Programas de monitoramento audiológico e reabilitação auditiva precoce devem ser oferecidos aos pacientes submetidos a esse tipo de tratamento.

Radiotherapy has been widely used given its increase in the successful outcomes and cure of some cancers. AIM: To evaluate the functionality of the auditory system in patients who underwent radiotherapy treatment for head and neck tumors. MATERIALS AND METHODS: From May 2007 to May 2008, otorhinolaryngological and audiological evaluation (Pure Tone Audiometry (air and bone conduction), Speech Audiometry, Tympanometry, Acoustic Reflex testing and Distortion Product Otoacoustic Emissions) were performed in 19 patients diagnosed with head and neck neoplasia and treated with radiotherapy. Prospective case series study. RESULTS: 10.5 percent left ears and 26.3 percent right ears had bilateral hearing loss soon after radiotherapy according to ASHA criteria. CONCLUSIONS: Radiotherapy treatment for head and neck cancer has ototoxic effects. Early programs of auditory rehabilitation should be offered to these patients.