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Side Effects of Radiation to the Abdomen or Pelvis

Most patients tolerate radiation to the pelvis or abdomen with minimal to moderate side effects. The bigger the area treated and the higher the dose... the more likely the side effects. With routine preOp or postOp doses of 4500-5000cGy patients have a 20% to 30% risk of postoperative complications and the risks go up with higher doses (like 6000cGy or up, see safe dose tables) and the risks are higher if the surgery is more extensive (see studies below).
    
For a discussion of chronic radiation damage to the small bowel go here and to the large bowel go here, For more specifics on pelvic radiation problems in men go here and in women go here, and for risk to pelvic bones go here.

Dose guidelines from RTOG protocols: 0529 (anal) and 0438 (liver)

Patients who have had cancer colon or rectal surgery may have even more problems (see large German study comparing preOp versus postOp radiation in rectal cancer) and when the radiation is combined with chemotherapy (particularly 5FU or Gemzar) the higher the likelihood of side effects (particularly diarrhea).

(In the German study the risk of serious complications in patients treated with major surgery and radiation: overall postoperative complications 34 - 36%, anastomatic leakage 12 - 13%, delayed sacral wound healing in 8 - 12%.)

The lower pelvis area tolerates radiation better than higher up on the abdomen...so the location of the treated area will effect tolerance. The most common side effects are noted below.

  • fatigue: this is quite common, getting as much rest as possible, trying to maintain the patients weight and monitoring the blood counts to avoid significant anemia may be helpful
  • loss of appetite: this is more common if the upper part of the abdomen is treated. Food supplements (like Meritene, Boost, Ensure) may be helpful... agents like Megace that stimulate the appetite may help
  • nausea and vomiting: this is generally not common unless the upper part of the abdomen (liver, pancreas or stomach) is getting treated. Anti-nausea medicine (Compazine, Kytril, Zofran) and anti-acids may be helpful. It's important the patient does not get dehydrated and may benefit from IV fluids
  • diarrhea, gas, abdominal cramps, frequent bowel movements: this is fairly common and may benefit from modifying the diet (avoiding milk products, roughage, going low residue) and many patients need Lomotil or Imodium
  • rectal irritation, pain or bleeding: occasionally the rectal area can get quite sore and irritate. Controlling diarrhea is useful and patients may benefit from rectal suppositories (like Anusol, Nupercainal, Preparation H) or soaking in a Sitz bath
  • most of the side effects described develop after the first week or two of treatment and generally fade away over a period of several weeks later. there is a small risk of long term complications (e.g. chronic diarrhea, problems with wound infections or delayed healing or a small bowel obstruction)
  • more detailed side effect information about pelvic radiation is found in the prostate cancer for men section and the gynecologic cancer section for women.
Other studies that discuss complications:
Complications after preoperative combined modality therapy and radical resection of locally advanced rectal cancer: a 14-year experience from a specialty service.

Chessin DB,J Am Coll Surg. 2005 Jun;200(6):876-82

Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.

Preoperative combined modality therapy followed by total mesorectal excision has emerged as the optimal treatment paradigm for locally advanced rectal cancer (T3 to 4, N1, or both). But its impact on postoperative complications has not been adequately evaluated. Our aims were to evaluate our comprehensive experience and identify factors predictive of complications in this patient population. STUDY DESIGN: The study group consisted of 297 consecutive patients with locally advanced rectal adenocarcinoma treated with preoperative combined modality therapy (radiation: 5,040 cGy; chemotherapy: 5-FU-based) and then operation.

Major complications were defined as those requiring medical or surgical treatment. A prospectively collected database was queried to determine the incidence of postoperative complications and associated clinicopathologic factors. RESULTS: Median followup was 43.9 months (range 0.8 to 128.6 months). There were no postoperative mortalities (within 30 days of operation). But there were 145 major complications in 98 patients (33% of study population). The most common complications were small bowel obstruction (n = 32 [11%]) and wound infection (n = 31 [10%]). There were eight anastomotic leaks (4%) and nine pelvic abscesses (4%) in patients treated with low anterior resection (n = 210).

CONCLUSIONS: Although postoperative mortalities are rare, complications requiring treatment can be anticipated in one-third of patients undergoing preoperative combined modality therapy and total mesorectal excision. A policy of selective fecal diversion after preoperative combined modality therapy and total mesorectal excision for locally advanced rectal cancer can achieve low rates of pelvic sepsis, but may lead to an increased incidence of small bowel obstruction.

Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service.
Enker WE, Ann Surg. 1999 Oct;230(4):544-52


Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York 10021, USA.

OBJECTIVE: To determine perioperative morbidity, survival, and local failure rates in a large group of consecutive patients with rectal cancer undergoing low anterior resection by multiple surgeons on a specialty service. The primary objective was to assess the surgical complications associated with preoperative radiation sequencing. SUMMARY BACKGROUND DATA: The goals in the treatment of rectal cancer are cure, local control, and preservation of sphincter, sexual, and bladder function. Surgical resection using sharp perimesorectal dissection is important for achieving these goals. The complications and mortality rate of this surgical strategy, particularly in the setting of preoperative chemoradiation, have not been well defined. METHODS: There were 1233 patients with primary rectal cancer treated at the authors' cancer center from 1987 to 1995. Of these, 681 underwent low anterior resection and/or coloanal anastomosis for primary rectal cancer. The surgical technique used the principles of sharp perimesorectal excision. Morbidity and mortality rates were compared between patients receiving preoperative chemoradiation (Preop RT, n = 150) and those not receiving preoperative chemoradiation (No Preop RT, n = 531). Recurrence and survival data were determined in patients undergoing curative resection (n = 583, 86%) among three groups of patients: those receiving Preop RT (n = 131), those receiving postoperative chemoradiation (Postop RT, n = 110), and those receiving no radiation therapy (No RT, n = 342).

RESULTS: The perioperative mortality rate was 0.6% (4/681). Postoperative complications occurred in 22% (153/681). The operative time, estimated blood loss, and rate of pelvic abscess formation without associated leak were higher in the Preop RT group than the No Preop RT group. However, the overall complication rate, rate of wound infection, anastomotic leak, and length of hospital stay were no different between Preop RT and No Preop RT patients.  CONCLUSION: The use of preoperative chemoradiation results in increased operative time, blood loss, and pelvic abscess formation but does not increase the rate of anastomotic leaks or the length of hospital stay after low anterior resection for rectal cancer. The 5-year actuarial overall survival rate for patients undergoing curative resection exceeded 80%, with a local recurrence rate of 10%.

Impact of neoadjuvant therapy on postoperative complications in patients undergoing resection for rectal adenocarcinoma.

Turner II,. Am Surg. 2004 Dec;70(12):1045-9

Surgical Oncology Service, Wake Forest University, Winston-Salem, North Carolina 27157, USA.

Surgical resection continues to be the mainstay of treatment for rectal cancer. Neoadjuvant therapy (chemotherapy and radiation) has also been shown to be efficacious. The impact of preoperative chemotherapy and radiation on postoperative complications is unclear. The purpose of this study is to evaluate the relationship of neoadjuvant therapy on postoperative complications in patients undergoing a resection of rectal cancer. A total of 325 patients who underwent curative resection for rectal cancer from 1984 to 2001 were retrospectively reviewed. Only cases with complete data sets who had undergone surgery at this institution were evaluable (257). The patients were divided into groups based on the operative procedure performed; abdominoperineal resection (APR) versus sphincter-sparing (SS) procedures (LAR/Transanal) and whether or not preoperative chemotherapy or radiation was administered.

 There was no significant difference between complication rates for APR and SS with 19 per cent and 14 per cent, respectively. The preoperative therapy had no effect on complications after APR. However, the SS group showed 21 per cent of the patients who received radiation had complications compared to 11 per cent in those who did not (P = 0.087). Complications in the SS group included leaks, wound infections, abscess, embolism, cardiac dysrhythmias, and myocardial infarctions. The 30-day mortality was 1.9 per cent for the entire cohort with no clear difference between groups. There was no significant difference in complication rate between APR and SS. In the APR group, neoadjuvant therapy had no impact on the incidence of complications. However, the SS group did show a trend between preoperative chemotherapy and radiation and complication rate. However, this may not outweigh the advantages of preoperative therapy in this setting.
 

Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure.

Bullard KM,  Dis Colon Rectum. 2005 Mar;48(3):438-43.

Department of Surgery, Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota, USA.

PURPOSE: Neoadjuvant radiation therapy has been used increasingly to downstage rectal cancer and decrease local recurrence. Despite its efficacy, preoperative radiation therapy may inhibit healing and contribute to wound complications. This study was designed to evaluate perineal wound complications after abdominoperineal resection. METHODS: The clinical records of a consecutive series of patients who underwent abdominoperineal resection for rectal carcinoma between 1988 and 2002 were reviewed. Demographic data, disease stage, and use of preoperative radiation therapy were recorded. Major wound complications included delayed wound healing (>1 month), wound infection requiring drainage/debridement, or reoperation.

RESULTS: A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 +/- 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900-5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes. CONCLUSIONS: Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.

Neoadjuvant chemoradiation increases the risk of pelvic sepsis after radical excision of rectal cancer.

Buie WD,. Dis Colon Rectum. 2005 Oct;48(10):1868-74.

Department of Surgery, University of Calgary, Calgary, Alberta, Canada.

PURPOSE: This study was designed to examine the effect of neoadjuvant chemoradiation on pelvic sepsis after mesorectal excision for rectal cancer. METHODS: A retrospective chart review was conducted for all patients who underwent curative mesorectal excision for rectal cancer during an eight-year period. Demographic, preoperative, perioperative data were collected. Pelvic sepsis was defined as clinical or radiographically demonstrable leak or a pelvic abscess. Neoadjuvant chemoradiation included 5,040 Gy in conjunction with three cycles of 5-fluorouracil-based chemotherapy, followed by a one-month waiting period.

RESULTS: From January 1994 to December 2002, 246 patients (151 males; mean age 68 (range, 36-97) years) underwent curative resection for rectal cancer. Procedures included 186 anterior resections, 52 abdominoperineal resections, and 8 Hartmann's. Of 60 patients (24.4 percent) who had neoadjuvant chemoradiation, 9 (15 percent) developed pelvic sepsis (3 leaks, 6 abscesses) compared with 9 of 186 (4.8 percent) after primary surgery (6 leaks, 3 abscesses; P < 0.01). Ninety-three patients had an anastomosis <or=6 cm from the anal verge. Of these, 9 patients (9.7 percent) developed pelvic sepsis (5 leaks, 4 abscesses): 5 of 28 (17.9 percent) after neoadjuvant chemoradiation vs. 4 of 65 (6.2 percent) after primary surgery (P = 0.22). Only 6 of 93 patients (6.5 percent) with an anastomosis >or=7 cm developed pelvic sepsis (5 leaks and 1 abscess), of whom 1 had preoperative radiation. Pelvic abscess developed in 3 of 24 patients after neoadjuvant chemotherapy and abdominoperineal resection. After primary abdominoperineal resection, none of the remaining 28 patients developed pelvic sepsis. A multivariable logistic regression model was constructed to determine predictors of sepsis. Neoadjuvant chemotherapy was the only variable that was predictive (odds ratio, 3.4; 95 percent confidence interval, 1.3-9). CONCLUSIONS: The addition of neoadjuvant chemoradiation to mesorectal excision significantly increased the rate of pelvic sepsis. This was particularly true for anastomoses in the lower third of the rectum. Fecal diversion should be considered in these patients.