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Case history

image A 59-year-old woman receiving definitive concurrent chemoradiotherapy for a T2N1M0 anal cancer was admitted with severe skin erythema and breakdown around the anal canal. She was opening her bowels between five and six times a day and had the feeling that she needed to constantly do so.

How and why do we use pelvic radiotherapy?

What are the early side effects of pelvic radiotherapy and how are they managed?

What are the late side effects of pelvic radiotherapy and how are they managed?

How and why do we use pelvic radiotherapy?

Pelvic radiotherapy is used in the management of urological, gynaecological and gastrointestinal malignancies. It may be delivered before (neoadjuvant) or after surgery (adjuvant) and as the main treatment modality in the curative (radical) or palliative setting. For some malignancies, chemoradiation allows organ preservation with good functional and excellent oncological outcomes.

The addition of chemotherapy may exacerbate some side effects and introduce additional risks. Patients are thus carefully selected based on their performance status. Some patients unfit for potentially curative surgery are often referred for radiotherapy and require evaluation of their comorbidities and end-organ function prior to treatment.

What are the early side effects of pelvic radiotherapy and how are they managed?

Any irradiated organ in the pelvis is susceptible to radiation toxicity, including skin, bladder, bowel, bones and genitalia. Patients may also experience fatigue. Acute side effects occur during treatment and up to 3 months following completion. It is important when evaluating symptoms to consider their origin in relation to the radiotherapy field.

Skin toxicity

Skin reactions are a significant burden among radiotherapy patients. Treatments delivered close to the skin (such as anal and vulval cancer) carry the greatest risk of a severe skin reaction. Managing skin toxicity in the pelvis is difficult given the contours of the body. Skinfolds increase radiation exposure and are areas to monitor carefully for skin breakdown. It is difficult to apply dressings in these regions and wounds are prone to infection. Broken skin should be swabbed for infection and treated according to culture sensitivities. Aqueous cream and Instillagel mixed in equal measures can help soothe skin. Flamazine cream is a water-based antibacterial cream used in severe skin reactions, although its metal content can alter radiation dosimetry and should not be applied during radiotherapy. Flamigel is an alternative preparation that is safe to use and delays the onset of moist desquamation.1

Bowel toxicity

Symptoms of rectal inflammation include bleeding, mucus production, urgency and tenesmus. Rectal bleeding is often mild and requires monitoring, although some radiotherapy treatment protocols require maintenance of haemoglobin above a set level to maximize effectiveness.2 The patient is given dietary advice to reduce vegetables and fibre. Fybogel helps regulate bowel motions; steroid suppositories such ...

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