Complications from large field intermediate dose infradiaphragmatic radiation: An analysis of the patterns of care outcome studies for Hodgkin's disease and seminoma

Abstract

There are only infrequent complications from intermediate dose infradiaphragmatic radiation to the para-aortics or para-aortic and iliac nodal regions as given in Hodgkin's disease or seminoma. Nonetheless, such complications can cause significant debility and may be lifelong. Treatment related factors associated with such complications should be identified and where possible, avoided. We have analyzed the records of 1,026 patients treated nationwide in the Patterns of Care Outcome Studies including the Hodgkin's national practice survey (387 patients), Hodgkin's large facility survey (253 patients), and Seminoma national practice survey (386 patients). There were 883 patients who received infradiaphragmatic radiation to the para-aortics or para-aortic and iliac regions. Complications which occurred in these patients included gastrointestinal injury, hepatitis, nephritis, gonadal injury, hematopoietic injury, second malignancy, and miscellaneous others. There were 139 complications of any severity and 35 major complications requiring hospitalization for management. The 3-year actuarial complication rates were 14% and 4% for any and major complications, respectively. There was a statistically significant increase in both any complications and major complications with dose ( p < .01). The most frequent complications were those related to gastrointestinal injury such as peptic ulceration, hemorrhage, chronic diarrhea, and intestinal obstruction. Major bowel complications comprised 60% ( 21 35 ) of major complications and increased with dose from 1% for doses <3,500 cGy to 3% for doses ≥3,500 cGy ( p = .03). This study indicates that total dose is an important factor in determining complications, particularly gastrointestinal injury, in patients receiving infradia-phragmatic radiation in Hodgkin's disease and seminoma and that prior G.I. disease is associated with an increased risk of radiation related bowel complication. The radiotherapist should seek to optimize the therapeutic ratio in these diseases where gross disease can be controlled with 3500 cGy or less with few exceptions.