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Oncology Radiation Fibrosis Syndrome

Updated: Jul 19

Radiation fibrosis syndrome describes the myriad clinical manifestations of progressive fibrotic tissue sclerosis resulting from radiation treatment. Radiation-induced damage can include "myelo-radiculo-plexo-neuro-myopathy," causing muscle weakness and dysfunction and contributing to neuromuscular injury.


Image of radiation to a patient's head

What are the symptoms of radiation fibrosis?

In general, radiation fibrosis syndrome may manifest as skin induration and thickening, muscle shortening and atrophy, limited joint mobility, lymphodema, mucosal fibrosis, ulceration, fistula, hollow organ stenosis, and pain.


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Does fibrosis from radiation go away?


Radiation fibrosis can be long-lasting, and though it may not be possible to completely cure it, there are many treatment options which can improve symptoms and reverse some of the changes. Newer radiation treatment strategies can minimise the risk that radiation-fibrosis develops at all.


Is radiation fibrosis progressive?


Radiation fibrosis syndrome (RFS) is a progressive fibrotic tissue sclerosis with various clinical symptoms in the irradiation field. It is usually a late complication of radiation therapy and may occur weeks or even years after treatment.


How is radiation fibrosis diagnosed?


On a CT scan (also known as CAT scan) healthy lung tissue looks nearly black, and scar tissue and inflammation appear grey or white. Pulmonary fibrosis caused by radiation therapy usually occurs in the specific areas where radiation therapy was used and has a distinct scarring pattern.

How do you get rid of radiation fibrosis?


For patients with established radiation-induced fibrosis, treatment is primarily symptomatic with management options including 4 general approaches, using (1) pharmaceuticals, (2) hyperbaric oxygen, (3) physiotherapy, and (4) microcurrent stimulation.


Can you have scar tissue from radiation?


Radiation can lead to permanent changes in the skin. You may develop new scars or notice changes in the color or texture of your skin. Radiation can also change the colour and texture of your hair or can cause permanent hair loss in the treated area.

Can radiation leave scar tissue?


Radiation following surgery creates changes to the surgical scar to make it harder and denser, as well as creating fibrotic tissue around the scar. Some of the mechanical factors that influence radiation damage include: type, duration, intensity, amount, and location of the radiation field.


Image of neuropathy, damage to nerves in or across the radiation field

Does radiation cause stiffness?


Radiation treatment can make your muscles and soft tissues (for example, ligaments and skin) stiff and tight. This condition is called radiation induced fibrosis. When your muscles are not moving properly they can cause pain or limit movement in other parts of your body.


How common is radiation induced fibrosis?


Radiation induced pulmonary fibrosis is a common complication of this therapy affecting 5–50% of patients, which significantly limits available treatment options even after successful eradication of the tumor itself.


Can radiotherapy cause lung fibrosis?


Radiotherapy can change the cells that line the lungs and cause a hardening and thickening of the tissue. This is called fibrosis. This can cause problems with breathlessness months or years after treatment. This is called a late effect.


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Can radiation cause respiratory issues?


Having radiotherapy to the chest can cause shortness of breath during and after radiotherapy. Shortness of breath will usually improve a few weeks after treatment but for some people it can continue long term.


How do you get rid of pulmonary fibrosis?


The lung scarring that occurs in pulmonary fibrosis can't be reversed, and no current treatment has proved effective in stopping progression of the disease. Some treatments may improve symptoms temporarily or slow the disease's progression. Others may help improve quality of life.


Does radiation shorten your life?


"Rapidly dividing cells, such as cancer cells, are more affected by radiation therapy than normal cells. The body may respond to this damage with fibrosis or scarring, though this is generally a mild process and typically does not cause any long-term problems that substantially affect quality of life.


Image of a patient being prepared for radiation treatment

What are the symptoms of radiation fibrosis syndrome?

  • Musculoskeletal pain.

  • Damage to healthy blood vessels leading to organised fibrosis, sheets of fibrous tissue laid down, so fibrocytes are unable to get nutrients so they die causing contractile fibrosis.

  • Progressive fibrotic tissue sclerosis.

  • Trismus - from radiation of muscles and nerves or mastication so unable to open mouth.

  • Shoulder problems from winging scapula due to muscle wasting in neck and between shoulder blades.

  • Rotator cuff muscle weakness causing tendonopathy, a weak painful arm and inflammation causing adhesive capsulitis.

  • Lateral arm pain from nerve inflammation.

  • Trigeminal and anterior cervical plexus neuralgia.

  • Axial spinal pain.

  • Spasticity.

  • Paraplegia.

  • Quadriplegia.

  • Spinal ataxia.

  • Dystonia.

  • Funicular pain.

  • Lymphodema.

  • Chronic inflammation.

  • Cervical Dystonia - spasm in head and neck, pain and weakness.

  • Head drop.

  • Decreased range of movement in the neck.

  • Fatigue.

  • Hair loss.

  • Dry mouth.

  • Impaired taste and appetite.

  • Heart disease.

  • Dermatitis.

  • Pulmonary fibrosis.

  • Cystitis.

  • Enteritis, colitis, proctitis.

  • Autonomic dysfunction - including bladder and bowel problems.

  • Otitis externa.

  • Skeletal growth arrest - due to affect on growth plates.

  • Scoliosis - S-bend in spine.

  • Osteoporosis - thinning of bone.

  • Osteoradionecrosis - damage to the bone causing fractures and infections.

  • Dysphasia - trouble swallowing.

  • Dysarthria - trouble speaking.

  • Cerebropathy - necrosis of the brain, damage to white matter, cognitive or psychiatric issues.

  • Neuropathy - damage to important nerves on the chest wall in radiation field innervating rotator cuff muscles. Seen in Hodgkins’s Lymphoma and some breast cancer patients.

  • Myopathy - Weakness and atrophy of muscles - in head and neck cancers and any cancer patients receiving high doses of radiation involving muscles, causing weakness and atrophy. Onset can be 20-30 years post radiation.

  • Myelopathy - damage to spinal cord.

  • Radiculopathy - when large nerve roots with less connective tissue over them are in the radiation field, eg upper cervical , C5/6 commonly affected in head and neck cancers and Hodgkins’s Lymphoma.

  • Plexopathy -from axilla radiation in the field in head and neck, breast cancers and Hodgkins’s Lymphoma patients.

  • Mononeuropathy - one nerve damaged.

  • Myelo-radiuculo-plexo-neuropathy - due to damage to spinal cord, nerve roots, plexus, local peripheral nerves and muscles.


Which are the main symptoms that a Cancer Rehab Physiotherapist can effect most successfully? And how?


Trismus


- prevention is more desirable than treatment.

- Home exercise program to maintain maximum ROM with mouth opening exercises and jaw mobility as soon as they start radiotherapy.

- If develop symptoms they require extensive exercise programs if necessary combined with Physio.

-Jaw opening devices, splints can be used to re stretch muscles, fighting against radiation tightness.

- Possible botox to decrease muscle spasm and pain so can stretch better.


Stiff neck, pain in spine, difficulty lifting head due to muscle spasm and damage to nerves


-Functional restoration.

-Improve quality of life.

-Education, explain symptoms and understanding of cervical dystonia, (neck stiffness).

-Manual therapy to stretch and release tight muscles and increase joint ROM.

-Exercise prescription - muscle strengthening, working synergistic muscles to help compensate for loss of muscle innervation and stretching.

- Possible botox to decrease muscle spasm and pain so can stretch better.

-Repetition of exercises and education.


Dropped Head Syndrome


- due to muscle imbalance, neck flexors and pecs are strong and upper neck extensors have impact of radiation so neck extension, rotator cuff and rhomboids between shoulder blades are weak.

-Postural retraining and core muscle training for a solid base.

-Improving alignment in trunk so that shoulders, back and neck will follow.

-Collar to neck when needs to rest to be able to do exercises and manage to go out when required.

-Improving alignment, posture and stretching as a start, then adding strengthening when there is an improvement in neck pain, spasm and fatigue throughout the day.

-Increasing muscle stamina and improving posture for a large functional improvement decreasing energy expenditure.

-Due to the insidious progression of weakness and dysfunction, which is unavoidable, adherence to a lifelong exercise program emphasising home maintenance exercises is important to maximise and maintain quality of life.

Images of patient's suffering with dropped head syndrome

Osteoporosis


-Education.

-Strength training and weight bearing exercises.


Musculoskeletal pain


-Education, explain symptoms.

-Manual therapy to stretch and release tight muscles and increase joint ROM.

-Exercise prescription - corrective muscle strengthening.


Shoulder problems from winging scapula due to muscle wasting in neck and between shoulder blades


-Exercise prescription - corrective muscle strengthening.


Rotator cuff muscle weakness causing tendonopathy, a weak painful arm and inflammation causing adhesive capsulitis


-Exercise prescription - corrective muscle strengthening.


Image of a patient receiving Physiotherapy exercises

Scoliosis


- Exercise program to lengthen shortened, tight tissues and strengthen weak muscles to provide balance.


Lymphodema


-Education, avoidance of actives exacerbating. Provision of pressure garments.

-Lymphodema massage.


Fatigue


-Establish cause checking whether global fatigue.

-When assessing and prescribing exercise include pacing and managing necessary activities during the day.

-Progressive exercise to assist fatigue management, discussing the benefits using research.

-Keep a fatigue diary to establish when their fatigue is worse and when most energised. Book appointments and schedule activities at the most manageable time of day. Have short rests of 20-30 minutes early afternoon if fatigued and avoid activities at their most fatigued times.


Heart disease


-Cardiovascular progressive exercise program.

-Education.



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What determines whether a patient will get fibrosis?

  • Type and dose of radiotherapy.

  • Which structures are in the radiation field.

  • Did the radiation accompany surgery?

  • Was a cancerous tumour removed from the neck and radical neck resection as abnormal anatomy and scarring has an effect on how the body responds to radiation.

  • Tissue of spinal cord not excluded from radiation field eg/ nasopharyngeal carcinoma cancer causing spasticity, paraplegia, quadriplegia or spinal ataxia.

  • Chemotherapy in addition to radiation therapy. A toxic dose detrimental to heart and lungs.

  • In Hodgkin’s Lymphoma, head and neck cancers, spinal mets and sometimes in extremity sarcomas due to high doses of radiation therapy when treating multiple areas including lymph nodes above and below the diaphragm.

  • An older spine with degenerative changes more likely to cause nerve damage.

  • Co morbidities in addition to cancer treatment.


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