Treatment toxicity
The adverse effects of radiotherapy and chemotherapy are classified in temporal groupings depending on the time of onset. Early effects are seen during treatment or within the first few weeks after its completion. Reactions are common, and can be very significant and symptomatic. Most common chemotherapy effects are early and although they resolve there can be long-term residual damage. Intermediate effects occur several weeks to months after the completion of treatment, and late effects are usually rare and are encountered many months to years after treatment. Functional impairments may take a very long time to become apparent; an example is memory problems in children who have received cranial irradiation. The development of a secondary malignancy is more common following radiotherapy.
Extravasation injury
During administration a drug can leak into the surrounding subcutaneous tissue. The consequences are local inflammatory reactions at the infusion site. There is no permanent damage if the drug is an irritant substance. Extravasation of vesicant agents has the potential to cause severe or irreversible tissue injury and necrosis (anthracyclines, vinca alkaloids). In some cases the tissue necrosis can require skin grafting and has the potential for extensive disfigurement. If extravasation is suspected, IV therapy should be stopped immediately and the site massaged to remove any obvious liquid from the site. Local protocol should then be followed, with early involvement of the plastic surgery team. Patency of intravenous access should be tested regularly with patients educated to report any pain or odd sensations.
Specific toxicities
Alopecia usually occurs 3–6 weeks after the first dose of some chemotherapeutic agents, producing significant psychological impact.
Cardiac toxicity can be in the form of arrhythmia (paclitaxel), acute pericarditis (radiotherapy), pericardial effusion and cardiomyopathy (anthracyclines and radiotherapy).
Gastrointestinal tract toxicity includes: stomatitis (doxorubicin, 5-fluorouracil), ulceration, diarrhoea (irinotecan, topotecan, paclitaxel), constipation (carboplatin), enteritis (5-fluorouracil, actinomycin-D, cisplatin, methotrexate, hydroxyurea, procarbazine), proctocolitis (radiotherapy) and oesophagitis (doxorubicin, cyclophosphamide).
Hepatic toxicity is due to direct effects on the hepatocytes and can result in cholestasis (6-mercaptopurine), acute liver necrosis (high-dose methotrexate, asparaginase, mithramycin), hepatic fibrosis (chronic low-dose methotrexate) and veno-occlusive disease (high-dose chemotherapy with autologous stem-cell rescue).
Musculoskeletal toxicity
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