Radiation Oncology/Toxicity grading/RTOG

RTOG/EORTC Radiation Toxicity Grading

• RTOG Common Toxicity Criteria
  • 1995 - PMID 7713792 — "Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC)." Cox JD et al. Int J Radiat Oncol Biol Phys. 1995 Mar 30;31(5):1341-6.

ACUTE

For all: 0 - no symptoms, 5 - death directly related to radiation effects

RTOG ACUTE Radiation Morbidity

Tissue	Grade 1	2	3	4
Skin	Follicular, faint or dull erythema / epilation / dry desquamation / decreased sweating	Tender or bright erythema, patchy moist desquamation / moderate edema	Confluent, moist desquamation other than skin folds, pitting edema	Ulceration, hemorrhage, necrosis
Mucous membrane	Irritation / may experience mild pain not requiring analgesic	Patchy mucositis that may produce an inflammatory serosanguinous discharge / may experience moderate pain requiring analgesia	Confluent fibrinous mucositis / may include severe pain requiring narcotic	Ulceration, hemorrhage or necrosis
Eye	Mild conjunctivitis w/ or w/o scleral injection / increased tearing	Moderate conjunctivitis w/ or w/o keratitis requiring steroids and/or antibiotics / dry eye requiring artificial tears / iritis with photophobia	Severe keratitis with corneal ulceration / objective decrease in visual acuity or in visual fields / acute glaucoma / panophthalmitis	Loss of vision (uni or bilateral)
Ear	Mild external otitis with erythema, pruritus, secondary to dry desquamation not requiring medication. Audiogram unchanged from baseline	Moderate external otitis requiring topical medication / serous otitis media / hypoacusis on testing only	Severe external otitis with discharge or moist desquamation / symptomatic hypoacusis / tinnitus, not drug related	Deafness
Salivary gland	Mild mouth dryness / slightly thickened saliva / may have slightly altered taste such as metallic taste / these changes not reflected in alteration in baseline feeding behavior, such as increased use of liquids with meals	Moderate to complete dryness / thick, sticky saliva / markedly altered taste	(none)	Acute salivary gland necrosis
Pharynx & esophagus	Mild dysphagia or odynophagia / may require topical anesthetic or non-narcotic analgesics / may require soft diet	Moderate dysphagia or odynophagia / may require narcotic analgesics / may require puree or liquid diet	Severe dysphagia or odynophagia with dehydration or weight loss > 15% from pretreatment baseline requiring NG feeding tube, IV fluids, or hyperalimentation	Complete obstruction, ulceration, perforation, fistula
Larynx	Mild or intermittent hoarseness / cough not requiring antitussive / erythema of mucosa	Persistent hoarseness but able to vocalize / referred ear pain, sore throat, patchy fibrinous exudate or mild arytenoid edema not requiring narcotic / cough requiring antitussive	Whispered speech, throat pain or referred ear pain requiring narcotic / confluent fibrinous exudate, marked arytenoid edema	Marked dyspnea, stridor or hemoptysis with tracheostomy or intubation necessary
Upper GI	Anorexia with ≤ 5% weight loss from pretreatment baseline / nausea not requiring antiemetics / abdominal discomfort not requiring parasympatholytic drugs or analgesics	Anorexia with ≤ 15% weight loss from pretreatment baseline / nausea and/or vomiting requiring antiemetics / abdominal pain requiring analgesics	Anorexia with > 15% weight loss from pretreatment baseline or requiring NG tube or parenteral support. Nausea and/or vomiting requiring tube or parenteral support / abdominal pain, severe despite medication / hematemesis or melena / abdominal distention (flat plate radiograph demonstrates distended bowel loops)	Ileus, subacute or acute obstruction, perforation, GI bleeding requiring transfusion / abdominal pain requiring tube decompression or bowel diversion
Lower GI / Pelvis	Increased frequency or change in quality of bowel habits not requiring medication / rectal discomfort not requiring analgesics	Diarrhea requiring parasympatholytic drugs (e.g. Lomotil) / mucous discharge not necessitating sanitary pads / rectal or abdominal pain requiring analgesics	Diarrhea requiring parenteral support / severe mucous or blood discharge necessitating sanitary pads / abdominal distention (flat plate radiograph demonstrates distended bowel loops)	Acute or subacute obstruction, fistula or perforation; GI bleeding requiring transfusion; abdominal pain or tenesmus requiring tube decompression or bowel diversion
Lung	Mild symptoms of dry cough or dyspnea on exertion	Persistent cough requiring narcotic, antitussive agents / dyspnea with minimal effort but not at rest	Severe cough unresponsive to narcotic antitussive agent or dyspnea at rest / clinical or radiological evidence of acute pneumonitis / intermittent oxygen or steroids may be required	Severe respiratory insufficiency / continuous oxygen or assisted ventilation
Genitourinary	Frequency of urination or nocturia twice pretreatment habit / dysuria, urgency not requiring medication	Frequency of urination or nocturia that is less frequent than every hour. Dysuria, urgency, bladder spasm requiring local anesthetic (e.g. Pyridium)	Frequency with urgency and nocturia hourly or more frequenty / dysuria, pelvis pain or bladder spasm requiring regular, frequent narcotic / gross hematuria with/without clot passage	Hematuria requiring transfusion / acute bladder obstruction not secondary to clot passage, ulceration, or necrosis
Heart	Asymptomatic but objective evidence of EKG changes or pericardial abnormalities without evidence of other heart disease	Symptomatic with EKG changes and radiological findings of congestive heart failure or pericardial disease / no specific treatment required	Congestive heart failure, angina pectoris, pericardial disease responding to therapy	Congestive heart failure, angina pectoris, pericardial disease, arrhythmias not responsive to nonsurgical measures
CNS	Fully functional status (i.e. able to work) with minor neurological findings, no medication needed	Neurological findings present sufficient to require home care / nursing assistance may be required / medications including steroids/antiseizure agents may be required	Neurological findings requiring hospitalization for initial management	Serious neurological impairment that includes paralysis, coma, or seizures > 3 per week despite medication / hospitalization required
HEME	1	2	3	4
WBC	3.0 - < 4.0	2.0 - < 3.0	1.0 - < 2.0	< 1.0
Platelets	75 - < 100	50 - < 75	25 - < 50	<25 or spontaneous bleeding
Neutrophils	1.5 - < 1.9	1.0 - < 1.5	0.5 - < 1.0	< 0.5 or sepsis
Hgb / Hct	11 - 9.5 (28% - < 32%)	< 9.5 - 7.5 ( < 28%)	< 7.5 - 5.0 (Packed cell transfusion required)	(none)

LATE

For all: 0 - no symptoms, 5 - death directly related to radiation effects

RTOG/EORTC LATE Radiation Morbidity

Tissue	Grade 1	2	3	4
Skin	Slight atrophy; pigmentation change; some hair loss	Patch atrophy; moderate telangiectasia; total hair loss	Marked atrophy; gross telangiectasia	Ulceration
Subcutaneous tissue	Slight induration (fibrosis) and loss of subcutaneous fat	Moderate fibrosis but asymptomatic; slight field contracture; <10% linear reduction	Severe induration and loss of subcutaneous tissue; field contracture > 10% linear measurement	Necrosis
Mucous membrane	Slight atrophy and dryness	Moderate atrophy and telangiectasia; little mucous	Marked atrophy with complete dryness	Ulceration
Salivary glands	Slight dryness of mouth; good response on stimulation	Moderate dryness of mouth; poor response on stimulation	Complete dryness of mouth; no response on stimulation	Fibrosis
Spinal cord	Mild L'Hermitte's syndrome	Severe L'Hermitte's syndrome	Objective neurological findings at or below cord level treated	Mono, para quadraplegia
Brain	Mild headache; slight lethargy	Moderate headache; great lethargy	Severe headache; severe CNS dysfunction (partial loss of power or dyskinesia)	Coma
Eye	Asymptomatic cataract; minor corneal ulceration or keratitis	Symptomatic cataract; moderate corneal ulceration; minor retinopathy or glaucoma	Severe keratitis; severe retinopathy or detachment	Panophthalmitis / blindness
Larynx	Hoarseness; slight arytenoid edema	Moderate arytenoid edema; chondritis	Severe edema; severe chondritis	Necrosis
Lung	Asymptomatic or mild symptoms (dry cough); slight radiographic appearances	Moderate symptomatic fibrosis or pneumonitis (severe cough); low grade fever; patchy radiographic appearances	Severe symptomatic fibrosis or pneumonitis; dense radiographic changes	Severe respiratory insufficiency / Continuous oxygen / assisted ventilation
Heart	Asymptomatic or mild symptoms; transient T wave inversion & ST changes; sinus tachy > 110 (at rest)	Moderate angina on effort; mild pericarditis; normal heart size; persistent abnormal T wave and ST changes; low ORS	Severe angina; pericardial effusion; constrictive pericarditis; moderate heart failure; cardiac enlargement; EKG abnormalities	Tamponade / severe heart failure; severe constrictive pericarditis
Esophagus	Mild fibrosis; slight difficulty in swallowing solids; no pain on swallowing	Unable to take solid food normally; swallowing semisolid food; dilatation may be indicated	Severe fibrosis; able to swallow only liquids; may have pain on swallowing; dilatation required	Necrosis / perforation fistula
Small/Large intestine	Mild diarrhea; mild cramping; bowel movement 5 times daily; slight rectal discharge or bleeding	Moderate diarrhea and colic; bowel movement > 5 times daily; excessive rectal mucus or intermittent bleeding	Obstruction or bleeding, requiring surgery	Necrosis / perforation fistula
Liver	Mild lassitude; nausea, dyspepsia; slightly abnormal liver function	Moderate symptoms; some abnormal liver function tests; serum albumin normal	Disabling hepatic insufficiency; liver function tests grossly abnormal; low albumin; edema or ascites	Necrosis / hepatic coma or encephalopathy
Kidney	Transient albuminuria; no hypertension; mild impairment of renal function; urea 25-35 mg/dL; creatinine 1.5-2.0 mg/dL; creatinine clearance > 75%	Persistent moderate albuminuria (2+); mild hypertension; no related anemia; moderate impairment of renal function; urea > 36-60; creatinine clearance 50-74%	Severe albuminuria; severe hypertension; persistent anemia (< 10); severe renal failure; urea > 60; creatinine > 4.0; creatinine clearance < 50%	Malignant hypertension; uremic coma; urea > 100
Bladder	Slight epithelial atrophy; minor telangiectasia (microscopic hematuria)	Moderate frequency; generalized telangiectasia; intermittent macroscopic hematuria	Severe frequency & dysuria; severe telangiectasia (often with petechiae); frequent hematuria; reduction in bladder capacity (<150 cc)	Necrosis/contracted bladder (capacity < 100 cc); severe hemorrhagic cystitis
Bone	Asymptomatic; no growth retardation; reduced bone density	Moderate pain or tenderness; growth retardation; irregular bone sclerosis	Severe pain or tenderness; complete arrest of bone growth; dense bone sclerosis	Necrosis / spontaneous fracture
Joint	Mild joint stiffness; slight limitation of movement	Moderate stiffness; intermittent or moderate joint pain; moderate limitation of movement	Severe joint stiffness; pain with severe limitation of movement	Necrosis / complete fixation