Radiation Oncology/Toxicity grading/RTOG

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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.


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)


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