# Radiation Oncology/Toxicity grading/RTOG

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RTOG/EORTC Radiation Toxicity Grading

## 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 |