Acute Radiation Morbidity Scoring Criteria Acute Radiation Links Skin Mucous Membrane Eye Ear Salivary Gland Pharynx/Esophagus Larynx Upper G.I. Lower G.I. Lung Genitourinary Heart CNS Hematologic WBC Platelets Neutrophils Hemoglobin Hematocrit [ 0 ] [ 1 ] [ 2 ] [ 3 ] [ 4 ] SKIN No change over baseline Follicular, faint or dull erythema/ epilation/dry desquamation/ decreased sweating Tender or bright erythema, patchy moist desquamation/ moderate edema Confluent, moist desquamatiom other than skin folds, pitting edema Ulceration, hemorrhage, necrosis MUCOUS MEMBRANE No change over baseline Injection/ may experience mild pain not requiring analgesic Patchy mucositis which may produce an inflammatory serosanguinitis discharge/ may experience moderate pain requiring analgesia Confluent fibrinous mucositis/ may include severe pain requiring narcotic Ulceration, hemorrhage or necrosis EYE No change Mild conjunctivitis with or without scleral injection/ increased tearing Moderate conjunctivitis with or without keratitis requiring steroids &/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/ panopthalmitis Loss of vision (unilateral or bilateral) EAR No change over baseline Mild external otitis with erythema, pruritis, secondary to dry desquamation not requiring medication. Audiogram unchanged from baseline Moderate external otitis requiring topical medication/ serious otitis medius/ hypoacusis on testing only Severe external otitis with dischange or moist desquamation/ symptomatic hypoacusis/tinnitus, not drug related Deafness SALIVARY GLAND No change over baseline 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 ------- Acute salivary gland necrosis PHARYNX & ESOPHAGUS No change over baseline 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 pre-treatment baseline) requiring N-G feeding tube, I.V. fluids or hyperalimentation Complete obstruction, ulceration, perforation, fistula LARYNX No change over baseline 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 G.I. No change 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 &/ or vomiting requiring antiemetics/ abdominal pain requiring analgesics Anorexia with >15% weight loss from pretreatment baseline or requiring N-G tube or parenteral support. Nausea &/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, performation, GI bleeding requiring transfusion/abdominal pain requiring tube decompression or bowel diversion LOWER G.I. INCLUDING PELVIS No change 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 pags/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 No change 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 radiologic evidence of acute pneumonitis/ intermittent oxygen or steroids may be required Severe respiratory insufficiency/ continuous oxygen or assisted ventilation GENITOURINARY No change Frequency of urination or nocturia twice pretreatment habit/ dysuria, urgency not requiring medication Frequency of urination or nocturia which is less frequent than every hour. Dysuria, urgency, bladder spasm requiring local anesthetic (e.g., Pyridium) Frequency with urgency and nocturia hourly or more frequently/ 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 No change over baseline Asymptomatic but objective evidence of EKG changes or pericardial abnormalities without evidence of other heart disease Symptomatic with EKG changes and radiologic 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 non-surgical measures CNS No change Fully functional status (i.e., able to work) with minor neurologic findings, no medication needed Neurologic findings present sufficient to require home case/ nursing assistance may be required/ medications including steroids/anti-seizure agents may be required Neurologic findings requiring hospitalization for initial management Serious neurologic impairment which includes paralysis, coma or seizures>3 per week despite medication/hospitalization required HEMATOLOGIC WBC (X 1000) >=4.0 3.0 - <4.0 2.0 - <3.0 1.0 - <2.0 <1.0 PLATELETS (X 1000) >=100 75 - <100 50 - <75 25 - <50 <25 or spontaneous bleeding NEUTROPHILS >=1.9 1.5 - <1.9 1.0 - <1.5 0.5 - <1.0 <0.5 or sepsis HEMOGLOBIN (GM %) >11 11-9.5 <9.5 - 7.5 <7.5 - 5.0 ------- HEMATOCRIT (%) >=32 28 - <32 <28 Packed cell transfusion required ------- GUIDELINES: The acute morbidity criteria are used to score/grade toxicity from radiation therapy. The critera are relevant from day 1, the commencement of therapy, through day 90. Therafter, the EORTC/RTOG Criteria of Late Effects are to be utilized. The evaluator must attempt to discriminate between disease- and treatment-related signs and symptoms. An accurate baseline evaluation prior to commencement of therapy is necessary. All toxicities Grade 3, 4 or 5* must be verified by the Principal Investigator. *ANY TOXICITY WHICH CAUSED DEATH IS GRADED 5.