A Dermatitis Control Program (DeCoP) for head and neck cancer patients receiving radiotherapy: a prospective phase II study

Clinical outcomes of scalp or face angiosarcoma treatment with intensity-modulated radiotherapy: a multicenter study

Combined modality therapy, including radiotherapy (RT), is a common treatment for scalp or face angiosarcoma. Although intensity-modulated radiotherapy (IMRT) can deliver homogeneous doses to the scalp or face, clinical data are limited. This multicenter study aimed to evaluate scalp or face angiosarcoma treated with definitive or post-operative IMRT. We retrospectively analyzed data from patients who received IMRT for scalp or face angiosarcoma at three institutions between January 2015 and March 2020. Local control (LC) rate, overall survival (OS), progression-free survival (PFS), recurrence patterns and toxicity were evaluated. Fifteen patients underwent IMRT during the study period. Definitive RT was performed on 10 patients and post-operative RT was performed on 5 patients. The 1-year LC rate was 85.7% (95% confidence interval [CI], 53.9-96.2%). The 1-year OS and PFS rates were 66.7% (95% CI, 37.5-84.6%) and 53.3% (95% CI, 26.3%-74.4%), respectively. Univariate analysis revealed that a clinical target volume over 500 cm3 was associated with poor LC. Distant metastasis was the most common recurrence pattern. All patients experienced Grade 2 or 3 radiation dermatitis, and five patients experienced grade ≥ 3 skin ulceration. One patient who underwent maintenance therapy with pazopanib developed Grade 5 skin ulceration. Fisher's exact test showed that post-operative RT was significantly associated with an increased risk of skin ulceration of grade ≥ 3. These results demonstrate that IMRT is a feasible and effective treatment for scalp or face angiosarcoma, although skin ulceration of grade ≥ 3 is a common adverse event in patients who receive post-operative RT.

Efficacy of Supportive Care for Radiodermatitis in Patients with Head and Neck Cancer: Supplementary Analysis of an Exploratory Phase II Trial

Self-care demonstrated efficacy in preventing severe acute radiation dermatitis among patients with head and neck squamous cell carcinoma undergoing chemoradiotherapy (CRT). This prospective trial aimed to confirm the feasibility and safety of transcutaneous electrical sensory stimulation while examining the relationship between changes in self-care behavior through supportive care interventions and the severity of acute radiation dermatitis during CRT. Patients underwent assessments for dermatitis grading (Grades 1 to ≥3) and were interviewed regarding self-care practices. The self-care questionnaires comprised six items, and a point was deducted for each task that the patient could not perform independently. Statistical analysis was performed to determine the association between G3 radiation dermatitis and the lowest self-care behavior scores. Of the 10 patients enrolled, three experienced G3 dermatitis. During CRT, six patients maintained their initial scores and did not develop ≥G3 dermatitis. Meanwhile, three of four patients with decreased scores exhibited ≥G3 dermatitis. The group with ≥G3 dermatitis had significantly lower scores than those with ≤G2 dermatitis, suggesting that the inability of patients to perform self-care routinely may lead to severe acute radiation dermatitis. Further prospective studies are needed to confirm the potential of self-care interventions in preventing severe dermatitis.

Current status and progress in research on dressing management for diabetic foot ulcer

Diabetic foot ulcer (DFU) is a major complication of diabetes and is associated with a high risk of lower limb amputation and mortality. During their lifetime, 19%-34% of patients with diabetes can develop DFU. It is estimated that 61% of DFU become infected and 15% of those with DFU require amputation. Furthermore, developing a DFU increases the risk of mortality by 50%-68% at 5 years, higher than some cancers. Current standard management of DFU includes surgical debridement, the use of topical dressings and wound decompression, vascular assessment, and glycemic control. Among these methods, local treatment with dressings builds a protective physical barrier, maintains a moist environment, and drains the exudate from DFU wounds. This review summarizes the development, pathophysiology, and healing mechanisms of DFU. The latest research progress and the main application of dressings in laboratory and clinical stage are also summarized. The dressings discussed in this review include traditional dressings (gauze, oil yarn, traditional Chinese medicine, and others), basic dressings (hydrogel, hydrocolloid, sponge, foam, film agents, and others), bacteriostatic dressings, composite dressings (collagen, nanomaterials, chitosan dressings, and others), bioactive dressings (scaffold dressings with stem cells, decellularized wound matrix, autologous platelet enrichment plasma, and others), and dressings that use modern technology (3D bioprinting, photothermal effects, bioelectric dressings, microneedle dressings, smart bandages, orthopedic prosthetics and regenerative medicine). The dressing management challenges and limitations are also summarized. The purpose of this review is to help readers understand the pathogenesis and healing mechanism of DFU, help physicians select dressings correctly, provide an updated overview of the potential of biomaterials and devices and their application in DFU management, and provide ideas for further exploration and development of dressings. Proper use of dressings can promote DFU healing, reduce the cost of treating DFU, and reduce patient pain.

Phase 3 Randomized Trial of Topical Steroid Versus Placebo for Prevention of Radiation Dermatitis in Patients With Head and Neck Cancer Receiving Chemoradiation

PURPOSE

Radiation dermatitis is one of the most common acute toxicities induced by chemoradiation therapy (CRT) for head and neck cancer (HNC). The benefit of topical steroids in the management of radiation dermatitis is still unclear. This phase 3, multi-institutional, randomized, double-blind, placebo-controlled trial evaluated the efficacy and safety of topical steroids for radiation dermatitis in patients with locally advanced HNC receiving CRT.

METHODS AND MATERIALS

Eligible patients were scheduled to receive bilateral neck irradiation (≥66 Gy) with concurrent cisplatin (≥200 mg/m²) as definitive or postoperative CRT. Patients were randomly assigned to receive either topical steroid or placebo when grade 1radiation dermatitis was observed or the total radiation dose reached 30 Gy. Basic skin care including gentle washing and moistening in the head and neck region was performed in both groups. The primary endpoint was the frequency of grade ≥2 radiation dermatitis, in accordance with the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Grading of radiation dermatitis was performed by independent central review using photographs taken weekly.

RESULTS

A total of 211 patients were enrolled (intention to treat: steroid 101 and placebo 102). The frequency of grade ≥2 radiation dermatitis was not significantly reduced with the steroid (73.3%; 95% confidence interval, 64.6%-81.9%) compared with the placebo (80.4%; 95% confidence interval, 72.7%-88.1%; P = .23), whereas the steroid significantly reduced the frequency of grade ≥3 radiation dermatitis (13.9% vs 25.5%; P = .034). No significant differences in adverse events, including local infection or compliance with CRT, were observed between the groups.

CONCLUSIONS

Topical steroid may reduce the severity of radiation dermatitis in patients with HNC and thus may become an important therapeutic tool in the management of radiation dermatitis.

Quality Assessment in Supportive Care in Head and Neck Cancer

Quality assessment is a key issue in every clinical intervention, to be periodically performed so to measure the adherence to standard and to possibly implement strategies to improve its performance. This topic is rarely discussed for what concerns supportive care; however, it is necessary to verify the quality of the supportive measures; “supportive care makes excellent cancer care possible,” as stated by the Multinational Association of Supportive Care in Cancer (MASCC). In this regard, the quality of supportive care in head and neck cancer patients is a crucial topic, both to allow administration of treatments according to planned dose intensity or surgical indications and to maintain or improve patients' quality of life. This paper aims to provide insight on state of the art supportive care and its future developments for locally advanced and recurrent/metastatic head and neck cancer, with a focus on quality assessment in relation to surgery, radiotherapy, and systemic therapy.

A Multicenter Phase II Trial of Docetaxel, Cisplatin, and Cetuximab (TPEx) Followed by Cetuximab and Concurrent Radiotherapy for Patients With Local Advanced Squamous Cell Carcinoma of the Head and Neck (CSPOR HN01: ECRIPS Study)

Background: Induction chemotherapy (IC) is a treatment option for locally advanced squamous cell carcinoma of the head and neck (LA SCCHN). However, treatment with docetaxel, cisplatin, and 5-FU (TPF) followed by cisplatin and radiotherapy is controversial because of toxicity concerns. The aim of this phase II study was to assess the feasibility of docetaxel, cisplatin, and cetuximab (TPEx) followed by cetuximab and concurrent radiotherapy for LA SCCHN.

Patients and Methods: We enrolled patients with histological evidence of squamous cell carcinoma of the oropharynx, hypopharynx, or larynx without distant metastases. IC comprised cisplatin (75 mg/m²) and docetaxel (75 mg/m²) on day 1, repeated every 3 weeks for up to three courses. Cetuximab was initiated at 400 mg/m², followed by 250 mg/m² doses weekly until the end of radiotherapy. Radiotherapy (70 Gy/35 fr/7 w) was initiated after the last docetaxel administration. The primary endpoint was the rate of treatment completion.

Results: We enrolled 54 patients (median age, 58 years) between August 2013 and October 2015. Our patients were 49 males and 5 females with hypopharyngeal (n = 28), oropharyngeal (n = 19), or laryngeal (n = 7) cancers, and 48 of them had stage IV disease. The overall response rate was 72.2% with a median follow-up of 36.1 months and a 3-year overall survival of 90.7%. The treatment completion rate was 76%; 50 patients (93%) received ≥2 courses of IC, and 41 (76%) completed radiotherapy. The frequencies of grade ≥3 febrile neutropenia or allergy/infusion reactions were 39% and 11%, respectively. There was one treatment-related death.

Conclusions: IC with TPEx followed by cetuximab with concurrent radiotherapy showed acceptable compliance for the treatment of LA SCCHN. However, high frequency of febrile neutropenia remains a challenge and further improvement in the management of TPEx is necessary.

Trial Registration: UMIN000009928

Topical steroid versus placebo for the prevention of radiation dermatitis in head and neck cancer patients receiving chemoradiotherapy: the study protocol of J-SUPPORT 1602 (TOPICS study), a randomized double-blinded phase 3 trial

Background

To date, the clinical benefit of topical steroid use has only been demonstrated for radiation dermatitis induced by 50–60 Gy irradiation in breast cancer. However, these agents are also often used clinically for the control of radiation dermatitis induced by high-dose (>60Gy) irradiation with chemotherapy in head and neck cancer. Despite this, the prophylactic efficacy of topical steroids for radiation dermatitis induced by high-dose irradiation is still unclear.

The aim of this study is to clarify the benefit of topical steroids in basic nursing care for radiation dermatitis induced by chemoradiotherapy in patients with head and neck cancer.

Methods

The study is being conducted as a multicenter 2-arm randomized double-blinded placebo-controlled Phase 3 trial in Japan. The study was started in May 2017, with participant enrollment between May 2017 and April 2019.

Patients scheduled to receive definitive or postoperative chemoradiotherapy for head and neck cancer are eligible for enrollment. All patients will receive chemoradiotherapy, consisting of single agent CDDP and 70-Gy irradiation. Bilateral neck irradiation is mandatory.

Supportive care for radiation dermatitis will consist of basic nursing care with topical steroid or placebo. When radiation dermatitis grade 1 is seen or total radiation dose reaches 30 Gy, minimally required intervention will be started as a first step.

If radiation dermatitis worsens to grade 2, the irradiated area will be covered with a moderately absorbent surgical pad and steroid or placebo topical cream.

The primary endpoint is a comparison of the proportion of patients with ≥ grade 2 radiation dermatitis by NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0.

Ethical approval has been obtained from all participating sites. The results of this study will be submitted for publication in international peer-reviewed journals and the key findings will be presented at international scientific conferences.

Discussion

Evidence supporting the benefit of adding topical steroids in general nursing care for radiation dermatitis induced by high-dose irradiation with chemotherapy is insufficient. This trial aims to clarify the clinical benefit of topical steroid for radiation dermatitis induced by high-dose irradiation with chemotherapy. The trial is ongoing and is currently recruiting.

Trial registration number

UMIN000027161. Protocol version 3.0, 18 April 2017.

Prevention and treatment of radiation-induced acute dermatitis in head and neck cancer patients: a systematic review

Acute dermatitis is the most common radio-induced side effect during treatment for head and neck cancer. The use of a wide variety of agents is reported to handle skin toxicity. Our aim was to review the literature and synthesize current available evidence. A comprehensive search was performed on multiple electronic databases until February 2017 and a systematic approach was carried out according to PRISMA guidelines. A total of 17 papers (950 patients on the whole) met the inclusion/exclusion criteria, with 12 randomized controlled trials and five nonrandomized observational and prospective studies. Generally speaking, there was no strong evidence to support the superiority of any specific intervention neither in prevention nor in therapeutic settings. Well-designed randomized studies including quality of life measurements are needed.

A prospective picture collection study for a grading atlas of radiation dermatitis for clinical trials in head-and-neck cancer patients

Radiation dermatitis is one of the most common acute toxicities of both radiotherapy and chemoradiotherapy. Many clinical trials have evaluated the level of toxicity using the Common Terminology Criteria for Adverse Events ver. 4.03. This criterion accounts for severity in a single sentence only, and no visual classification guide has been available. Thus, there is a risk of subjective interpretation by the individual investigator. This contrasts with the situation with hematologic toxicities, which can be interpreted objectively. The aim of this prospective picture collection study was to develop a grading tool for use in establishing the severity of radiation dermatitis in clinical trials. A total of 118 patients who were scheduled to receive definitive or postoperative radiotherapy or chemoradiotherapy were enrolled from the four participating cancer centers. All researchers in our group used the same model of camera under the same shooting conditions to maintain consistent photographic quality. In all, 1600 photographs were collected. Of these, 100 photographs qualified for the first round of selection and were then graded by six experts, basically in accordance with the CTCAE ver. 4.03 (JCOG ver. in Japanese). After further study, 38 photographs were selected as representing typical models for Grade 1-4 radiation dermatitis; the radiation dermatitis grading atlas was produced from these photographs. The atlas will play a major role in ensuring that the dermatitis rating system is consistent between the institutions participating in trials. We hope that this will contribute to improving the quality of clinical trials, and also to improving the level of routine clinical practice.

Asian expert recommendation on management of skin and mucosal effects of radiation, with or without the addition of cetuximab or chemotherapy, in treatment of head and neck squamous cell carcinoma

With increasing numbers of patients with unresectable locoregionally advanced (LA) head and neck squamous cell carcinoma (HNSCC) receiving cetuximab/radiotherapy (RT), several guidelines on the early detection and management of skin-related toxicities have been developed. Considering the existing management guidelines for these treatment-induced conditions, clinical applicability and standardization of grading methods has remained a cause of concern globally, particularly in Asian countries. In this study, we attempted to collate the literature and clinical experience across Asian countries to compile a practical and implementable set of recommendations for Asian oncologists to manage skin- and mucosa-related toxicities arising from different types of radiation, with or without the addition of cetuximab or chemotherapy. In December 2013, an international panel of experts in the field of head and neck cancer management assembled for an Asia-Pacific head and neck cancer expert panel meeting in China. The compilation of discussion outcomes of this meeting and literature data ultimately led to the development of a set of recommendations for physicians with regards to the approach and management of dermatological conditions arising from RT, chemotherapy/RT and cetuximab/RT, and similarly for the approach and management of mucositis resulting from RT, with or without the addition of chemotherapy or cetuximab. These recommendations helped to adapt guidelines published in the literature or text books into bedside practice, and may also serve as a starting point for developing individual institutional side-effect management protocols with adequate training and education.

DeCoP, a Dermatitis Control Program using a moderately absorbent surgical pad for head and neck cancer patients receiving radiotherapy: a retrospective analysis

OBJECTIVE

We evaluated the clinical characteristics of a Dermatitis Control Program based on a moderately absorbent surgical pad for head and neck cancer patients undergoing (chemo)radiotherapy.

METHODS

We retrospectively reviewed patients who underwent definitive radiotherapy or post-operative radiotherapy and were treated during radiotherapy with a Dermatitis Control Program using a moderately absorbent surgical pad from May 2011 through April 2012. The main protocol was the 'Dermatitis Control Program', a systematic program which consists of a three-step ladder. When radiation dermatitis reached Grade 2, the irradiated area was covered with a moderately absorbent surgical pad. All outpatients and their families were instructed on how to cover and moisten the irradiated area. Radiation dermatitis was evaluated by physicians or nurses at an outpatient clinic and reviewed from photographs.

RESULTS

A total of 116 head and neck cancer patients were treated by definitive or adjuvant (chemo)radiotherapy in our hospital from May 2011 through April 2012. Of these, 85 patients managed their dermatitis using a new device and they were reviewed. Fifty-five patients received chemoradiotherapy, of whom 22 received induction chemotherapy before chemoradiotherapy. Median radiation dose at the onset of Grade 2 dermatitis was 60.0 Gy (range 40-71.2 Gy). Median time to recover from the end of radiotherapy was 10.5 days (range 0-25 days). The rate of recovery from Grade 2 dermatitis within 2 weeks after the end of radiotherapy was 89.4%. The rate of Grade 3 dermatitis was 7.1, with 6.7% in radiotherapy and 7.3% in chemoradiotherapy.

CONCLUSIONS

This study suggests that the DeCoP protocol with a moderately absorbent surgical pad might be useful for the treatment of radiation dermatitis in clinical practice.