Dermatologic Sequelae Associated with Radiation Therapy

Radiation injury and gut microbiota-based treatment

The exposure to either medical sources or accidental radiation can cause varying degrees of radiation injury (RI). RI is a common disease involving multiple human body parts and organs, yet effective treatments are currently limited. Accumulating evidence suggests gut microbiota are closely associated with the development and prevention of various RI. This article summarizes 10 common types of RI and their possible mechanisms. It also highlights the changes and potential microbiota-based treatments for RI, including probiotics, metabolites, and microbiota transplantation. Additionally, a 5P-Framework is proposed to provide a comprehensive strategy for managing RI.

Evaluation of the effect of herbal agents as management of radiodermatitis in breast cancer patients: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of herbal agents in the prevention and therapy of radiodermatitis in breast cancer patients.

METHODS

Randomized controlled trials were searched from databases such as PubMed, Web of Science, Embase, Cochrane Library, and Chinese National Knowledge Infrastructure (CNKI) to assess the effectiveness of herbal agents compared to a standard medication or placebo in prevention or treatment of radiodermatitis in breast cancer.

RESULTS

Data from 16 studies involving 1994 patients were included. This meta-analysis included 10 clinical trials of 562 breast cancer patients treated with calendula, silymarin, or aloe vera for the prevention of radiodermatitis. Silymarin showed positive effects in ameliorating the damage of radiodermatitis, whereas the efficacy of calendula and aloe vera in the treatment of radiodermatitis lacks sufficient evidence.

CONCLUSIONS

Herbal medicine may show therapeutic effects on radiodermatitis in breast cancer, but more comprehensive investigations and clinical trials are required in the future.

Exploring the alterations and function of skin microbiome mediated by ionizing radiation injury

Background

Radiation-induced skin injury (RISI) is still the most common and severe side effect of radiotherapy. The role of the skin’s microbial barrier in the pathogenesis and progression of RISI needs to be fully investigated.

Methods

This study aimed to explore the alterations in and functions of the skin microbiota in RISI. We applied the unculturable approach to characterize the cutaneous microbiomes of a radiation-induced animal model by sequencing the V1–V3 regions of the 16S ribosomal RNA (rRNA) gene. Combined with the downloaded clinical data of patients, a comprehensive analysis was performed to identify potential radioprotective species and metabolic pathways.

Results

There were no significant differences in the alpha diversity indices (Sobs, Shannon, Simpson, Ace, and Chao) between the acute radiation injury and control groups. Phylum-level analysis of the RISI microbiomes exhibited significant predominance of Firmicutes (mean abundance = 67%, corrected p = 0.0035). The high abundance of Firmicutes was significantly associated with rapid healing of RISI (average relative abundance = 52%; Kruskal–Wallis: p = 5.7E−4). Among its members, Streptococcus, Staphylococcus, Acetivibrio ethanolgignens group, Peptostreptococcus, Anaerofilum, and UCG-002 [linear discriminant analysis (LDA) > 3, p < 0.05] were identified as the core genera of Firmicutes. In addition, Lachnosiraceae and Lactobacillus occupied an important position in the interaction network (r > 0.6, p < 0.05). The differential metabolic pathways of RISI were mainly associated with carbohydrate metabolism (butanoate and propanoate metabolism), amino acid metabolism (tryptophan and histidine metabolism), energy metabolism, and lipid metabolism (fatty acid degradation and biosynthesis).

Conclusion

This study provides new insights into the potential mechanism and skin microbial changes in the progression of RISI. The overwhelming predominance of members of Firmicutes, including Streptococcaceae, Staphylococcaceae, Lachnospiraceae, and Lactobacillus, is potentially related to rapid healing of RISI. The microbiota–metabolite axis plays a critical role in RISI and provides promising therapeutic targets for the treatment of adverse side effects.

Prevention of Radiodermatitis With Topical Chinese Herbal Medicine: A Systematic Review and Meta-Analysis

Objectives: Topical Chinese herbal medicine (TCHM) is widely used to prevent radiodermatitis in patients who receive radiation therapy in China. However, evidence regarding its efficacy remains limited. The purpose of the review is to evaluate the effects of TCHM in preventing radiodermatitis.

Methods: The protocol of this review was registered in PROSPERO (CRD42020220620). Relevant clinical trials were identified (from January 1, 2010, to April 24, 2022) through 11 electronic databases, including PubMed, SpringerLink, Proquest, the Cochrane Central Register of Controlled Trials, Scopus, the ProQuest Dissertation & Theses Global, PsycINFO, Applied Social Sciences Index and Abstracts, the Chinese National Knowledge Infrastructure Databases, Wangfang Data Knowledge Service Platform, and the Chongqing VIP Chinese Science and Technology Periodical Database. The quality of the included trials was assessed through a risk of bias assessment using Version 2 of the Cochrane risk-of-bias tool (RoB 2.0). We included RCTs that compared TCHM single used or as adjunctive treatment with routine drugs, conventional therapy, or placebo for cancer patients who are about to start radiation therapy and do not possess any type of dermatitis or skin lesions at that time. Primary outcomes of interest were the incidence of radiodermatitis and the grade of radiodermatitis according to the RTOG (Radiation Therapy Oncology Group). Secondary outcomes included the recovery time of skin and mucosa, the occurrence time of radiodermatitis, the radiation dose, quality of life, and adverse events. Data were summarized using risk ratio (RR) calculations and 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI for continuous outcomes. Certainty of the evidence was assessed according to the GRADE criteria.

Results: In this review, 38 randomized controlled trials (RCTs) were included. Risk of bias assessment through RoB 2.0 showed that two studies were rated as low risk, two studies were rated as high risk, and the rest were rated as having some concerns. Compared with routine drugs, TCHM may have an advantage in reducing RTOG grading (RR = 0.46, 95%CI 0.35–0.60), decreasing the recovery time of radiodermatitis (MD = −2.35, 95%CI 3.58 to −1.12 days), delaying the occurrence of radiodermatitis (MD = 2.36, 95%CI 1.74–2.98), and improving the quality of life of patients (RR = 1.46, 95%CI 1.03–2.06). Compared with conventional therapy, TCHM may also have an advantage in decreasing the grade of RTOG (RR = 0.28, 95%CI 0.21–0.38).

Conclusion: Current low evidence revealed that TCHM may have better efficacy in the prevention of radiodermatitis; however, more high-quality RCTs are still warranted to testify this conclusion.

Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020220620), identifier (PROSPERO 2020 CRD42020220620).

Bullous pemphigoid and radiotherapy: case report and literature review update

Bullous pemphigoid (BP) is a common autoimmune bullous disease generally occurring in elderly patients. Itchy and tense blisters on normal skin or erythematous and edematous lesions on the trunk and extremities usually characterize BP. Trigger factors are still unclear while several case reports suggest a potential role of radiotherapy (RT) as BP trigger for disease onset or recrudescence. A review was performed to provide an update of literature. A case report of a patient affected by BP undergoing two radiotherapy courses for a primary breast cancer was also reported. A comprehensive review of the published literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review included studies describing BP and its relationships with RT treatments. A total of 13 articles were reviewed. Studies characteristics analysis resulted in eleven case reports, one case series and one large-scale case– control study. Literature update confirms the existence of a reasonable connection between RT and BP. Case report showed that a multidisciplinary management seems to assure the feasibility of RT in patients affected by BP, not depriving them of standard therapeutic opportunities.

Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity

OBJECTIVE

Radiation-induced skin injuries such as lesions (RSLs) and dermatitis are the most common complication during radiotherapy (RT) for nasopharyngeal carcinoma, but little is known about risk factors unique to oncology. This study sought a greater understanding of these risk factors to stratify patients based on risk and guide clinical decision-making.

METHODS

Investigators analyzed the data of 864 consecutive patients referred to the RT center of the Southern Theater General Hospital for a new RSL from 2013 to 2019. These patients were followed up for an average of approximately 16 months until their death or March 30, 2020, whichever came first. Multivariate logistic regression analysis and Cox proportional hazards model were used to identify predictors of grade 3 or 4 dermatitis.

RESULTS

The main causes of treatment interruption included dermatitis and oral mucositis. Significant patient-specific risk factors for RSLs included current smoking, current drinking, and lower Karnofsky Performance Scale score and significant procedure-specific risk factors included receiving intensity-modulated radiation therapy (IMRT), hyperfractionated RT, induction chemotherapy, multicycle chemotherapy, and taxol- and cisplatin-based drugs. The three factors that independently predicted risk of RSL were IMRT, lower Karnofsky Performance Scale score, and multicycle chemotherapy. Comparing predictive factors among patients with severe RSL revealed that patients who received IMRT were more likely to develop grade 3 or 4 dermatitis.

CONCLUSIONS

Oncology providers should note that IMRT is an aggressive technique with a trend toward increased RSL. Providers should pay special attention to adverse effects to skin in patients with nasopharyngeal carcinoma.

Skin Manifestations after Ionizing Radiation Exposure: A Systematic Review

Morphological and functional skin alterations secondary to the action of ionizing radiation are well documented. In addition to its application in the medical field, ionizing radiation represents a public health problem for diagnostic and therapeutic purposes due to the potential risk of exposure to unexpected events, such as nuclear accidents or malicious acts. With regard to the use of ionizing radiations in the medical field, today, they constitute a fundamental therapeutic method for various neoplastic pathologies. Therefore, the onset of adverse skin events induced by radiation represents a widespread and not negligible problem, affecting 95% of patients undergoing radiotherapy. A systematic literature search was performed from July 2021 up to August 2021 using PubMed, Embase, and Cochrane databases. Articles were screened by title, abstract and full text as needed. A manual search among the references of the included papers was also performed. This systematic review describes the various skin reactions that can arise following exposure to ionizing radiation and which significantly impact the quality of life, especially in cancer patients.

Radiation-Associated Angiosarcoma of the Breast and Chest Wall Treated with Thermography-Controlled, Contactless wIRA-Hyperthermia and Hypofractionated Re-Irradiation

Simple Summary

This retrospective study reports on 10 patients with radiation-associated angiosarcoma of the breast and chest wall treated during the past decade. In this rare disease local control is highly dependent on the extent of surgery. Further treatment options are urgently needed. Re-iradiation in combination with localized hyperthermia should be considered for adjuvant and definitive treatment of nonresectable radiation-associated angiosarcomas. The presented hypofractionated re-irradiation schedule with 5 × 4 Gy once per week immediately following wIRA-hyperthermia is a promising option to further reduce the radiation dose recommended so far. This could reduce side effects without compromising local control.

Abstract

Background: Radiation-associated angiosarcoma of the breast (RAASB) is a rare, challenging disease, with surgery being the accepted basic therapeutic approach. In contrast, the role of adjuvant and systemic therapies is a subject of some controversy. Local recurrence rates reported in the literature are mostly heterogeneous and are highly dependent on the extent of surgery. In cases of locally recurrent or unresectable RAASB, prognosis is very poor. Methods: We retrospectively report on 10 consecutive RAASB patients, most of them presenting with locally recurrent or unresectable RAASB, which were treated with thermography-controlled water-filtered infrared-A (wIRA) superficial hyperthermia (HT) immediately followed by re-irradiation (re-RT). Patients with RAASB were graded based on their tumor extent before onset of radiotherapy (RT). Results: We recorded a local control (LC) rate dependent on tumor extent ranging from a high LC rate of 100% (two of two patients) in the adjuvant setting with an R0 or R2 resection to a limited LC rate of 33% (one of three patients) in patients with inoperable, macroscopic tumor lesions. Conclusion: Combined HT and re-RT should be considered as an option (a) for adjuvant treatment of RAASB, especially in cases with positive resection margins and after surgery of local recurrence (LR), and (b) for definitive treatment of unresectable RAASB.

Efficacy of different plant extracts in the prevention of radiation dermatitis in radiotherapy patients with nasopharyngeal carcinoma: A protocol for a Bayesian network meta-analysis

BACKGROUND

Radiation dermatitis is a common complication in patients with nasopharyngeal carcinoma (NPC) when treated with radiotherapy. Plant extracts have good effects on the prevention of radiation dermatitis in patients with NPC when treated with radiotherapy. However, there is insufficient comparison among the currently used plant extracts. Therefore, the purpose of this study was to explore the efficacy of different plant extracts in the prevention of radiation dermatitis in patients with NPC by Bayesian network meta-analysis.

METHODS

We searched Chinese and English databases to collect all randomized controlled trials (RCT) of plant extracts for the prevention of radiation dermatitis in NPC patients who underwent radiotherapy up to October 2020. Two researchers then independently screened articles, extracted data and evaluated the quality selected literatures. All data were processed by Stata 14.0 and WinBUGS V.1.4.3.

RESULTS

We applied Bayesian statistical model for network meta-analysis, ranked the effects of various plant extracts, and adopted GRADE method to explain the results.

CONCLUSION

Our study is expected to provide high-quality evidence-based medicine advice for the prevention of radiation dermatitis in patients suffering from NPC undergoing radiotherapy.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and will be shared on social media platforms. This review would be disseminated in a peer-reviewed journal or conference presentations.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/6SV45.