A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. CNS Cancer Consortium

Instruments and scales for the evaluation of acute radiation dermatitis: A systematic review

Various assessment instruments have been proposed to document and evaluate radiation dermatitis. In this systematic review, we identified nineteen instruments or scales for the evaluation of radiation dermatitis and performed a critical review of the signs and symptoms included in each of them. Of those scales, only two have been validated. There is a need to revise the currently used instruments so to improve their capability to measure all relevant aspects of radiation dermatitis and their severity. In addition, it would be important to add the patients' view of their conditions and how they affect their lives. Finally, in order to be useful in clinical and research settings, instruments for evaluation of radiation dermatitis should be submitted to the validation process that is currently prescribed in the field of outcome measures development.

Jia-Wei-Si-Miao-Yong-An Fang stimulates the healing of acute radiation-induced cutaneous wounds through MAPK/ERK pathway

ETHNOPHARMACOLOGICAL RELEVANCE

A famous traditional oral Chinese medicine formula, Si-Miao-Yong-An decoction, has been used to treat thromboangiitis obliterans from the Qing Dynasty. Because its therapeutic principles including clearing away heat, detoxification, accelerating blood circulation and relieving pains are consistent with acute radiation-induced cutaneous wounds in traditional Chinese medicine, we tried to add herbs and improve them into an external dosage form, called Jia-Wei-Si-Miao-Yong-An Fang (JWSMYA). However, its mechanism on radiation-induced cutaneous wounds is still unknown.

AIM OF THE STUDY

This study evaluated the therapeutic effect of JWSMYA and investigated the mechanism of repair and anti-fibrosis on acute radiation-induced cutaneous wounds with JWSMYA.

MATERIALS AND METHODS

Firstly, we prepared JWSMYA, and determined the composition through UHPLC LC-MS/MS. Then we used ionizing radiation to make a cutaneous wound model of rats, and observed wound healing through their skin injury score, wound contraction percentage and histological staining. In addition, immunohistochemical staining, Western blot analysis, qRT-PCR and Elisa were used to explore wound rehabilitation and anti-fibrosis mechanisms.

RESULTS

An in vivo assay revealed that JWSMYA promoted the repairment of acute radiation-induced cutaneous wounds, facilitated MAPK/ERK phosphorylation, inhibited PI3K/AKT activation, reduced the level of alpha-smooth muscle actin (a-sma), collagen type-I alpha 2 (Col1a2) and transforming growth factor-beta 1 (TGF-β1) in cutaneous tissues. However, no statistical difference was found in vascular endothelial growth factor (VEGF).

CONCLUSION

JWSMYA accelerated the repair of acute radiation-induced cutaneous wounds, which might be associated with the MAPK/ERK pathway. In addition, PI3K/AKT might be associated with the inhibition of fibrosis and the promotion of high-quality wound healing.

MASCC clinical practice guidelines for the prevention and management of acute radiation dermatitis: part 1) systematic review

Acute radiation dermatitis (ARD) commonly develops in cancer patients undergoing radiotherapy and is often characterized by erythema, desquamation, and pain. A systematic review was conducted to summarize the current evidence on interventions for the prevention and management of ARD. Databases were searched from 1946 to September 2020 to identify all original studies that evaluated an intervention for the prevention or management of ARD, with an updated search conducted in January 2023. A total of 235 original studies were included in this review, including 149 randomized controlled trials (RCTs). Most interventions could not be recommended due to a low quality of evidence, lack of supporting evidence, or conflicting findings across multiple trials. Photobiomodulation therapy, Mepitel® film, mometasone furoate, betamethasone, olive oil, and oral enzyme mixtures showed promising results across multiple RCTs. Recommendations could not be made solely based on the published evidence due to limited high-quality evidence. As such, Delphi consensus recommendations will be reported in a separate publication.

Comparative Evaluation of Topical Corticosteroid and Moisturizer in the Prevention of Radiodermatitis in Breast Cancer Radiotherapy

Background:

Radiodermatitis is a frequent side effect of breast cancer radiotherapy (RT). Treating radiation oncologist should know the prevention and treatment of every grade of radiodermatitis.

Aims:

The aim of this study was to compare the topical corticosteroid and moisturizer usage in breast cancer RT.

Materials and Methods:

Fifty patients with early-stage breast cancer undergoing breast-conserving surgery referred to our department for adjuvant RT between October 2009 and October 2016 were compared with regard to topical steroid or moisturizer usage. Patients were followed up weekly after the start of treatment.

Results:

Mean age was 46 years. Twenty-four patients had stage 1 breast cancer and 26 patients had stage 2 disease. KPS (Karnofsky performance score) was 100 for all patients. Five patients (20.8%) had grade 2 and seven (29.1%) patients had grade 1 acute radiodermatitis in the first group. Eleven (42.3%) patients had grade 2 and 12 (46.1%) patients had grade 1 acute radiodermatitis in the second group. Thirteen (54.1%) patients in the first group had no acute radiodermatitis and three (11.5%) patients in the second group had no acute radiodermatitis. No patient in either group experienced grade 3 radiodermatitis.

Conclusions:

Daily use of topical betamethasone for breast cancer RT improves dermal sparing, reduces acute radiodermatitis, and may be recommended for patients receiving RT to the breast.

Space Radiation Biology for "Living in Space"

Space travel has advanced significantly over the last six decades with astronauts spending up to 6 months at the International Space Station. Nonetheless, the living environment while in outer space is extremely challenging to astronauts. In particular, exposure to space radiation represents a serious potential long-term threat to the health of astronauts because the amount of radiation exposure accumulates during their time in space. Therefore, health risks associated with exposure to space radiation are an important topic in space travel, and characterizing space radiation in detail is essential for improving the safety of space missions. In the first part of this review, we provide an overview of the space radiation environment and briefly present current and future endeavors that monitor different space radiation environments. We then present research evaluating adverse biological effects caused by exposure to various space radiation environments and how these can be reduced. We especially consider the deleterious effects on cellular DNA and how cells activate DNA repair mechanisms. The latest technologies being developed, e.g., a fluorescent ubiquitination-based cell cycle indicator, to measure real-time cell cycle progression and DNA damage caused by exposure to ultraviolet radiation are presented. Progress in examining the combined effects of microgravity and radiation to animals and plants are summarized, and our current understanding of the relationship between psychological stress and radiation is presented. Finally, we provide details about protective agents and the study of organisms that are highly resistant to radiation and how their biological mechanisms may aid developing novel technologies that alleviate biological damage caused by radiation. Future research that furthers our understanding of the effects of space radiation on human health will facilitate risk-mitigating strategies to enable long-term space and planetary exploration.

Parthenolide Selectively Sensitizes Prostate Tumor Tissue to Radiotherapy while Protecting Healthy Tissues In Vivo

Radiotherapy is widely used in cancer treatment, however the benefits can be limited by radiation-induced damage to neighboring normal tissues. Parthenolide (PTL) exhibits anti-inflammatory and anti-tumor properties and selectively induces radiosensitivity in prostate cancer cell lines, while protecting primary prostate epithelial cell lines from radiation-induced damage. Low doses of radiation have also been shown to protect from subsequent high-dose-radiation-induced apoptosis as well as DNA damage. These properties of PTL and low-dose radiation could be used to improve radiotherapy by killing more tumor cells and less normal cells. Sixteen-week-old male Transgenic Adenocarcinoma of the Mouse Prostate (TRAMP) and C57BL/6J mice were treated with PTL (40 mg/kg), dimethylaminoparthenolide (DMAPT, a PTL analogue with increased bioavailability) (100 mg/kg), or vehicle control three times over one week prior to combinations of low (10 mGy) and high (6 Gy) doses of whole-body X-irradiation. Tissues were analyzed for apoptosis at a range of time points up to 72 h postirradiation. Both PTL and DMAPT protected normal tissues, but not prostate tumor tissues, from a significant proportion of high-dose-radiation-induced apoptosis. DMAPT provided superior protection compared to PTL in normal dorsolateral prostate (71.7% reduction, P = 0.026), spleen (48.2% reduction, P = 0.0001) and colorectal tissue (38.0% reduction, P = 0.0002), and doubled radiation-induced apoptosis in TRAMP prostate tumor tissue (101.3% increase, P = 0.039). Both drugs induced the greatest radiosensitivity in TRAMP prostate tissue in areas with higher grade prostatic intraepithelial neoplasia (PIN) lesions. A 10 mGy dose delivered 3 h prior to a 6 Gy dose induced a radioadaptive apoptosis response in normal C57Bl/6J prostate (28.4% reduction, P = 0.045) and normal TRAMP spleen (13.6% reduction, P = 0.047), however the low-dose-adaptive radioprotection did not significantly add to the PTL/DMAPT-induced protection in normal tissues, nor did it affect tumor kill. These results support the use of the more bioavailable DMAPT and low-dose radiation, alone or in combination as useful radioprotectors of normal tissues to alleviate radiotherapy-induced side-effects in patients. The enhanced radiosensitisation in prostate tissues displaying high-grade PIN suggests that DMAPT also holds promise for targeted therapy of advanced prostate cancer, which may go on to become metastatic. The redox mechanisms involved in the differential radioprotection observed here suggest that increased radiotherapy efficacy by DMAPT is more broadly applicable to a range of cancer types.

Current Status of Targeted Radioprotection and Radiation Injury Mitigation and Treatment Agents: A Critical Review of the Literature

As more cancer patients survive their disease, concerns about radiation therapy-induced side effects have increased. The concept of radioprotection and radiation injury mitigation and treatment offers the possibility to enhance the therapeutic ratio of radiation therapy by limiting radiation therapy-induced normal tissue injury without compromising its antitumor effect. Advances in the understanding of the underlying mechanisms of radiation toxicity have stimulated radiation oncologists to target these pathways across different organ systems. These generalized radiation injury mechanisms include production of free radicals such as superoxides, activation of inflammatory pathways, and vascular endothelial dysfunction leading to tissue hypoxia. There is a significant body of literature evaluating the effectiveness of various treatments in preventing, mitigating, or treating radiation-induced normal tissue injury. Whereas some reviews have focused on a specific disease site or agent, this critical review focuses on a mechanistic classification of activity and assesses multiple agents across different disease sites. The classification of agents used herein further offers a useful framework to organize the multitude of treatments that have been studied. Many commonly available treatments have demonstrated benefit in prevention, mitigation, and/or treatment of radiation toxicity and warrant further investigation. These drug-based approaches to radioprotection and radiation injury mitigation and treatment represent an important method of making radiation therapy safer.

RelB Expression Determines the Differential Effects of Ascorbic Acid in Normal and Cancer Cells

Cancer cells typically experience higher oxidative stress than normal cells, such that elevating pro-oxidant levels can trigger cancer cell death. Although pre-exposure to mild oxidative agents will sensitize cancer cells to radiation, this pre-exposure may also activate the adaptive stress defense system in normal cells. Ascorbic acid is a prototype redox modulator that when infused intravenously appears to kill cancers without injury to normal tissues; however, the mechanisms involved remain elusive. In this study, we show how ascorbic acid kills cancer cells and sensitizes prostate cancer to radiation therapy while also conferring protection upon normal prostate epithelial cells against radiation-induced injury. We found that the NF-κB transcription factor RelB is a pivotal determinant in the differential radiosensitization effects of ascorbic acid in prostate cancer cells and normal prostate epithelial cells. Mechanistically, high reactive oxygen species concentrations suppress RelB in cancer cells. RelB suppression decreases expression of the sirtuin SIRT3 and the powerful antioxidant MnSOD, which in turn increases oxidative and metabolic stresses in prostate cancer cells. In contrast, ascorbic acid enhances RelB expression in normal cells, improving antioxidant and metabolic defenses against radiation injury. In addition to showing how RelB mediates the differential effects of ascorbic acid on cancer and normal tissue radiosensitivities, our work also provides a proof of concept for the existence of redox modulators that can improve the efficacy of radiotherapy while protecting against normal tissue injury in cancer settings. Cancer Res; 77(6); 1345-56. ©2017 AACR.

Radiodermatitis: A Review of Our Current Understanding

Radiodermatitis (radiation dermatitis, radiation-induced skin reactions, or radiation injury) is a significant side effect of ionizing radiation delivered to the skin during cancer treatment as well as a result of nuclear attacks and disasters, such as that which occurred in Fukushima in 2011. More specifically, 95 % of cancer patients receiving radiation therapy will develop some form of radiodermatitis, including erythema, dry desquamation, and moist desquamation. These radiation skin reactions result in a myriad of complications, including delays in treatment, diminished aesthetic appeal, and reduced quality of life. Recent technological advancements and novel treatment regimens have only been successful in partly ameliorating these adverse side effects. This article examines the current knowledge surrounding the pathogenesis, clinical manifestations, differential diagnoses, prevention, and management of radiodermatitis. Future research should examine therapies that incorporate the current understanding of the pathophysiology of radiodermatitis while measuring effectiveness using objective and universal outcome measures.

Efficacy and Interaction of Antioxidant Supplements as Adjuvant Therapy in Cancer Treatment: A Systematic Review

Oxidative stress is a key component in carcinogenesis. Although radiation produces reactive oxygen species, some anticancer agents such as alkylating agents, platinum and antitumor antibiotics exert cytotoxicity by generating free radicals. Nonenzymatic exogenous antioxidants such as vitamins, minerals, and polyphenols can quench ROS activity. However, whether antioxidants alter antitumor effects during radiotherapy and some types of chemotherapy remains unclear. In the present study, we reviewed antioxidants as an adjuvant therapy for cancer patients during chemotherapy or radiotherapy. Electronic literature searches were performed to select all randomized controlled clinical trials (RCTs) in which antioxidants were administered to cancer patients along with chemotherapy or radiotherapy. Articles or abstracts written in English were included. In total, 399 reports received primary screening. Duplicated articles and those meeting the exclusion criteria (not RCT, not human, and no oral administration) were excluded. Finally, 49 reports matching the inclusion criteria were included. It was difficult to determine whether antioxidants affect treatment outcomes or whether antioxidants ameliorate adverse effects induced by chemotherapy and radiotherapy. It is desirable to use an evidence-based method to select supplements best suited to cancer patients. Although there are many opinions about risks or benefits of antioxidant supplementation, we could mostly conclude that the harm caused by antioxidant supplementation remains unclear for patients during cancer therapy, except for smokers undergoing radiotherapy.

Foam dressing with epidermal growth factor for severe radiation dermatitis in head and neck cancer patients

This study was conducted to evaluate the effects of foam dressing with human recombinant human epidermal growth factor (rhEGF) on the healing process in head and neck cancer patients who experience radiation-induced dermatitis (RID). Seven patients, including three with oropharyngeal, two with nasopharyngeal and one each with hypopharyngeal and laryngeal carcinoma, who underwent radiotherapy (RT) for head and neck cancer at the Asan Medical Center from March to December 2008 were prospectively included in this study. Patients who showed severe RID (more than wet desquamation) on the supraclavicular fossa or neck areas were treated by wound cleaning and debridement of granulation tissue, followed by daily rhEGF spray and foam dressing. Median time to stop exudates and reepithelialisation was 4 days. Within 14 days (median 8 days), all patients showed complete healing of RID and no longer required dressings. This new method of treatment with dressing containing rhEGF may have the potential to accelerate the healing process in patients with RID. A case-control study is needed to confirm this finding.

The science of dermocosmetics and its role in dermatology

Our increased knowledge of normal skin physiology has ushered in a subtle revolution in cosmetic science. Originally designed as preparations to enhance personal appearance by direct application on to the skin, cosmetics have now taken on a new role in dermatology, through the support of the management of many skin disorders. This evolving role of cosmetics in skin care is primarily due to scientific and technological advancements that have changed our understanding of normal skin physiology and how cosmetics modify its appearance both physically and biologically. The vast array of techniques currently available to investigate skin responsivity to multiple stimuli has brought about a new era in cosmetic and dermocosmetic development based on a robust understanding of skin physiology and its varied responses to commonly encountered environmental insults. Most cosmetic research is undertaken on reconstructed skin models crucial in dermatological research, given the strict ban imposed by the European Union on animal testing. In addition, the design and conduct of trials evaluating cosmetics now follow rules comparable to those used in the development and evaluation of pharmaceutical products. Cosmetic research should now aim to ensure all trials adhere to strictly reproducible and scientifically sound methodologies. The objective of this review is to provide an overview of the multidisciplinary scientific approach used in formulating dermocosmetics, and to examine the major advances in dermocosmetic development and assessment, the safety and regulatory guidelines governing their production and the exciting future outlook for these dermocosmetic processes following good practice rules.

The use of antioxidants in radiotherapy-induced skin toxicity

Radiation-induced skin damage is one of the most common complications of radiotherapy. In order to combat these side effects, patients often turn to alternative therapies, which often include antioxidants. Antioxidants such as those in the polyphenol chemical class, xanthine derivatives, tocepherol, sucralfate, and ascorbate have been studied for their use in either preventing or treating radiotherapy-induced skin damage. Apart from their known role as free radical scavengers, some of these antioxidants appear to alter cytokine release affecting cutaneous and systemic changes. We review the role of antioxidants in treating and preventing radiation-induced skin damage as well as the possible complications of using such therapy.

A prospective randomized, placebo-controlled skin care study in women diagnosed with breast cancer undergoing radiation therapy

PURPOSE/OBJECTIVES

To compare the effectiveness of three different skin care products versus a placebo in reducing the incidence of radiation therapy-induced skin reactions prophylactically.

DESIGN

Prospective randomized, double-blinded, placebo-controlled study.

SETTING

A radiation oncology department at a National Cancer Institute-designated comprehensive cancer center in the southeastern United States.

SAMPLE

208 women with breast cancer who were to receive whole breast radiation therapy.

METHODS

Patients were invited to participate after radiation therapy was documented as part of their treatment plan. Patients applied a skin care product starting on the first day of treatment and were assessed weekly by their radiation oncology nurse.

MAIN RESEARCH VARIABLES

Skin reaction score and skin product.

FINDINGS

None of the products were statistically better than placebo in preventing skin reactions. Increases in skin reaction over time did not vary with treatment group for the linear (p = 0.16) and nonlinear (p = 0.94) effects of time and for both time components tested together (p = 0.41).

CONCLUSIONS

Ninety-five percent of women participating in this study experienced a radiation therapy-induced skin reaction.

IMPLICATIONS FOR NURSING

The development of guidelines to support safe patient care is encouraged because patients prefer to take action rather than do nothing. However, the findings do not demonstrate improved clinical outcomes with the use of skin care products. Healthcare providers should proactively educate patients about acute skin reactions and self-care strategies to minimize skin breakdown.

Management of skin toxicity during radiation therapy: a review of the evidence

Acute skin toxicity occurs in the majority of the patients undergoing radical radiotherapy. While a variety of topical agents and dressing are used to ameliorate side effects, there is minimal evidence to support their use. The aims of this study were to systematically review evidence on acute skin toxicity management and to assess the current practices in ANZ. A systematic review of the literature was conducted on studies published between 1980 and 2008. A meta-analysis was performed on articles on clinical trials reporting grade II or greater toxicity. Analyses were divided into breast (the most common site) and other sites. A survey of Radiation Oncology departments across ANZ was conducted to identify patterns of practices and compare these with the published evidence. Twenty-nine articles were reviewed. Only seven articles demonstrated statistically significant results for management of side-effects. These were for topical corticosteroids, hyaluronic acid, sucralfate, calendula, Cavilon cream (3M, St Paul, Minnesota, USA) and silver leaf dressing. Meta-analysis demonstrated statistical significance for the prophylactic use of topical agents in the management acute toxicity. The survey of departments had a low response rate but demonstrated variation in skin care practices across ANZ. A considerable number of these practices were based only on anecdotal evidence. Lack of evidence in the literature for the care of radiation skin reactions was associated with variation in practice. Only a limited number of studies have demonstrated a significant benefit of specific topical agents. There is a need for objective and prospective recording of skin toxicity to collect meaningful comparative data on which to base recommendations for practice.

Predictive factors of radiation-induced skin toxicity in breast cancer patients

Background

To assess the factors affecting the incidence of radiation-induced dermatitis in breast cancer patients treated with adjuvant 3 D conformal radiotherapy by the analysis of dosimetry and topical treatments.

Methods

Between September 2002 and July 2009, 158 breast cancer patients were treated with adjuvant 3 D conformal radiotherapy after undergoing surgery. Before November 2006, 90 patients were subjected to therapeutic skin care group and topical corticosteroid therapy was used for acute radiation dermatitis. Thereafter, 68 patients received prophylactic topical therapy from the beginning of radiotherapy. The two groups did not differ significantly in respect of clinical and treatment factors. Furthermore, the possible mechanisms responsible for the effects of topical treatment on radiation-induced dermatitis were investigated in vivo.

Results

The incidence of radiation-induced moist desquamation was 23% across 158 patients. Higher volume receiving 107% of prescribed dose within PTV (PTV-V_107%; >28.6%) and volume receiving 110% of prescribed dose within treated volume (TV-V_110%; > 5.13%), and no prophylactic topical therapy for irradiated skin, were associated with higher incidence of acute radiation dermatitis. The protective effect of prophylactic topical treatment was more pronounced in patients with TV-V_110% > 5.13%. Furthermore, using irradiated mice, we demonstrated that topical steroid cream significantly attenuated irradiation-induced inflammation, causing a decrease in expression of inflammatory cytokines and TGF-beta 1.

Conclusion

TV-V_110% > 5.13% may be an important predictor for radiation induced dermatitis. Prophylactic topical treatment for irradiated skin can significantly improve the tolerance of skin to adjuvant radiotherapy, especially for patients with higher TV-V_110%.

Radioprotectors and mitigators of radiation-induced normal tissue injury

Radiation is used in the treatment of a broad range of malignancies. Exposure of normal tissue to radiation may result in both acute and chronic toxicities that can result in an inability to deliver the intended therapy, a range of symptoms, and a decrease in quality of life. Radioprotectors are compounds that are designed to reduce the damage in normal tissues caused by radiation. These compounds are often antioxidants and must be present before or at the time of radiation for effectiveness. Other agents, termed mitigators, may be used to minimize toxicity even after radiation has been delivered. Herein, we review agents in clinical use or in development as radioprotectors and mitigators of radiation-induced normal tissue injury. Few agents are approved for clinical use, but many new compounds show promising results in preclinical testing.

Mometasone furoate effect on acute skin toxicity in breast cancer patients receiving radiotherapy: a phase III double-blind, randomized trial from the North Central Cancer Treatment Group N06C4

PURPOSE

A two-arm, double-blind, randomized trial was performed to evaluate the effect of 0.1% mometasone furoate (MMF) on acute skin-related toxicity in patients undergoing breast or chest wall radiotherapy.

METHODS AND MATERIALS

Patients with ductal carcinoma in situ or invasive breast carcinoma who were undergoing external beam radiotherapy to the breast or chest wall were randomly assigned to apply 0.1% MMF or placebo cream daily. The primary study endpoint was the provider-assessed maximal grade of Common Terminology Criteria for Adverse Events, version 3.0, radiation dermatitis. The secondary endpoints included provider-assessed Common Terminology Criteria for Adverse Events Grade 3 or greater radiation dermatitis and adverse event monitoring. The patient-reported outcome measures included the Skindex-16, the Skin Toxicity Assessment Tool, a Symptom Experience Diary, and a quality-of-life self-assessment. An assessment was performed at baseline, weekly during radiotherapy, and for 2 weeks after radiotherapy.

RESULTS

A total of 176 patients were enrolled between September 21, 2007, and December 7, 2007. The provider-assessed primary endpoint showed no difference in the mean maximum grade of radiation dermatitis by treatment arm (1.2 for MMF vs. 1.3 for placebo; p = .18). Common Terminology Criteria for Adverse Events toxicity was greater in the placebo group (p = .04), primarily from pruritus. For the patient-reported outcome measures, the maximum Skindex-16 score for the MMF group showed less itching (p = .008), less irritation (p = .01), less symptom persistence or recurrence (p = .02), and less annoyance with skin problems (p = .04). The group's maximal Skin Toxicity Assessment Tool score showed less burning sensation (p = .02) and less itching (p = .002).

CONCLUSION

Patients receiving daily MMF during radiotherapy might experience reduced acute skin toxicity compared with patients receiving placebo.

Incidence and correlates of radiation dermatitis in children and adolescents receiving radiation therapy for the treatment of paediatric sarcomas

AIMS

To investigate the relationship between the maximum grade of skin toxicity, radiation dose and clinical variables in children receiving treatment for sarcomas involving the bone and soft tissue.

MATERIALS AND METHODS

Between January 2003 and July 2006, 82 patients with musculoskeletal tumours on an Institutional Review Board (IRB)-approved prospective study at St. Jude Children's Research Hospital received three-dimensional conformal or intensity-modulated radiation therapy for local tumour control. Radiation dermatitis was graded according to the National Cancer Institute's Common Toxicity Criteria version 2.0 during and after radiation therapy. The dose to the skin was calculated for each patient from the radiation treatment plan.

RESULTS

The radiation doses delivered to the primary tumour ranged from 4140 to 7020cGy, with a mean dose of 5040cGy. The maximum recorded grade of skin toxicity was: grade 0: seven patients (8.6%); grade 1: 26 patients (31.7%); grade 2: 37 patients (45.1%); grade 3: 10 patients (12.2%); grade 4: two patients (2.4%). A significant association for increased grade of skin toxicity was observed between dose (P<0.01), volume of skin treated above 4000cGy (P=0.03), use of a bolus (P<0.01), Caucasian race (P<0.01) and related pain (P<0.01).

CONCLUSIONS

These findings suggest that the delivered dose, use of a bolus, the volume treated, and race may be used in the clinical setting to predict patients at risk for skin toxicity. Alterations in treatment technique and early therapeutic intervention may help to reduce or eliminate radiation-induced skin side-effects and associated pain.

Study of qingre liyan decoction in treating and preventing acute radioactive oral mucositis

OBJECTIVE

To study the effect of Qingre Liyan Decoction (QRLYD) in the prevention and treatment of acute radiative oral mucositis (AROM), and to explore the mechanism of QRLYD by detecting epidermal growth factor (EGF) and T lymphocytes (CD3, CD4, and CD8).

METHODS

Sixty patients conforming with the standard were randomly assigned to two groups, 30 patients in each group. Patients in the trial group were treated with QRLYD, and those in the control group were treated with Dobell's solution, both groups receiving conventional radiation treatment. The treatment course for both groups was 6 weeks on average. Blood routine test, CD3, CD4, and CD8 in the peripheral blood and EGF in the saliva were detected one day before and on the 14th and 28th day of radio-therapy.

RESULTS

Patients in the trial group were in good condition with normal spirits and intake of food and drinks. The incidence of AROM is lower and the effect in preventing AROM is higher in the trial group than those in the control group (P<0.05). The EGF in saliva, and CD4 and CD8 in the blood of patients in the trial group were higher than those in the control group (P<0.05).

CONCLUSION

QRLYD can cure and prevent AROM. The mechanism may be related with its effects in enhancing body immunity and promoting salivary EGF.

The clinical and histopathological effects of prednisone on acute radiation-induced dermatitis in dogs: a placebo-controlled, randomized, double-blind, prospective clinical trial

This study evaluated and compared the clinical and histopathological effects of prednisone on acute radiation-induced dermatitis (ARID) in dogs treated with 48 Gray of fractionated irradiation targeted to the skin surface. The study was designed as a double-blind, randomized, placebo-controlled prospective clinical trial. Twenty-two otherwise healthy companion dogs completed the clinical study. Three dogs were excluded from complete histopathological analysis because the owner declined one (one dog) or both (two dogs) biopsies. The study duration for each dog was 36 days from the start of radiation therapy (RT) to the first re-examination post RT. Dogs were treated with either oral prednisone at 0.5 mg kg(-1) or sugar pill, daily. All dogs received 48 Gray of fractionated, standardized RT, beginning 2 weeks after tumour excision. Acute Radiation Morbidity Scores, Cutaneous Toxicity Extent and Severity scores, digital images, and impression cytology were carried out on days 1, 8, 15, 22 and 36. Four-millimetre skin specimens from days 15 (RT-11) and 36 (2 weeks after the last RT dose) were scored by a pathologist and a dermatologist, blind to specimen identity. A one-way analysis of variance for longitudinal data was used to compare scores between groups. Spearman's rho correlation coefficient was used to measure strength of association between clinical and histopathology scores (HPS). There was no significant difference in CUTES, AMS or HPS scores between groups. There was a strong correlation between clinical and HPS scores. Prednisone did not decrease ARID severity clinically or histopathologically.

Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study

BACKGROUND AND AIMS

Radiation induced wet desquamation of skin in carcinoma breast patients is a painful condition. In this study topical beclomethasone dipropionate spray was used as prophylaxis with the purpose of reducing risk of the wet desquamation of skin in irradiated field.

MATERIALS AND METHODS

Sixty patients of carcinoma breast were planned for postoperative loco regional radiotherapy (50 Gy in 25 fraction over five weeks) were prospectively randomized into two groups (1) steroid group-patients were advised to use beclomethasone dipropionate spray in irradiated axilla from day one of radiotherapy, (2) control group-patients were not allowed to use any topical agent in irradiated area. Radiation induced skin reaction was noted in terms of erythema, dry desquamation and wet desquamation weekly till end of prescribed 50 Gy dose of the radiation therapy.

STATISTICAL METHOD

Chi-square test was used to see the statistical significance of the difference in wet desquamation between two arms of the study. Chi-square value and P-value was calculated for the difference of wet desquamation in two study arms.

RESULT

In steroid group 4/30 (13.33%) patients developed wet desquamation of the axillary skin at the end of the radiotherapy. For the control group, this figure was 11/30 (36.66%). The difference in wet desquamation of the axillary skin in the two groups was statistically significant (P-value = 0.0369).

CONCLUSION

Topical steroid (beclomethasone dipropionate spray) for skin during radiotherapy significantly reduces the risk of wet desquamation of the skin.

Prevention and Treatment of Acute Radiation Dermatitis: A Literature Review

PURPOSE/OBJECTIVES

To review historical and current research data on prevention and treatment of acute radiation dermatitis.

DATA SOURCES

18 research trials and 1 case report published from 1967-2001 and 1 unpublished research trial from 1972.

DATA SYNTHESIS

Washing the skin with mild soap and water and the hair with mild shampoo is safe during radiation therapy. Biafine (Medix Pharmaceuticals, Inc., Largo, FL), chamomile cream, almond ointment, topical vitamin C, and gentian violet have not been proven effective and should not be used. Transparent, hydrocolloid, and hydrogel dressings have been beneficial, as have sucralfate cream and corticosteroid cream. Aloe vera may be beneficial and is not harmful.

CONCLUSIONS

The existing scientific data are lacking in quantity and quality. The current body of evidence is unable to provide clinicians with comprehensive guidelines for prevention and management of acute radiation dermatitis.

IMPLICATIONS FOR NURSING

Nurse clinicians and nurse scientists must partner to conduct further research to add to the limited resources about the prevention and management of acute radiation dermatitis and develop comprehensive evidence-based clinical practice guidelines.

The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline

GOALS OF WORK

To develop a practice guideline report on the questions: What are the optimal methods to prevent acute skin reactions (occurring within the first 6 months of irradiation) related to radiation therapy? What are the optimal methods to manage acute skin reactions related to radiation therapy?

MATERIALS AND METHODS

Cancer Care Ontario's Supportive Care Guidelines Group (SCGG) conducted a systematic review of literature on this topic. Evidence-based recommendations were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners.

MAIN RESULTS

Twenty-eight trials meeting the inclusion criteria were identified. Of the twenty-three trials that evaluated preventative methods, washing was the only practice which significantly prevented skin reaction. Some evidence suggested topical steroid creams and calendula ointment might be effective. None of the five trials evaluating skin reaction management detected a positive effect using steroid cream, sucralfate cream, or dressings.

CONCLUSIONS

Skin washing, including gentle washing with water alone with or without mild soap, should be permitted in patients receiving radiation therapy to prevent acute skin reaction. There is insufficient evidence to support or refute specific topical or oral agents for the prevention or management of acute skin reaction. In the expert opinion from the SCGG, the use of a plain, non-scented, lanolin-free hydrophilic cream may be helpful in preventing radiation skin reactions. In addition, a low dose (i.e., 1%) corticosteroid cream may be beneficial in the reduction of itching and irritation.

Phase III Trial of an Emulsion Containing Trolamine for the Prevention of Radiation Dermatitis in Patients With Advanced Squamous Cell Carcinoma of the Head and Neck: Results of Radiation Therapy Oncology Group Trial 99-13

Purpose

This multicentered phase III trial was designed to compare an emulsion containing trolamine against the usual supportive care within each participating institution for patients with head and neck cancer undergoing radiation therapy.

Patients and Methods

Patients with biopsy-proven squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx were randomly assigned to one of the following treatments: prophylactic trolamine emulsion, interventional trolamine emulsion, or declared institutional preference. The primary outcome was the reduction in grade 2 or higher skin toxicity, as per National Cancer Institute Common Toxicity Criteria version 2.0. Secondary outcomes included patient-reported quality of life (QOL).

Results

From October 2000 to April 2002, 547 patients from 51 institutions were entered onto the trial. The average age was 59 years. Patients were predominately male (79%) and most continued to use tobacco products (52%). The rates of grade 2 or higher radiation dermatitis were 79%, 77%, and 79% in the prophylactic, interventional, and institutional preference arms of the study, respectively. No significant differences in QOL were found.

Conclusion

The results of this trial demonstrate no advantage for the use of trolamine in reducing the incidence of grade 2 or higher radiation dermatitis or improving patient-reported QOL. The use of 15 different local standards of care highlights the need to continue research that will result in evidence-based recommendations to reduce the burden of radiation dermatitis.

Novel approaches to radiotherapy-induced skin reactions: A literature review

Patients undergoing radiotherapy treatment will receive some degree of skin damage. Internationally there are many preventative and treatment options recommended, with varying degrees of evidence of success. This review explores the possible benefits of various plant-based treatments within the context of other novel treatments. The evidence suggests that using a hydrophilic substance such as Aloe vera gel or vegetable oil that is high in essential fatty acids, is as effective as mild steroid creams such as 1% hydrocortisone in reducing the severity of reactions. Additionally with plant-based treatments there does not appear to be side effects such as may occur with steroids. There remains great scope for further studies either replicating some of these current studies or exploring other options such as the use of essential oils or other herbal extracts.

Final report of the safety assessment of L-Ascorbic Acid, Calcium Ascorbate, Magnesium Ascorbate, Magnesium Ascorbyl Phosphate, Sodium Ascorbate, and Sodium Ascorbyl Phosphate as used in cosmetics

L-Ascorbic Acid, Calcium Ascorbate, Magnesium Ascorbate, Magnesium Ascorbyl Phosphate, Sodium Ascorbate, and Sodium Ascorbyl Phosphate function in cosmetic formulations primarily as antioxidants. Ascorbic Acid is commonly called Vitamin C. Ascorbic Acid is used as an antioxidant and pH adjuster in a large variety of cosmetic formulations, over 3/4 of which were hair dyes and colors at concentrations between 0.3% and 0.6%. For other uses, the reported concentrations were either very low (<0.01%) or in the 5% to 10% range. Calcium Ascorbate and Magnesium Ascorbate are described as antioxidants and skin conditioning agents--miscellaneous for use in cosmetics, but are not currently used. Sodium Ascorbyl Phosphate functions as an antioxidant in cosmetic products and is used at concentrations ranging from 0.01% to 3%. Magnesium Ascorbyl Phosphate functions as an antioxidant in cosmetics and was reported being used at concentrations from 0.001% to 3%. Sodium Ascorbate also functions as an antioxidant in cosmetics at concentrations from 0.0003% to 0.3%. Related ingredients (Ascorbyl Palmitate, Ascorbyl Dipalmitate, Ascorbyl Stearate, Erythorbic Acid, and Sodium Erythorbate) have been previously reviewed by the Cosmetic Ingredient Review (CIR) Expert Panel and found "to be safe for use as cosmetic ingredients in the present practices of good use." Ascorbic Acid is a generally recognized as safe (GRAS) substance for use as a chemical preservative in foods and as a nutrient and/or dietary supplement. Calcium Ascorbate and Sodium Ascorbate are listed as GRAS substances for use as chemical preservatives. L-Ascorbic Acid is readily and reversibly oxidized to L-dehydroascorbic acid and both forms exist in equilibrium in the body. Permeation rates of Ascorbic Acid through whole and stripped mouse skin were 3.43 +/- 0.74 microg/cm(2)/h and 33.2 +/- 5.2 microg/cm(2)/h. Acute oral and parenteral studies in mice, rats, rabbits, guinea pigs, dogs, and cats demonstrated little toxicity. Ascorbic Acid and Sodium Ascorbate acted as a nitrosation inhibitor in several food and cosmetic product studies. No compound-related clinical signs or gross or microscopic pathological effects were observed in either mice, rats, or guinea pigs in short-term studies. Male guinea pigs fed a control basal diet and given up to 250 mg Ascorbic Acid orally for 20 weeks had similar hemoglobin, blood glucose, serum iron, liver iron, and liver glycogen levels compared to control values. Male and female F344/N rats and B6C3F(1) mice were fed diets containing up to 100,000 ppm Ascorbic Acid for 13 weeks with little toxicity. Chronic Ascorbic Acid feeding studies showed toxic effects at dosages above 25 mg/kg body weight (bw) in rats and guinea pigs. Groups of male and female rats given daily doses up to 2000 mg/kg bw Ascorbic Acid for 2 years had no macro- or microscopically detectable toxic lesions. Mice given Ascorbic Acid subcutaneous and intravenous daily doses (500 to 1000 mg/kg bw) for 7 days had no changes in appetite, weight gain, and general behavior; and histological examination of various organs showed no changes. Ascorbic Acid was a photoprotectant when applied to mice and pig skin before exposure to ultraviolet (UV) radiation. The inhibition of UV-induced suppression of contact hypersensitivity was also noted. Magnesium Ascorbyl Phosphate administration immediately after exposure in hairless mice significantly delayed skin tumor formation and hyperplasia induced by chronic exposure to UV radiation. Pregnant mice and rats were given daily oral doses of Ascorbic Acid up to 1000 mg/kg bw with no indications of adult-toxic, teratogenic, or fetotoxic effects. Ascorbic Acid and Sodium Ascorbate were not genotoxic in several bacterial and mammalian test systems, consistent with the antioxidant properties of these chemicals. In the presence of certain enzyme systems or metal ions, evidence of genotoxicity was seen. The National Toxicology Program (NTP) conducted a 2-year oral carcinogenesis bioassay of Ascorbic Acid (25,000 and 50,000 ppm) in F344/N rats and B6C3F(1) mice. Ascorbic Acid was not carcinogenic in either sex of both rats and mice. Inhibition of carcinogenesis and tumor growth related to Ascorbic Acid's antioxidant properties has been reported. Sodium Ascorbate has been shown to promote the development of urinary carcinomas in two-stage carcinogenesis studies. Dermal application of Ascorbic Acid to patients with radiation dermatitis and burn victims had no adverse effects. Ascorbic Acid was a photoprotectant in clinical human UV studies at doses well above the minimal erythema dose (MED). An opaque cream containing 5% Ascorbic Acid did not induce dermal sensitization in 103 human subjects. A product containing 10% Ascorbic Acid was nonirritant in a 4-day minicumulative patch assay on human skin and a facial treatment containing 10% Ascorbic Acid was not a contact sensitizer in a maximization assay on 26 humans. Because of the structural and functional similarities of these ingredients, the Panel believes that the data on one ingredient can be extrapolated to all of them. The Expert Panel attributed the finding that Ascorbic Acid was genotoxic in these few assay systems due to the presence of other chemicals, e.g., metals, or certain enzyme systems, which effectively convert Ascorbic Acid's antioxidant action to that of a pro-oxidant. When Ascorbic Acid acts as an antioxidant, the Panel concluded that Ascorbic Acid is not genotoxic. Supporting this view were the carcinogenicity studies conducted by the NTP, which demonstrated no evidence of carcinogenicity. Ascorbic Acid was found to effectively inhibit nitrosamine yield in several test systems. The Panel did review studies in which Sodium Ascorbate acted as a tumor promoter in animals. These results were considered to be related to the concentration of sodium ions and the pH of urine in the test animals. Similar effects were seen with sodium bicarbonate. Because of the concern that certain metal ions may combine with these ingredients to produce pro-oxidant activity, the Panel cautioned formulators to be certain that these ingredients are acting as antioxidants in cosmetic formulations. The Panel believed that the clinical experience in which Ascorbic Acid was used on damaged skin with no adverse effects and the repeat-insult patch test (RIPT) using 5% Ascorbic Acid with negative results supports the finding that this group of ingredients does not present a risk of skin sensitization. These data coupled with an absence of reports in the clinical literature of Ascorbic Acid sensitization strongly support the safety of these ingredients.