Vitamin D ointment for prevention of radiation dermatitis in breast cancer patients

Loss of Nrf2 aggravates ionizing radiation-induced intestinal injury by activating the cGAS/STING pathway via Pirin

Ionizing radiation (IR)-induced intestinal injury remains a major limiting factor in abdominal radiation therapy, and its pathogenesis remains unclear. In this study, mouse models of IR-induced intestinal injury were established, and the effect of IR on nuclear factor erythroid 2-related factor 2 (Nrf2) was determined. More severe IR-induced intestinal damage was observed in Nrf2 knockout (KO) mice than in wild-type mice. Then, the negative regulation of cyclic GMP-AMP synthase/stimulator of interferon genes (cGAS/STING) signaling by Nrf2 was examined both in vivo and in vitro after IR. This was accompanied by alterations in the intestinal neutrophil and macrophage populations in mice. Subsequently, the effect of the cGAS/STING pathway on the intestinal toxicity of IR was also investigated. Moreover, the downregulation of cGAS/STING by Nrf2 via its target gene, Pirin, was confirmed using transfection assays. A rescue experiment with Pirin was also conducted using adeno-associated virus in Nrf2 KO mice. Finally, the protective effect of calcitriol against IR-induced intestinal injury, along with increased Nrf2 and Pirin levels and decreased cGAS, pSTING, and interferon-beta levels, were observed. Taken together, our results suggest that Nrf2 alleviates IR-induced intestinal injury through Pirin-mediated inhibition of the innate immunity-related cGAS/STING pathway.

Cosmetic considerations after breast cancer treatment

Treatments for breast cancer can have an array of adverse effects, including hair loss, scarring, and irritated skin. These physical outcomes can, in turn, lead to body image concerns, anxiety, and depression. Fortunately, there is growing evidence that certain cosmetic therapies can improve patient self-image. Here we review various cosmetic treatment options including hair camouflage, eyebrow and eyelash camouflage, treatments for hirsutism, nipple and areola tattooing, post-mastectomy scar tattooing, treatments for dry skin/xerosis, removal of post-radiation telangiectasias, and lightening of post-radiation hyperpigmentation. For each patient concern, we report potential procedures, clinical evidence of impact on quality of life, special considerations, and safety concerns. This article aims to equip dermatologists with resources so that they may effectively counsel breast cancer survivors who express treatment-related cosmetic concerns.

The effect of various interventions on the prevention of radiation dermatitis: a network meta-analysis

OBJECTIVE

High doses of radiation, while effective at destroying tumor tissues, also result in radiation dermatitis (RD) at irradiated sites, which is one of the most common complications in cancer radiotherapy. Currently, no standardized protocols for the prevention and treatment of RD have been established in clinical practices, and severe RD can compromise treatment efficacy and reduce patients' quality of life. This systematic review and network meta-analysis (NMA) aims to compare the effectiveness of various interventions in preventing RD in patients.

METHODS

As of June 2023, four databases, including PubMed, Embase, Web of Science, and the Cochrane Library, were searched, with a total of 19 interventions obtained for comparative analysis of their effectiveness in preventing RD. The Cochrane risk-of-bias tool was employed to screen literature, extract data, and appraise the quality of the studies by two researchers. Bayesian network meta-analysis (NMA) was conducted utilizing StataSE 15 and R 4.2.3.

RESULTS

A total of 33 studies involving 4307 patients were included in this analysis. From the 33 studies, 19 interventions, encompassing Barrier Films and Dressings (BFD), Boron_Gel, Best supportive care, Corticosteroids_cream, Doxepin_cream, Eau Thermale Avèn_gel, Epidermal Growth Factor_cream, Hyaluronan_cream, Medicinal_Plants, Mineral_Oil, Olive oil and calcium hydroxide (OOCH), Photobiomodulation therapy, Recove_cream, Silicone_gel, Silver sulfadiazine (SSD), Timolol_Gel, Trolamine, VitD_Gel, and VitE_Gel, were retrieved and compared. The NMA results indicated that Hyaluronan_cream (SUCRA: 94.9%) was highly effective in preventing Grade 0/1 RD. Meanwhile, OOCH (SUCRA: 95.7%) demonstrated the most prominent effect in preventing ≥ Grade 2 RD.

CONCLUSION

The study reveals that Hyaluronan_cream and OOCH are two promising treatments for the prevention of RD in patients undergoing radiotherapy. Future research might focus on validating the efficacy of these two therapies with large sample sizes and on identifying an optimal intervention strategy.

Serum 25-hydroxy vitamin-D levels in head and neck cancer chemoradiation therapy: Potential in cancer therapeutics

BACKGROUND

To evaluate the relation between serum-25-hydroxy Vitamin-D levels (S25OHVDL) and concurrent chemoradiation therapy (CTRT) toxicities in patients of head and neck squamous cell cancer (HNSCC).

METHODS

After an institutional ethics committee approval, consecutive HNSCC patients who received radical/adjuvant CTRT were prospectively evaluated. Patients were assessed for CTRT toxicities using Common Terminology Criteria for Adverse Events version 5.0 (CTCAE-v5.0) and the response was evaluated according to Response Evaluation Criteria In Solid Tumors version 1.1 (RECIST-1.1). S25OHVDL was assessed at the time of the first follow-up. Patients were divided into group A (Optimal) and group B (suboptimal) according to S25OHVDL. The treatment toxicities were correlated with S25OHVDL.

RESULTS

Twenty-eight patients were evaluated for the study. S25OHVDL was optimal in eight (28.57%) and suboptimal in 20 patients (71.42%). Mucositis and radiation dermatitis were significantly more in subgroup B ( P -value 0.0011 and 0.0505, respectively). Relatively lower but nonsignificant hemoglobin and peripheral white blood cell counts were observed in subgroup B.

CONCLUSION

Suboptimal S25OHVDL was associated with significantly more skin and mucosal toxicities in HNSCC patients treated with CTRT.

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.

Acute Radiation Syndrome and the Microbiome: Impact and Review

Study of the human microbiota has been a centuries-long endeavor, but since the inception of the National Institutes of Health (NIH) Human Microbiome Project in 2007, research has greatly expanded, including the space involving radiation injury. As acute radiation syndrome (ARS) is multisystemic, the microbiome niches across all areas of the body may be affected. This review highlights advances in radiation research examining the effect of irradiation on the microbiome and its potential use as a target for medical countermeasures or biodosimetry approaches, or as a medical countermeasure itself. The authors also address animal model considerations for designing studies, and the potential to use the microbiome as a biomarker to assess radiation exposure and predict outcome. Recent research has shown that the microbiome holds enormous potential for mitigation of radiation injury, in the context of both radiotherapy and radiological/nuclear public health emergencies. Gaps still exist, but the field is moving forward with much promise.

Management of grade 3 acute dermatitis with moist desquamation after adjuvant chest wall radiotherapy: a case report

We reported a successful case management of G3 skin acute dermatitis in a 32-year-old woman affected by locally advanced breast cancer underwent adjuvant chest wall irradiation. Skin acute toxicity with dry desquamation areas was treated daily with dressing medication using physiological solution, oxygen therapy and applying hyaluronic acid gauze. At the end of radiotherapy treatment, G3 skin acute dermatitis with moist desquamation was observed, so the patient continued advanced wound dressing shifted to twice weekly with physiological solution, oxygen therapy and applying hydrocolloid dressing. The patient completed radiotherapy treatment without interruption and one month after treatment acute skin toxicity was resolved with pain relief. We suggest that advanced dressing with trained nursing staff is essential in this sub-set of patients due to guaranteed continuation of radiotherapy treatment, indispensable to ensure patient cure.

Radiodermatitis in Patients With Cancer: Systematic Review and Meta-Analysis

PROBLEM IDENTIFICATION

A systematic review and meta-analysis was conducted to inform the development of guidelines on the management of radiodermatitis among patients with cancer.

LITERATURE SEARCH

The authors updated a systematic review to include available literature published through September 30, 2019.

DATA EVALUATION

Two investigators assessed risk of bias using the Cochrane Collaboration risk-of-bias tool and certainty of the evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

SYNTHESIS

The use of deodorant/antiperspirant had no effect on development of radiodermatitis. Aloe vera and emu oil were equivalent or less effective than standard care. Oral curcumin had a minimal beneficial effect. Nonsteroidal topical interventions had a minimal beneficial effect on the development of moist desquamation and relief of itching while causing a small increase for grade 2 radiodermatitis. Topical calendula increased risk for the development of radiodermatitis. Topical steroids and dressings each showed benefits to minimize the development of radiodermatitis and moist desquamation while lowering rates of patient-reported symptoms, such as pain and pruritus.

IMPLICATIONS FOR RESEARCH

Symptom management strategies for radiodermatitis among patients with cancer that are likely to be effective include topical nonsteroidals, topical steroids, and dressings.

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ONS Guidelines™ for Cancer Treatment-Related Radiodermatitis

PURPOSE

Radiodermatitis is a side effect of radiation therapy. Evidence-based interventions to minimize severity or delay progression are important for clinical care. This guideline intends to support individuals with cancer, clinicians, and others in decisions regarding radiodermatitis treatment.

METHODOLOGIC APPROACH

A panel of healthcare professionals with patient representation was convened to develop a national clinical practice guideline for the management of radiodermatitis. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology and the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines were followed. The Cochrane Collaboration risk-of-bias tool was used, and certainty of the evidence was assessed using the GRADE approach. A quantitative and narrative synthesis of the evidence was completed.

FINDINGS

The panel agreed on eight recommendations and made a conditional recommendation for deodorant/antiperspirant. Aloe vera and oral curcumin had knowledge gaps and were recommended only in the context of a clinical trial. The panel suggested against emu oil, calendula, and nonsteroidal interventions.

IMPLICATIONS FOR NURSING

This guideline summarizes evidence-based interventions for the management of radiodermatitis to guide clinical care.

SUPPLEMENTARY MATERIAL CAN BE FOUND AT HTTPS

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Protective effects of doxepin cream on radiation dermatitis in breast cancer: A single arm double-blind randomized clinical trial

AIMS

Breast cancer is the most frequently occurring cancer in women. Lumpectomy followed by radiotherapy is suggested to be as effective as a total mastectomy. Radiation-induced dermatitis often occurs as a result of breast radiotherapy. Recent studies suggest that doxepin has promising anti-inflammatory properties. This study was undertaken to evaluate the effects of doxepin therapy on radiation dermatitis.

METHODS

A double-blind randomized clinical trial was launched from 2016 to 2017, with a total of 48 patients who had undergone breast-conserving surgery and received postoperative radiation therapy. Radiotherapy was applied 5 days per week for 5 weeks. Adverse dermatological effects were evaluated by a physician at the beginning of the fifth week of radiotherapy and the patients were then randomly assigned (1:1 ratio) to receive either doxepin (5%) or placebo cream for 7 days.

RESULTS

There were no significant differences in the dermatitis grade between doxepin and placebo groups at baseline (P > .5). The occurrence of acute dermatitis (grade 2 or higher) was significantly lower with the use of doxepin than with placebo (P ≤ .0001, Zα = 1.96 at 95% confidence interval).

CONCLUSION

Doxepin cream prevents dermatitis grade 2 or higher during post-operative breast irradiation. Doxepin cream is easy to use, affordable and prevents pain and irritation.

Vitamin D, gut microbiota, and radiation-related resistance: a love-hate triangle

Radiation resistance is a serious issue in radiotherapy. Increasing evidence indicates that the human gut microbiome plays a role in the development of radiation resistance. Vitamin D is an important supplement for cancer patients treated with radiotherapy. Against this background, this paper reviewed research regarding the associations among vitamin D, microbiota dysbiosis, and radiation resistance. A hypothesis is developed to describe the relationships among vitamin D, the gut microbiota, and radiotherapy outcomes. Radiotherapy changes the composition of the gut microbiota, which in turn influence the serum level of vitamin D, and its distribution and metabolism in the body. Alteration of vitamin D level influences the patient response to radiotherapy, where the underlying mechanisms may be associated with the intestinal microenvironment, immune molecules in the intestines, gut microbiome metabolites, and signaling pathways associated with vitamin D receptors. Our understanding of the contribution of vitamin D and the gut microbiota to radiotherapy outcomes has been increasing gradually. A better understanding of the relationships among vitamin D, the gut microbiota, and radiotherapy outcomes will shed more light on radiation resistance, and also promote the development of new strategies for overcoming it, thus addressing an important challenge associated with the currently available radiotherapy modalities for cancer patients.

Skin diseases of the breast and nipple: Inflammatory and infectious diseases

Certain dermatologic conditions are unique to the breast and nipple, whereas others may incidentally involve these structures. All require a nuanced approach to diagnosis and treatment because of the functional, sexual, and aesthetic importance of this area. The lactating patient requires special management because certain treatment options are contraindicated. All dermatologic conditions involving the breast and nipple require careful evaluation because malignancy of the breast can be mistaken for a benign condition or may trigger the development of certain dermatologic conditions. The second article in this continuing medical education series reviews common and uncommon inflammatory and infectious conditions of the breast and nipple and provides insight into both the diagnosis and the treatment of this heterogeneous group of diseases. For the purposes of this article, these conditions are divided into 4 distinct categories: 1) dermatitis; 2) radiation-induced changes; 3) mastitis; and 4) miscellaneous dermatologic conditions of the breast and nipple.

International Survey on the Use of Complementary and Alternative Medicines for Common Toxicities of Radiation Therapy

Purpose

Complementary and alternative medicines (CAMs) are widely used by patients with cancer. However, little is known about the extent to which these potential remedies are used internationally to treat the most common toxicities of radiation therapy. We report on the results of an international survey that assessed the use of CAMs.

Methods and Materials

Surveys were distributed to 1174 practicing radiation oncologists. Questions evaluated the perceptions of CAMs and specific practice patterns for the use of CAM remedies in the treatment of common radiation-induced toxicities (eg, skin, fatigue, nausea, diarrhea, and mucositis/xerostomia). The responses were compared between the groups using the χ² test and stratified on the basis of provider location, number of years in practice, and perception of CAMs.

Results

A total of 114 radiation oncologists from 29 different countries completed the survey, with a balanced distribution between North American (n = 56) and non-North American (n = 58) providers. Among the responding clinicians, 63% recommended CAMs in their practice. The proportion of clinicians who recommend CAMs for radiation toxicities did not significantly vary when stratified by provider’s number of years in practice (P = .23) or location (United States/Canada vs other; P = .74). Overall, providers reported that 29.4% of their patients use CAMs, and 87.7% reported that their practice encouraged or was neutral on CAM use, whereas 12.3% recommended stopping CAMs. The most common sources of patient information on CAMs were the Internet (75.4%), friends (60.5%), and family (58.8%). Clinicians reported the highest use of CAMs for radiation skin toxicity at 66.7%, followed by 48.2% for fatigue, 40.4% for nausea, and 36.8% for mucositis/xerostomia.

Conclusions

Nearly two-thirds of the surveyed radiation oncologists recommend CAMs for radiation-related toxicities; however, they estimated that less than one third of patients use CAMs for this purpose. This suggests a need for further investigation and perhaps greater patient education on the roles of CAMs in treating radiation toxicities.