Dynamic skin changes of acute radiation dermatitis revealed byin vivoreflectance confocal microscopy

Grade IV Radiation Skin Injury on the Neck of a Patient with Tonsillar Carcinoma: A Case Report

ABSTRACT

Radiation therapy is often accompanied by skin toxicity in the irradiated area and radiation-induced DNA damage to skin tissue cells in the surrounding pigmented area. This case report describes a patient with radiation-induced skin injury who received wound treatment and psychological intervention with satisfactory results. A 60-year-old woman was admitted to the authors' hospital on January 18, 2021, with radiation-induced skin injury caused by carbon ion radiotherapy for tonsillar carcinoma. The patient underwent wound repair combined with psychological intervention (30 minutes per dressing change). Over a period of 1 month, the wound area was reduced from 11 × 12 cm2 to 1 × 1 cm2, and wound symptoms (exudate, blood odor, wound infection, wound edge dehydration and curling, periwound skin peeling, dryness, and hyperkeratosis) improved. The patient's anxiety factor scores decreased from 18 to 1, and her depression factor scores decreased from 16 to 3. When the patient was discharged from the hospital after 1 month of treatment, she had a satisfactory self-image and normal social activities.

Amelioration of Acute Radiation Dermatitis in Breast Cancer Patients by a Bioadhesive Barrier-Forming Gel (Episil): A Single-Center, Open, Parallel, Randomized, Phase I/II Controlled Trial

Episil is a bioadhesive barrier-forming liquid gel that can relieve mucositis caused by radiotherapy (RT) and effectively relieve pain. The purpose of this trial is to compare the efficacy and safety of Episil in improving acute radiation dermatitis (ARD) in patients with breast cancer. This study included patients who met the criteria for postoperative RT for breast cancer. The primary end point was the grade of RD during treatment. A total of 102 patients were included in this study. The patients were grouped in a 2:1 ratio using the randomized number table method: 67 patients received Episil combined with conventional skin care (the Episil group), whereas the remaining 35 patients served as the control group and received conventional skin care only (the control group). According to the grading criteria of the Radiation Therapy Oncology Group (RTOG), the skin reaction rate and severity were significantly better in the Episil group than the control group (24.62%, 72.31%, 3.08, 0, 0 vs. 0, 85.71%, 14.29%, 0, 0, 0) across grades 0 to 4 (P < 0.05). The itchiness score exhibited s significant reduction in the Episil group as compared with the control group (P < 0.05). The results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) showed that the overall health (z = -5.855, P < 0.001) and overall quality of life (z = -6.583, P < 0.001) were better in the Episil group than the control group after RT. Overall, in patients with breast cancer receiving RT, the topical application of Episil may significantly reduce the grading of ARD, alleviate patient symptoms, and improve the patient's overall quality of life.

Development and performance validation of a low-cost algorithms-based hyperspectral imaging system for radiodermatitis assessment

Whilst radiotherapy (RT) is widely used for cancer treatment, radiodermatitis caused by RT is one most common severe side effect affecting 95% cancer patients. Accurate radiodermatitis assessment and classification is essential to adopt timely treatment, management and monitoring, which all depend on reliable and objective tools for radiodermatitis grading. We therefore, in this work, reported the development and grading performance validation of a low-cost (∼2318.2 CNY) algorithms-based hyperspectral imaging (aHSI) system for radiodermatitis assessment. The low-cost aHSI system was enabled through Monte Carlo (MC) simulations conducted on multi-spectra acquired from a custom built low-cost multispectral imaging (MSI) system, deriving algorithms-based hyper-spectra with spectral resolution of 1 nm. The MSI system was based on sequentially illuminated narrow-band light-emitting diodes (LEDs) and a CMOS camera. Erythema induced artificially on healthy volunteers was measured by the aHSI system developed, with algorithms-based hyper-spectra and skin layer resolved physiological parameters (i.e., the blood volume fraction (BVF) and the oxygen saturation of hemoglobin in blood, et. al.) derivation using MC simulations. The MC simulations derived BVF and the oxygen saturation of hemoglobin in blood showed significant (P < 0.001, analysis of variance: ANOVA) increase with erythema. Further 1D-convolution neural network (CNN) implemented on the algorithms-based hyper-spectra leads to an overall classification accuracy of 93.1%, suggesting the great potential of low-cost aHSI system developed for radiodermatitis assessment.

Acute Radiation Dermatitis Evaluation with Reflectance Confocal Microscopy: A Prospective Study

Background: During radiotherapy (RT), most breast cancer patients experience ionizing radiation (IR)-induced skin injury—acute radiation dermatitis (ARD). The severity of ARD is determined by a physician according to CTCAE or RTOG scales, which are subjective. Reflectance confocal microscopy (RCM) is a noninvasive skin imaging technique offering cellular resolution. Digital dermoscopy (DD) performed in conjugation with RCM can provide more information regarding skin toxicity. The purpose of this study is to create an RCM and DD features-based ARD assessment scale, to assess the association with CTCAE scale and possible predictive value. Methods: One hundred and three breast cancer patients during RT were recruited; every week, clinical symptoms of ARD (CTCAE scale) were evaluated and RCM, together with digital dermoscopy (DD), was performed. Results: According to RCM; after 2 RT weeks, exocytosis and/or spongiosis were present in 94% of patients; after 3 weeks, mild contrast cells (MMCs) were detected in 45%; disarrayed epidermis (DE) was present in 66% of patients after 4 weeks and in 93% after 5 weeks; abnormal dermal papillae (ADP) were present in 68% of patients after 5 weeks. The coefficients of RCM features (RCM_coef) alone and together with dermoscopically determined erythema (RCM-ERY_coef) were significantly associated with ARD severity grade. RCM_coef is a significant predictive factor for the clinical manifestation of ARD. Conclusions: RCM features of irradiated skin appear earlier than clinical symptoms, have a characteristic course, and allow the severity of ARD to be predicted.

Reflectance Confocal Microscopy, Optical Coherence Tomography, and Multiphoton Microscopy in Inflammatory Skin Disease Diagnosis

BACKGROUND AND OBJECTIVES

Technological advances in medicine have brought about many novel skin imaging devices. This review aims to evaluate the scientific evidence supporting the use of noninvasive optical imaging techniques to aid in the diagnosis and prognosis of inflammatory skin diseases.

STUDY DESIGN/MATERIALS AND METHODS

PubMed and Scopus were searched in September 2020 according to PRISMA guidelines for articles using reflectance confocal microscopy (RCM), optical coherence tomography (OCT), and multiphoton microscopy (MPM) in inflammatory skin diseases, excluding studies monitoring treatment efficacy.

RESULTS

At the time of the study, there were 66 articles that addressed the utilization of noninvasive imaging in interface, spongiotic, psoriasiform, vesiculobullous, and fibrosing/sclerosing inflammatory skin dermatoses: RCM was utilized in 46, OCT in 16, and MPM in 5 articles. RCM was most investigated in psoriasiform dermatoses, whereas OCT and MPM were both most investigated in spongiotic dermatoses, including atopic dermatitis and allergic contact dermatitis.

CONCLUSIONS

There is preliminary evidence to support the diagnostic potential of noninvasive optical imaging techniques in inflammatory skin diseases. Improvements in the devices and further correlation with histology will help broaden their utility. Additional studies are needed to determine the parameters for diagnostic features, disease differentiation, and staging of inflammatory skin conditions. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

In vivo imaging characterization of basal cell carcinoma and cutaneous response to high-dose ionizing radiation therapy: A prospective study of reflectance confocal microscopy, dermoscopy, and ultrasonography

BACKGROUND

Radiation therapy (RT) is a treatment option for select skin cancers. The histologic effects of RT on normal skin or skin cancers are not well characterized. Dermoscopy, high-frequency ultrasonography (HFUS), and reflectance confocal microscopy (RCM) are noninvasive imaging modalities that may help characterize RT response.

OBJECTIVES

To describe changes in the tumor and surrounding skin of patients with basal cell carcinoma (BCC) treated with RT.

METHODS

The study was conducted between 2014 and 2018. Patients with biopsy-proven BCCs were treated with 42 Gy in 6 fractions using a commercially available brachytherapy device. Dermoscopy, HFUS, and RCM were performed before treatment and at 6 weeks, 3 months, and 12 months after RT.

RESULTS

A total of 137 imaging assessments (RCM + dermoscopy + HFUS) were performed in 12 patients. BCC-specific features were present in 81.8%, 91%, and 17% of patients imaged with dermoscopy, RCM, and HFUS at baseline, respectively, before treatment. After treatment, the resolution of these features was noted in 33.4%, 91.7%, and 100% of patients imaged with the respective modalities. No recurrences were seen after a mean of 31.7 months of follow-up.

LIMITATIONS

Small sample size and no histopathologic correlation.

CONCLUSION

Dermoscopy and HFUS were not as reliable as RCM at characterizing BCC RT response.

Characterization of early-stage cutaneous radiation injury by using optical coherence tomography angiography

Cutaneous radiation injury (CRI) is a skin injury caused by exposure to high dose ionizing radiation (IR). Diagnosis and treatment of CRI is difficult due to its initial clinically latent period and the following inflammatory bursts. Early detection of CRI before clinical symptoms will be helpful for effective treatment, and various optical methods have been applied with limitations. Here we show that optical coherence tomography angiography (OCTA) could detect changes in the skin during the latent period in CRI mouse models non-invasively. CRI was induced on the mouse hindlimb with exposure to various IR doses and the injured skin regions were imaged longitudinally by OCTA until the onset of clinical symptoms. OCTA detected several changes in the skin including the skin thickening, the dilation of large blood vessels, and the irregularity in vessel boundaries. Some of OCTA findings were confirmed by histology. The study results showed that OCTA could be used for early CRI detection.

APPLICATION OF REFLECTANCE CONFOCAL MICROSCOPY FOR EARLY DIAGNOSIS OF RADIATION-INDUCED ACUTE DERMATITIS IN RADIOSENSITIVE PATIENT: CASE STUDY

According to the guidelines on cancer treatment up to 52% of newly diagnosed cancer patients should be treated with external beam radiotherapy. Ionizing radiation (IR)-induced skin injury (radiation dermatitis) occurs in up to 95% of radiotherapy patients and can manifest from mild erythema till necrosis and ulceration. Individual radiosensitivity was proposed to be an important factor for the development of adverse reactions to IR. Therefore, assessment of radiosensitivity could be useful in predicting and dealing with radiation injuries caused by both radiotherapy and accidental overexposure. Here, we present a case of early diagnosis of IR-induced skin lesions performed by reflectance confocal microscopy in comparison to clinical evaluation in a highly radiosensitive patient.

Comparison between reflectance confocal microscopy and 2-photon microscopy in early detection of cutaneous radiation injury in a mouse model in vivo

Cutaneous radiation injury (CRI) is a skin injury caused by high-dose exposure of ionizing radiation (IR). For proper treatment, early detection of CRI before clinical symptoms is important. Optical microscopic techniques such as reflectance confocal microscopy (RCM) and 2-photon microscopy (TPM) have been tested as the early diagnosis method by detecting cellular changes. In this study, RCM and TPM were compared in the detection of cellular changes caused by CRI in an in vivo mouse model. CRI was induced on the mouse hindlimb skin with various IR doses and the injured skin regions were imaged longitudinally by both modalities until the onset of clinical symptoms. Both RCM and TPM detected the changes of epidermal cells and sebaceous glands before clinical symptoms in different optical contrasts. RCM detected changes of cell morphology and scattering property based on light reflection. TPM detected detail changes of cellular structures based on autofluorescence of cells. Since both RCM and TPM were sensitive to the early stage CRI by using different contrasts, the optimal method for clinical CRI diagnosis could be either individual methods or their combination.

Noninvasive assessment of cutaneous alterations in mice exposed to whole body gamma irradiation using optical imaging techniques

We report the results of a study carried out to investigate the potential of optical techniques such as optical coherence tomography, Mueller matrix spectroscopy, and cross-polarization imaging for noninvasive monitoring of the ionizing radiation exposure-induced alterations in cutaneous tissue of mice. Radiation dose-dependent changes were observed in tissue microvasculature and tissue optical parameters like retardance and depolarization as early as 1 h post radiation exposure. Results suggest that these optical techniques may allow early detection of radiation dose-dependent alterations which could help in screening of population exposed to radiation.

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.

In vivo characterization of early-stage radiation skin injury in a mouse model by two-photon microscopy

Ionizing radiation (IR) injury is tissue damage caused by high energy electromagnetic waves such as X-ray and gamma ray. Diagnosis and treatment of IR injury are difficult due to its characteristics of clinically latent post-irradiation periods and the following successive and unpredictable inflammatory bursts. Skin is one of the many sensitive organs to IR and bears local injury upon exposure. Early-stage diagnosis of IR skin injury is essential in order to maximize treatment efficiency and to prevent the aggravation of IR injury. In this study, early-stage changes of the IR injured skin at the cellular level were characterized in an in vivo mouse model by two-photon microscopy (TPM). Various IR doses were applied to the mouse hind limbs and the injured skin regions were imaged daily for 6 days after IR irradiation. Changes in the morphology and distribution of the epidermal cells and damage of the sebaceous glands were observed before clinical symptoms. These results showed that TPM is sensitive to early-stage changes of IR skin injury and may be useful for its diagnosis.

Assessment of changes in lentigo maligna during radiotherapy by in-vivo reflectance confocal microscopy: a pilot study

BACKGROUND

Radiotherapy is an effective treatment for therapy of lentigo maligna (LM).

OBJECTIVES

To investigate the usefulness of in-vivo reflectance confocal microscopy (RCM) in radiotherapy of LM and document the changes within the lesions during treatment.

METHODS

A total of six lesions in six patients were investigated by RCM before, during and after radiotherapy. For diagnostic assessment three observers with experience in RCM diagnosis, blinded as to the stage of treatment, assessed the RCM images of each lesion and documented the findings by consensus.

RESULTS

Epidermal disarray worsened in three patients during radiotherapy and superficial necrosis was observed in four patients. Large pagetoid round/dendritic cells decreased or even vanished during or after radiotherapy. Dilated vessels and apoptotic cells were seen in all patients during radiotherapy as well as an increase of inflammatory cells in the epidermis and dermis in most of the patients. Dendritic cells with small dendrites were observed during radiotherapy in all patients with an increase in number in three patients. Melanophages appeared in five patients at least once during the examination period. All RCM images were assessed correctly by the three observers.

CONCLUSIONS

Reflectance confocal microscopy is a useful method to visualize changes during and after radiotherapy and might also be used for early detection of potential treatment failures. In addition, it might be helpful in planning radiotherapy.