Objective measurements of radiotherapy-induced erythema

Assessment of Tissue Oxygenation and Radiation Dermatitis Pre-, During, and Post-Radiation Therapy in Breast Cancer Patients

Over 95% of breast cancer patients treated with radiation therapy (RT) undergo an adverse skin reaction known as radiation dermatitis (RD). Assessment of severity or grading of RD is clinically visual and hence subjective. Our objective is to determine sub-clinical tissue oxygenation (oxygen saturation) changes in response to RT in breast cancer patients using near-infrared spectroscopic imaging and correlate these changes to RD grading. A 4-8 week longitudinal pilot imaging study was carried out on 10 RT-treated breast cancer patients. Non-contact near-infrared spectroscopic (NIRS) imaging was performed on the irradiated ipsilateral and the contralateral breast/chest wall, axilla and lower neck regions before RT, across the weeks of RT, and during follow-up after RT ended. Significant changes (p < 0.05) in oxygen saturation (StO2) of irradiated and contralateral breast/chest wall and axilla regions were observed across weeks of RT. The overall drop in StO2 was negatively correlated to RD scaling (in 7 out of 9 cases) and was higher in the irradiated regions when compared to its contralateral region. Differences in the pre-RT StO2 between ipsilateral and contralateral chest wall is a potential predictor of the severity of RD. The subclinical recovery of StO2 to its original state was longer than the visual recovery in RD grading scale, as observed from the post-RT assessment of tissue oxygenation.

Skin erythema assessment techniques

Skin erythema may present owing to many causes. One of the common causes is prolonged exposure to sunrays. Other than sun exposure, skin erythema is an accompanying sign of dermatologic diseases, such as psoriasis and acne. Quantifying skin erythema in patients enables the dermatologist to assess the patient's skin health. Quantitative assessment of skin erythema has been the focus of several studies. The clinical standard for erythema evaluation is visual assessment; however, this standard has some deficiencies. For instance, visual assessment is subjective and ineffectual for precise color information exchange. To overcome these limitations, in the past three decades various methodologies have been developed in an attempt to achieve objective erythema assessments, such as diffuse reflectance spectroscopy and both optical and nonoptical systems. This review considers the studies published during the past three decades and discusses the performance, the mathematical tactics for computation, and the limited capabilities of erythema assessment techniques for cutaneous diseases. The achievements and limitations of the current techniques in erythema assessment are presented. The advantages and development trends of optical and nonoptical methods are presented to make the reader aware of the present technological advances and their potential for dermatological disease research.

MEASUREMENT OF SKIN DOSE AND RADIATION-INDUCED CHANGES IN SKIN MICROCIRCULATION IN CHRONIC TOTAL OCCLUSION PERCUTANEOUS CARDIAC INTERVENTIONS (CTO-PCI)

Skin injuries may occur when radiation doses to the skin exceed 2 Gy. This study aimed to measure changes in skin microcirculation in patients undergoing chronic total occlusion percutaneous coronary interventions (CTO-PCI). In 14 patients, peak skin dose (PSD) was estimated with radiographic films and skin microcirculation was assessed with laser speckle contrast imaging (LSCI), before, 1 day after the intervention, and 4-6 weeks later. The mean PSD was 1.8 ± 0.9 Gy. Peak skin microcirculation increased by 12% from 45 ± 6 PU before to 50 ± 9 PU 1 day after the intervention (p = 0.01), and returned to 46 ± 8 PU after 4-6 weeks (p = 0.15). There was no significant correlation between PSD and the change in perfusion, neither 1 day (r = -0.13, p = 0.69) nor 4-6 weeks after the intervention (r = 0.33, p = 0.35). These results suggest that there are no radiation-induced microvascular changes in the skin after CTO-PCI at skin doses below 2 Gy.

Hyperspectral imaging assessment for radiotherapy induced skin-erythema: Pilot study

Skin cancer (SC) is a widely spread disease in the USA, Canada, and Australia. Skin cancer patients may be treated by many different techniques including radiation therapy. However, radiation therapy has side effects, which may range from skin erythema to skin necrosis. As erythema is the early evidence of exposure to radiation, monitoring erythema is important to prevent more severe reactions. Visual assessment (VA) is the gold standard for evaluating erythema. Nevertheless, VA is not ideal, since it depends on the observer's experience and skills. Digital photography and hyperspectral imaging (HSI) are optical techniques that provide an opportunity for objective assessment of erythema. Erythema indices were computed from the spectral data using Dawson's technique. The Dawson relative erythema index proved to be highly correlated (97.1 %) with clinical visual assessment scores. In addition, on the 7th session of radiation therapy, the relative erythema index differentiates with 99 % significance between irradiated and non-radiated skin regions. In this study, HSI is compared to digital photography for skin erythema statistical classification.

Non-invasive quantitative measures of qualitative grading effectiveness as the indices of acute radiation dermatitis in breast cancer patients

Background

Recent improvement of machinery evaluation for the skin changes in various therapies enabled us to evaluate fine changes quantitatively. In this study, we performed evaluation of the changes in radiation dermatitis (RD) using quantitative and qualitative methods, and verified the validity of the conventional qualitative assessment for clinical use.

Methods

Forty-three breast cancer patients received conventional fractionated radiotherapy to whole breast after breast-conserving surgery. Erythema, pigmentation and skin dryness were evaluated qualitatively, and biophysical parameters of RD were measured using a Multi-Display Device MDD4 with a Corneometer for capacitance, a Tewameter for transepidermal water loss (TEWL), a Mexameter for erythema index and melanin index. Measurements were performed periodically until 1 year.

Results

The quantitative manifestations developed serially from skin erythema followed by dryness and pigmentation. Quantitative measurements detected the effects of irradiation earlier than that of qualitative indices. However, the grades of the domains in RD by qualitative and quantitative assessment showed similar time courses and peak periods. However, no significant correlation was observed between the skin dryness grade and skin barrier function. In contrast to serial increase in pigmentation grades, melanin index showed initial decrease followed by marked increase with significant correlation with pigmentation grades.

Conclusion

Subjectively and objectively measured results of RD were almost similar course and peak points through the study. Therefore, validity of the conventional qualitative scoring for RD is confirmed by the present quantitative assessments. Instrumental evaluations revealed the presence of modest inflammatory changes before radiotherapy and long-lasting skin dryness, suggesting indication of intervention for RD.

Changes in skin microcirculation during radiation therapy for breast cancer

BACKGROUND

The majority of breast cancer patients who receive radiation treatment are affected by acute radiation-induced skin changes. The assessment of these changes is usually done by subjective methods, which complicates the comparison between different treatments or patient groups. This study investigates the feasibility of new robust methods for monitoring skin microcirculation to objectively assess and quantify acute skin reactions during radiation treatment.

MATERIAL AND METHODS

Laser Doppler flowmetry, laser speckle contrast imaging, and polarized light spectroscopy imaging were used to measure radiation-induced changes in microvascular perfusion and red blood cell concentration (RBC) in the skin of 15 patients undergoing adjuvant radiation therapy for breast cancer. Measurements were made before treatment, once a week during treatment, and directly after the last fraction.

RESULTS

In the treated breast, perfusion and RBC concentration were increased after 1-5 fractions (2.66-13.3 Gy) compared to baseline. The largest effects were seen in the areola and the medial area. No changes in perfusion and RBC concentration were seen in the untreated breast. In contrast, Radiation Therapy Oncology Group (RTOG) scores were increased only after 2 weeks of treatment, which demonstrates the potential of the proposed methods for early assessment of skin changes. Also, there was a moderate to good correlation between the perfusion (r = 0.52) and RBC concentration (r = 0.59) and the RTOG score given a week later.

CONCLUSION

We conclude that radiation-induced microvascular changes in the skin can be objectively measured using novel camera-based techniques before visual changes in the skin are apparent. Objective measurement of microvascular changes in the skin may be valuable in the comparison of skin reactions between different radiation treatments and possibly in predicting acute skin effects at an earlier stage.

Preemptive treatment with Xonrid®, a medical device to reduce radiation induced dermatitis in head and neck cancer patients receiving curative treatment: a pilot study

PURPOSE

The purpose of this study was to investigate efficacy, safety and tolerability of Xonrid®, a new medical device, in preventing radiation dermatitis associated with head and neck cancer (HNC) radiotherapy (RT).

METHODS

In this monocentric, prospective pilot study, adult consecutive HNC patients who were planned to receive curative RT with or without chemotherapy were enrolled. Patients were instructed to apply Xonrid® on the irradiated area during treatment continuing until 2 weeks after the completion of RT or the development of severe skin toxicity. Toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 scale. The patient reported outcome measures included the Skindex-16 questionnaire and patient satisfaction. Skin reflectance spectra were analyzed to objectively evaluate dermatitis.

RESULTS

In total, 41 subjects were enrolled (30 males, median age 60 years). No skin adverse events were recorded either in the skin area where the product was applied or in the nearby skin over the entire period of administration. At the end of RT, nine patients (22%) presented G1, 31 (76%) G2, and one patient (2%) G3 skin toxicity (after 5 weeks). Seven and 20 patients reached skin maximum toxicity at the fourth week and after the seventh week, respectively. An increasing trend of median spectrophotometry scores along with skin toxicity grades was observed. A correlation between Skindex-16 scores and skin toxicity grade during treatment was found.

CONCLUSIONS

Our study results suggest that Xonrid® is well tolerated, safe, and effective in minimizing and delaying high-grade radiation dermatitis in HNC patients.

Role of interleukin-1β in radiation-enhancement of MDA-MB-231 breast cancer cell invasion

The ability of radiation to increase the invasiveness of cancer cells is associated with the inflammatory response, which is induced in almost all irradiated patients. For breast cancer patients, elevated plasma levels of the inflammatory cytokine interleukin-1β (IL1β) persisted for a few weeks after completion of radiotherapy. The aim of this study was to determine whether IL1β is involved in the enhancement of breast cancer cell invasion induced by radiation. The role of IL1β was assessed with invasion chambers where irradiated fibroblasts were used as chemoattractant for the MDA-MB-231 breast cancer cells plated in the upper compartment. The ability of IL1β to stimulate the expression of cyclooxygenase-2 (COX-2) and biosynthesis of the prostaglandin E2 (PGE2) in MDA-MB-231 cells were also determined. Our results show that radiation-enhancement of MDA-MB-231 cell invasion was prevented with an anti-IL1β antibody. The production of IL1β was increased in irradiated fibroblasts, while the invasiveness of the MDA-MB-231 cells not exposed to irradiated fibroblasts was favored by adding this cytokine. Furthermore, addition of the COX-2 inhibitor NS-398 prevented the stimulation of cancer cell invasion induced either by irradiated fibroblasts or IL1β. We propose that the effect of IL1β on the invasiveness of the MDA-MB-231 cells involves elevation of matrix metalloproteinase-9 (MMP-9) production, induction of COX-2 expression and PGE2 biosynthesis. In conclusion, this study supports the involvement of IL1β in the radiation-enhancement of breast cancer cell invasion.

Update on techniques for the quantitation of facial skin characteristics

The purpose of this article is to review the strategies and methods for quantifying treatment outcomes, perhaps defined by the consumer/patient as a "decrease in perceived age." The demand for the rejuvenation of facial skin is expected to increase as the population ages and seeks optimal outcomes from the array of available treatment modalities. This information will be of value to the plastic surgeon in collaborating with patients on evaluation and treatment strategies.

Ability of radiation therapists to assess radiation-induced skin toxicity

INTRODUCTION

Radiation therapy has seen enhancement of the radiation therapist (RT) role, with RTs and nurses performing duties that were traditionally in the radiation oncologist's (RO) domain. This study aimed to assess whether RTs can consistently grade radiation-induced skin toxicity and their concordance with the gradings given by ROs.

METHOD

Digital photographs of skin reactions were taken at weeks 1, 3 and 6 of radiotherapy on nine patients with breast cancer. The randomly ordered photographs were reviewed once by eight ROs and four RO registrars and on two occasions separated by 6 weeks by 17 RTs. All graded the skin toxicities using the revised Radiation Therapy Oncology Group system.

RESULTS

No significant difference was seen between the median scores of the RTs at the first scoring session and the RO/Registrar group. The RTs at both measurement times showed greater inter-rater reliability than the RO/Registrars (W = 0.6866, time 1 and 0.6981 time 2, vs. 0.6517), with the experienced RTs the most consistent (W = 0.7078). The RTs also showed high intra-rater reliability (rho = 0.8461, P < 0.0010).

CONCLUSION

These results from RTs with no specific preparation indicate that experienced RTs could assess breast cancer skin toxicity as part of their role.

Hyperspectral imaging for early detection of oxygenation and perfusion changes in irradiated skin

Studies examining acute oxygenation and perfusion changes in irradiated skin are limited. Hyperspectral imaging (HSI), a method of wide-field, diffuse reflectance spectroscopy, provides noninvasive, quantified measurements of cutaneous oxygenation and perfusion. This study examines whether HSI can assess acute changes in oxygenation and perfusion following irradiation. Skin on both flanks of nude mice (n=20) was exposed to 50 Gy of beta radiation from a strontium-90 source. Hyperspectral images were obtained before irradiation and on selected days for three weeks. Skin reaction assessment was performed concurrently with HSI. Desquamative injury formed in all irradiated areas. Skin reactions were first seen on day 7, with peak formation on day 14, and resolution beginning by day 21. HSI demonstrated increased tissue oxygenation on day 1 before cutaneous changes were observed (p<0.001). Further increases over baseline were seen on day 14, but returned to baseline levels by day 21. For perfusion, similar increases were seen on days 1 and 14. Unlike tissue oxygenation, perfusion was decreased below baseline on day 21 (p<0.002). HSI allows for complete visualization and quantification of tissue oxygenation and perfusion changes in irradiated skin, and may also allow prediction of acute skin reactions based on early changes seen after irradiation.

NIR and skin impedance spectroscopic measurements for studying the effect of coffee and alcohol on skin, and dysplastic naevi

BACKGROUND/PURPOSE

Near infrared and impedance spectroscopy can be used for clinical skin measurements and need to be evaluated for possible confounding factors; (i) are skin conditions of the patient and the subsequent skin measurements influenced by alcohol and/or coffee consumption and (ii) are measurements of dysplastic naevi (DN) reproducible over time and significantly different compared to reference skin.

METHODS

Near infrared and skin impedance spectroscopic data were analysed multivariately. In the first study, the skin characteristics of 15 healthy individuals were examined related to body location, gender, individual differences, and consumption of coffee or alcohol. The second study included five patients diagnosed with dysplastic naevi syndrome. Measurements were taken on DN and reference skin over time.

RESULTS

In the first study, body location and gender had a major influence on measurement scores. Inter-individual skin characteristics and coffee or alcohol effects on skin characteristics were of minor importance. In the second study, it was shown that DN can be differentiated from reference skin and the measurements are stable over time.

CONCLUSIONS

Moderate consumption of alcohol and coffee did not influence the results of the measurements. It is possible to follow, stable or changed, characteristics of DN over time.

Radiation-enhancement of MDA-MB-231 breast cancer cell invasion prevented by a cyclooxygenase-2 inhibitor

BACKGROUND

Recent evidences support that radiation can promote the invasion of cancer cells. As interactions between cancer cells and surrounding stromal cells can have an important role in tumour progression, we determined whether an irradiation to fibroblasts can enhance the invasiveness of breast cancer cells. The role of cyclooxygenase-2 (COX-2), an inflammatory enzyme frequently induced by radiotherapy, was investigated.

METHODS

Irradiated 3T3 fibroblasts were plated in the lower compartment of invasion chambers and used as chemoattractant for non-irradiated human breast cancer cell MDA-MB-231, which are oestrogen receptor negative (ER(-)) and the oestrogen receptor positive (ER(+)) MCF-7 cells. Stimulation of COX-2 expression in irradiated 3T3 cells was measured by a semi-quantitative qPCR and western blot. Capacity of the major product of COX-2, the prostaglandin E2 (PGE(2)), to stimulate the production of the matrix metalloproteinase-2 (MMP-2) and cancer cell invasion were assessed with a zymography gel and invasion chambers.

RESULTS

Irradiation (5 Gy) of 3T3 fibroblasts increased COX-2 expression and enhanced by 5.8-fold the invasiveness of non-irradiated MDA-MB-231 cells, while their migration was not modified. Addition of the COX-2 inhibitor NS-398 completely prevented radiation-enhancement of cancer cell invasion. Further supporting the potential role of COX-2, addition of PGE(2) has increased cancer cell invasion and release of MMP-2 from the MDA-MB-231 cells. This effect of radiation was dependant on the expression of membrane type 1 (MT1)-MMP, which is required to activate the MMP-2, but was not associated with the ER status. Although irradiated fibroblasts stimulated the invasiveness of MDA-MB-231 ER(-) cells, no enhancement was measured with the ER(+) cell line MCF-7.

CONCLUSIONS

Radiation-enhancement of breast cancer cell invasion induced by irradiated 3T3 fibroblasts is not dependant on the ER status, but rather the expression of MT1-MMP. This adverse effect of radiation can be prevented by a specific COX-2 inhibitor.

Significant differences in skin irritation by common suture materials assessed by a comparative computerized objective method

BACKGROUND

Erythema can be described only through subjective evaluation, except when it is quantified by digital image analysis software. Using such software, the authors performed comparisons of the erythema produced after skin closure of clean surgical wounds. Five suture materials were compared with respect to the local skin irritation that was caused. Different quantities of erythema are produced by suture material after the skin closure of clean surgical wounds. The authors present an objective method of measuring how unreactive a suture material is in comparison with another when applied to the skin.

METHODS

The suture materials polydioxanone, polypropylene blue, polyamide 6, metallic clips, and polyglactin were compared in the present study. Digital photographs of 100 patients were compared by means of software, evaluating red color superiority (mean value of red color) in the region surrounding the wound.

RESULTS

The least to most irritation caused to the skin by different suture materials was established for paired data. The Kolmogorov-Smirnov criterion and the Wilcoxon signed rank test were used. Polydioxanone was found to have the best performance, followed in order by polyglactin, polyamide, polypropylene, and metallic clips. Immediately after suture removal, differences between the effects of suture materials were statistically significant on postoperative day 10.

CONCLUSIONS

Absorbable sutures can be used in skin closure of clean surgical wounds and can produce less erythematous reaction than nonabsorbable ones. Digital image analysis is a reliable method of quantitative evaluation of skin erythema resulting after skin closure of surgical wounds.

Comparison of three instrumental methods for the objective evaluation of radiotherapy induced erythema in breast cancer patients and a study of the effect of skin lotions

A non-blinded three armed study of the effect of Aloe vera, Essex and no lotion on erythema was performed. The erythema is an effect of radiotherapy treatment in breast cancer patients. The study required testing of objective methods for measuring the erythema. The chosen experimental methods were Near Infrared Spectroscopy, Laser Doppler Imaging and Digital Colour Photography. The experimental setup was made in such a way that in parallel with testing the effect of the lotions there was also a test of the sensitivity of the instruments. Fifty women were selected consecutively to participate in the study. They were all subjected to treatment with high-energy electrons (9-20 MeV) after mastectomy, 2 Gy/day to a total dose of 50 Gy. Measurements were performed before the start of radiotherapy and thereafter once a week during the course of treatment. Aloe vera and Essex lotion were applied twice every radiation day in selected sites. The increase in skin redness could be monitored with all techniques with a detection limit of 8 Gy for Digital Colour Photography and Near Infrared Spectroscopy and 18 Gy for Laser Doppler Imaging. In clinical practice our recommendation is to use Digital Colour Photography. No significant median differences were observed between the pairs no lotion-Essex, no lotion-Aloe vera and Essex-Aloe vera for any of the techniques tested.

Use of digital photography and image analysis techniques to quantify erythema in health care workers

BACKGROUND/AIMS

Nosocomial infections affect up to 26% of ICU patients. Compliance with the required hand hygiene procedures remains low, rarely exceeding 50%, with skin irritation as one of the main reasons for lack of conformity. The aim was to quantify the epidermal barrier effects, particularly erythema, from repetitive exposure to hand hygiene procedures among health care workers (HCWs) using an objective, reliable clinical method that could evaluate the entire hand surface.

METHODS

The hand skin of HCWs was evaluated before the initial scrub and at the end of multiple 2-3 days work cycles during spring (n=54) and winter (n=60) trials. The skin condition was measured with live visual skin evaluation (LSG), digital image analysis (DIA) of high-resolution digital images, and visual perception evaluation (VPS) of image pairs.

RESULTS

The HCWs had significantly higher values of erythema than the non-HCW control group with all methods. Knuckle erythema increased over the cycle in both seasons. It decreased during recovery in spring and continued to increase during recovery in winter. For the DIA area of excess redness, the quantitative measure of erythema, the decrease over the cycle in spring was significantly different than the increase over the cycle in winter. Minimal changes in area of excess redness occurred during recovery in both seasons. With the VPS, both judges found a decrease in erythema during recovery in spring and an increase during recovery in winter, indicating significant differences for spring vs. winter (P<0.05). No differences in VPS erythema were seen for either product set over the work cycle during spring. Correlations were observed for (1) results for the VPS vs. the LSG method and (2) between excess erythema (mu+sigma) from DIA and the VPS erythema scores. Relatively low correlations were found between the DIA and VPS methods, i.e., knuckle mu+sigma and VPS erythema.

CONCLUSIONS

Significant work cycle effects for spring vs. winter were observed with DIA, while significant effects were found during the recovery period with VPS. DIA produced an objective quantitative measure of erythema that was not limited or influenced by other aspects of skin irritation (e.g., dryness, scaling) or texture encountered in the visual methods of LSG and VPS. The DIA method minimizes the difficulty in differentiating erythema severity. Standardization of image capture and processing allows assessment of skin condition across clinical locations. The VPS is a more reliable way to compare skin condition at different times, i.e. beginning vs. the end of a treatment cycle, because images are viewed simultaneously and can be carefully examined for differences.