Management of radiation wounds

Management of Radiation-induced Tissue Injuries: A Review of Current Treatment Strategies

Although radiation therapy remains an integral component in cancer treatment, the sequela of tissue damage can result in long-term morbidity and mortality for patients. This article aimed to perform a comprehensive review of the current literature for both nonsurgical and surgical management strategies for radiation-induced injuries.

Methods

A literature search was performed on PubMed to review the current described management and treatment options for radiation-induced injuries. Patient demographics, medical diagnoses, complications, strategies of management care, and outcomes were reviewed.

Results

The most commonly described management options and reconstructive techniques of radiation wounds were analyzed and reported.

Conclusions

Consideration of current techniques and outcomes in the management of radiation-induced wounds demonstrates that impaired wound healing remains a major problem. This literature review provides a detailed overview of the most frequently used therapies with recommendations for surgeons.

[The use of modern dressings after complex treatment of malignant tumors of the maxillofacial region]

The number of patients with malignant tumors of the head and neck is constantly growing. However, after a favorable outcome of complex treatment patients may experience adverse consequences. Surgeon should understand conditions of surrounding tissues that have undergone radiation therapy. It is necessary for special management because regenerative potential of postoperative wounds decreased. The search and development of effective wound dressings are aimed at reducing the risks of postoperative complications and improving the quality of life of this group of patients.

Fungating Malignancies: Management of a Distinct Wound Entity

GENERAL PURPOSE

To provide information on the surgical management of fungating malignancies as a distinct wound entity.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Identify characteristics of patients in a study examining the treatment of fungating malignancies.2. Select common symptoms experienced by patients with fungating malignancies.3. Explain issues related to the surgical treatment of fungating malignancies.4. Identify a reason why patients with fungating breast masses may avoid medical care.

Urinary Bladder Matrix Improves Irradiated Wound Healing in a Murine Model

ABSTRACT

Radiation skin damage is associated with chronic wounds and poor healing. Existing localized treatment modalities have limited benefit. Therefore, there has been increased interest in biologically based solutions. In this study, we aimed to determine the effect of topical urinary bladder matrix (UBM) on chronic irradiated skin wounds using an established murine model. Our findings demonstrated that topical urinary bladder matrix significantly accelerated the healing of irradiated wounds on day 7 (P = 0.0216), day 14 (P = 0.0140), and day 21 (P = 0.0393). Histologically, urinary bladder matrix treatment was associated with higher-quality reorganization and reepithelialization of wounds, an increased density of myofibroblasts (P = 0.0004), and increased collagen deposition (P < 0.0001). In addition, quantitative real-time polymerase chain reaction data demonstrated decreased expression of profibrotic mediators (P = 0.0049). We conclude that urinary bladder matrix may be a useful, noninvasive, adjunctive therapy for the treatment of chronic irradiated skin wounds.

The "Double hit": Free tissue transfer is optimal in comorbid population with irradiated wounds for successful limb salvage

BACKGROUND

Radiation therapy causes histopathologic changes in tissues, including fibrosis, loss of tissue planes, and vascular damage, which can lead to chronic wound formation. Patients with nonhealing, irradiated wounds and comorbidities that affect microvasculature suffer a "double hit", which leads to delayed wound healing. Local wound care and grafts are commonly insufficient. In this study, we evaluated limb salvage outcomes and long-term complications after free tissue transfer (FTT) in patients with chronic, irradiated leg wounds.

METHODS

We retrospectively reviewed patients with irradiated lower extremity wounds who underwent FTT from 2012 to 2017. Primary outcomes included limb salvage, ambulation, and overall flap success. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue.

RESULTS

Seven free flaps in six patients were identified. Average age was 68.4 years and average BMI was 27.8 kg/m². Comorbid conditions included hypertension (57.1%), peripheral vascular disease (57.1%), underlying hypercoagulability (42.9%), diabetes (14.3%), and tobacco use (14.3%). Wounds were present for an average of 25.5 months prior to FTT. Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients could ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years.

CONCLUSIONS

Radiation therapy in a comorbid population often leads to the formation of chronic nonhealing wounds. We advocate for earlier consideration of FTT to provide healthy vascularized tissues, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved.

Impact of Patient Factors and Management Strategies on Outcomes After Transverse Posterior Cordotomy

OBJECTIVES/HYPOTHESIS

Carbon dioxide laser transverse posterior cordotomy (TPC) aims to improve airway aperture in patients with glottic obstruction. Postoperative complications may worsen airway compromise and necessitate additional interventions. We sought to identify factors impacting outcomes after TPC.

STUDY DESIGN

Retrospective chart review.

METHODS

Medical records of patients who underwent TPC for glottic airway obstruction at a tertiary-care medical center between 2008 and 2018 were reviewed. Demographics, comorbidities, and intra- and postoperative management strategies were analyzed.

RESULTS

Twenty patients who underwent TPC for glottic airway obstruction met inclusion criteria. The mean age was 57 years, and 13 patients were female. Mean follow-up time was 442 days. Seven patients had posterior glottic stenosis, and 13 had bilateral vocal fold paralysis. Twelve patients developed postoperative complications including granuloma formation (four patients), hospital readmission for dyspnea due to glottic edema (five patients), need for revision surgery (nine patients), or failure to decannulate tracheotomy (five patients). Eight patients had an uncomplicated recovery with improved dyspnea, with two patients with tracheotomies decannulated. Patients with a history of smoking tobacco were more likely to experience complications (P = .035). There were no significant differences in outcomes with respect to history of head and neck radiation or gastroesophageal reflux disease. Steroid injection at the surgical site and postoperative medications did not significantly impact outcomes. With respect to granuloma formation, none of the variables analyzed reached significance.

CONCLUSIONS

History of tobacco use increases complication rates after TPC. Other patient comorbidities and intra- and postoperative management strategies do not impact outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1066-1070, 2021.

Radiation-Induced Wound Infections in Operated Soft Tissue Sarcomas: An Unbelievable Challenge in a Series of Five Cases

INTRODUCTION

The standard modality for the treatment of soft tissue sarcomas is a wide excision followed by radiation therapy either in the form of external beam radiation or brachytherapy. Radiation therapy thus is an integral part of management and limb salvage in these cases. This, however, subjects the irradiated tissue to a greater risk for necrosis and local infection. This study suggests a protocol to manage these infections. A multimodal approach to these problems is important. Studies have shown that the use of negative pressure wound therapy (NPWT) in non-healing wounds significantly reduces edema by removing excessive fluid from the wound bed as well as facilitating removal of the infective pathogen after an aggressive wound debridement. The author has judiciously used NPWT in each of these patients with encouraging results. With no well-defined guidelines to manage radiation-induced wound infections, this retrospective study gives an overview and protocol for a systematic approach.

CASE REPORT

This is a retrospective series of five cases managed between January 2014 and December 2016. All were men with a mean age of 30.6 years with a mean follow-up of 27 months. We analyzed their demographic, clinical data, history, wound locations, primary diagnosis on histopathology, organisms isolated on culture, surgical details, antibiotics administered, and special interventions such as skin flaps or grafting and clinical outcome.Of the five, three patients received exclusive external beam radiation therapy (EBRT) and two were given intralesional brachytherapy and EBRT. Three received additional chemotherapy. 7/9 isolated organisms were multidrug-resistant mean 5.4 cycles of NPWT after aggressive debridement was needed to achieve healthy granulation tissue bed. Wounds were closed at median 31.5 days (three split-thickness split skin grafting, one local rotation flap, and one healing with secondary intention). We had two mortalities secondary to metastasis.

CONCLUSION

We recommend aggressive debridement, prolonged use of NPWT in infected irradiated wounds, and appropriate antibiotics with soft tissue cover by a multidisciplinary team to achieve good results.

The CD73/Ado System-A New Player in RT Induced Adverse Late Effects

Radiotherapy (RT) is a central component of standard treatment for many cancer patients. RT alone or in multimodal treatment strategies has a documented contribution to enhanced local control and overall survival of cancer patients, and cancer cure. Clinical RT aims at maximizing tumor control, while minimizing the risk for RT-induced adverse late effects. However, acute and late toxicities of IR in normal tissues are still important biological barriers to successful RT: While curative RT may not be tolerable, sub-optimal tolerable RT doses will lead to fatal outcomes by local recurrence or metastatic disease, even when accepting adverse normal tissue effects that decrease the quality of life of irradiated cancer patients. Technical improvements in treatment planning and the increasing use of particle therapy have allowed for a more accurate delivery of IR to the tumor volume and have thereby helped to improve the safety profile of RT for many solid tumors. With these technical and physical strategies reaching their natural limits, current research for improving the therapeutic gain of RT focuses on innovative biological concepts that either selectively limit the adverse effects of RT in normal tissues without protecting the tumor or specifically increase the radiosensitivity of the tumor tissue without enhancing the risk of normal tissue complications. The biology-based optimization of RT requires the identification of biological factors that are linked to differential radiosensitivity of normal or tumor tissues, and are amenable to therapeutic targeting. Extracellular adenosine is an endogenous mediator critical to the maintenance of homeostasis in various tissues. Adenosine is either released from stressed or injured cells or generated from extracellular adenine nucleotides by the concerted action of the ectoenzymes ectoapyrase (CD39) and 5′ ectonucleotidase (NT5E, CD73) that catabolize ATP to adenosine. Recent work revealed a role of the immunoregulatory CD73/adenosine system in radiation-induced fibrotic disease in normal tissues suggesting a potential use as novel therapeutic target for normal tissue protection. The present review summarizes relevant findings on the pathologic roles of CD73 and adenosine in radiation-induced fibrosis in different organs (lung, skin, gut, and kidney) that have been obtained in preclinical models and proposes a refined model of radiation-induced normal tissue toxicity including the disease-promoting effects of radiation-induced activation of CD73/adenosine signaling in the irradiated tissue environment. However, expression and activity of the CD73/adenosine system in the tumor environment has also been linked to increased tumor growth and tumor immune escape, at least in preclinical models. Therefore, we will discuss the use of pharmacologic inhibition of CD73/adenosine-signaling as a promising strategy for improving the therapeutic gain of RT by targeting both, malignant tumor growth and adverse late effects of RT with a focus on fibrotic disease. The consideration of the therapeutic window is particularly important in view of the increasing use of RT in combination with various molecularly targeted agents and immunotherapy to enhance the tumor radiation response, as such combinations may result in increased or novel toxicities, as well as the increasing number of cancer survivors.

The effectiveness and safety of X-PDT for cutaneous squamous cell carcinoma and melanoma

Aim: To clarify the effectiveness and safety of x-ray-activated photodynamic therapy (X-PDT) for cutaneous squamous cell carcinoma (SCC) and melanoma. Materials & methods: Copper-cysteamine nanoparticles were used as a photosensitizer of X-PDT. The dark toxicity and cytotoxicity were studied in vitro. Tumor volume, microvessel density and acute toxicity of mice were evaluated in vivo. Results: Without x-ray irradiation, copper-cysteamine nanoparticles were nontoxic for keratinocyte cells. XL50 cells (SCC) were more sensitive to X-PDT than B16F10 cells (melanoma). X-PDT successfully inhibited the growth of SCC in vivo (p < 0.05), while the B16F10 melanoma was resistant. Microvessel density in SCC tissue was remarkably reduced (p < 0.05). No obvious acute toxicity reaction was observed. Conclusion: X-PDT is a safe and effective treatment for SCC.

Management of a chronic radiation necrosis wound with lyopreserved placental membrane containing viable cells

This case report describes management of a chronic radiation wound in a patient with multiple comorbidities using a lyopreserved placental membrane containing viable cells (vLPM). Positive outcomes suggest that vLPM provides a good conservative management option for patients with compromised wound healing due to radiation and comorbidities.

Radiation-Induced Wound Infections in Operated Soft Tissue Sarcomas: An Unbelievable Challenge in a Series of Five Cases

Introduction

The standard modality for the treatment of soft tissue sarcomas is a wide excision followed by radiation therapy either in the form of external beam radiation or brachytherapy. Radiation therapy thus is an integral part of management and limb salvage in these cases. This, however, subjects the irradiated tissue to a greater risk for necrosis and local infection. This study suggests a protocol to manage these infections. A multimodal approach to these problems is important. Studies have shown that the use of negative pressure wound therapy (NPWT) in non-healing wounds significantly reduces edema by removing excessive fluid from the wound bed as well as facilitating removal of the infective pathogen after an aggressive wound debridement. The author has judiciously used NPWT in each of these patients with encouraging results. With no well-defined guidelines to manage radiation-induced wound infections, this retrospective study gives an overview and protocol for a systematic approach.

Case Report

This is a retrospective series of five cases managed between January 2014 and December 2016. All were men with a mean age of 30.6 years with a mean follow-up of 27 months. We analyzed their demographic, clinical data, history, wound locations, primary diagnosis on histopathology, organisms isolated on culture, surgical details, antibiotics administered, and special interventions such as skin flaps or grafting and clinical outcome.Of the five, three patients received exclusive external beam radiation therapy (EBRT) and two were given intralesional brachytherapy and EBRT. Three received additional chemotherapy. 7/9 isolated organisms were multidrug-resistant mean 5.4 cycles of NPWT after aggressive debridement was needed to achieve healthy granulation tissue bed. Wounds were closed at median 31.5 days (three split-thickness split skin grafting, one local rotation flap, and one healing with secondary intention). We had two mortalities secondary to metastasis.

Conclusion

We recommend aggressive debridement, prolonged use of NPWT in infected irradiated wounds, and appropriate antibiotics with soft tissue cover by a multidisciplinary team to achieve good results.

Does neoadjuvant therapy increase the incidence of anastomotic leakage after anterior resection for mid and low rectal cancer? A systematic review and meta-analysis

AIM

The aim was to evaluate the association of neoadjuvant therapy with increases in the incidence of anastomotic leakage (AL) after middle and low rectal anterior resection.

METHOD

The electronic databases of PubMed, Web of Science, Scopus and Ovid were searched between 1980 and 2015. The random effects model was used to model the pooled data to determine the odds ratio with 95% confidence interval. Heterogeneity was evaluated using the Q test and I² statistics. Subgroup, sensitivity and meta-regression analysis was conducted to explore heterogeneity.

RESULTS

Neoadjuvant therapy was not shown to increase the incidence of postoperative AL as demonstrated by an OR of 1.16 [95% CI 0.99-1.36; P = 0.07 (random effects model)]. The subgroup analysis of neoadjuvant radiotherapy using the random effects model suggested that it did not increase the rate of postoperative AL (OR = 1.24, 95% CI 0.97-1.58; P = 0.08). The subgroup analysis of neoadjuvant chemoradiotherapy indicated that the rate of postoperative AL again did not increase with an OR = 1.06 [95% CI 0.86-1.30; P = 0.59 (random effects model)]. The interval to surgery after neoadjuvant therapy and preoperative radiotherapy (short or long course) was not associated with an increased incidence of postoperative AL.

CONCLUSION

Neoadjuvant therapy does not appear to increase the incidence of postoperative AL after anterior resection for mid and low rectal cancer. In addition, neither the interval to surgery after neoadjuvant therapy nor the radiotherapy regimen increases the rate of postoperative AL.

Prophylactic transanal decompression tube versus non-prophylactic transanal decompression tube for anastomotic leakage prevention in low anterior resection for rectal cancer: a meta-analysis

BACKGROUND

Transanal decompression tube (TDT), an alternative intervention believed to have potential equivalent efficacy in reducing anastomotic leakage after rectal cancer surgery and lower complication rates compared to protective stoma, was sporadically applied in some medical centers during recent decade. The objective of this meta-analysis was to evaluate the effect of the TDT in preventing the anastomotic leakage after low anterior resection for rectal cancer.

METHODS

The studies comparing TDT and non-TDT in rectal cancer were researched up to March 22, 2016 without language preference, in databases of PubMed, Web of Science, Cochrane library, International Clinical Trials Registry Platform, and National Clinical Trials Registry. The rates of anastomotic leakage, bleeding, and re-operation were separately calculated and compared between TDT and non-TDT groups using RevMan 5.3. Funnel plots, and Egger's tests were used to evaluate the publication biases of the studies.

RESULTS

Two prospective randomized controlled trial studies and five observational cohort studies with 833 participants in TDT group and 939 participants in non-TDT group were finally included in this meta-analysis. The results indicated that the TDT group had lower anastomotic leakage rate than non-TDT group with significant RR (RR 0.44; 95 % CI 0.29-0.66; P < 0.0001) and heterogeneity (I ² = 33 %; P = 0.18). So did the re-operation rate, with RR (RR 0.16; 95 % CI 0.07-0.37; P < 0.0001) and heterogeneity among the studies (I ² = 0 %; P = 0.80). There was no significant difference in anastomotic bleeding rates (RR 1.48; 95 % CI 0.79-2.77; P = 0.22) (I ² = 58 %; P = 0.09). No publication bias was found by Egger's test (anastomotic leakage rate, Pr > |z| = 0.224; re-operation rate, Pr > |z| = 0.425).

CONCLUSIONS

TDT might be an efficient and economic intervention in preventing anastomotic leakage after rectal cancer surgery.

Pioneering technique using Acellular Dermal Matrix in the rescue of a radiation ulcer

BACKGROUND

Radiotherapy as an adjuvant to mastectomy is integral to the treatment of breast cancer, but can result in skin ulceration. Skin ulceration following radiotherapy is traditionally managed by removing the implant and allowing the skin to heal by secondary intention.

CASE REPORT

A 42-year-old woman underwent radiotherapy following a breast reconstruction. She developed a 2 x 3cm radiation ulcer. The ulcer was managed by removing the implant and performing capsulectomy. A Beckers 50 expander was placed and reinforced with acellular dermal matrix inferolaterally. At follow-up the patient had a good cosmetic outcome.

CONCLUSION

Post-radiation skin ulcers present a challenge to treat with no current standardised management. The use of acellular dermal matrix may present a new technique to promote healing in these testing cases.

[Extensor mechanism allograft and radiotherapy in the treatment of soft tissue sarcomas around the knee: Presentation of two clinical cases]

OBJECTIVE

Knee involvement of soft tissue sarcomas is rare and very difficult to treat. Reconstruction of the extensor mechanism of the knee is essential to restore the functionality. Functional outcome is compromised by poor soft tissue coverage, adjuvant local radiotherapy, and resection of the extensor apparatus. No results were found in the literature as regards treatment by resection and reconstruction of the extensor mechanism in combination with adjuvant radiotherapy. The effects of radiotherapy are also unknown in the allografts.

MATERIAL AND METHOD

. Two cases are presented of soft tissue sarcoma around de knee treated by resection, reconstruction of the extensor mechanism with cryopreserved cadaver allograft, and local radiotherapy.

RESULTS

After more than 3 years of follow up, both patients are free of disease and have a good joint balance.

DISCUSSION AND CONCLUSIONS

Resection of the tumor with adequate safety margins and reconstruction using cadaveric allograft preserves the extensor mechanism and function of the limb. The soft tissue coverage is an added problem that can be solved by propeller fasciocutaneous flap coverage. After surgery, the limb must be immobilized with a knee brace locked in extension. Local radiotherapy contributes to local control of the disease. The reconstruction of the extensor mechanism of the knee with allograft is a functional alternative to amputation, and it does not contraindicate adjuvant radiotherapy to improve local control of the disease.

Does Preoperative Radio(chemo)therapy Increase Anastomotic Leakage in Rectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials

Objective. Preoperative radio(chemo)therapy (pR(C)T) appears to increase postoperative complications of rectal cancer resection, but clinical trials have reported conflicting results. The objective of this meta-analysis was performed to assess the effects of pR(C)T on anastomotic leak after rectal cancer resection. Methods. PubMed, Embase, and the Cochrane Library were searched from January 1980 to January 2014. Randomized controlled trials included all original articles reporting anastomotic leak in patients with rectal cancer, among whom some received preoperative radiotherapy or chemoradiotherapy while others did not. The analysed end-points were the anastomotic leak. Result. Seven randomized controlled trials with 3375 patients were included in the meta-analysis. 1660 forming the group undergoing preoperative radiotherapy or chemoradiotherapy versus 1715 patients undergoing without preoperative radiotherapy or chemoradiotherapy. The meta-analyses found that pR(C)T was not an independent risk factor for anastomotic leakage (OR 1.02, 95% CI 0.80-1.30; P = 0.88). Subgroups analysis was performed and the result was not altered. Conclusions. Current evidence demonstrates that pR(C)T did not increase the risk of postoperative anastomotic leak after rectal cancer resection in patients.

Preoperative risk factors for anastomotic leakage after resection for colorectal cancer: a systematic review and meta-analysis

AIM

Colorectal anastomotic leakage is a serious complication. Despite extensive research, no consensus on the most important preoperative risk factors exists. The aim of this systematic review and meta-analysis was to evaluate risk factors for anastomotic leakage in patients operated with colorectal resection.

METHOD

The databases MEDLINE, Embase and CINAHL were searched for prospective observational studies on preoperative risk factors for anastomotic leakage. Meta-analyses were performed on outcomes based on odds ratios (OR) from multivariate regression analyses. The Newcastle-Ottawa scale was used for bias assessment within studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels.

RESULTS

This review included 23 studies evaluating 110,272 patients undergoing colorectal resection for cancer. The meta-analyses found that a low rectal anastomosis [OR = 3.26 (95% CI: 2.31-4.62)], male gender [OR = 1.48 (95% CI: 1.37-1.60)] and preoperative radiotherapy [OR = 1.65 (95% CI: 1.06-2.56)] may be risk factors for anastomotic leakage. Primarily as a result of observational design, the quality of evidence was regarded as moderate or low for these risk factors according to the GRADE approach.

CONCLUSION

Based on the best available evidence, important preoperative risk factors for colorectal anastomotic leakage have been identified. Knowledge on risk factors may influence treatment and procedure-related decisions, and possibly reduce the leakage rate.

Publication, publication, publication

Pharyngocutaneous fistulas following large oncological surgical resection of the upper aerodigestive tract are common and typically heal over a number of weeks. A pharyngostome is a surgically created non-healing opening into the pharynx, which is far less common and often difficult to manage.