Radiation Ulcers Treatment & Management
- Author: Martha Matthews, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
The malignant potential of radiation has been recognized since 1902, when skin cancer was diagnosed in a patient who worked with the newly invented x-ray machine. By the 1920s, cancers were identified in uranium miners and in watch-dial painters who worked with radium.
Infections and inflammation, which are believed to have a co-carcinogenic effect, compound the carcinogenic potential of irradiated tissue. As a result of the vascular changes noted in Etiology and the resultant hypoxia, irradiated fields have a decreased capacity to fight infection. Impaired delivery of antibiotics also hinders the eradication of infection. As a result, use topical antibiotics, preferably those with tissue penetrance capabilities, to decontaminate irradiated wound beds. See the image below.
Osteoradionecrosis (radiation osteitis) also illustrates the importance of decontamination. Although osteoradionecrosis is primarily a complication of radiation therapy resulting from altered vascularity of irradiated bone, the presence of bacteria in the wound bed exacerbates its development. For example, mandibles with recently extracted teeth that are exposed to radiation have an increased incidence of osteoradionecrosis compared with mandibles that are given the opportunity to heal after tooth extraction before radiation therapy.
When radiation ulcers are treated, consider all potential radiation effects, as they all are interrelated. Basic tenets must be followed in the treatment of radiation ulcers. For example, radiation ulcers tend to be painful (secondary to hypoxia), and this pain often necessitates surgical intervention. As a result of the pain and the usual lengthy treatment plans, patients need to be supported emotionally. Before any surgery is performed, ascertain the potential for malignancy.
Regarding acute radiation injury, radiation therapy, even when properly administered, may cause adverse skin effects. The injury first manifests as erythema followed by edema and pain. The skin desquamates, mimicking a thermal burn. Superinfection may cause extended tissue loss. Industrial accidents involving high dosages may produce the same effects, which may even progress to tissue loss. Treatment is supportive and includes protection from further trauma and use of topical antimicrobials, eg, silver sulfadiazine for partial-thickness skin losses. If frank, full-thickness ulcerations develop, they are unlikely to heal with purely medical intervention.
Chronic radiation injury decreases the ability of the body to tolerate bacterial contamination. When elective surgery is undertaken through radiated tissue, meticulous technique, gentle tissue handling, and antibiotic prophylaxis are essential.
Hyperbaric oxygen treatment is of value in healing of tissues of the head and neck, anus and rectum. It can also be useful in preventing osteoradionecrosis of the mandible when dental work is needed after radiation.
While hyperbaric oxygen treatment has been demonstrated in a small number of studies to be effective in treating radiation injury in the head, neck, and distal bowel and in the prevention of osteoradionecrosis of the mandible after dental extractions, the evidence for or against its' utility in other body areas is weak.
Medical therapy with amifostine reduces the incidence of xerostomia. No other medical therapies are proven to reduce the effects of radiation injury.
Tissue exposure to radiation, whether therapeutic or incidental, raises problems or concerns for surgeons in terms of the malignant potential of the irradiated bed and wound healing issues (eg, hypoxia, infection). The plastic surgeon faces the additional problem of reconstructing the wound or ulceration that results from radiation damage. Surgery through radiated fields can result in poor wound healing, even when the radiated field is intact.
When planning an operation, clinicians should realize that the zone of injury typically is larger than that initially anticipated; therefore, widely excise the ulcer. See the images below.
Immediate, tension-free reconstruction should be performed at the time of ulcer excision since granulation tissue tends not to arise in irradiated beds. Because skin grafts typically fail, arterial-based flaps (free, locoregional, musculocutaneous, or fasciocutaneous) are the preferred means of reconstruction. These flaps fill the defect the ulcer leaves, and their vascularity enhances local blood flow in the compromised wound bed. This last point relates to the controversy over irradiated vessels. As noted in Medical Therapy, these vessels are generally regarded as impaired, and this impairment leads to hypoxia.
Decreased patency rates of microvascular anastomoses in irradiated vessels support this theory. However, data Mulholland et al reported refute these results and suggest equal patencies in microvascular anastomoses between irradiated flaps and nonirradiated flaps. Mulholland et al nevertheless note an association between free-flap failure and an increased interval between radiation therapy and reconstruction, suggesting the progressive, ongoing destruction caused by radiation.
Promising new data indicate that radiation injury to tissues may be reversed with transplantation of autologous fat into the radiated area. The transfer of adipose-derived adult stem cells may provide new cells to heal the radiation damage. Autologous fat is harvested using liposuction techniques and injected into the area of damage.
Examine any suspicious area with biopsy to look for malignancy (Marjolin ulcer). Optimize nutrition. Plan for wound coverage to bring in new blood supply.
Consider the following issues during surgery:
Vascular fibrosis may cause excessive bleeding. Prepare for possible transfusion in large wounds.
Meticulous tissue handling is required.
Completely remove infected, necrotic, and compromised tissue.
Wound coverage usually involves regional or distant muscle or myocutaneous flaps that can provide new blood supply to the wound.
Irradiated vascular pedicles do not adversely affect flap success in local flaps; however, irradiated flaps do have lowered success rates.
When free tissue transfer is used, special care should be taken with irradiated recipient vessels because they are more friable and damaged than normal vessels.
Irradiated tissues are less tolerant of bacterial contamination, wound tension, and poor technique than nonirradiated tissues. Healing is slow. Wound-closure techniques should account for this difference.
Avoidance of wound trauma is paramount. Wound complications, such as seroma, hematoma, and dehiscence, should be handled aggressively. Irradiated wounds heal poorly by secondary intention.
If malignancy was present in the wound, frequent follow-up is indicated because these tumors are frequently aggressive.
Wound healing problems are common. Common causes of problems include insufficient resection of the involved tissue, unrecognized malignancy, mechanical trauma or excessive tension on the wound, untreated seroma or hematoma with secondary infection, and reconstructive choices dependent on the recipient bed for vascularity (eg, skin grafts rather than flaps).
Future and Controversies
Great interest exists for the development of radioprotectants to prevent radiation injury. As of now, these are not clinically available. Many studies are being performed to evaluate delivery modalities and schedules to minimize acute and late adverse effects. As cancer treatment improves, the number of people who survive long enough to have the late effects of radiation and of recurrent and secondary tumors will increase. The need for reconstruction will persist unless effective means can be found to prevent or reverse the effects of radiation.
Stem cell therapy, using autologous adult adipose-derived stem cells, may be found to reverse or ameliorate the long-term deleterious effects of radiation.
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