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Radiation Ulcers Treatment & Management

  • Author: Martha Matthews, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
 
Updated: Mar 15, 2016
 

Medical Therapy

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.

Case A. Cutaneous injury caused by irradiation to Case A. Cutaneous injury caused by irradiation to treat advanced lung cancer with metastases to the head and spine. View illustrates radiation burns to the head and neck region. Note the residual silver sulfadiazine and mafenide acetate cream on the patient's face and ears, which was applied to treat the injury and prevent infectious complications.

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.[11]

Medical therapy with amifostine reduces the incidence of xerostomia. No other medical therapies are proven to reduce the effects of radiation injury.

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Surgical Therapy

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.[12]

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.

Case B. This patient presented to the plastic surg Case B. This patient presented to the plastic surgeon with complaints of a small opening along her mid sternum. She was receiving follow-up care from her primary physician, who had been treating the wound with parenteral antibiotics, with no improvement. The patient's history was noteworthy for previous left radical mastectomy followed by cobalt radiation approximately 20 years ago. At first glance, the wound appeared to be a small, draining sinus surrounded by the erythema typically seen with radiation-damaged skin.
Case B. The patient was scheduled for debridement Case B. The patient was scheduled for debridement of the affected area. Use of a myocutaneous flap was planned because a large area of underlying osteonecrosis was suspected. Image depicts the extensively débrided chest wall. Most of the sternum and numerous costochondral cartilages were excised.

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.

Case B. Photograph obtained after a right-sided pe Case B. Photograph obtained after a right-sided pectoralis major myocutaneous flap was used to close the resultant defect. The pectoralis muscle was disinserted at the shoulder to facilitate movement of the flap across the midline.

Decreased patency rates of microvascular anastomoses in irradiated vessels support this theory.[13] However, data Mulholland et al reported refute these results and suggest equal patencies in microvascular anastomoses between irradiated flaps and nonirradiated flaps.[14] 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.[15] 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.

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Preoperative Details

Examine any suspicious area with biopsy to look for malignancy (Marjolin ulcer). Optimize nutrition. Plan for wound coverage to bring in new blood supply.

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Intraoperative Details

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.
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Postoperative Details

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.

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Follow-up

If malignancy was present in the wound, frequent follow-up is indicated because these tumors are frequently aggressive.

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Complications

Wound healing problems are common.[16] 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).

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Future and Controversies

Great interest exists for the development of radioprotectants to prevent radiation injury.[17] 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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Contributor Information and Disclosures
Author

Martha Matthews, MD Associate Professor of Surgery, Cooper Medical School of Rowan University

Martha Matthews, MD is a member of the following medical societies: American Cleft Palate-Craniofacial Association, American Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons, American College of Surgeons, American Society of Maxillofacial Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Heidi D Williams, MD Private Practice Mt. Pleasant, South Carolina

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Wayne Karl Stadelmann, MD Stadelmann Plastic Surgery, PC

Wayne Karl Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Society of Plastic Surgeons, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

References
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  2. Wei KC, Yang KC, Mar GY, et al. STROBE-Radiation Ulcer: An Overlooked Complication of Fluoroscopic Intervention: A Cross-Sectional Study. Medicine (Baltimore). 2015 Dec. 94 (48):e2178. [Medline]. [Full Text].

  3. O'Sullivan B, Levin W. Late radiation-related fibrosis: pathogenesis, manifestations, and current management. Semin Radiat Oncol. 2003 Jul. 13(3):274-89. [Medline].

  4. Miller SH, Rudolph R. Healing in the irradiated wound. Clin Plast Surg. 1990 Jul. 17(3):503-8. [Medline].

  5. Guelinckx PJ, Boeckx WD, Fossion E, Gruwez JA. Scanning electron microscopy of irradiated recipient blood vessels in head and neck free flaps. Plast Reconstr Surg. 1984 Aug. 74(2):217-26. [Medline].

  6. Xu Y, Parmar K, Du F, Price BD, Sun Y. The radioprotective agent WR1065 protects cells from radiation damage by regulating the activity of the Tip60 acetyltransferase. Int J Biochem Mol Biol. 2011. 2(4):295-302. [Medline]. [Full Text].

  7. Rudolph R, Arganese T, Woodward M. The ultrastructure and etiology of chronic radiotherapy damage in human skin. Ann Plast Surg. 1982 Oct. 9(4):282-92. [Medline].

  8. Rudolph R, Tripuraneni P, Koziol JA, et al. Normal transcutaneous oxygen pressure in skin after radiation therapy for cancer [published erratum appears in Cancer 1995 Mar 1;75(5):1218]. Cancer. 1994 Dec 1. 74(11):3063-70. [Medline].

  9. Tattini C, Manchio J, Zaporojan V, et al. Role of TGF-beta and FGF in the treatment of radiation-impaired wounds using a novel drug delivery system. Plast Reconstr Surg. 2008 Oct. 122(4):1036-45. [Medline].

  10. Chen MY, Mai HQ, Sun R, et al. Clinical findings and imaging features of 67 nasopharyngeal carcinoma patients with postradiation nasopharyngeal necrosis. Chin J Cancer. 2013 Oct. 32(10):533-8. [Medline]. [Full Text].

  11. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2012 May 16. 5:CD005005. [Medline].

  12. Fujioka M. Surgical Reconstruction of Radiation Injuries. Adv Wound Care (New Rochelle). 2014 Jan 1. 3 (1):25-37. [Medline]. [Full Text].

  13. Watson JS. Experimental microvascular anastomoses in radiated vessels: a study of the patency rate and the histopathology of healing. Plast Reconstr Surg. 1979 Apr. 63(4):525-33. [Medline].

  14. Mulholland S, Boyd JB, McCabe S, et al. Recipient vessels in head and neck microsurgery: radiation effect and vessel access. Plast Reconstr Surg. 1993 Sep. 92(4):628-32. [Medline].

  15. Rigotti G, Marchi A, Galie M, Baroni G, Benati D, Krampera M. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007 Apr 15. 119(5):1409-22; discussion 1423-4. [Medline].

  16. Payne WG, Naidu DK, Wheeler CK, et al. Wound Healing in Patients With Cancer. Eplasty. 2008 Jan 11. 8:e9. [Medline].

  17. Grdina D, Murley J, Kataoka Y. Radioprotectants: Current Status and New Directions. Oncology. 2002. 63(suppl2):2-10. [Medline].

  18. Ariyan S. Radiation injury. Plastic Surgery. 2nd ed. 2006. Vol 1: 835-53.

  19. Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev. 2005 Jul 20. CD005005. [Medline]. [Full Text].

 
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Case A. Cutaneous injury caused by irradiation of the chest wall to treat advanced lung cancer with metastases to the head and spine. This patient was transferred to a burn unit for adequate care of the burns and ulcerations caused by the radiation treatments.
Case A. Cutaneous injury caused by irradiation to the chest wall to treat advanced lung cancer with metastases to the head and spine.
Case A. Cutaneous injury caused by irradiation to treat advanced lung cancer with metastases to the head and spine. View illustrates radiation burns to the head and neck region. Note the residual silver sulfadiazine and mafenide acetate cream on the patient's face and ears, which was applied to treat the injury and prevent infectious complications.
Case A. Cutaneous injury caused by irradiation to treat advanced lung cancer with metastases to the head and spine.
Case A. Cutaneous injury caused by irradiation to treat advanced lung cancer with metastases to the head and spine.
Case A. Cutaneous injury caused by irradiation to treat advanced lung cancer with metastases to the head and spine. View shows the posterior aspects of the patient's ears and neck.
Case B. This patient presented to the plastic surgeon with complaints of a small opening along her mid sternum. She was receiving follow-up care from her primary physician, who had been treating the wound with parenteral antibiotics, with no improvement. The patient's history was noteworthy for previous left radical mastectomy followed by cobalt radiation approximately 20 years ago. At first glance, the wound appeared to be a small, draining sinus surrounded by the erythema typically seen with radiation-damaged skin.
Case B. The patient was scheduled for debridement of the affected area. Use of a myocutaneous flap was planned because a large area of underlying osteonecrosis was suspected. Image depicts the extensively débrided chest wall. Most of the sternum and numerous costochondral cartilages were excised.
Case B. Photograph obtained after a right-sided pectoralis major myocutaneous flap was used to close the resultant defect. The pectoralis muscle was disinserted at the shoulder to facilitate movement of the flap across the midline.
 
 
 
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