Considerations When Treating Wounds Resulting From Radiotherapy

In this video, Dr. Terry Treadwell discusses factors to consider when encountering wounds resulting from radiotherapy as shared in their case series poster presentation (The Treatment of Wounds Occurring in Radiated Tissue with Nitric Oxide / Plasma Therapy) at SAWC Spring in National Harbor, Maryland, April 26-30, 2023.

Transcript:

Hello, this is Dr. Terry Treadwell. As many of you know, I'm the medical director for the Institute for Advanced Wound Care in Montgomery, Alabama.

The question tonight has been about wounds caused by radiation therapy. Radiation therapy has been around for over 100 years, in which it's been used to treat different types of malignancies, and for the most part it does a pretty good job controlling different types of tumors that can be very difficult to treat. Unfortunately, there are some significant side effects with radiation therapy. We can have acute wounds result from radiation therapy and we can have chronic wounds associated with radiation therapy. The problem is that for the most part, radiation therapy can damage the cells, not only the cancer cells, but also the normal tissue cells, mainly fibroblast, so that it really slows down any kind of healing, and it is a struggle to maintain the normal skin structure after radiation therapy.

The radiation also damages the blood vessels and the circulation. It involves the microcirculation, and as a result, you have vascular insufficiency to the entire area that's been treated with radiation therapy. The interesting part about the microcirculation problem is that it's not just a here and now type of situation. As soon as you quit the radiation therapy and it has a chance to heal, then it's not necessarily true that the microvascular damage will stop. Microvascular damage can be progressive for years after radiation therapy has been delivered for whatever reason. So this can be another problem that we have, and one of the main reasons we see chronic wounds related to radiation therapy.

The third thing that we see is an abnormal inflammatory response that occurs in all the tissues involved in radiation therapy. So if you have a patient who has an acute wound, most of these can occur within 10 to 14 days after radiation is begun, we see radiation dermatitis where the skin just gets very irritated and red, and this sometimes will progress to actual ulcerations with full-thickness injuries. Sometimes you can treat the dermatitis and hopefully it will resolve without any further problems. However, others can occur some 3 months to later, even many years after the fact, that you turn up with an ulceration in that area that has been radiated. One of the prime reasons for getting an area of radiation necrosis, if you will, is that the malignancy that is radiated, especially if you're radiating skin cancer, this tissue dies quickly and you're left with a hole in the leg. Then you have to figure out a way to get that closed when you also have surrounding tissue that has cells that are damaged, has poor circulation, and also has an abnormal inflammatory response.

So these are some of the things that must be considered when you're approaching a wound that is the result of radiation therapy, or in tissue that has been irradiated. So even from an acute standpoint or a chronic standpoint, the overview is the same. First, you want to look and see if there's a problem with a lot of irritation, a lot of inflammatory action. This is generally more of a problem in the acute wound. You have to do whatever you can with skin protectant and things along those lines to try to take care of the wounds itself and to reduce an inflammatory action and try to protect the skin. In the chronic wounds, you also are involved with the inflammatory action, but then you have to deal with the cells that are not there and not functioning well, as well as the circulation problem.

As you know, there are very few real good treatments for radiation-induced injuries, especially the chronic wounds. Probably the one that has been used the most in these very chronic wounds that are open for long periods of time, and they can be open for up to 20 years without any suggestion of closure. We will see those, and many times they would use skin flaps to try to bring in healthy tissue as well as blood supply, but this isn't a 100% guarantee. It would be nice if we could come up with another therapy that would actually help heal the wounds, both acute and chronic, without having to resort to big flap type of operative procedures.

But the thing that you need to look at is, of course, the patient has the inflammatory response. They can also get infections in these tissues, which must be evaluated before you can really get any kind of response, and then try to evaluate the circulation if you can. There's very little way to really check the sailor [sic] activity unless you would just measure the healing rate. Whatever it is, these are exceedingly difficult. Many, many different types of therapies have been attempted. Everything from different kinds of wound dressings to skin grafts, split-thickness skin grafts, up to the flaps that we mentioned. Hyperbaric oxygen has been utilized, and some people think it works exceedingly well. We've not had much luck, even with radiated wounds, with hyperbaric oxygen, but it is one of the therapies that is available for that.

So we need to look at this and try to make the best informed opinion that we can about what the wound needs and what we can provide for it to try to get the wound to close. There's some new technologies that are coming down the road, which hopefully we can talk about a little later, that we may find very useful for this type of problem. But for the most part, if you're doing the evaluation, you do like any other wound, and you do with the basic evaluation for infection, inflammation, drainage, sailor content [sic], circulation in the whole thing, to see what chance you might have of getting this wound to close with appropriate therapy. And then you'd have to see what therapy you have available that might meet the needs of that wound, and realizing that healing will be very slow at the best and problematic also.