Management of fluoroscopy-induced radiation ulcer: One-stage radical excision and immediate reconstruction

An innovative targeted therapy for fluoroscopy-induced chronic radiation dermatitis

Fluoroscopy-induced chronic radiation dermatitis (FICRD) is a complication of fluoroscopy-guided intervention. Unlike acute radiation dermatitis, FICRD is different as delayed onset and usually appears without preexisting acute dermatitis. Unfortunately, the chronic and progressive pathology of FICRD makes it difficult to treat, and some patients need to receive wide excision and reconstruction surgery. Due to lack of standard treatment, investigating underlying mechanism is needed in order to develop an effective therapy. Herein, the Hippo pathway is specifically identified using an RNA-seq analysis in mild damaged skin specimens of patients with FICRD. Furthermore, specific increase of the Yes-associated protein (YAP1), an effector of the Hippo pathway, in skin region with mild damage plays a protective role for keratinocytes via positively regulating the numerous downstream genes involved in different biological processes. Interestingly, irradiated-keratinocytes inhibit activation of fibroblasts under TGF-β1 treatment via remote control by an exosome containing YAP1. More importantly, targeting one of YAP1 downstream genes, nuclear receptor subfamily 3 group C member 1 (NR3C1), which encodes glucocorticoid receptor, has revealed its therapeutic potential to treat FICRD by inhibiting fibroblasts activation in vitro and preventing formation of radiation ulcers in a mouse model and in patients with FICRD. Taken together, this translational research demonstrates the critical role of YAP1 in FICRD and identification of a feasible, effective therapy for patients with FICRD. KEY MESSAGES: • YAP1 overexpression in skin specimens of radiation dermatitis from FICRD patient. • Radiation-induced YAP1 expression plays protective roles by promoting DNA damage repair and inhibiting fibrosis via remote control of exosomal YAP1. • YAP1 positively regulates NR3C1 which encodes glucocorticoid receptor expression. • Targeting glucocorticoid receptor by prednisolone has therapeutic potential for FICRD patient.

Local dose reference levels during transarterial chemoembolization procedure

The aim of this study was to develop local diagnostic reference levels (LDRL) during Transarterial chemoembolization (TACE). This cross-sectional study reports radiation dose indicators of 108 patients in a Mexican hospital, obtained over a period of 35 months. Kerma-area product (P_KA), air-kerma at the reference point (K_{a, r}), and descriptive statistical analysis were examined according to sociodemographic characteristics of the sample patients. The LDRL obtained were then compared to a similar international framework. The present study contributes to the establishment of a TACE LDRL and identifies significant correlations among radiology factors and dosimetric quantities obtained.

Histopathology of fluoroscopy-induced radiation ulcer: a case series study in comparison with morphea

BACKGROUND AND OBJECTIVES

Histopathologic diagnosis of fluoroscopy-induced radiation ulcer (FIRU) can be challenging if the past history of radiation exposure is unknown. Morphea is the most important differential diagnosis. This study was intended to identify clinical and pathologic features that can be used to distinguish FIRU from morphea.

PATIENTS AND METHODS

We performed a retrospective study on 25 specimens from 15 patients with FIRU and 21 specimens from 21 patients with morphea. Clinical findings and pathological features were analyzed.

RESULTS

Thirteen of 15 patients (86.7 %) with FIRU underwent angioplasty for coronary artery disease, and eleven patients had lesions in the right subscapular area. Compared with morphea, FIRU patients were more likely to display non-inflammatory infiltrates (28 %), bizarre fibroblasts (100 %), sclerosis (48 %), telangiectasia (96 %), vascular damage (64 %), and loss of skin appendages (100 %). In morphea, bizarre fibroblasts were rare (14 %), while telangiectasia (62 %) and loss of skin appendages (62 %) were variable. Loss of CD34+ cells and compression of elastic fibers could not be used to distinguish between FIRU and morphea.

CONCLUSIONS

Skin lesion in the right subscapular area with presence of bizarre fibroblasts, sclerosis, telangiectasia, and loss of cutaneous appendages as seen with histology are highly characteristic of the radiation damage associated with fluoroscopic angiography.

Management of radiation-induced ulcers by singlestage reconstructive surgery: a prospective study

Radiation-induced ulcers are a late-stage skin reaction after radiation therapy for cancer treatment. The present study examined the possibility of using a single-stage reconstructive procedure to manage radiation-related wounds. This prospective study recruited 30 participants who underwent radiation treatment for cancer or hemangioma. The patients ranged in age from 15 to 80 years. They were admitted to the Plastic, Reconstructive, and Regenerative Centre of Viet Nam National Burn Hospital from October 2013 to September 2017. For each patient, the surgeons discussed which reconstructive method would yield the best outcome. Patients' demographic data and information on the radiation-induced ulcer, the reconstructive method used, complications, and length of hospital stay were recorded. The mean age of all participants was 50 ± 36.3 years, and female patients were predominant (83.3%). Eighteen perforator flaps, five random-pattern flaps, three free flaps, three tissue expander flaps, and one full-thickness skin graft were employed, with no instances of recurrence or complications, except for total flap loss in two cases. The median length of stay was 43 days. These data suggest that immediate reconstruction may be a valuable option for managing radiation-induced ulcers.

Reducing the risk of skin injuries in cardiac catheterization procedures: Optimization proposal for obese patients

PURPOSE

During interventional cardiology procedures, high doses of X-ray may be delivered to patients. This is especially critical in cases of obese patients and/or high obliquity projections. High dose rates can then be produced in patients' skin as well as insufficient image quality due to regulatory limitations in the X-ray tube output working in the fluoroscopy mode. In this paper, an optimization action is proposed to reduce patient entrance dose rate and preserve image quality in cases of thick patients.

METHODS

The action is based on the evaluation of dose rate to the patient and image quality in a new fluoroscopy protocol with less frame rate (7.5 vs. 15 frames/s) and higher spectral shape filter (0.4 vs. 0.1 mm Cu). The new protocol is tested in an angiography room using a PMMA phantom and a test object.

RESULTS

The new fluoroscopy protocol (7.5 fr/s and 0.4 mm Cu) reduces entrance surface air kerma in 70%-10% (depending on PMMA thickness), preserving the incident air kerma per frame at the image detector. While at lower PMMA thickness, the MTF measured with bar pattern is better for the default protocol; at PMMA thickness between 32 and 37 cm, the optimized protocol produces better image quality indicators.

CONCLUSIONS

This work demonstrates that in the case of high thicknesses of PMMA (32-37 cm), increasing spectral beam filter and reducing frame rate may help improve image quality and maintain entrance surface air kerma so as to fulfil the regulatory requirements.

Using X-rays in photodynamic therapy: an overview

Photodynamic therapy is a therapeutic option to treat cancer and other diseases.