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Case History

Image not available. A 54-year-old woman who completed a fractionated course of radiotherapy to her breast seven days ago presents with redness and tenderness/pain in the breast accompanied by general malaise.

What is radiotherapy-related acute skin toxicity?

How should the patient be assessed?

What else should be excluded?

How can you manage the problem?


What is radiotherapy-related acute skin toxicity?

Image not available. The cells in the basal layer of the epidermis constantly divide to form the upper layers of the skin, with a turnover time of about 25 days. Radiation damages the DNA of stem cells in the basal layer, resulting in apoptosis, mitotic cell death and an inflammatory response. The sequential nature of a course of radiotherapy interrupts ongoing repair processes, thus consolidating injury.1,2

Acute skin toxicity secondary to radiotherapy usually occurs at 12–14 days and the severity is dependent upon the following:

  • Patient-related factors:

    • treatment site (head and neck cancer, breast cancer, vulval cancer, anal canal cancer and skin cancer)

    • radiation sensitivity (related to genetic predisposition)

    • comorbidity (pre-existing skin infiltration by cancer, chronic oedema, ulceration or infection)

    • obesity (skin folds are more at risk).

  • Treatment-related factors:

    • radiation dose (high-dose treatments cause more problems)

    • radiotherapy beam energy (kilovoltage photons or electrons)

    • use of bolus (increases dose to skin)

    • immobilization masks

    • concurrent chemotherapy.

Symptoms of skin toxicity include: itching, discomfort or pain, erythema, ulceration, scab formation and functional impairment.

The majority of data on radiotherapy-induced acute skin toxicity comes from patients receiving radiotherapy to the breast region and head and neck region. Acute skin toxicity can also be a serious problem in anal/lower rectal and some gynaecological treatments (dose is concentrated in folds), and is an expected problem in skin cancer treatments. Owing to the likely distribution of radiation beams and subsequent dosage, severe acute skin toxicities are rare in other tumour groups.

In most patients who have 4–6 weeks of radiotherapy, skin side effects will develop during the course. In shorter courses of therapy the acute toxicity can occur after completion of the course, and this can cause alarm.

How should the patient be assessed?

Skin changes look like sunburn or burns, and they occur only in the treated area, often with a very sharp demarcation from normal skin. A number of grading systems exist to help assess the severity of an acute skin toxicity and give guidance for management. Commonly used in the UK are the Radiation Therapy Oncology Group (RTOG) Acute Radiation Morbidity Scoring Criteria (Table 28.1).3,4 Desquamation refers to the loss of the epithelium exposing the underlying dermal layer.

Table 28.1Radiation Therapy Oncology Group (RTOG) Acute Radiation Morbidity Scoring Criteria

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