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Introduction • A skin care working party was set up to produce evidence based practice skin care guidelines, including recommendations for the treatment and prevention of moist desquamation. An audit of 259 patients in 2008 revealed that 7% of patients developed moist desquamation. • A literature search by members of the skin care working party found several studies looking at the prevention of skin reactions 1-6 . One of these studies looked into the use of cavilon no sting barrier film (CNSBF) in post mastectomy treatments 6 . The results from the study suggested that the use of CNSBF could reduce the incidence of moist desquamation in this group of patients. An in-house audit was devised to assess the effectiveness of CNSBF in other patient groups. • Numerous studies have previously looked at the treatment of moist desquamation 7-11 . No one treatment intervention has been proven superior to any other 9 . • However our existing clinical practice needed updating to follow best practice moist wound healing principles. • PolyMem dressing was chosen and assessed for its efficacy in the treatment of moist desquamation. Its appealing properties included odour reduction, non adherence, absorbency, wound cleansing as well as healing and pain relief. Methods and Materials • 40 patients were identified at high risk of developing friction related moist desquamation (RTOG score 2b and above) using the results gained from the previous audit (see table 1). • These 40 patients were given CNSBF to apply during their treatment. The application started twice weekly. Once RTOG 2b was reached, the applications were increased to every other day. Their RTOG score was initially recorded weekly, then increased to twice weekly once 2b was reached. Each patient was issued with a 28mL spray bottle and given verbal instructions for use. • 20 patients who developed RTOG 2b were given PolyMem dressings applied as per the manufacturers instructions and their RTOG score recorded twice weekly. Their pain score was recorded before and after application using the following adapted pain measurement scale by McCaffrey and Beebe (1989) as supplied by Activa Healthcare Ltd. Table 1: Patient groups identified as being at high risk of developing RTOG 2b skin reactions Results - CNSBF • Of the 40 patients identified as being at high risk, 17 (42.5%) patients developed stage 2b or greater skin reactions, 3 of these later developed stage 3 and none of the patients in the study developed stage 4 (Graph 1). • Stage 2b was not observed in any of the cases until week 3. Table 2 shows a summary of the weekly skin reactions over 2b observed in different patient groups including risk factors associated with these patients. 8 of these patients went from 0 to 2b in the space of a week, 3 from 1 to 2b and 2 from 2a to 3. • The Radiographers observed a marked improvement in the skin reactions generally and in particular for patients treated for anal carcinoma that used CNSBF where the 2b area tended to be limited to the perineal region. In two anal carcinoma patients their groin and genital areas were missed in the application process, stage 2b was reached at week 3 in these areas, compared to week 5 for the perineum. • Some skin reactions did not follow the usual gradual progression through stage 1, 2a, 2b,and instead went straight to 2a or 2b. • Two patients reported a sensitivity to CNSBF - a mild erythematous rash developed in the application area early on in the study - therefore all patients were tested for sensitivity outside the treatment area 24 hours before CNSBF was applied, a further 2 patients subsequently showed sensitivity reactions and were excluded from the study. Table 2:- RTOG weekly score PolyMem • Of the 17 patients reaching stage 2b+ in the CNSBF audit, 11 were given PolyMem to use (one patient was non compliant and a second patient did not like the dressing and therefore did not use it. The remaining patients were given gentian violet to apply by the clinician before PolyMem could be used). • A total of 20 patients were given the dressing. Table 3 shows at which RTOG score PolyMem dressings were instigated and to which sites. • PolyMem was generally used after the patient had received a minimum of 20Gy. • PolyMem was found to have reduced pain scores between 1 and 4 points in 14 of the 19 patients studied. Wilcoxon Signed Ranks Test showed that this is a significant reduction (p<0.001). Table 3:- RTOG score and number of patients* issued withnPolyMem dressing (*NB some patients used the dressing in multiple sites) Discussion • From the results of the study there appears to be a delay in the presentation of acute skin reactions. This is highlighted in two anal carcinoma patients where stage 2b was reached in areas missed by the CNSBF application 2 weeks before the areas that had CNSBF applied. • 57.5% of high risk patients did not reach the expected 2b skin reactions negating the need for further interventions, overall this may reduce the cost in treating these patients skin reactions long term as well as improving overall cosmetic results and the patients experience of treatment. • We are unable to offer an explanation as to why the skin reactions appeared to miss stages of reactions. • Initially patients were asked to apply the CNSBF themselves, however Radiographers noted a better coverage and consequently a better reaction if the CNSBF was applied by Radiographers, this also encouraged Radiographers to assess the skin reaction more frequently and intervene earlier with PolyMem. • The application process takes 30 seconds and due to the small number of patients requiring application, this has no overall impact on treatment unit throughput. • In some patients there was a build up of CNSBF when the patient was unable to adequately wash the treatment area although this did not appear to effect the overall results. One breast patient stopped using CNSBF as her perfuse sweating caused a build up of fluid beneath the film causing discomfort. PolyMem • There is a significant pain reduction for many patients. This is due to an inhibition by the polymeric membrane of the dressing on the nociceptor reaction, which has also been proven to reduce inflammation, bruising and oedema 13,14 on both broken and intact skin. • The wound cleansing properties of the dressing ensured that the risk of infection was reduced while the dressing was in place as well as ensuring ease of dressing changes and the time required was minimised. • Wound healing commenced in some patients even whilst continuing with radiotherapy treatment. • PolyMem also acted as an anti-inflammatory when it was instigated at stage 2a, particularly in the anal/perineal region. • Feedback from patients was positive, from ease of use to pain and odour relieving properties. No patients showed signs of sensitivity. • Some areas still remain difficult to dress and ensure the dressing is secure e.g. scrotal, vulval regions. Often this was effectively managed by encouraging patients to use scrotal supports and nettolast pants. Cost implications (as per October 2009 NHS supplies catalogue prices) • 1 bottle of spray (£8.26) lasted for 4 weeks of application (18 patients). 22 patients required another bottle. • Of these 40 patients, 11 received PolyMem dressings. Two sizes were ordered (10x61cm roll (£12.21 per roll) and 13x13cm dressings (£4.21 per dressing)), both dressings were cut to size as required and changed daily. Total cost per patient was dependant on when the dressing was issued the maximum cost for a single patient was for 5 rolls (£61.05). As the dressing is freely available in the community G.P.s were able to prescribe the dressing for the patients once its effectiveness was established with only 1 dressing needing to be issued by the department. Conclusion • Due to the effectiveness of the CNSBF it is now routinely applied by Radiographers to pre-identified high risk patients, however all patients are tested for sensitivity prior to its application. • CNSBF is also used to preserve skin marks required for superficial x-ray and electron treatments. • PolyMem is now issued by Radiographers to all patients presenting with 2b skin reaction. • In patients being treated for lower rectal / anal cancers the authors would recommend the instigation of PolyMem at 2a skin reactions, particularly when the patient has a heavy mucosal discharge and therefore the skin is likely to macerate and breakdown. • Future studies are warranted in the use of CNSBF where patients are used as their own control to fully establish CNSBF effectiveness in the prevention of acute radiotherapy induced moist desquamation. References 1. Pommier, P., Gomez, F., Sunyach, M.P., D’Hombres, A., Carrie, C. and Montbarbon, X., Phase III Randomized Trial of Calendula Officinalis Compared With Trolamine for the Prevention of Acute Dermatitis During Irradiation for Breast Cancer. J Clin Oncol, 2004. 22(8): p. 1447- 1453. 2. Wheat, J., Currie, G. and Coulter, K., Wheatgrass Extract As A Topical Skin Agent For Acute Radiation Skin Toxicity In Breast Radiation Therapy: A Randomised Controlled Trial. Journal of the Australian Traditional-Medicine Society, 2006. 12(3). 3. Liguori, V., Guillemin, C., Pesce, G.F., Mirimanoff, R.O. and Bernier, J., Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiotherapy and Oncology, 1997. 42(2): p. 155-161. 4. Berardesca, E., Primavera, G., Carrera, M., Pinnaro, P., Messina, M. and Arcangeli, G., A double-blind, randomised, placebo-controlled clinical study to evaluate a topical hyaluronic acid-based, hydrolipidic treatment for radiation dermatitis. (Abstract 1366). European Journal of Cancer Supplements, 2005. 3(2): p. 394. 5. Richardson, J., Smith, J.E., McIntyre, M., Thomas, R. and Pilkington, K., Aloe Vera for preventing radiation-induced skin reactions: A systematic literature review. Clinical Oncology, 2005. 17: p. 478-484. 6. Graham, P., Browne, L., Capp, A., Fox, C., Graham, J., Hollis, J., et al., Randomized, paired comparison of No-Sting Barrier Film versus sorbolene cream (10% glycerine) skin care during postmastectomy irradiation. International Journal of Radiation Oncology, Biology, Physics, 2004. 58(1): p. 241-6. 7. Gollins, S.W., Gaffney, C.C. and Slade, S., RCT on gentian violet versus a hydrogel dressing for radiotherapy-induced moist skin desquamation. Journal of Wound Care, 2008. 17(6): p. 268-275. 8. Patwardhan, A., Sharma, V. and Dinshaw, K., Duoderm CGF Vs Gentian Violet 1% dressing in treatment of radiation induced ulcers. The World Council of Enterostomal Therapists Journal, 2002. 22(2): p. 32-38. 9. Kedge, E.M., A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients. Radiography, 2008. In Press, Corrected Proof. 10. Atiyeh, B., Costagliola, M., Hayek, S. and Dibo, S., Effect of silver on burn wound infection control and healing: Review of the literature. Burns, 2007. 33: p. 139-148. 11. Wasiak, J., Cleland, H. and Campbell, F., Dressings for superficial and partial thickness burns (Review). The Cochraine Library, 2008( 4). 12. McCaffrey M and Beebe A. Pain; A clinical manual for Nursing practice. St Louis, MO; CV Mosby Co. 1989 13. Sessions RC Can a drug free dressing decrease inflammation and wound pain? What does the evidence say? Poster presentation at 22nd Annual Symposium on Advanced Wound Care and WHS meeting April 26-29 2009 14. Sessions RC. Examining the Evidence for a Drug Free Dressing’s ability to Decrease Wound Pain. Poster presentation at 21st Annual Symposium on Advanced Wound Care and WHS meeting April 24-27 2008 Treatment site is in the anal-genital area e.g. vulva, vagina, penis, scrotum, anus, groins Radical limbs Obese radical pelvis patients (with skin folds in treatment area) Breast patients needing orfit immobilisation bras Radical face and neck having concurrent chemotherapy or bolus Week Number RTOG Score Diagnosis Risk factors 3 2b 3 x Breast 2 x Anus Large cup size, tangential pair, Parallel Pair, bolus, concurrent chemo 4 2b 2 x Anus 1 x Rectum 1 x Vulva As Above (same pts) Concurrent chemo, Parallel pair, bolus, concurrent chemo 5 2b 5 x Anus 3 x Rectum 1 x Penis 1 x Groin As above Concurrent chemo, Parallel pair, concurrent chemo High total dose, bolus, vac bag 3 1 x Vulva 1 x Groin/scrotum Parallel pair, bolus, concurrent chemo High dose, electrons 6 2b 4 x Anus 1 x Groin As above Same pt as wk 5 3 1 x Vulva 1 x Groin/scrotum 1 x Anus Same pt as wk 5 Same pt as wk 5 7 2b 1 x Groin 1 x Femur / groin Same pt as wk 5+6 High total dose, vac bag RTOG Score No. of Patients Site 0 0 1 2 1 – Inframammary fold 1 – Genital area 2a 6 1 – Inframammary fold 5 – Anal / perineal area 2b 13 1 – Axilla 1 – Inframammary fold 1 – Scrotum 2 – Under abdominal fold 4 – Groin 4 – Anal / perineal area 3 1 1 – Anterior commisure Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation Authors: Claire Bode 1 Helen Woodman 2 , Radiotherapy Department, Queen Elizabeth Hospital, Birmingham, B15 2TH 1 – Training and education Facilitator, 2 – Macmillan Paediatric Liaison Radiographer

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Page 1: Two Novel Treatments for the Prevention and Treatment of ...• The wound cleansing properties of the dressing ensured that the risk of infection was reduced while the dressing was

Introduction

• Askincareworkingpartywassetuptoproduceevidencebasedpracticeskincareguidelines,includingrecommendationsforthetreatmentandpreventionofmoistdesquamation.Anauditof259patientsin2008revealedthat7%ofpatientsdevelopedmoistdesquamation.

• Aliteraturesearchbymembersoftheskincareworkingpartyfoundseveralstudieslookingatthepreventionofskinreactions1-6.Oneofthesestudieslookedintotheuseofcavilonnostingbarrierfilm(CNSBF)inpostmastectomytreatments6.TheresultsfromthestudysuggestedthattheuseofCNSBFcouldreducetheincidenceofmoistdesquamationinthisgroupofpatients.Anin-houseauditwasdevisedtoassesstheeffectivenessofCNSBFinotherpatientgroups.

• Numerousstudieshavepreviouslylookedatthetreatmentofmoistdesquamation7-11.Noonetreatmentinterventionhasbeenprovensuperiortoanyother9.

• Howeverourexistingclinicalpracticeneededupdatingtofollowbestpracticemoistwoundhealingprinciples.

• PolyMemdressingwaschosenandassessedforitsefficacyinthetreatmentofmoistdesquamation.Itsappealingpropertiesincludedodourreduction,nonadherence,absorbency,woundcleansingaswellashealingandpainrelief.

Methods and Materials

• 40patientswereidentifiedathighriskofdevelopingfrictionrelatedmoistdesquamation(RTOGscore2bandabove)usingtheresultsgainedfromthepreviousaudit(seetable1).

• These40patientsweregivenCNSBFtoapplyduringtheirtreatment.Theapplicationstartedtwiceweekly.OnceRTOG2bwasreached,theapplicationswereincreasedtoeveryotherday.TheirRTOGscorewasinitiallyrecordedweekly,thenincreasedtotwiceweeklyonce2bwasreached.Eachpatientwasissuedwitha28mLspraybottleandgivenverbalinstructionsforuse.

• 20patientswhodevelopedRTOG2bweregivenPolyMemdressingsappliedasperthemanufacturersinstructionsandtheirRTOGscorerecordedtwiceweekly.TheirpainscorewasrecordedbeforeandafterapplicationusingthefollowingadaptedpainmeasurementscalebyMcCaffreyandBeebe(1989)assuppliedbyActivaHealthcareLtd.

Table 1: Patient groups identified as being at high risk of developing RTOG 2b skin reactions

Results - CNSBF

• Ofthe40patientsidentifiedasbeingathighrisk,17(42.5%)patientsdevelopedstage2borgreaterskinreactions,3oftheselaterdevelopedstage3andnoneofthepatientsinthestudydevelopedstage4(Graph1).

• Stage2bwasnotobservedinanyofthecasesuntilweek3.Table2showsasummaryoftheweeklyskinreactionsover2bobservedindifferentpatientgroupsincludingriskfactorsassociatedwiththesepatients.8ofthesepatientswentfrom0to2binthespaceofaweek,3from1to2band2from2ato3.

• TheRadiographersobservedamarkedimprovementintheskinreactionsgenerallyandinparticularforpatientstreatedforanalcarcinomathatusedCNSBFwherethe2bareatendedtobelimitedtotheperinealregion.Intwoanalcarcinomapatientstheirgroinandgenitalareasweremissedintheapplicationprocess,stage2bwasreachedatweek3intheseareas,comparedtoweek5fortheperineum.

• Someskinreactionsdidnotfollowtheusualgradualprogressionthroughstage1,2a,2b,andinsteadwentstraightto2aor2b.

• TwopatientsreportedasensitivitytoCNSBF-amilderythematousrashdevelopedintheapplicationareaearlyoninthestudy-thereforeallpatientsweretestedforsensitivityoutsidethetreatmentarea24hoursbeforeCNSBFwasapplied,afurther2patientssubsequentlyshowedsensitivityreactionsandwereexcludedfromthestudy.

Table 2:- RTOG weekly score

PolyMem

• Ofthe17patientsreachingstage2b+intheCNSBFaudit,11weregivenPolyMemtouse(onepatientwasnoncompliantandasecondpatientdidnotlikethedressingandthereforedidnotuseit.TheremainingpatientsweregivengentianviolettoapplybytheclinicianbeforePolyMemcouldbeused).

• Atotalof20patientsweregiventhedressing.Table3showsatwhichRTOGscorePolyMemdressingswereinstigatedandtowhichsites.

• PolyMemwasgenerallyusedafterthepatienthadreceivedaminimumof20Gy.

• PolyMemwasfoundtohavereducedpainscoresbetween1and4pointsin14ofthe19patientsstudied.WilcoxonSignedRanksTestshowedthatthisisasignificantreduction(p<0.001).

Table 3:- RTOG score and number of patients* issued withnPolyMem dressing(*NBsomepatientsusedthedressinginmultiplesites)

Discussion

• Fromtheresultsofthestudythereappearstobeadelayinthepresentationofacuteskinreactions.Thisishighlightedintwoanalcarcinomapatientswherestage2bwasreachedinareasmissedbytheCNSBFapplication2weeksbeforetheareasthathadCNSBFapplied.

• 57.5%ofhighriskpatientsdidnotreachtheexpected2bskinreactionsnegatingtheneedforfurtherinterventions,overallthismayreducethecostintreatingthesepatientsskinreactionslongtermaswellasimprovingoverallcosmeticresultsandthepatientsexperienceoftreatment.

• Weareunabletoofferanexplanationastowhytheskinreactionsappearedtomissstagesofreactions.

• InitiallypatientswereaskedtoapplytheCNSBFthemselves,howeverRadiographersnotedabettercoverageandconsequentlyabetterreactioniftheCNSBFwasappliedbyRadiographers,thisalsoencouragedRadiographerstoassesstheskinreactionmorefrequentlyandinterveneearlierwithPolyMem.

• Theapplicationprocesstakes30secondsandduetothesmallnumberofpatientsrequiringapplication,thishasnooverallimpactontreatmentunitthroughput.

• InsomepatientstherewasabuildupofCNSBFwhenthepatientwasunabletoadequatelywashthetreatmentareaalthoughthisdidnotappeartoeffecttheoverallresults.OnebreastpatientstoppedusingCNSBFasherperfusesweatingcausedabuildupoffluidbeneaththefilmcausingdiscomfort.

PolyMem

• Thereisasignificantpainreductionformanypatients.Thisisduetoaninhibitionbythepolymericmembraneofthedressingonthenociceptorreaction,whichhasalsobeenproventoreduceinflammation,bruisingandoedema13,14onbothbrokenandintactskin.

• Thewoundcleansingpropertiesofthedressingensuredthattheriskofinfectionwasreducedwhilethedressingwasinplaceaswellasensuringeaseofdressingchangesandthetimerequiredwasminimised.

• Woundhealingcommencedinsomepatientsevenwhilstcontinuingwithradiotherapytreatment.

• PolyMemalsoactedasananti-inflammatorywhenitwasinstigatedatstage2a,particularlyintheanal/perinealregion.

• Feedbackfrompatientswaspositive,fromeaseofusetopainandodourrelievingproperties.Nopatientsshowedsignsofsensitivity.

• Someareasstillremaindifficulttodressandensurethedressingissecuree.g.scrotal,vulvalregions.Oftenthiswaseffectivelymanagedbyencouragingpatientstousescrotalsupportsandnettolastpants.

Cost implications

(asperOctober2009NHSsuppliescatalogueprices)

• 1bottleofspray(£8.26)lastedfor4weeksofapplication(18patients).22patientsrequiredanotherbottle.

• Ofthese40patients,11receivedPolyMemdressings.Twosizeswereordered(10x61cmroll(£12.21perroll)and13x13cmdressings(£4.21perdressing)),bothdressingswerecuttosizeasrequiredandchangeddaily.Totalcostperpatientwasdependantonwhenthedressingwasissuedthemaximumcostforasinglepatientwasfor5rolls(£61.05).AsthedressingisfreelyavailableinthecommunityG.P.swereabletoprescribethedressingforthepatientsonceitseffectivenesswasestablishedwithonly1dressingneedingtobeissuedbythedepartment.

Conclusion

• DuetotheeffectivenessoftheCNSBFitisnowroutinelyappliedbyRadiographerstopre-identifiedhighriskpatients,howeverallpatientsaretestedforsensitivitypriortoitsapplication.

• CNSBFisalsousedtopreserveskinmarksrequiredforsuperficialx-rayandelectrontreatments.

• PolyMemisnowissuedbyRadiographerstoallpatientspresentingwith2bskinreaction.

• Inpatientsbeingtreatedforlowerrectal/analcancerstheauthorswouldrecommendtheinstigationofPolyMemat2askinreactions,particularlywhenthepatienthasaheavymucosaldischargeandthereforetheskinislikelytomacerateandbreakdown.

• FuturestudiesarewarrantedintheuseofCNSBFwherepatientsareusedastheirowncontroltofullyestablishCNSBFeffectivenessinthepreventionofacuteradiotherapyinducedmoistdesquamation.

References1. Pommier,P.,Gomez,F.,Sunyach,M.P.,D’Hombres,A.,Carrie,C.andMontbarbon,X.,PhaseIIIRandomizedTrialofCalendulaOfficinalis

ComparedWithTrolamineforthePreventionofAcuteDermatitisDuringIrradiationforBreastCancer.JClinOncol,2004.22(8):p.1447-1453.

2. Wheat,J.,Currie,G.andCoulter,K.,WheatgrassExtractAsATopicalSkinAgentForAcuteRadiationSkinToxicityInBreastRadiationTherapy:ARandomisedControlledTrial.JournaloftheAustralianTraditional-MedicineSociety,2006.12(3).

3. Liguori,V.,Guillemin,C.,Pesce,G.F.,Mirimanoff,R.O.andBernier,J.,Double-blind,randomizedclinicalstudycomparinghyaluronicacidcreamtoplaceboinpatientstreatedwithradiotherapy.RadiotherapyandOncology,1997.42(2):p.155-161.

4. Berardesca,E.,Primavera,G.,Carrera,M.,Pinnaro,P.,Messina,M.andArcangeli,G.,Adouble-blind,randomised,placebo-controlledclinicalstudytoevaluateatopicalhyaluronicacid-based,hydrolipidictreatmentforradiationdermatitis.(Abstract1366).EuropeanJournalofCancerSupplements,2005.3(2):p.394.

5. Richardson,J.,Smith,J.E.,McIntyre,M.,Thomas,R.andPilkington,K.,AloeVeraforpreventingradiation-inducedskinreactions:Asystematicliteraturereview.ClinicalOncology,2005.17:p.478-484.

6. Graham,P.,Browne,L.,Capp,A.,Fox,C.,Graham,J.,Hollis,J.,etal.,Randomized,pairedcomparisonofNo-StingBarrierFilmversussorbolenecream(10%glycerine)skincareduringpostmastectomyirradiation.InternationalJournalofRadiationOncology,Biology,Physics,2004.58(1):p.241-6.

7. Gollins,S.W.,Gaffney,C.C.andSlade,S.,RCTongentianvioletversusahydrogeldressingforradiotherapy-inducedmoistskindesquamation.JournalofWoundCare,2008.17(6):p.268-275.

8. Patwardhan,A.,Sharma,V.andDinshaw,K.,DuodermCGFVsGentianViolet1%dressingintreatmentofradiationinducedulcers.TheWorldCouncilofEnterostomalTherapistsJournal,2002.22(2):p.32-38.

9. Kedge,E.M.,Asystematicreviewtoinvestigatetheeffectivenessandacceptabilityofinterventionsformoistdesquamationinradiotherapypatients.Radiography,2008.InPress,CorrectedProof.

10. Atiyeh,B.,Costagliola,M.,Hayek,S.andDibo,S.,Effectofsilveronburnwoundinfectioncontrolandhealing:Reviewoftheliterature.Burns,2007.33:p.139-148.

11. Wasiak,J.,Cleland,H.andCampbell,F.,Dressingsforsuperficialandpartialthicknessburns(Review).TheCochraineLibrary,2008(4).

12. McCaffreyMandBeebeA.Pain;AclinicalmanualforNursingpractice.StLouis,MO;CVMosbyCo.1989

13. SessionsRCCanadrugfreedressingdecreaseinflammationandwoundpain?Whatdoestheevidencesay?Posterpresentationat22ndAnnualSymposiumonAdvancedWoundCareandWHSmeetingApril26-292009

14. SessionsRC.ExaminingtheEvidenceforaDrugFreeDressing’sabilitytoDecreaseWoundPain.Posterpresentationat21stAnnualSymposiumonAdvancedWoundCareandWHSmeetingApril24-272008

Treatmentsiteisintheanal-genitalareae.g.vulva,vagina,penis,scrotum,anus,groins

Radicallimbs

Obeseradicalpelvispatients(withskinfoldsintreatmentarea)

Breastpatientsneedingorfitimmobilisationbras

Radicalfaceandneckhavingconcurrentchemotherapyorbolus

Week Number

RTOG Score Diagnosis Risk factors

3 2b3xBreast2xAnus

Largecupsize,tangentialpair,ParallelPair,bolus,concurrentchemo

4 2b2xAnus1xRectum1xVulva

AsAbove(samepts)Concurrentchemo,Parallelpair,bolus,concurrentchemo

5

2b

5xAnus3xRectum1xPenis1xGroin

AsaboveConcurrentchemo,Parallelpair,concurrentchemoHightotaldose,bolus,vacbag

31xVulva1xGroin/scrotum

Parallelpair,bolus,concurrentchemoHighdose,electrons

6

2b4xAnus1xGroin

AsaboveSameptaswk5

31xVulva1xGroin/scrotum1xAnus

Sameptaswk5Sameptaswk5

7 2b1xGroin1xFemur/groin

Sameptaswk5+6Hightotaldose,vacbag

RTOG Score No. of Patients Site

0 0

1 21–Inframammaryfold

1–Genitalarea

2a 61–Inframammaryfold5–Anal/perinealarea

2b 13

1–Axilla1–Inframammaryfold1–Scrotum2–Underabdominalfold4–Groin4–Anal/perinealarea

3 1 1–Anteriorcommisure

Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation Authors: Claire Bode1 Helen Woodman2, Radiotherapy Department, Queen Elizabeth Hospital, Birmingham, B15 2TH 1 – Training and education Facilitator, 2 – Macmillan Paediatric Liaison Radiographer

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