RADIATION COMPLICATIONS

Urol Case Rep. 2017 Feb 3;11:66-68. doi: 10.1016/j.eucr.2017.01.005. eCollection 2017 Feb.

A Case of Delayed Radiation Myelopathy of the Thoracic Vertebrae Following Low Dose Radiation Therapy for Metastatic Renal Cell Carcinoma.

Delayed radiation myelopathy (DRM) is a rare disorder that rapidly leads to disabilities, and the median incubation period was reported to be about 2 years (from 6 months to a few years). In this report, we describe a 61-year-old woman who presented with rapid progressive numbness and weakness in both legs 22 months after palliative radiation therapy with 39 Gy in 3 Gy fractions. She was diagnosed with DRM of the thoracic vertebrae and was treated sequentially with corticosteroids, heparin, and hyperbaric oxygen therapy.

However, they were not effective, and complete paralysis of the legs occurred in 3 months.

 

HyperMED Case Study  - 19 year old male Glioblastoma & brain radiation necrosis

These investigations were taken prior to attending for Hyperbaric Oxygenation.

Below Left: PRIOR to surgery, chemo and radiation

Below right: AFTER surgery, chemo and radiation

  • Prior to Hyperbaric Oxygenation the MRI revealed a brain mass measuring 7.5cm/4.2cm/6.0cm (MRI image on the above right).

  • AFTER 170 hours HBOT – MRI revealed the mass reduction now measuring 5.5cm/3.2cm/4.2cm.

 

  • MRI performed after conventional oncology including surgery, chemotherapy and radiation unfortunately revealed an aggressive increase in tumor size. During 2002 this young man started to complain of headaches and numbness down his right arm. Medical review including a CT Scan showed a brain tumour. He was sent straight to hospital and a diagnosis of 'Glioblastoma' was made confirmed on biopsy. He was operated on and the family informed that they were able to remove a certain portion of the tumour. He was then treated with chemotherapy and we were told that the tumour had shrunk dramatically.

  • An additional 6-weeks of radiation therapy with follow up MRI confirmed that the tumour had not only grown back but in fact had increased dramatically and described as 'extremely aggressive'. He did not respond to additional chemotherapy. The family were informed that nothing further could be done.

  • After 70-hours of Hyperbaric Oxygenation the family report significant change - 'improved energy, less seizures, less headaches, a stronger appetite and overall feeling stronger every day.'

  • After 170-hours of HBOT with continuing medical management, an additional MRI investigation was directed. The results are outstanding!

  • 'I am of the opinion that provision for continued Hyperbaric Oxygenation may have not just improved his quality of life; but possibly altered the outcome of this young man. The requirement for HBOT is early in the disease process and not as a last resort!' - Hooper

  • Hyperbaric Oxygenation is NOT recommended as a cure; but should be recommended as part of an integrated clinical approach that monitors the course of the condition with appropriate clinical investigations and is tailored to the treatment requirements of that individual.

Braz J Otorhinolaryngol. 2017 Feb 27. pii: S1808-8694(17)30033-2. doi: 10.1016/j.bjorl.2017.02.001. [Epub ahead of print]

Anti-inflammatory effects of hyperbaric oxygen on irradiated laryngeal tissues.

Arıcıgil M1, Dündar MA2, Yücel A3, Arbağ H2, Arslan A4, Aktan M5, Fındık S6, Kılınç İ7.

Author information

Abstract

INTRODUCTION:

To manage the complications of irradiation of head and neck tissue is a challenging issue for the otolaryngologist. Definitive treatment of these complications is still controversial. Recently, hyperbaric oxygen therapy is promising option for these complications.

OBJECTIVE:

In this study, we used biochemical and histopathological methods to investigate the efficacy of hyperbaric oxygen against the inflammatory effects of radiotherapy in blood and laryngeal tissues when radiotherapy and hyperbaric oxygen are administered on the same day.

METHODS:

Thirty-two Wistar Albino rats were divided into four groups. The control group was given no treatment, the hyperbaric oxygen group was given only hyperbaric oxygen therapy, the radiotherapy group was given only radiotherapy, and the radiotherapy plus hyperbaricoxygen group was given both treatments on the same day.

RESULTS:

Histopathological and biochemical evaluations of specimens were performed. Serum tumor necrosis factor-α, interleukin-1β, and tissue inflammation levels were significantly higher in the radiotherapy group than in the radiotherapy plus hyperbaric oxygen group, whereas interleukin-10 was higher in the radiotherapy plus hyperbaric oxygen group.

CONCLUSION:

When radiotherapy and hyperbaric oxygen are administered on the same day, inflammatory cytokines and tissue inflammation can be reduced in an early period of radiation injury.

Risk and survival outcomes of radiation-induced CNS tumors.

PubMed

Lee, Jessica W; Wernicke, A Gabriella

2016-08-01

Patients treated with cranial radiation are at risk of developing secondary CNS tumors. Understanding the incidence, treatment, and long-term outcomes of radiation-induced CNS tumors plays a role in clinical decision-making and patient education. Additionally, as meningiomas and pituitary tumors have been detected at increasing rates across all ages and may potentially be treated with radiation, it is important to know and communicate the risk of secondary tumors in children and adults. After conducting an extensive literature search, we identified publications that report incidence and long-term outcomes of radiation-induced CNS tumors.

We reviewed 14 studies in children, which reported that radiation confers a 7- to 10-fold increase in subsequent CNS tumors, with a 20-year cumulative incidence ranging from 1.03 to 28.9 %. The latency period for secondary tumors ranged from 5.5 to 30 years, with gliomas developing in 5-10 years and meningiomas developing around 15 years after radiation.

We also reviewed seven studies in adults, where the two strongest studies showed no increased risk while the remaining studies found a higher risk compared to the general population. The latency period for secondary CNS tumors in adults ranged from 5 to 34 years. Treatment and long-term outcomes of radiation-induced CNS tumors have been documented in four case series, which did not conclusively demonstrate that secondary CNS tumors fared worse than primary CNS tumors. Radiation-induced CNS tumors remain a rare occurrence that should not by itself impede radiationtreatment. Additional investigation is needed on the risk of radiation-induced tumors in adults and the long-term outcomes of these tumors.

N Z Med J. 2016 Dec 2;129(1446):79-83.

The effectiveness of hyperbaric oxygen therapy (HBOT) in radiation-induced haemorrhagic cystitis.

Chong V1, Rice M1.

Author information

Abstract

INTRODUCTION:

Radiation cystitis is one of the possible complications from pelvic radiotherapy. Hyperbaric oxygen (HBOT) improves tissue oxygenation and healing of scarred tissue.

AIMS:

To assess the efficacy of hyperbaric oxygen therapy (HBOT) in the management of radiation-induced haemorrhagic cystitis in patients with urological cancers.

METHODS:

This is a retrospective review on all patients with macroscopic haematuria secondary to radiation induced haemorrhagic cystitis who were treated with hyperbaric oxygen therapy (HBOT) between 2009 and 2013. The primary outcome is symptomatic assessment (either complete resolution, partial resolution or no change).

RESULTS:

A total of 12 patients with radiation-induced cystitis secondary to urological cancer were included in this study with a mean follow-up of 443 days. The mean age was 78 years. Complete resolution of haematuria was seen in six out of 12 patients. Partial response was achieved in two patients where one required two courses of HBOT and one required three courses of HBOT. As a result, the overall improvement of haematuria after HBOT was 67%. A total of four patients had no response to HBOT.

CONCLUSION:

Radiation-induced cystitis is a difficult clinical problem to treat. HBOT is not a magic bullet but it may be another alternative treatment option we have at this point in time.

Asia Pac J Clin Oncol. 2015 Mar;11(1):68-77. doi: 10.1111/ajco.12289. Epub 2014 Nov 9.

Hyperbaric oxygen therapy for chronic radiation-induced tissue injuries: Australasia's largest study

Tahir AR1, Westhuyzen J, Dass J, Collins MK, Webb R, Hewitt S, Fon P, McKay M.

Author information

  • 1Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; North Coast Cancer Institute, Coffs Harbour, Australia.

Abstract

AIM:

Chronic radiation injuries, although uncommon, are associated with poor quality of life in oncology patients. The present study assesses the efficacy and safety of hyperbaric oxygen therapy in the management of chronic radiation-induced tissue injuries.

METHODS:

A retrospective analysis was performed in 276 consecutive patients treated with hyperbaric oxygen therapy for chronic radiation-induced tissue injuries at the Hyperbaric Medicine Unit, Townsville, Queensland, between March 1995 and March 2008. Of these patients, 189 (68%) had complete follow-up data and were assessed.

RESULTS:

A total of 265 events of chronic radiation tissue injury were experienced by the 189 patients treated with hyperbaric oxygen therapy. Osteoradionecrosis prophylaxis due to radiation-induced dental disease had an overall response rate of 96% (P = 0.00003; Wilcoxon matched-pairs signed-rank test). The overall response rates for established osteoradionecrosis of mandible, soft tissue necrosis of head and neck, and xerostomia were 86% (P = 0.00001), 85% (P = 0.002) and 64% (P = 0.0001), respectively. The overall response rates for soft tissue necrosis at other sites, chronic radiation proctitis and hemorrhagic cystitis were 84% (P = 0.03), 95% (P = 0.0001) and 85% (P = 0.03), respectively. The total complication rate after hyperbaric oxygen therapy was 15.9%, comprising reversible ear barotrauma (10.6%), reversible ocular barotrauma (4.2%), dental complications (0.5%) and myocardial infarction (0.5%).

CONCLUSION:

Our study demonstrates that hyperbaric oxygen therapy can be effectively used in a variety of chronic radiation-induced tissue injuries; its favorable risk profile suggests it should be considered for patients with radiation-induced tissue injuries.

 

Ann Vasc Surg. 2015 Feb;29(2):206-14. doi: 10.1016/j.avsg.2014.07.034. Epub 2014 Oct 13.

Hyperbaric oxygen treatment outcome for different indications from a single center

Skeik N1, Porten BR2, Isaacson E2, Seong J2, Klosterman DL3, Garberich RF2, Alexander JQ4, Rizvi A5, Manunga JM Jr5, Cragg A6, Graber J7, Alden P8, Sullivan T9.

Author information

  • 1Vascular Medicine, Minneapolis Heart Institute Vascular Medicine, Minneapolis, MN; Hyperbaric and Oxygen Center, Minneapolis Heart Institute Vascular Medicine, Minneapolis, MN; Thrombophilia and Anticoagulation Clinic, Minneapolis Heart Institute Vascular Medicine, Minneapolis, MN. Electronic address: Nedaa.Skeik@allina.com.

  • 2Minneapolis Heart Institute Foundation, Minneapolis, MN.

  • 3Hyperbaric Oxygen Clinic, Abbott Northwestern Hospital, Minneapolis, MN.

  • 4Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN.

  • 5Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN.

  • 6Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; University of Minnesota, Minneapolis, MN.

  • 7Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; Mission Surgery Program-Guatemala Surgery, Minneapolis, MN.

  • 8Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; Wound Clinic at Abbott Northwestern Hospital, Minneapolis, MN.

  • 9Minneapolis Heart Institute Foundation, Minneapolis, MN; University of Minnesota, Minneapolis, MN; Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; Abbott Northwestern Hospital Vascular Center, Minneapolis, MN.

Abstract

BACKGROUND:

Hyperbaric oxygen (HBO) is used as an adjunctive therapy for a variety of indications. However, there is a lack of high-quality research evaluating HBO treatment outcomes for different indications available in the current literature.

METHODS:

We retrospectively reviewed all patients who underwent HBO therapy at a single hyperbaric center from January 2010 to December 2013 using predetermined criteria to analyze successful, improved, or failed treatment outcomes for the following indications: chronic refractory osteomyelitis, diabetic foot ulcer, failed flap or skin graft, osteoradionecrosis, soft tissue radiation necrosis, and multiple coexisting indications.

RESULTS:

  • Among the included 181 patients treated with adjunctive HBO at our center, 81.8% had either successful or improved treatment outcomes. A successful or improved outcome was observed in 82.6% of patients treated for chronic refractory osteomyelitis (n = 23), 74.1% for diabetic foot ulcer (n = 27), 75.7% for failed flap or skin graft (n = 33), 95.7% for osteoradionecrosis (n = 23), 88.1% for soft tissue radiation necrosis (n = 42), and 72.4% for multiple coexisting indications (n = 29). Among 4 patients treated for other indications, 100% of the cases were either successful or improved.

CONCLUSIONS:

This study has provided a comprehensive outcome survey of using HBO for the previously mentioned indications at our center. It supplements the literature with more evidence to support the consideration of HBO in different indications.

 

Undersea Hyperb Med. 2014 Mar-Apr;41(2):87-96.

Hyperbaric oxygen treatment for post-radiation central nervous system injury: a retrospective case series

Valadão J, Pearl J, Verma S, Helms A, Whelan H.

Abstract

Increased use of radiation therapy and increasing life spans following radiation treatment has led to an increase in the finding of post-radiation central nervous system injury in patients who have previously undergone radiation treatments. At this time, information regarding treatment for patients suffering from this serious side effect is limited and not readily available. It is imperative to examine possible treatment options, complications and success rates for these patients.

This retrospective review will look at 10 patients who underwent hyperbaric oxygen therapy for post-radiation injury to the central nervous system. Review and investigation of the subjective, clinical and radiologic outcomes of these patients was conducted. It was determined that for patients with post-radiation central nervous system injury it is important to distinguish the exact diagnosis for each patient. For those patients with radiation necrosis, conclusion was made that hyperbaric oxygen (HBO2) therapy does lead to improvement in subjective, clinical and radiologic outcomes. However, the results were not consistent across all patients. For those patients with non-specific delayed radiation injury, findings showed that HBO2 does not lead to any improvement. Therefore, we conclude that for those patients who have been diagnosed with radiation necrosis of the central nervous system, we recommend HBO2 therapy as a potential treatment option for some patients.

 

Diving Hyperb Med. 2014 Sep;44(3):163-6.

Survey of referral patterns and attitudes toward hyperbaric oxygen treatment among Danish oncologists, ear, nose and throat surgeons and oral and maxillofacial surgeons

Forner L1, Lee A2, Jansen EC3.

Author information

  • 1Department of Anaesthesia, Department of Oral and Maxillofacial Surgery, Copenhagen University Hospital Blegdamsvej 9, DK-2100 Copenhagen, Denmark, Phone: +45-(0)2-639-6440, E-mail: lone.forner@rh.regionh.dk.

  • 2Centre for Applied Health Services Research and Technology Assessment, University of Southern Denmark, Odense, Denmark.

  • 3Department of Anaesthesia, Copenhagen University Hospital, Copenhagen, Denmark.

Abstract

In head and neck cancer patients with late radiation injury, hyperbaric oxygen (HBO) is used for therapeutic or prophylactic reasons against soft-tissue and osteoradionecrosis (ORN). Twenty-nine departments of oncology, ENT, oral and maxillofacial (OMF) surgery were surveyed using the Enalyzer tool (www.enalyzer.com), of whom 21 responded. Data were incomplete in four returns. Within the previous year, 14 departments had referred at least one patient for hyperbaric oxygen therapy (HBOT). There appears to be a generally positive attitude in Danish OMF, ENT and oncology departments towards referral of patients with ORN for HBOT. However, there is an increasing desire for better evidence for its role in head and neck cancer in the prevention and treatment of soft-tissue injury and osteonecrosis following radiotherapy.

 

Undersea Hyperb Med. 2013 Jul-Aug;40(4):351-62.

Potential roles of hyperbaric oxygenation in the treatments of brain tumors

Kohshi K, Beppu T, Tanaka K, Ogawa K, Inoue O, Kukita I, Clarke RE.

Source

Division of Hyperbaric Medicine and Emergency Medicine, University Hospital of the Ryukyus, Okinawa, Japan. kohshi@med.u-ryukyu.ac.jp

Abstract

Over the past 50 years hyperbaric oxygen (HBO2) therapy has been used in a wide variety of medical conditions, and one of them is cancer. Many clinical studies have been conducted to evaluate potential therapeutic effects of HBO2 as a part of cancer treatment. This review briefly summaries the potential role of HBO2 therapy in the treatment of malignant tumors and radiation injury of the brain. HBO2 therapy is used for the enhancement of radiosensitivity in the treatment of some cancers, including malignant brain tumors.

  • Radiotherapy within 15 minutes following HBO2 exposure, a relatively new treatment regimen, has been studied at several institutes and has demonstrated promising clinical results for malignant gliomas of the brain. HBO2 therapy also increases sensitivity to some antineoplastic agents; non-randomized clinical trials using carboplatin-based chemotherapy combined with HBO2 show a significant advantage in survival for recurrent malignant gliomas.

  • The possibilities of combining HBO2 therapy with radiotherapy and/or chemotherapy to overcome newly diagnosed and recurrent malignant gliomas deserve extensive clinical trials. HBO2 therapy also shows promising potential for the treatment and/or prevention of radiation injury of the brain after stereotactic radiosurgery for brain lesions. The possibilities with HBO2 to enhance the therapeutic effect of irradiation per se, and to even increase the radiation dose if there are ways to combat the side effects, should boost new scientific interest into the whole field of oncology looking for new armamentaria to fight cancer.

 

Acta Cir Bras. 2012 Jun;27(6):383-7.

Combination hyperbaric oxygen and temozolomide therapy in C6 rat glioma model

Dagıstan Y1, Karaca I, Bozkurt ER, Ozar E, Yagmurlu K, Toklu A, Bilir A.

Author information

Abstract

PURPOSE:

Temozolomide (TMZ) has anti-tumor activity in patients with malignant glioma. Hyperbaric oxygen (HBO) may enhance the efficacy of certain therapies that are limited because of the hypoxic tumor microenvironment. We examined the combined effects of TMZ-HBO in a rat glioma model.

METHODS:

After stereotactic injection of C6/LacZ rat glioma cells into the Wistar rats brain, the rats were randomly assigned to three treatment groups [group 1, control treatment; group 2, TMZ alone; group 3, a combination of TMZ and HBO]. Rats were sacrificed 18 days after treatment, and number of intra-/peri-tumoral vessels, microendothelial proliferations, immunohistochemistry and necrotic area were evaluated.

RESULTS:

Tumoral tissue was stained only sparsely with GFAP. Temozolomide treatment was significantly decreased in tumor tissue intratumoral vessel number / total tumor area level. The level of Ki67 was significantly decreased in the tumor tissue of the group 3. Additionally, the total necrotic area / total tumor volume (%) was decreased significantly in tumor tissue of the group 3 rats compared to group 1 and 2.

CONCLUSION:

The combination of hyperbaric oxygen with temozolomide produced an important reduction in glioma growth and effective approach to the treatment of glioblastoma.

 

Undersea Hyperb Med. 2012 Nov-Dec;39(6):1121-39.

Hyperbaric oxygen therapy and delayed radiation injuries (soft tissue and bony necrosis): 2012 update

Feldmeier JJ.

Source

Radiation Oncology, University of Toledo Medical Center, Toledo, Ohio, USA. jfeldmeier@aol.com

Abstract

Informal surveys at CME meetings have shown that approximately one-third of patients in the United States receive hyperbaric oxygen (HBO2) for delayed radiation injury. More than 600,000 patients receive radiation for malignancy in our country annually, and about one-half will be long-term survivors. Serious radiation complications occur in 5-10% of survivors. A large population of patients is therefore at risk for radiation injury. HBO2 has been applied to treat patients with radiation injury since the mid-1970s.

Published results are consistently positive, but the level of evidence for individual publications is usually not high level, consisting mostly of case series and case reports. Only a rare randomized controlled trial has been accomplished. Radiation injury is one of the UHMS "approved" indications, and third-party payors will usually reimburse for this application. This updated review summarizes the publications available reporting results in treating radiation-injured patients. Mechanisms of HBO2 in radiation injury are discussed briefly. Outcome is reported on a mostly anatomic basis though due to the nature of the injury a positive outcome at one anatomic site is supportive of HBO2 at other sites. The potential benefit of prophylactic HBO2 before frank damage is also discussed in high-risk patients. The concerns of HBO2 enhancing growth of or precipitating recurrence of malignancy is discussed and largely refuted.

 

 

 

Radiation Necrosis

 

Background

  • Approximately 35,000 new cases of intracranial tumors are diagnosed in the United States each year, of which 15,000 are primary brain tumors. Radiation therapy can be primary or adjunctive for the treatment of these brain tumors, and for conditions such as arterio-venous malformations.

  • Radiation induced necrosis can be divided into focal necrosis, and diffuse white matter injury. Both injuries are believed to result from increased tissue pressure from edema, vascular injury leading to infarction, damage to endothelial cells, and fibrinoid necrosis of small arteries and arterioles. Damage to oligodendroglial supporting cells with demyelination, reactive gliosis, and coagulation necrosis also may occur.

  • Brain radiation necrosis is often considered a late finding; often appearing within 3-months but in many cases up to several years after treatment is completed. Approximately 3-9% of patients irradiated for brain tumors develop clinically detectable focal radiation necrosis. The breakdown of white matter may induce marked edema and mass effect. Clinicians may incorrectly suspect tumor recurrence; embarking on another round of radiation with ultimate consequences. Diffuse white matter injury develops in at least 40% of patients irradiated for intracranial neoplasms following large volume or whole brain.

  • Decreased intellectual functioning has been observed in adults after cranial irradiation. All post radiation patients who have suffered cognitive decline should be investigated for the effects of radiation necrosis. Certain cognitive functions such as memory may be more susceptible to decline than others, and may prevent patients from returning to their premorbid occupation. Clinical features range from mild lassitude or personality change to incapacitating dementia. Some patients with cerebral atrophy may have gait disturbance and urinary incontinence similar to the syndrome of normal pressure hydrocephalus. The nervous system of the child has many sites vulnerable to radiation damage.

  • The diagnosis of radiation necrosis may be difficult to confirm. MRI may show a contrast-enhancing mass with extensive white matter alterations and hyperintensity of the periventricular white matter. Cerebral cortical atrophy is manifest as enlarged cerebral sulci and ventricular dilatation.

  • Many patients with radiographic changes have no symptoms, but in those who do, the degree of impairment correlates approximately with the severity of the MRI appearance. Many patients have a mixture of tumor and radiation necrosis, and a biopsy may be necessary to distinguish. Neither symptoms nor radiographic findings clearly distinguish radiation necrosis from tumor.

  • Emerging techniques involving PET scan and SPECT studies have been useful in differentiating differentiate radionecrosis from recurrent tumor. There may also be a role for MRI spectroscopy.

  • The benefit of Hyperbaric Oxygen Therapy for radiation-induced bone and soft tissue damage has been extensively reported in osteoradionecrosis, cystitis, proctitis, and other soft tissues. HBOT raises the tissue pO2 creating a steep Oxygen gradient, which initiates cellular and vascular repair mechanisms.

  • Wound healing requires Oxygen delivery to the injured tissues. Radiation damaged tissue has lost blood supply and is Oxygen deprived (hypoxia). Chronic radiation complications result from scarring and narrowing of the blood vessels within the area that received radiation. Hyperbaric Oxygen Therapy provides a better healing environment and leads to the growth of new blood vessels in a process called re-vascularization. It also fights infection by direct bacteriocidal effects.

  • Extensive trials are being conducted and in particular the University of Cincinnati and at Duke University . Both have instituted comprehensive, multidisciplinary approaches with ongoing clinical and imaging assessments. The "teams" include radiation oncology, neurosurgery, neurology and hyperbaric medicine. The participants in the Duke protocol are followed with periodic neuropsychological testing as well.

  • There is mounting evidence that HBOT can be of significant value in the treatment of brain radiation necrosis in fact: it appears that HBOT is the only treatment potentially capable of reversing brain radiation necrosis.

  • In addition; we recommend that individuals review Internet sources including PubMed, MedScape, etc. for publications regarding Brain Radiation Necrosis and Hyperbaric Oxygen Therapy.