Delayed Radiation Tissue Injury: Soft Tissue and Osteoradionecrosis
HyOx’s clinical outcomes are extremely successful in patients with delayed radiation tissue and bone injuries; most notably in breast, prostate, and head and neck cancers. Hyperbaric oxygen therapy intervention works to grow new blood vessels (angiogenesis) and fibroblasts (cells that promote healing by producing collagen) to not only help medications, surgeries and other procedures alleviate symptoms including swelling and chronic pain, but to affect and heal the radiation damage itself.
Various conditions and complications may result from radiation therapy in some patients affecting normal, non-cancerous cells from decreased blood flow and oxygenation. As radiation therapy works to eradicate cancer, much of the oxygen content in the radiated tissue is lost and, in some patients damage is caused in the surrounding area. The collateral damage may result in compromised tissue, wounds and other complications needing the benefit of hyperbaric oxygen therapy.
Radiation therapy may cause injuries ranging in severance and occurrence from decreased blood flow and oxygenation.
Previously radiated areas of the body may show signs of soft tissue or bone death (necrosis) from radiation therapy months, even years, following treatment for cancer. Radiation damaged tissue has lost blood supply (ischemic) and is oxygen deprived (hypoxic). In most cases, this soft tissue radionecrosis (STRN) and osteoradionecrosis (ORN), is avoided, but the radiated tissue (commonly in breast and prostate cancer patients) and bone (especially the jaw in head and neck cancer patients) is still not as viable as normal, non-radiated tissue. Without adjunctive hyperbaric oxygen therapy intervention, additional conditions like radiation cystitis (bladder) and proctitis (prostate) are difficult to heal. Healing success rates are high.
To help ensure a successful surgical outcome for procedures involving previously radiated sites and to prevent necrosis from happening, adjunctive hyperbaric oxygen therapy is approved pre- and post-surgery to help ensure a good outcome with set evidence-based protocols covered by most insurances.
Cancer patients experiencing complications from radiation therapy may benefit from the therapeutic and healing effects of adjunctive hyperbaric oxygen therapy by its ability to:
Counter the compromised soft tissue and bones from radiation therapy preparing the injured site for surgery (i.e., breast reconstruction by a plastics and reconstruction surgeon) or dental work (following the Marx Protocol in tandem with an oral and maxillofacial surgeon or dentist). For osteoradionecrosis, the areas of the body most commonly damaged are the lower jaw, chest wall, pelvis, vertebral column, and skull.
Deliver high concentrations of oxygen to irradiated tissues to stimulate angiogenesis which reverses the vascular changes induced by radiation if significant fibrosis and ischemia have not already occurred. Tissue oxygenation is an important and effective mechanism of hyperbaric oxygen therapy in radiation injury since a consistent cause and manifestation of the complication is vascular obliteration and stromal fibrosis.
Reduce fibrosis.
Mobilizes and induces an increase of stem cells within irradiated tissues (1).
Speeds the recovery of soft tissues and bone affected by radiation therapy’s fibro-atrophic effect (2) manifested by vascular changes characterized by obliterative endarteritis.
Enhances angiogenesis in hypoxic tissues (3) and bone as ORN is a result of an avascular, aspetic necrosis.
Restores immune mechanisms that have become dysfunctional due to hypoxia which affects neutrophilic killings of organisms as phagocytosis becomes inefficient.
Re-establishes mandibular continuity for dentures and also helps rehabilitation for cosmesis and mastication (4).
Supports initial tissue metabolic demands post-reconstructive surgery for ORN.
Assists certain antibiotics to work more effectively in soft tissue and bone infections by augmenting their transport across bacterial cell walls – this function is oxygen dependent and in a hypoxic environment impaired or disabled (tissue oxygen tension below 20-30 mmHg) (5).
Resolves hematuria in radiation cystitis patients (6).
Boosts the viability and vascularity of previously irradiated breast tissue prior to and post reconstructive surgery.
Stimulates angiogenesis / neovascularization in hypoxic tissues following the Marx Protocol for ORN (30 treatments pre- and 10 post-extraction) to achieve uncomplicated healing and viable tissue prior to surgery. (7, 8) *May require more treatments for mandibular resection and reconstruction success.
WHEN TO CALL HYOX:
Pre- and post-surgery in a previously radiated tissue and bone, especially in breast reconstruction surgery or in the prostate area or prior to dental surgery in head and neck cancer patients to ensure the jawbone is viable. In osteoradionecrosis, optimal clinical outcomes are achieved with appropriate surgical intervention to successfully eradicate all necrotic bone.
Immediately when signs a flap or graft is compromised in irradiated tissue in the breast or abdominal area, or in cases of decreased perfusion or hypoxia appear by clinical judgment or by transcutaneous oximetry and laser Doppler studies.
Immediately, when a post-surgical site shows signs of dehiscence, necrosis, blistering, erythema (swelling), and infection.
References:
(1) Goldstein LJ, Gallaher KA, Bauer SM et al. Endothelial progenitor cell release into circulation is triggered by hyperoxia-induced increases in bone marrow nitric oxide. Stem Cells. 2006; 24:2309-2318.
(2) Delanian S, Lefaix J. Current management for late normal tissue injury: radiation-induced fibrosis and necrosis. Semin Radiat Oncol 2007; 17:99-107.
(3) Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg 1990; 160: 519-524.
(4) Marx RE. Radiation injury to tissue. In: Kindwall EP, ed. Hyperbaric Medicine Practice, Second Edition. Flagstaff, Best Publishing, 1999, pp. 665.723.
(5) Mader JT, et al. Hyperbaric oxygen as adjunctive therapy for osteomyelitis. Infect Dis Clin North Am, 1990. 4(3): 433-40.
(6) Corman JM, McClure D., Pritchett R, Kozlowski P, Hampson NB. Treatment of radiation induced hemorrhagic cystitis with hyperbaric oxygen. J Urol 2003; 160: 2200-2.
(7) Marx, RE, Ames JR. The use of hyperbaric oxygen in bony reconstruction of the irradiated and tissue deficient patient. J Oral Maxillofac Surg 1982; 40:412-9.
(8) Chavez JA, Adkinson CD. Adjunctive hyperbaric oxygen in irradiated patients requiring dental extractions: outcomes and complications. J Oral Maxillofac Surg 2001; 59:518-22.
Osteoradionecrosis (ORN)
A side effect from cancer treatment is bone cell damage, called osteoradionecrosis (ORN). ORN also affects the blood cells supplying the bone. Wounds to the damaged bone fail to heal because of hypoxia or an inadequate supply of oxygen.
Hyperbaric oxygen therapy works to reverse the damage to the bone through tissue oxygenation. ORN is also treated with debridement or surgical intervention depending on the severity and stage following the Marx Protocol.
Referral Protocol:
Soft-tissue Radionecrosis
Patients who undergo radiation therapy sometimes experience complications long after the treatment. Soft tissue radionecrosis, especially of the head and neck, was studied by R.E. Marx, DDS. Dr. Marx found hyperbaric oxygen therapy to be useful “prior to surgery to create well-vascularized tissue that would subsequently heal and accept bone grafts.” The research, conducted at Wilford Hall Medical Center of the U.S. Air Force in San Antonio, Texas, has set the treatment protocols for HyOx.
Hyperbaric oxygen therapy delivered at HyOx works to heal the soft tissue by promoting angiogenesis, the growth of blood vessels into a tissue involving the development of new capillary blood vessels, in the injured areas. This allows for improved oxygenation and nutrition.