DOI: 10.3857/jkstro.2010.28.1.16 방사선치료를받은유방암환자의방사선피부염발생정도및관련인자들의분석 전북대학교병원방사선종양학과 *, 예수병원방사선종양학과 이선영 * ㆍ권형철 * ㆍ김정수 * ㆍ이희관 목적 : 방사선치료를받은유방암환자에서치료로인한방사선피부염의발생을감소시킬수있는지알아보기위해서전단계로서피부염발생정도와이와관련된인자들을분석해보았다. 대상및방법 : 2007 년 1월부터 2009 년 6월까지전북대병원방사선종양학과에서근치적목적의유방보존절제술및방사선치료를받은침윤성유방암환자 338명중, 보상체를사용하거나반대측유방의방사선치료기왕력이있는환자를제외한 284명에서, 전자선추가치료를시행하기전전체유방에 50 Gy 방사선조사후, 방사선피부염이발생된정도와 Radiation Therapy Oncology Group (RTOG) 2도이상의중증피부염을보인환자에서발생정도에영향을미칠수있는요인들을분석하였다. 결과 : RTOG 등급 0 또는 1과 2도이상의경증및중증방사선피부염은각각 207명과 77명에서관찰되었다. 2도이상중등도이상의방사선피부염이발생한 77명의환자에서림프액저류에의한림프낭과림프부종은방사선피부염의회복을방해하는데관련된요소로분석되었으며각각통계적으로유의한수준을나타냈다 (p=0.003, p=0.001). 그리고피부면역세포및사이토카인활성화에의한반창고과민반응과호르몬치료병용도피부에영향을미치는관련요소로분석되었으며각각통계학적으로유의한수준을나타냈다 (p=0.001, p=0.025). 결론 : 방사선치료를받은대부분의유방암환자에서경증또는중증정도의방사선피부염이발생되었으며, 림프낭, 림프부종및반창고과민반응등은방사선피부염의정도에통계학적으로유의한수준의영향을미치는요소로분석되었다. 따라서림프낭이존재하는경우방사선치료전제거가우선되어야하며, 반창고과민반응이있는환자의경우치료중주의깊은관찰과특히중등도이상의피부염환자들에게는치료부위의피부에대한지속적인보습교육이필요하다고본다. 핵심용어 : 유방암, 방사선치료, 방사선피부염 서 유방암은현재우리나라여성에서발병률이급격하게증가하고있는암 1) 으로주치료방법은수술로, 변형근치적절제술또는유방보존절제술및감시림프절생검혹은액와림프절절제술을시행하고있다. 2) 그러나유방보존절제술만시행하는경우국소재발률이높기때문에재발율의감소및생존율향상을위하여수술후방사선치료를시행하고있으며, 치료는전체유방에 X-선을이용하 이논문은 2009 년 12 월 10 일접수하여 2010 년 1 월 14 일채택되었음. 책임저자 : 권형철, 전북대학교병원방사선종양학과 Tel: 063)250-1195, Fax: 063)250-1192 E-mail: hckwon@chonbuk.ac.kr 론 여 45 50 Gy를조사한후종양이존재하였던부위에 10 Gy의전자선을이용한추가치료를시행하고있다. 2 4) 이런표준분할조사는현재큰부작용없이종양제어에효과적 4) 이라고보고되고있으나, 2004년 Harper 등 5) 은유방보존절제술후방사선치료를받은환자의 90% 에서 1등급이상의방사선피부염이발생하였다고보고하였으며, Lopez 등 6) 은 92% 에서유방홍반이, 35% 에서습성피부탈락 (moist desquamation) 등의중등도이상의급성피부염이관찰되었다고보고하였다. 이런피부염은방사선치료로인해발생하는가장흔한부작용중하나다. 2,7,8) 일단방사선피부염이발생하면특별한치료법이없는상태이며, 피부염정도가심해지면통증과습진이발생하여일시적인방사선치료중단및환자들의치료순응도감소등부정적인영향을주고있다. 그리고중등도이상의방사선피 - 16 -
이선영외 3 인 : 방사선치료를받은유방암환자의방사선피부염발생정도및관련인자들의분석 Table 1. Characteristics of Breast Cancer Patients Who Received Radiation Therapy No. (%) Age (yr) Range (mean) 27 75 (49.6) Tumor site Rt breast 165 (58.1) Lt breast 119 (41.9) Clinical stage T1micN0M0 8 (2.8) T1N0-3M0 206 (72.5) T2N0-3M0 67 (23.6) T3/4N0-3M0 3 (1.1) Pathology Microinvasive carcinoma 8 (2.8) Invasive ductal carcinoma 255 (89.8) Others* 21 (7.4) Lymph node treatment SLNBx 181 (63.7) ALNDx 103 (36.3) Yes 224 (78.9) No 60 (21.1) Hormone therapy Yes 203 (71.5) No 81 (28.5) *medullary carcinoma, mucinous carcinoma, invasive lobular carcinoma, invasive papillary carcinoma, infiltrating carcinoma, sentinel lymph node biopsy, axillary lymph node dissection. 부염발생은유방보존절제술후남아있는유방의미용측면에서도섬유화의증가및색소침착등에의하여부정적인영향을나타내고있다. 9) 이런방사선피부염은치료방법및환자의방사선민감도에따라다르게나타는데, 10,11) 외인적인자로항암동시방사선치료, 피부윤곽결손부위의보상체의사용이나전자선사용등이관련있다고보고되고있으며, 내인적인자로는피부손상치유정도와거대유방및유전적인자들도관련되어있다고보고되고있다. 2,5 13) 이에본저자들은유방보존절제술후 10 Gy의전자선추가치료를시행하기전, 전체유방에 50 Gy 방사선치료를받은유방암환자에서방사선치료로인한방사선피부염의발생을감소시킬수있는지알아보기위한전연구로서피부염발생정도와이와관련된인자들을분석해보았다. 대상및방법 2007년 1월부터 2009년 6월까지전북대학교병원에서근치적목적의유방보존절제술및감시림프절생검혹은액와림프절절제술을시행후방사선치료를받은침윤성유방암환자 338명을대상으로하였다. 그중심한유방조직결손으로조직보상체를사용하였거나이전에이미반대쪽유방암으로방사선치료의기왕력이있거나, 양측성유방암으로양측유방에동시에방사선치료를시행한환자는제외하였다. 전자선추가치료를시행하기전전체유방에 50 Gy의방사선치료가완료된 284명에대하여방사선피부염의발생정도를분석하였고, Radiation Therapy Oncology Group (RTOG) 등급 2 이상의중등도이상의방사선피부염이발생한환자군의경우피부염에영향을미칠수있는외인및내인적인자에관한분석을하였다. 분석대상환자 284명의연령은 27 75세 ( 평균값, 49.6 세 ) 이며, 모두여성환자였다. 원발부위는우측유방이 165명, 좌측유방이 119명이었으며, 임상병기별환자는 T1micN0M0, T1N0-3M0, T2N0-3M0 그리고 T3/4N0-3M0에서각각 8명, 206명, 67명및 3명이었다. 병리학적소견상미세침습암은 8명, 침윤성관상피암은 255명이었으며, 그외침윤성수질암, 점액성암이관찰되었다. 대상환자는모두유방보존절제술을시행하였으며, 그중감시림프절생검과액와림프절절제술은각각 181명및 103명에게시행되었다. 대상환자중방사선치료전항암화학치료를받은환자는 224명이었으며, 방사선치료와함께호르몬치료를시행한환자는 203명이었다 (Table 1). 방사선치료는 6 MV 선형가속기 (Siemens, Munchen, Germany; Varian, Palo Alto, CA, USA) 를이용하였으며, 전산화치료계획을이용하여 95% 등선량곡선에맞추어접선조사를시행하였고, 하루 200 cgy의분할선량으로전체유방에 50 Gy를조사하였다. 방사선치료시작평균시점은수술후항암화학제를사용하지않은경우수술시행날로부터 3.2주, 항암화학제를사용한경우는마지막항암화학치료날로부터 4.1주이었다. 방사선치료를위한치료기준점은염료로표시후지워짐을예방하기위하여뉴플러스롤 ( 동아제약, 대구, 한국 ) 및픽스롤 ( 영케미칼, 대구, 한국 ) 을부착하였으며, 과거반창고에의한과민성피부염이발생한기왕력이있거나, 치료용반창고부착후발진과습진등의과민성피부염이발생한환자의경우는반창고과민반응이있다고진단하여반창고를피부에부착하지않았다. 대상환자의방사선피부염정도평가는 RTOG 등급 14) 에따랐으며, 매주일회이상환자들의피부상태를평가하였고, 피부염의정도가심한환자의경우는 2일간격으로치료전피부상태를확인한후치료를진행하였다. 통계처리는 SPSS ver. 12.0 (SPSS Inc., Chicago, II, USA) 프로그램을이용하였으며, 피부염발생과관련된인자들의 - 17 -
비교는단변량분석인 log-rank를사용하였으며, 유의수준은 0.05 이내로설정하였다. 결 Table 2. The Degree and Incidence of Radiation Dermatitis in the Breast Cancer Patients Who Received Radiation Therapy 과 1. 방사선피부염의발생정도및빈도 전체유방에 50 Gy 방사선치료를시행한 284명의환자중방사선피부염이관찰되지않았던 RGOG 등급 0의경우는 9명 (3.2%), RGOG 등급 1, 2 및 3의경우는 198명 (69.7%), 54명 (19.0%) 및 23명 (8.1%) 으로관찰되었다. RGOG 등급 1 이하의경도방사선피부염을보인환자 207명 (72.9%) 의경우는방사선치료중다른처치없이치료중단순한관찰만을하였으며, RTOG 등급 2 이상의중증피부염이발생된 77명 (27.1%) 의경우에서는병변회복을위하여일시적으로방사선치료를중단하였거나, 습포나외용스테로이드도포등의처치가필요하였다 (Table 2). 2. 방사선피부염에영향을주는내인및외인인자 경도의방사선피부염이발생한환자 207명중외인인자에해당되는항암화학요법은 164명 (79.2%), 액와림프절절제술은 78명 (37.7%), 그리고호르몬치료는 153명 (73.9%) 에서각각시행되었고, 반창고알레르기는반응은 16명 (7.7%) 에서발견되었다. 내인인자에해당되는에스트로겐수용체 (estrogen receptor), 프로게스테론수용체 (progesteron receptor), p53, cerb2, CD31, CK5/6, 림프낭및림프부종은 207명중 192명 (92.7%), 187명 (90.4%), 151명 (76.3%), 54명 (26.1%), 14명 (6.8%), 9명 (4.3%), 8명 (3.9%) 및 10명 (4.8%) 에서각각존재하였다 (Table 3). 중등도 2 이상의방사선피부염이발생한 77명중외인인자에해당되는항암화학요법은 60명 (77.9%), 액와림프절절제술은 25명 (32.5%), 그리고호르몬치료는 50명 (64.9%) 에서각각시행되었으며, 이외외인인자에해당하는반창고알레르기는반응은 20명 (26%) 에서발견되었다. 내인인자에해당되는에스트로겐수용체, 프로게스테론수용체, RTOG* grade No. (%) Grade 0 9 (3.2) Grade 1 198 (69.7) Grade 2 54 (19.0) Grade 3 23 (8.1) Grade 4 0 *Radiation Therapy Oncology Group. p53, cerb2, CD31, CK5/6, 림프낭및림프부종은 207명중 50명 (64.9%), 56명 (72.7%), 48명 (62.3%), 21명 (27.3%), 9명 (11.7%), 5명 (6.5%), 12명 (15.6%), 12명 (15.6%) 에서각각존재하였다 (Table 4). 3. 방사선피부염발생에영향을미치는인자들의단변량분석 방사선치료를받은유방암환자에서방사선피부염에영 Table 3. Characteristics of Extrinsic and Intrinsic Factors Which Affect Non and Mild Radiation Dermatitis in the Breast Cancer Patients Who Received Radiation Therapy (N=207) Characteristics Yes (%) No (%) ALNDx* Hormonal therapy Tamoxifen Zoladex Aromatase inhibitors Others Plaster allergy Estrogen receptor Progesteron receptor p53 cerb2 CD31 CK5/6 Lymphocele Lymphedema Table 4. Characteristics of Extrinsic and Intrinsic Factors Which Affect Moderate and Severe Radiation Dermatitis in the Breast Cancer Patients Who Received Radiation Therapy (N=77) Characteristics Yes (%) No (%) ALNDx* Hormonal therapy Tamoxifen Zoladex Aromatase inhibitors Plaster allergy Estrogen receptor Progesteron receptor p53 cerb2 CD31 CK5/6 Lymphocele Lymphedema 164 (79.2) 78 (37.7) 34 (21.6) 40 (26.1) 70 (45.8) 9 (6.5) 16 (7.7) 192 (92.7) 187 (90.4) 151 (76.3) 54 (26.1) 14 (6.8) 9 (4.3) 8 (3.9) 10 (4.8) 60 (77.9) 25 (32.5) 50 (64.9) 14 (28) 11 (22) 25 (50) 20 (26) 50 (64.9) 48 (62.3) 9 (11.7) 5 (6.5) 43 (20.8) 129 (62.3) 43 (26.1) 15 (7.3) 20 (9.6) 56 (23.7) 193 (93.2) 198 (95.7) *axillary lymph node dissection, anastrozole, arimidex, fareston, zometa. *axillary lymph node dissection, anastrozole, arimidex. 17 (22.1) 52 (67.5) 27 (35.1) 27 (34.1) 29 (37.7) 68 (88.3) 72 (93.5) - 18 -
이선영외 3 인 : 방사선치료를받은유방암환자의방사선피부염발생정도및관련인자들의분석 Table 5. Univariate Analysis of Extrinsic and Intrinsic Factors Which Affect Radiation Dermatitis in the Breast Cancer Patients Who Received Radiation Therapy Non and mild dermatitis group (N=207) Moderate and severe dermatitis group (N=77) p-value Interval time of initial radiation treatment (wk) After chemotherapy After surgery Yes No ALNDx* Yes No Hormone therapy Yes No Estrogen receptor Progesteron receptor p53 cerb2 CD31 CK5/6 Plaster allergy Lymphocele Lymphedema 4.7 4.5 164 (79.2) 43 (20.8) 78 (37.7) 129 (62.3) 43 (26.1) 15 (7.3) 192 (92.7) 20 (9.6) 187 (90.4) 56 (23.7) 151 (76.3) 54 (26.1) 193 (93.2) 14 (6.8) 198 (95.7) 9 (4.3) 16 (7.7) 8 (3.9) 10 (4.8) 4.1 3.2 60 (77.9) 17 (22.1) 25 (32.5) 52 (67.5) 50 (54.9) 27 (35.1) 27 (34.1) 50 (64.9) 29 (37.7) 48 (62.3) 68 (88.3) 9 (11.7) 72 (93.5) 5 (6.5) 20 (26) 0.809 0.057 0.811 0.417 0.025 0.013 0.019 0.083 0.840 0.176 0.458 0.001 0.003 0.001 Values are presented as number (%). *axillary lymph node dissection. 향을미칠수있는외적및내적인자들에의한단변량분석을한결과는다음과같다. 외적인자인호르몬치료및반창고알레르기그리고내적인자인에스트로겐및프로게스테론수용체, 림프낭및림프부종의존재유무등은방사선피부염에영향을미치는인자들로서통계학적으로유의수준을보였다. 반면에방사선치료의시작시점, 항암화학요법및액와림프절절제술시행여부, p53, cerb2, CD31, CK5/6 등의존재유무는방사선피부염에영향을미치는데통계학적으로유의한수준을보여주지못했다 (Table 5). 고안및결론유방암환자에서유방보존절제술후국소재발률을낮 추고생존율을높이기위해시행하고있는전체유방방사선치료는, 전체유방을제거하지않고, 일부유방을보존한다는면에서미용측면및환자의심리적인면에서도만족스러운결과가보고되고있다. 2) 그러나, 방사선피부염은치료중많은환자들에게불편감을주는흔한부작용으로, 경도의피부염은치료받는피부의건조화나각질화등이관찰되고, 다른치료처치없이방사선치료를마칠수있으나, 중등도이상의피부염은습성피부탈락이나습진등의발생과심한통증으로일시적인방사선치료의중단을가져와환자의치료의순응도를감소시키는요인으로작용할수있으며, 장기적인미용측면에서도남아있는유방의섬유화증가및색소침착등의부정적인영향을미치는것으로알려져있다. 15,16) 이런피부염은방사선치료중보상체사용에의한피부선량의불균등분포, - 19 -
항암화학요법과방사선치료의병용요법, 호르몬제재의병용투여등외적인자와거대유방, 흡연, 혈관확장증등의유전적결체조직질환이있거나수술부위상처가감염된경우또는림프액이순환이원활하게이루어지지않는내적인자가존재하는경우발생이증가한다고보고되고있다. 5,13) 방사선조사로인한피부염이관찰되기시작하는시기는대개치료시작후 2주정도다. 이는피부를구성하는세포의정상순환주기와연관된다. 피부는표피와진피로이루어져있으며, 진피의기저층에있는간세포가분화증식하여표피층으로이동하는데는약 14일정도가소요된다. 5) 따라서세포의순환주기에따라정상피부에방사선치료시작후 2 4주내에건조, 각질화및부종등의급성피부반응이관찰되며, 3 6주사이에는조사부위의진피내간세포가고갈되어습성피부탈락및습진등의피부염이발생하게된다. 이러한급성발적은방사선조사기간동안세포내사이토카인의활성화를일으켜피부염정도를악화시키는것으로알려져있다. 5,12) Meeren 17) 에의하면, 피부에방사선조사를한경우혈관내막세포및면역세포들이활성화되어 IL-6, IL-8 등의사이토카인들을분비하게되고, 분비된사이토카인들은단핵세포및거대대식세포를활성화시켜연쇄반응으로 TNF-α 등의여러사이토카인이다시분비되어피부염이발생된다는기전을보고하였다. 18,19) 본연구에서도방사선피부염은대부분의환자에서치료시작 2주후부터관찰되었으며, 특히중등도이상의환자에서습성피부탈락등은간세포가고갈하기시작하는 3주후부터, 방사선치료선량이평균 3,700 cgy 일때발생빈도및정도가증가하는것이관찰되었다. 중등도이상의방사선피부염이발생한환자들중반창고과민반응이높은비율로관찰되었는데, 현재사용하고있는반창고의접착력을높이기쓰이는로진 (rosin) 이라는물질과면역세포의반응에서상관관계를생각해볼수있다. 특히접촉성피부과민반응이있는환자에서피부내비만세포나단핵구등여러면역세포들은로진과상호작용을하여여러사이토카인을분비하게되고, 일단감작에의한과민반응이발생하면연쇄반응에의해유사한물질과접촉하여도피부의과민반응은발생하는것으로알려져있으며, 20) 자외선이나이온화방사선에노출될경우피부염발생정도는더증가하는것으로보고되고있다. 17,19) 이는이미감작된면역반응이방사선조사후분비된여러사이토카인들에의해연쇄반응을일으켰기때문이라생각할수있으며, 본연구에서반창고과민반응환자들의비율이높은이유도이미감작된면역반응이방사선 조사로인해악화되었기때문이라생각할수있다. 본연구에서유방암을부분절제한수술부위에서생긴지속적인림프낭및수술받은팔에생기는림프부종으로인한림프액저류가있는경우방사선피부염의정도가증가되는것이관찰되었다. 이는창상이치유되는되는과정중육아종의형성및흡수에있어서림프액의원활한흐름이중요한역할을하며, 림프낭및림프부종으로인한림프액이저류가된경우창상의치유를지연시키는인자 21) 로작용하여, 피부염발생정도를악화시키는요인으로작용하였다고생각할수있다. 또한, 방사선치료와호르몬치료를동시에시행한환자에서시행하지않은환자에비하여방사선피부염발생이증가하였고, 또한에스트로겐및프로게스테론수용체가존재하는경우에도증가하는것으로관찰되었는데, 이는호르몬치료의시행여부와관계있는인자로생각할수있다. 그러나타목시펜을복용한경우 TGF-β 분비증가에의한섬유화진행에의해피부염이증가한다는결과와, 2) 다양한호르몬제재에따른방사선피부염발생정도의차이는관찰되지않았다. 본연구에서원발종양의발생부위, 병기, 병리조직소견, 항암화학치료여부, 액와임파절절제술시행여부와또한 p53, cerb2, CD31 및 CK5/6 등의유방암예후와관련된유전적인자존재여부는방사선피부염발생과관련하여통계학적으로유의할만한차이를보이지않았다. 반면에림프낭, 림프부종및반창고과민반응은유의한수준을보였다. 이는내외인자모두가방사선피부염발생에관여할수있다고본다. 방사선피부염의부작용을줄이기위해최근세기조절방사선치료의도입 22) 및여러가지예방적차원의외용연고에대한연구가진행되고있으며, 18,23) 특히방사선조사로인해분비되는여러사이토카인과염증반응의완화를위하여피부의보습의중요성이 Harper 등 5) 여러연구들에서발표되고있고있다. 14 18) 현재사용되고있는외용연고의경우주된기전은피부의염증반응을줄이고보습을유지시켜주는것으로보고 14,18,23) 되고있으며, Merchant 18) 나 Primavera 23) 의외용연고도포시방사선피부염예방정도에대한보고에서도치료시작부터매일꾸준히도포를한환자군에서시행하지않은환자군에비교하여피부염발생및중등도이상의빈도가감소되었음이확인되었다. 본원에서도방사선피부염예방을위하여보습목적의연고를처방하였으나실제적으로방사선치료시연고를꾸준히도포한환자는전체환자의 60% 에미치지못하였으며, 환자 1인당방사선치료완료까지사용한연고도포 - 20 -
이선영외 3 인 : 방사선치료를받은유방암환자의방사선피부염발생정도및관련인자들의분석 양은 0.5개미만으로연고의도포가제대로이루어지지않았음이확인되었다. 이는위험요소가있는환자군에서보습의중요성에대한교육및방사선치료시발생가능한피부염의심각성에대한교육이부족하였다고생각할수있다. 유방암환자에서호르몬제재의복용은재발을낮추고생존율을높이는것으로보고되고있으며, 2) 방사선피부염을줄이기위하여호르몬제재의복용을방사선치료중중단할수는없다. 따라서예방가능한다른인자들에대한주의가필요하다. 본연구결과로보아림프낭이존재하는경우치료전림프낭의제거가필요하며, 창상피부의회복을위하여수술후방사선치료시작은수술경계에서재발위험요소 2) 가없다면창상이충분히회복된이후시작하는것이바람직하다하겠으며, 반창고과민반응이있는환자의경우나치료중피부염발생가능성이높은위험군환자에서는치료기간중주의깊은관찰및치료피부의지속적인보습의중요성에대한교육이필요하다고생각한다. 참고문헌 1. Central Cancer Registry Center. Annual Report of the Central Cancer in Korea: 2005.01 2007.12. Seoul; Ministry for Health, Welfare and Family Affairs, 2010 2. Haffty BG, Buchholz TA, Perez CA. Early stage breast cancer. In: Halperin EC, Perez CA, Brady LW, eds. Principles and Practice of Radiation Oncology. 5th ed. Philadelphia, Lippincott Williams & Wilkins. 2007:1175-1291 3. Ha CC, Lee MZ. Radiation therapy for operable breast cancer after conservative surgery. J Korean Soc Ther Radiol Oncol 2002;20:309-315 4. Hiraoka M, Mitsumori M, Kokubo M. The Roles and Controversies of Radiation Therapy in Breast Conserving Therapy for Breast Cancer. Breast Cancer 1997;4:127-133 5. Harper JL, Franklin LE, Jenrette JM, Aguero EG. Skin toxicity during breast irradiation: pathophysiology and management. South Med J 2004;97:989-993 6. Lopez E, Nunez MI, Guerrero MR, et al. Breast cancer acute radiotherapy morbidity evaluated by different scoring systems. Breast Cancer Res Treat 2002;73:127-134 7. Jill Stein. Postmastectomy radiation may cause skin toxicity and pain. In: 13th Annual Meeting of the European Cancer conference; 2005 Oct 31; Paris, France 8. Collen EB, Mayer MN. Acute effects of radiation treatment: skin reactions. Can Vet J 2006;47:931-935 9. Fujishiro S, Mitsumori M, Kokubo M, et al. Cosmetic results and complications after breast conserving therapy for early breast cancer. Breast Cancer 2000;7:57-63 10. Rosen EM, Fan S, Rockwell S, Goldberg ID. The molecular and cellular basis of radiosensitivity: implications for understanding how normal tissues and tumors respond to therapeutic radiation. Cancer Invest 1999;17:56-72 11. Turesson I, Nyman J, Holmberg E, Oden A. Prognostic factors for acute and late skin reactions in radiotherapy patients. Int J Radiat Oncol Biol Phys 1996;36:1065-1075 12. Andreassen CN, Alsner J, Overgaard M, Overgaard J. Prediction of normal tissue radiosensitivity from polymorphisms in candidate genes. Radiother Oncol 2003;69:127-135 13. Isomura M, Oya N, Tachiiri S, et al. IL12RB2 and ABCA1 genes are associated with susceptibility to radiation dermatitis. Clin Cancer Res 2008;14:6683-6689 14. Fisher J, Scott C, Stevens R, et al. Randomized phase III study comparing Best Supportive Care to Biafine asa prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97-13. Int J Radiat Oncol Biol Phys 2000;48: 1307-1310 15. Wickline MM. Prevention and treatment of acute radiation dermatitis: a literature review. Oncol Nurs Forum 2004;31:237-247 16. Walker VA. Skin care during radiotherapy. Nurs Times 1982;78:2068-2070 17. Meeren AV, Bertho JM, Vandamme M, Gaugler MH. Ionizing radiation enhances IL-6 and IL-8 production by human endothelial cells. Mediators Inflamm 1997;6:185-193 18. Merchant TE, Bosley C, Smith J, et al. A phase III trial comparing an anionic phospholipid-based cream and aloe vera-based gel in the prevention of radiation dermatitis in pediatric patients. Radiat Oncol 2007;2:45 19. Muller K, Meineke V. Radiation-induced alterations in cytokine production by skin cells. Exp Hematol 2007;35:96-104 20. Dooms-Goossens A, Boden G, Aupaix F, Bruze M. Allergic contact dermatitis from adhesive plaster due to colophony and epoxy resin. Contact Dermatitis 1993;28:120-121 21. Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature 2008;453:314-321 22. Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 2008;26: 2085-2092 23. Primavera G, Carrera M, Berardesca E, et al. A double-blind, vehicle-controlled clinical study to evaluate the efficacy of MAS065D (XClair), a hyaluronic acid-based formulation, in the management of radiation-induced dermatitis. Cutan Ocul Toxicol 2006;25:165-171 - 21 -
Abstract An Analysis of the Incidence and Related Factors for Radiation Dermatitis in Breast Cancer Patients Who Received Radiation Therapy Sun Young Lee, M.D.*, Hyoung Cheol Kwon, M.D.*, Jung Soo Kim, M.D.*, and Heui-Kwan Lee, M.D. Department of Radiation Oncology, * Chonbuk National University Hospital, Prebyterian Medical Center, Jeonju, Korea Purpose: We analyzed the incidence and related factors of radiation dermatitis; at first, to recognize whether a decrease in radiation dermatitis is possible or not in breast cancer patients who received radiation therapy. Materials and Methods: Of 338 patients, 284 with invasive breast cancer who received breast conservation surgery with radiotherapy at Chonbuk National University Hospital from January 2007 to June 2009 were evaluated. Patients who also underwent bolus, previous contralateral breast irradiation and irradiation on both breasts were excluded. For patients who appeared to have greater than moderate radiation dermatitis, the incidence and relating factors for radiation dermatitis were analyzed retrospectively. Results: A total of 207 and 77 patients appeared to have RTOG grade 0/1 or above RTOG grade 2 radiation dermatitis, respectively. The factors found to be statistically significant for the 77 patients who appeared to have greater than moderate radiation dermatitis include the presence of lymphocele due to the stasis of lymph and lymph edema which affect the healing disturbance of radiation dermatitis (p=0.003, p=0.001). Moreover, an allergic reaction to plaster due to the immune cells of skin and the activation of cytokine and concomitant hormonal therapy were also statistically significant factors (p=0.001, p=0.025). Conclusion: Most of the breast cancer patients who received radiation therapy appeared to have a greater than mild case of radiation dermatitis. Lymphocele, lymphedema, an allergy to plaster and concomitant hormonal therapy which affect radiation dermatitis were found to be significant factors. Consequently, we should eliminate lymphocele prior to radiation treatment for patients who appear to have an allergic reaction to plaster. We should also instruct patients of methods to maintain skin moisture if they appear to have a greater than moderate case of radiation dermatitis. Key Words: Breast Neoplasms, Radiation therapy, Radiation dermatitis - 22 -