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Implementing Evidence Based Practice in the Prevention of Radiodermatitis in an Outpatient Radiation Oncology Department
Poster Viewing Session E467
Volume 93 Number 3S Supplement 2015 delivery using a continuous synchronized beam delivery system. Continuous tracking of three LED markers, in conjunction with the timedependent radiographic position of the fiducial, was used to build correlation models to guide robot’s compensation of the first-order target motion. Internal data from the system log-file was accessed to obtain marker model point positions, radiographic target positions, and the positional correlation error at the series of periodic time-points, analysis of which yielded a measure of the tracking accuracy. Results: Comparison of the 178 stereoscopic images defining the true target position with the 496 model points used for tracking yielded a mean positional correlation error of 1.8mm, 1.1mm, 1.8mm in x, y, z (system coordinates), with respective standard deviations of 1.4mm, 0.9mm, and 1.4mm. The mean radial 3D correlation error for the entirety of the treatment was 3.2mm with a standard deviation of 1.6mm; 90% of points had less than 5.5mm radial deviation, with outliers constituting model rebuilding. Conclusion: While phantom and animal experiments have produced preliminary data on the cardiac tracking under model conditions, the study presents the first in-patient determination of tracking accuracy for VT radio-ablation. Considering the mean magnitude and standard deviation of the 3D positional correlation error, a minimum 5mm margin should be used to account for accuracy of such surrogate-based tracking delivery. Author Disclosure: B.P. Fahimian: None. B.W. Loo: None. S.G. Soltys: None. P. Zei: Research Grant; CyberHeart, Inc. A.T. Lo: None. P.J. Maguire: Partnership; CyberHeart, Inc. CEO; CyberHeart, Inc. E. Gardner: Consultant; CyberHeart, Inc. L. Wang: None.
3166 Treatment (TX) of Dupuytren’s Contracture (DC) and Ledderhose Disease (LD) With Radiation Therapy (RT) A.J. Crimaldi II,1 J. Walsh,1 J. Symanowski,1 M.R. Haake,1 D.R. McHaffie,1 H.J. Sharp,1 B.J. Moeller,1 V.V. Thakkar,1 R.J. McCammon,1 R.S. Prabhu,1 G.C. Mitro,2 J. Konefal,2 T.G. Trautmann,2 S.R. Plunkett,2 R.W. Fraser,1 and S.H. Burri1; 1Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 2Southeast Radiation Oncology Group, Charlotte, NC Purpose/Objective(s): Dupuytren’s Contracture (DC) and Ledderhose Disease (LD) are progressive non-malignant diseases involving the hands/ feet, caused by abnormal fibromatosis via fibroblastic proliferation and disorderly collagen deposition with resulting fascial thickening. Disease progression (DzP) causes: in the hands severe finger contractions/loss of function; in the feet difficulties with sports/walking. Surgical therapy, the traditional tx has recurrence rates as high as 73-100%. Options for nonsurgical management include: steroid injections, collagenase injections, cryotherapy, and needle aponeurotomy; all with high-recurrence rates. In this analysis, we retrospectively analyzed outcomes of patients (pts) with early onset DC and/or LD treated with RT. Materials/Methods: All pts were treated from January 2008 through December 2014. Thirty-three pts with 70 sites were treated with RT, 44 hand sites (63%) and 26 feet sites (37%). Patients were 16 males (48%) and 17 females (52%). The age range of the pts was 36-72 years with a mean/median age of 54. The number of pts per decade was: 30’s: 1, 40’s: 10, 50’s: 12, 60’s: 8, and 70’s: 2 pts, respectively. No tx sites had previous surgical intervention. Staging of the 44 hand sites by Tubiana’s classification were: 34 Stage N (77%), 8 Stage I (18%), and 2 Stage II (5%). All feet treated had visible nodules on exam. All sites were treated with an enface 6 MeV electron field using 0.5cm bolus at d90. Total dose was 30 Gy delivered via a split course: 15 Gy/5 factions followed by a 6 week break, then the additional 15 Gy. Patients were seen by a physician to assess response to tx and interviewed after tx to assess satisfaction with RT. Results: Median follow-up was 15 months (mos) (range 1-70 mos) with the mode being 10 mos. Tx was well tolerated by pts, with 20/70 (29%) of the sites experiencing acute grade 1 erythema of the skin, which resolved within 4 weeks after tx. No pts experienced grade 2 or higher toxicities. Sixty-five out of 70 (93%) sites responded to tx with 28/70 (40%) showing improvement in symptoms (a decrease in size of palmar/plantar nodules or increase in degrees of flexion) and 37/70 (53%) sites remaining stable; DzP-new
nodules or worsening contracture occurred in 5/70 (7%) of the sites, with 4 in-field failures, 1 marginal DzP. 3/70 (4%) pts developed new disease outside the tx field or in another extremity. A significant rate of long-term toxicity (dry skin) was noted in 6 of 16 (37.5%) male pts (all hand sites) over that of female pts 0 of 17 (0%) and the 2-sided Fisher exact P-value for the comparison of these rates was .007. No pts have required surgical intervention after RT. 31/33 (94%) pts were satisfied with the tx outcome. Conclusion: A hypofractionated split course of RT is an effective option for the management of early stage DC and LD. Treatment was well tolerated in our series with no grade 2 or higher toxicities. The response rate to tx was 93% at a median of 15 mos follow-up. Radiation therapy is an effective non-invasive alternative to surgery for these pts. Author Disclosure: A.J. Crimaldi: None. J. Walsh: None. J. Symanowski: None. M.R. Haake: None. D.R. McHaffie: None. H.J. Sharp: None. B.J. Moeller: None. V.V. Thakkar: None. R.J. McCammon: None. R.S. Prabhu: None. G.C. Mitro: None. J. Konefal: None. T.G. Trautmann: None. S.R. Plunkett: None. R.W. Fraser: None. S.H. Burri: None.
3167 Implementing Evidence Based Practice in the Prevention of Radiodermatitis in an Outpatient Radiation Oncology Department M.L. King, D. Grunick, E. McDonald, and R. Mitchell; Cleveland Clinic Foundation, Cleveland, OH Purpose/Objective(s): Radiation dermatitis is one of the most frequently observed acute side effects of radiation treatment. It can have a negative impact on quality of life and can cause delays in treatment. The current standard of care varies and is often based on anecdotal evidence. Most departments use a petroleum based gel. Calendula lotion is a less frequently recommended skin product. Is there recent research demonstrating significant effectiveness of calendula cream compared to petroleum based gel in decreasing radiation dermatitis to support a change in practice? Materials/Methods: A literature synthesis was completed. Picot question: among cancer patients who are undergoing radiation therapy, is treatment with a calendula lotion, as compared to treatment with a petroleum-based gel, less likely to have radiation dermatitis? There is some evidence that calendula is effective in reducing radiation dermatitis. It should be used in combination with skin cleansing, frequent assessments, and consistent education. There are many different calendula products on the market and personal preferences such as cost, availability, and ease of use should be considered with product recommendations. Patients should be informed that petroleum based gel does not cause harm, but there is no data to support any benefit. In addition, the Oncology Nursing Society lists calendula lotion as likely to be effective and petroleum based gel as effectiveness not established. Evidence pointed to a need to a change in practice. A power point presentation for nursing staff in the department of radiation oncology was completed to disseminate the findings of the literature review. Calendula lotions were recommended for use during treatment. Data was collected on patient preference of lotions used during radiation treatment including: effectiveness, ease of purchasing the product, cost, and ease of application. Twenty-one breast cancer patients undergoing daily radiation treatments were evaluated. Data was collected during weekly on treatment visit. Results: The data collected found that all patients thought the calendula products were non-greasy and easy to apply. There was an 85% patient satisfaction with the lotion use on intact skin. A small % found the calendula products difficult to find and expensive. A new recommended skin care handout was completed, which included a list of products of various price ranges and where they could be purchased. Implications for practice: health care professionals can enhance patient care by providing education on evidenced based self-management measures. Conclusion: The change in practice on recommended skin care product resulted in 85% patient satisfaction and also promoted the use of evidencebased practice in radiation dermatitis. Author Disclosure: M.L. King: None. D. Grunick: None. E. McDonald: None. R. Mitchell: None.
Volume 93 Number 3S Supplement 2015 delivery using a continuous synchronized beam delivery system. Continuous tracking of three LED markers, in conjunction with the timedependent radiographic position of the fiducial, was used to build correlation models to guide robot’s compensation of the first-order target motion. Internal data from the system log-file was accessed to obtain marker model point positions, radiographic target positions, and the positional correlation error at the series of periodic time-points, analysis of which yielded a measure of the tracking accuracy. Results: Comparison of the 178 stereoscopic images defining the true target position with the 496 model points used for tracking yielded a mean positional correlation error of 1.8mm, 1.1mm, 1.8mm in x, y, z (system coordinates), with respective standard deviations of 1.4mm, 0.9mm, and 1.4mm. The mean radial 3D correlation error for the entirety of the treatment was 3.2mm with a standard deviation of 1.6mm; 90% of points had less than 5.5mm radial deviation, with outliers constituting model rebuilding. Conclusion: While phantom and animal experiments have produced preliminary data on the cardiac tracking under model conditions, the study presents the first in-patient determination of tracking accuracy for VT radio-ablation. Considering the mean magnitude and standard deviation of the 3D positional correlation error, a minimum 5mm margin should be used to account for accuracy of such surrogate-based tracking delivery. Author Disclosure: B.P. Fahimian: None. B.W. Loo: None. S.G. Soltys: None. P. Zei: Research Grant; CyberHeart, Inc. A.T. Lo: None. P.J. Maguire: Partnership; CyberHeart, Inc. CEO; CyberHeart, Inc. E. Gardner: Consultant; CyberHeart, Inc. L. Wang: None.
3166 Treatment (TX) of Dupuytren’s Contracture (DC) and Ledderhose Disease (LD) With Radiation Therapy (RT) A.J. Crimaldi II,1 J. Walsh,1 J. Symanowski,1 M.R. Haake,1 D.R. McHaffie,1 H.J. Sharp,1 B.J. Moeller,1 V.V. Thakkar,1 R.J. McCammon,1 R.S. Prabhu,1 G.C. Mitro,2 J. Konefal,2 T.G. Trautmann,2 S.R. Plunkett,2 R.W. Fraser,1 and S.H. Burri1; 1Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 2Southeast Radiation Oncology Group, Charlotte, NC Purpose/Objective(s): Dupuytren’s Contracture (DC) and Ledderhose Disease (LD) are progressive non-malignant diseases involving the hands/ feet, caused by abnormal fibromatosis via fibroblastic proliferation and disorderly collagen deposition with resulting fascial thickening. Disease progression (DzP) causes: in the hands severe finger contractions/loss of function; in the feet difficulties with sports/walking. Surgical therapy, the traditional tx has recurrence rates as high as 73-100%. Options for nonsurgical management include: steroid injections, collagenase injections, cryotherapy, and needle aponeurotomy; all with high-recurrence rates. In this analysis, we retrospectively analyzed outcomes of patients (pts) with early onset DC and/or LD treated with RT. Materials/Methods: All pts were treated from January 2008 through December 2014. Thirty-three pts with 70 sites were treated with RT, 44 hand sites (63%) and 26 feet sites (37%). Patients were 16 males (48%) and 17 females (52%). The age range of the pts was 36-72 years with a mean/median age of 54. The number of pts per decade was: 30’s: 1, 40’s: 10, 50’s: 12, 60’s: 8, and 70’s: 2 pts, respectively. No tx sites had previous surgical intervention. Staging of the 44 hand sites by Tubiana’s classification were: 34 Stage N (77%), 8 Stage I (18%), and 2 Stage II (5%). All feet treated had visible nodules on exam. All sites were treated with an enface 6 MeV electron field using 0.5cm bolus at d90. Total dose was 30 Gy delivered via a split course: 15 Gy/5 factions followed by a 6 week break, then the additional 15 Gy. Patients were seen by a physician to assess response to tx and interviewed after tx to assess satisfaction with RT. Results: Median follow-up was 15 months (mos) (range 1-70 mos) with the mode being 10 mos. Tx was well tolerated by pts, with 20/70 (29%) of the sites experiencing acute grade 1 erythema of the skin, which resolved within 4 weeks after tx. No pts experienced grade 2 or higher toxicities. Sixty-five out of 70 (93%) sites responded to tx with 28/70 (40%) showing improvement in symptoms (a decrease in size of palmar/plantar nodules or increase in degrees of flexion) and 37/70 (53%) sites remaining stable; DzP-new
nodules or worsening contracture occurred in 5/70 (7%) of the sites, with 4 in-field failures, 1 marginal DzP. 3/70 (4%) pts developed new disease outside the tx field or in another extremity. A significant rate of long-term toxicity (dry skin) was noted in 6 of 16 (37.5%) male pts (all hand sites) over that of female pts 0 of 17 (0%) and the 2-sided Fisher exact P-value for the comparison of these rates was .007. No pts have required surgical intervention after RT. 31/33 (94%) pts were satisfied with the tx outcome. Conclusion: A hypofractionated split course of RT is an effective option for the management of early stage DC and LD. Treatment was well tolerated in our series with no grade 2 or higher toxicities. The response rate to tx was 93% at a median of 15 mos follow-up. Radiation therapy is an effective non-invasive alternative to surgery for these pts. Author Disclosure: A.J. Crimaldi: None. J. Walsh: None. J. Symanowski: None. M.R. Haake: None. D.R. McHaffie: None. H.J. Sharp: None. B.J. Moeller: None. V.V. Thakkar: None. R.J. McCammon: None. R.S. Prabhu: None. G.C. Mitro: None. J. Konefal: None. T.G. Trautmann: None. S.R. Plunkett: None. R.W. Fraser: None. S.H. Burri: None.
3167 Implementing Evidence Based Practice in the Prevention of Radiodermatitis in an Outpatient Radiation Oncology Department M.L. King, D. Grunick, E. McDonald, and R. Mitchell; Cleveland Clinic Foundation, Cleveland, OH Purpose/Objective(s): Radiation dermatitis is one of the most frequently observed acute side effects of radiation treatment. It can have a negative impact on quality of life and can cause delays in treatment. The current standard of care varies and is often based on anecdotal evidence. Most departments use a petroleum based gel. Calendula lotion is a less frequently recommended skin product. Is there recent research demonstrating significant effectiveness of calendula cream compared to petroleum based gel in decreasing radiation dermatitis to support a change in practice? Materials/Methods: A literature synthesis was completed. Picot question: among cancer patients who are undergoing radiation therapy, is treatment with a calendula lotion, as compared to treatment with a petroleum-based gel, less likely to have radiation dermatitis? There is some evidence that calendula is effective in reducing radiation dermatitis. It should be used in combination with skin cleansing, frequent assessments, and consistent education. There are many different calendula products on the market and personal preferences such as cost, availability, and ease of use should be considered with product recommendations. Patients should be informed that petroleum based gel does not cause harm, but there is no data to support any benefit. In addition, the Oncology Nursing Society lists calendula lotion as likely to be effective and petroleum based gel as effectiveness not established. Evidence pointed to a need to a change in practice. A power point presentation for nursing staff in the department of radiation oncology was completed to disseminate the findings of the literature review. Calendula lotions were recommended for use during treatment. Data was collected on patient preference of lotions used during radiation treatment including: effectiveness, ease of purchasing the product, cost, and ease of application. Twenty-one breast cancer patients undergoing daily radiation treatments were evaluated. Data was collected during weekly on treatment visit. Results: The data collected found that all patients thought the calendula products were non-greasy and easy to apply. There was an 85% patient satisfaction with the lotion use on intact skin. A small % found the calendula products difficult to find and expensive. A new recommended skin care handout was completed, which included a list of products of various price ranges and where they could be purchased. Implications for practice: health care professionals can enhance patient care by providing education on evidenced based self-management measures. Conclusion: The change in practice on recommended skin care product resulted in 85% patient satisfaction and also promoted the use of evidencebased practice in radiation dermatitis. Author Disclosure: M.L. King: None. D. Grunick: None. E. McDonald: None. R. Mitchell: None.