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Skale nasilenia popromiennego odczynu skóry

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Popromienny odczyn skóry stanowi jeden z najczęstszych skutków ubocznych radioterapii. W diagnostyce i terapii tych powikłań pomocne narzędzia stanowią m.in skale RTOG, EORTC, LENT-SOMA oraz NCI, które pozwalają ocenić stopień nasilenia odczynu.

Radioterapia jest jedną z najskuteczniejszych, nieoperacyjnych metod leczenia nowotworów. Jednym z jej możliwych powikłań są zmiany skórne. Przyczyną powstania tej reakcji jest napromienienie tkanek zdrowych. Dla niektórych pacjentów nasilenie objawów skórnych skutkuje przerwaniem terapii. By wdrożyć odpowiednie leczenie i pielęgnację uszkodzonej skóry, należy określić stopień nasilenia odczynu popromiennego. W tym celu powstały specjalne skale, które służą do oceny nasilenia odczynu i ewaluacji wyników leczenia z uwzględnieniem różnych rodzajów objawów oraz czasu ich wystąpienia.

Skale oceny wczesnych powikłań – CTC i NCI

Do rozpoznawania wczesnych powikłań popromiennych służy skala Common Toxicity Criteria. Uwzględnia ona 260 objawów w odniesieniu do 24 narządów i układów. Oceny dokonuje się w skali od G0 – brak odczynu, do stopnia G5, oznaczającego zgon.

Kolejną skalą dla wczesnych odczynów popromiennych, jest opracowana przez National Cancer Institute pięciostopniowa skala NCI CTCAE, która uwzględnia stadia odczynu popromiennego, poczynając od łagodnego zaczerwienienia lub suchego złuszczania, po zgon.

Stopień Skala NCI
0 Brak zmian
I Łagodne zaczerwienienie lub suche złuszczanie
II Średnie zaczerwienienie, ograniczone złuszczanie na wilgotno, obrzęk o średnim nasileniu
III Zlewne złuszczenia na wilgotno w okolicach innych niż fałdy skórne, krwawienia po małym urazie
IV Martwica i/lub owrzodzenia ze ścieńczeniem skóry, samoistne krwawienia
V Zgon

Źródło: J. Michalewska, Odczyny popromienne w radioterapii oraz popromienne zapalenie skóry, Zeszyty Naukowe WCO, Letters in Oncology Science 2017;14(3)

LENT-SOMA – klasyfikacja późnych odczynów

Skala Late Effects on Normal Tissue – Subjective, Objective Management and Analytic (LENT-SOMA) należy do stosowanych w praktyce klinicznej systemów klasyfikacji późnych odczynów popromiennych. Za jej pomocą ocenić można poziom zwłóknienia skóry, a także stwierdzić obecność teleagniektazji i przebarwień. System LENT-SOMA podzielono na część subiektywną i obiektywną, w ramach których oceny nasilenia objawów dokonują odpowiednio pacjent i lekarz. Skala zawiera informacje na temat postępowania w kierunku łagodzenia objawów oraz uwzględnia metody oceny funkcji narządów. Oceny nasilenia dokonuje się w skali od G1 do G4.

Rodzaj powikłania Stopień 0 Stopień I Stopień II Stopień III
Zwłóknienia Brak Delikatne zwiększenie gęstości tkanki wyczuwalne palpacyjnie Zdecydowane zwiększenie gęstości tkanki wyczuwalne palpacyjnie Silnie zaznaczone zwiększenie gęstości tkanki z retrakcją i unieruchomieniem
Naczyniaki Brak < 1 cm2 1–4 cm2 > 4 cm2
Przebarwienie skóry Brak różnicy w stosunku do barwy skóry Niewielkie przebarwienie Znaczne przebarwienie  

Tabela: Skala LENT-SOMA; źródło: M. Wiśniewski, M. Graczyk, M. Szpinda i wsp., Popromienne zapalenie skóry — zasady postępowania, Medycyna Paliatywna w Praktyce 2013; 7, 2

Skale dla wczesnych i późnych powikłań skórnych

Najczęściej wykorzystywanymi narzędziami do oceny odczynu popromiennego są system The European Organization for Research and Treatment of Cancer (EORTC) oraz skala Radiation Therapy Oncology Group (RTOG). Obie skale służą do oceny wczesnych i późnych skórnych powikłań popromiennych. Skale opracowano z uwzględnieniem różnych rodzajów tkanek i narządów.

Objawy skali EORTC i RTOG uszeregowano od stopnia G0, czyli braku odczynu, po stopień G5 – oznaczający zgon w wyniku powikłań popromiennych.

Stopień Skala RTOG
0 Brak zmian
I Plamki i/lub wysypka drobnogrudkowa lub zaczerwienienie, bezobjawowe
II Plamki i/lub wysypka drobnogrudkowa lub silne zaczerwienienie ze świądem
III Uogólniona objawowa wysypka grudkowa, przebarwienia lub wysypka pęcherzykowa
IV Złuszczające lub wrzodziejące zapalenie skóry
V Zgon

Źródło: J. Michalewska, Odczyny popromienne w radioterapii oraz popromienne zapalenie skóry, Zeszyty Naukowe WCO, Letters in Oncology Science 2017;14(3)

Do rzadziej wykorzystywanych narzędzi diagnostycznych należy skala Dische’a, przy użyciu której ocenia się odczyn w błonie śluzowej jamy ustnej, gardła oraz krtani w radioterapii hyperfrakcjonowanej. Uwzględnia ona intensywność i metody terapii objawów, którym przydziela się od 1 do 3 punktów. W ocenie skutków ubocznych radioterapii stosuje się również klasyfikację STU – Severity-Time Units, która ocenia wczesny odczyn w obrębie błony śluzowej. Skala uwzględnia czas pojawiania się odczynu, moment jego największego nasilenia oraz szybkość gojenia.

Źródła:

Michalewska, Odczyny popromienne w radioterapii oraz popromienne zapalenie skóry, Zeszyty Naukowe WCO, Letters in Oncology Science 2017;14(3)

Wiśniewski, M. Graczyk, M. Szpinda i wsp., Popromienne zapalenie skóry — zasady postępowania, Medycyna Paliatywna w Praktyce 2013; 7, 2

Przeczytaj także: Radykalne leczenie raka piersi – metody i możliwe powikłania

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