Radiodermatitis incidents in cancer patients receiving radiotherapy at

Introduction: Radiodermatitis or radiation dermatitis is a side effect that produced in the skin and its adnexal as a consequence of exposure to radiotherapy. Several factors influence the occurrence of radiodermatitis: factors related to the patient (intrinsic), such as age, race, comorbid conditions, nutritional status, and factors associated with treatment (extrinsic), such as dosage of radiotherapy, fractionation and radiotherapy techniques. Methods and results: This study is a descriptive observational study with the prospective approach in 50 patients who received radiotherapy in Haji Adam Malik Hospital, Medan-Indonesia. Anamneses and dermatological examinations conducted to all subjects on the first day, three weeks, and eight weeks during radiotherapy. From this study, the majority of the patients are women in age of 40-60 years old. The most clinical features are erythema macular rash (100%), and the most location is in the Colli region. The majority of the total dose is 5000-5900 cGy, and the most fractionation used 31-40 fractions. Conclusions: The results of this study indicate that elderly, high radiotherapy total dose, and fractionation leads to an increased risk of radiodermatitis case.


INTRODUCTIONS
][3] Several factors affect the onset of radiodermatitis, including factors associated with radiotherapies (extrinsic), such as radiotherapy dosage, radiotherapy fractionation, radiotherapy techniques, and intrinsic factors, such as genetics, age, radiation exposed areas, comorbidities of other diseases. 3,4adiotherapy provides a radiation-biological effect of cellular effects that inhibit mitosis and increase cell permeability. 5Ionizing radiation disrupts the cell differentiation process in the epidermal layer.Cell proliferation disorders occur due to activation of cytokines and growth factor. 6urthermore, synthesis of other proinflammatory mediators and proteases in the vicinity of fibroblasts occurs. 7,8Endothelial cell damage activates the coagulation system component which further leads to inflammatory processes and cytokine production which eventually delay the re-epithelization process. 1,9cute radiodermatitis usually occurs 2-3 weeks from the start of radiotherapy up to 3-4 weeks after radiotherapy completed.Acute radiodermatitis manifestations include erythema, edema, pain, pruritus, pigmentation, desquamation, hair loss, nail changes, vesicles or bull formation, erosion or ulceration. 10Dry desquamation is characterized by squama and pruritus.Wet desquamation is characterized by serous fluid and occurs 4 to 5 weeks after radiation. 11Chronic radiodermatitis can occur several months to years after completion of radiotherapy in the form of permanent damage to the dermis layer. 12esearch on radiodermatitis is scarce in Indonesia, so this study aims to examine radiodermatitis in Haji Adam Malik Central Hospital of Medan.

METHODS
This study is a descriptive observational study with the prospective approach.

ORIGINAL ARTICLE
Fifty patients with cancer receiving radiotherapy included in the study.A history and dermatologic examination performed on day one before receiving radiotherapy, week 3 and week 8.Total dose and fractionation radiotherapy were obtained from radiology doctor in charge of the patient.The collected data was then processed and then presented in the form of frequency tables and analyzed descriptively.

RESULTS
In this study, it is known that the largest age group is 40-60 years old as many as 34 people (68%), where the incidence happens more in women 29 people (58%).Clinical features of erythema are 50 (100%), with the most common site of the lesion is the Colli region of 16 (32%).The most common dose of radiotherapy is 5000-5900 cGy of 42 people (84%), and the most common fractionation is 31-40 fractions of 27 people (54%).
Distribution of the clinical picture by age appears when older the patient then the more severe the clinical picture appears.Distribution of clinical features by sex showed that women give a more severe clinical picture when compared with men.Distribution of clinical features based on total doses of radiotherapy seen as a higher total dose of radiotherapy provides a more severe clinical picture.Distribution of clinical features based on fractionation appears that patients who received higher fractionation gave more severe clinical features.

DISCUSSIONS
The sample average age of this study is 50.1 years.Most subjects in tage group 40-60 years of 34 peoples  13 This study suggests that older age increases the risk of radiodermatitis, which in older age there is a decrease in the re-epithelialization process and dermis atrophy resulting in an extension of healing time. 12Largest group gender is women 29 people (58%).Altoparlak et al. in his study concluded that there was no difference between the sexes of both men and women. 13he most common clinical features are macular erythema of 50 people (100%).López et al. in his study found that clinical features are erythema macula (91.7%), dry desquamation (29.6%) and wet desquamation (35.2%). 8Barkham et al. found 80 -90% of radiodermatitis patients gave clinical features of macular erythema. 14Locations of the most common lesions is in the Colli region of 16 patients (32%).Brown and Rzucidlo et al. states that every area of the body has a different sensitivity to radiation, and the most sensitive parts of the body are in the anterior colli, the extremities, the chest, the abdomen and the facial area.

ORIGINAL ARTICLE
In this study found the most common dose of radiotherapy was 5000-5900 cGy of 42 people (84%).Porock et al.In his research state that high doses of radiotherapy tend to cause severe reactions in patients.The larger the dose of ionizing radiation, the greater the likelihood of damage it causes. 16he most typical fractionation is 31-40 fractions of 27 people (54%).The fractionation method is done by dividing the total radiation dose into smaller daily doses, making it possible for the skin to repair due to damage caused by radiotherapy.If the amount of fractionation is high, then the number of cells will continue to decrease and will give clinical effects of radiodermatitis. 17istribution of the clinical picture by age appears older the patient the more severe the clinical picture appears.Andrade et al. in his study found that the majority of patients with radiodermatitis occur in the age group of 58-67 years. 18In elderly, wound healing process due to exposure to radiotherapy longer than younger age.This factor is due to the degeneration process, inadequate food intake, decreased immunity and decreased circulation. 8,10Distribution of clinical picture by sex is seen as giving women a more severe clinical picture when compared with men.Meyer et al. in his study of head and neck cancer patients found that women were more at risk of radiodermatitis than men with a ratio of 1: 4. 19 Distribution of clinical features based on total doses of radiotherapy seen as a high total dose of radiotherapy provides a more severe clinical picture.Porock et al. in his research stated that the high dose of radiotherapy tends to cause more severe skin reactions.The greater the ionizing radiation dose, the greater the likelihood of the damage it causes. 15The distribution of clinical features based on fractionation appears that patients who get the fractionation give a heavier clinical picture.Langhe et al. in his study it was found that patients who received higher fractionation gave more severe clinical features. 21Fractionation method was done by dividing the total dose of radiation into smaller daily doses, making it possible for the skin to repair due to radiotherapy damage, when exposure of radiation sustained over several weeks, the more severe the damage to basal cells in the epidermis. 22

CONCLUSIONS
In this study, there were 50 subjects with radiodermatitis and its showed as follows: From the patient side: The most sex is female (58%) with the largest age group is 40-60 years (68%).In all patients, clinical features of macular erythema were 50 (100%) and the most common site of the lesion was the Colli region of 16 patients (32%).Clinical features of radiodermatitis are more severe in female patients and older age.From the side of radiotherapy: The total radiotherapy dose that most caused of radiodermatitis are 5000-5900 cGy as much as 42 people (84%) and fractionation is 31-40 fractions of 27 people (54%).Clinical features of radiodermatitis are more severe in patients who receive a higher total dose of radiotherapy and fractionation.

RECOMMENDATION
1. Research needs to be done on radiodermatitis incidents in the cancer patients receiving radiotherapy at other health centers and at different times to be comparable in studying the case of radiodermatitis 2. With this research is expected to be a learning material for clinical practitioners to be considered in performing services when finding cases of radiodermatitis so that health services are given to be optimal.