1. FOREWORD Chemotherapy and Radiotherapy are commonly used in the treatments of a wide range of illnesses associated with cancer. The difficulties encountered by the embalmer when attempting to embalm a case that has been subjected to Chemotherapy and Radiotherapy are very complex and varied in nature. The chemotherapy and radiotherapy treatments create an environment that warrants specific care and attention and the illnesses that call for these treatments provide their own share of challenges to the practicing embalmer. MEDICAL TREATMENTS CHEMOTHERAPY Definition Chemotherapy is the treatment of infections and other disease with chemical agents that are designed to destroy cancer cells on a selective basis. Cytoxic Agents. The pharmacologic compound (cytoxic) agents used in cancer treatments generally function in the same manner as ionising radiation. This means that the cytoxic agents do not kill the cancer cells but they impair the ability of the cancer cells to replicate. They do so by interfering with acid activities associated with cell division. For this reason the question of uncontrolled contamination towards close contact workers becomes a safety issue and certain protocols have been implemented to safeguard persons likely to become affected by excessive radiation exposure. Chemotherapeutic agents are drugs and they cause cellular and tissue changes within the body. The drug induced changes may be relatively minor in nature but when the drugs cause major changes, serious problems with the preservational effectiveness of the embalming chemicals can occur. Major changes could include the decreased permeability of the cell membranes and the retention of nitrogenous wastes in the body systems and structures. When the permeability of the cell membrane becomes decreased it’s much more difficult for the preservative to come into contact with the cell protein and subsequently cell and tissue decomposition will continue to develop. The nitrogenous waste build up within the body contains ammonia and this will further hamper preservation by neutralising the formaldehyde. The liver, which is the body’s main detoxification organ will attempt to change the drug to an innocuous form however with prolonged exposure the hepatic enzymes will not be able to keep up and serious damage may occur to this organ. This may lead to liver failure and jaundice. Eventually the heart, the blood vessels, the skin, the kidneys and lungs will also have their function ability impaired to the point where the distribution and effectiveness of the embalming solution may become severely compromised. As chemotherapy reaches all parts of the body, not just the cancer cells, all parts of the body may experience side effects that will have direct influence on the strength and technique of the embalming. It is not just the physical presence of the cytoxic agent that causes problems but more so the physiological effects that they cause to the body that will have a direct influence upon the embalming. Side Effects Common side effects of chemotherapy that may have an influence upon the embalming processes may include; Loose and easy detachable hair. Extreme care must be implemented when washing, drying, styling or otherwise handling the hair as the hair can easily become detached. In many instances the hair has thinned or disappeared prior to death and it may become necessary to tone residual hair to blend with artificial hairpieces or wigs. Reduced ability of the blood to clot With reduced ability of the blood to clot there may be many surface bruises and discolorations that need bleaching and cosmetology. With large areas of bruising it is good practice to hypodermic preservative in and around the area to ensure good localised saturation. Increased likelihood of opportunistic infections Chemotherapy effects white blood cells and reduce the ability of the living body to fight against infections. It is common for chemotherapy patients to be on various types of antibiotics and any drug administered to the body will not just add toxins requiring additional preservative, but also have direct effect on body changes. Antibiotics become lodged into the cell membrane and they have an affinity with metallic ions. This chelating process attracts the body’s abundant supply of calcium ions that in turn encapsulates the cell membrane Shingles Shingles will leave vesicular eruptions on the surface of the skin that will be prone to secondary infections. These areas are unsightly and specialised cosmetic treatments may be necessary to overcome the appearance. Jaundice Yellowing of tissues is counteracted by higher strength special purpose fluids that meet with the increased demand for preservative. An additional dye may be added to the arterial fluid which will aid in masking discoloration. External applications of cosmetics are usually necessary to optimise final presentation. Purpura and Petechia Purpura is an extravascular bruise upon the surface of the skin due to fragile capillaries. The purpuras can vary greatly in size and can lead to embalming problems in a variety of ways. Pupuras and petechia will not clear with arterial injection and they tend to enlarge with additional fluid during the embalming. Eventually the skin layers will separate into the condition known as desquamation ( skin slip). If the purpuras have ruptured, it is recommended that the loose skin be removed and surface packs of phenol be applied to these locations. The phenol bleaches the discolorations while drying and cauterising broken surfaces. A stronger arterial fluid should be used at a lower flow rate and if possible these areas should be injected separately from the rest of the body. For larger and more difficult areas of purpura with skin slip, a surface pack of embalming Gel, (Syngel) may be applied for a period of time. After the embalming and when these areas are completely dry they may be restored and cosmetised. These areas of skin will always be weak and additional care should be taken so as not to worsen the skin slip while massaging or dressing. If the areas of concern are non viewing areas it is good practice to cover them with waterproof wrapping to avoid possible leakage and staining into clothing. RADIOISOTOPES Chemotherapy may involve the oral ingestion of a radioactive element (radioisotope) which eventually passes through the patient’s system. When a patient receives oral unsealed radioactive substances they must be isolated during the half life of the radioisotope to prevent radiation exposure to other persons in close contact. Safe management of body wastes such as faeces and urine becomes a matter of protocol. Bandages and other surgical wrappings also need to be managed in a way that prevents radioactive exposure to the care provider. The danger to the embalmer can occur when the patient dies prior to the half life of the radioisotope and he is called to transfer and embalm the remains. RADIOTHERAPY Definition Radiotherapy is the treatment of disease by using x-rays or gamma rays, usually from a cobalt source, to deter the proliferation of malignant cells. Radiation therapy works by preventing cells from growing and dividing by impairing the DNA synthesis. The rays are concentrated to specific regions where the presence of tumour cells exist and any normal cells inadvertently affected are able to quickly recover. POTENTIAL SIDE EFFECTS OF EXTERNAL RADIATION THERAPY Edema With an excess of moisture in the body cavities and tissues, the preservative will be subjected to a higher than usual secondary dilution. The body tissues will swell to an unnatural appearance and there will be an increased possibility of skin slip. Leakage may also be a problem and the remains will develop unpleasant odours. The most serious concern lies in the fact that the excess fluid may contain waste products that the kidneys have not been able to excrete (urine), and these poisons will quickly cause tissue decomposition that resist standard strength preservatives. Edema cases provide an ideal moisture environment for bacterial growth. It is advisable to use multipoint injection methods with edema cases and the additional incision sites become useful as drainage outlets for intercellular fluid (pitting odema). Elevation encourages a gravitational flow towards these openings and the embalmer can assist the movement of excess fluid by massaging in these directions. A high strength, high index fluid is best and in severe cases a waterless injection may be considered. Thorough cavity aspiration is important and if possible re-aspirate after 24 hours and use at least 2 bottles of high firming cavity fluid to reinject these areas. If a restricted cervical injection method is used the operator can avoid dehydrating the head by mixing a separate fluid with a restorative co injection chemical. Pre-injection fluids for edemic cases should be avoided and if fluid reduction leaves wrinkles a tissue reducer will aid in removing them. Anorexia Radiation therapy can cause anorexia and this presents emaciation due to protein loss. (Atrophy) Using a lower index solution containing restorative co injection towards the head is beneficial and it may become necessary to hypodermic tissue builder to fine tune the facial features. A recent photo of the deceased may assist in identifying a more normal appearance. Diarrhoea and Vomiting Diarrhoea and vomiting are common side effects to radiotherapy and this can cause dehydration of all tissues. A pre-injection is best for dehydrated cases followed by a low to medium index preservative fluid. This will lessen the likelihood of further dehydration occurring without compromising preservation. Radiation Burns Radiotherapy can cause skin reactions during or after treatments. A common reaction is the appearance of reddened areas, not unlike sunburn, called radiation burns. The effect can be that the skin can be very dry and shedding and peeling can occur. If this is the case the areas in question may brown off after embalming, giving the appearance of razor burn and these areas will require cosmetic repair. If blisters are evident they will need to be opened and drained with a surface pack of cavity fluid or syngel applied in an effort to preserve and dry these areas prior to cosmetology. This is especially true if the areas are in viewable locations. Hyperpigmentation The natural pigments of the skin can become very dark and require cosmetology if they fail to lighten after arterial injection. INTERNAL RADIATION THERAPY Radioactive implants A radioactive implant is a small container holding a radioactive isotope that is imbedded into tissues for the purpose of interstitial radiotherapy. The implants may be seeled in capsules, wires, tubes or needles, and they are inserted directly into a tumour or body cavity. These methods of radiation therapy must be assessed using the half life protocols before casual contact is made by care providers as the implant may transmit rays to outside the human body. With relatively low emission rates it is generally considered safe for care providers, including embalmers, as long as the implants are not opened or otherwise tampered with. All chemotherapy and radiotherapy treatments are administered by trained professionals who have legal responsibilities to ensure other health care professionals, including embalmers, can identify with and implement safe practices when working within a radioactive environment. If a patient dies, the isotope administrator will determine the risk factors of contamination by a complex means of evaluating which particular isotope has been used and of what strength for how long. If necessary they will remove any hazardous materials prior to releasing the body for autopsy or funeral preparation. If the radioactive remains cannot be controlled to safe exposure limits then the remains will not be released until the correct number of half days have elapsed. Any remains that may still constitute a risk to the embalmer will have a label attached identifying the radionuclide and its activity at the time of death. In these situations the embalmer will need to consult the radiation safety officer at the hospital where the treatment was given and gain specialised advice on how to further eliminate the risk of unsafe exposure. CONCLUSION There are very few embalming cases beyond the competent embalmer’s expertise. Optimum results for chemotherapy and radiotherapy embalming cases are achieved by using stronger preservatives and special purpose fluids along with thorough cavity work and detailed surface treatments. Radiation exposure levels are routinely depleted by hospital safety officers before releasing the remains to Funeral Directors with labelling attached to advise when any other precautions are necessary prior to embalming. Chemotherapy and radiotherapy cases can be safely handled by adopting established protocols and employing good embalming techniques throughout the entire procedure.