Radiation recall: A well recognized but neglected phenomenon

Nitrofurantoin-induced radiation recall dermatitis

Radiation recall dermatitis (RRD) is an inflammatory skin reaction that develops in a previously quiescent radiation field triggered most commonly by chemotherapy, particularly anthracyclines and taxanes. Radiation-recall dermatitis secondary to antibiotic therapy is quite rare. The patient is 61-year-old female with a history of squamous cell carcinoma of the left breast treated with neoadjuvant carboplatin, paclitaxel, and anthracycline chemotherapy followed by surgery and subsequent whole breast radiation 6040 cGy. Eight years after completion of her radiation she developed diffuse redness of the left breast after two doses of nitrofurantoin taken for a urinary tract infection. On examination, vital signs were stable and she had an erythematous and excoriated rash on her left breast that clinically appeared to be cellulitis. Given her clinical history, coupled with the temporal relationship of starting an antibiotic, strong consideration was given for antibiotic-induced RRD. Nitrofurantoin was discontinued, and the rash resolved completely within several days. This case demonstrates an example of RRD which is the development of an acute inflammatory skin reaction of a previously irradiated area most commonly triggered by chemotherapeutic agents. This case highlights antimicrobial therapy as a rare cause of RRD and underscores the importance of considering RRD in a patient presenting with an acute rash over a previously irradiated area while on antimicrobial therapy.

Radiation Recall in a Patient with Intrahepatic Cholangiocarcinoma: Case Report and a Literature Review

Radiation recall dermatitis (RRD) is a rare and poorly understood phenomenon, constituting an inflammatory skin reaction to a previously irradiated area of skin following the administration of certain agents, usually chemotherapy. Our patient developed RRD 66 years after receiving radiation therapy; to the best of our knowledge, this is the longest reported period in the literature. The mainstay of therapy is to withhold the agent that elicited the adverse reaction, followed by symptomatic management. Subjecting patients to further chemotherapy can provoke another episode of RRD. Therefore, clinical judgment in this regard is usually recommended.

Isodose 20 Gy found as a threshold dose for radiation recall dermatitis

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Radiation recall phenomenum.

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Radiation recall dermatitis.

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The observation suggested a threshold dose for the occurrence of the recall effect.

Radiation recall is a rare phenomenon that can be observed in the field of radiotherapy, months or years after irradiation when a patient is exposed to certain pharmaceutical agents. In this report, we relate a case of radiation recall dermatitis induced after the application of a topical natural cream, 2 years after the initial radiotherapy treatment. Skin reactions were severe and limited to the irradiated volume, whereas a large part of the skin where the cream was applied outside the radiation field was strictly normal. More precisely, the radiation recall dermatitis matched with the isodose 20 Gy, whereas no recall reaction was observed in the lower dose areas (5, 10 or 15 Gy) despite these areas were also largely exposed to the cream. In conclusion, this is the first report that could provide a threshold dose for the occurrence of a radiation recall dermatitis, which was not observed below 20 Gy, in the context of this topical reagent.

Radiation recall pneumonitis in the setting of immunotherapy and radiation: a focused review

Radiation recall pneumonitis (RRP) is an entity described as pneumonitis localized to a previously irradiated field after exposure to a systemic agent. It has previously been described in the literature in the context of chemotherapeutic agents as well as certain biologics. With immunotherapy taking a more prominent role in the treatment of several different malignancies and its own baseline risk of pneumonitis, it is important to explore the likelihood of RRP, specifically in those patients who have been previously treated with radiation therapy. The current literature regarding RRP with checkpoint inhibitors is reviewed in this article. Alongside this review, we report a case of RRP after pembrolizumab initiation in a patient in our practice.

Radiation recall pneumonitis induced by nivolumab in a patient with renal cell carcinoma

Introduction

A radiation recall reaction in previously irradiated lungs is known as radiation recall pneumonitis. We encountered a rare case of radiation recall pneumonitis induced by nivolumab 9 months after palliative radiotherapy to the ribs.

Case presentation

The patient was a 69-year-old woman with renal cell carcinoma. She had received various drugs and palliative irradiation, which was followed by nivolumab treatment, for renal cell carcinoma. Three days after the initial nivolumab administration, she presented with respiratory symptoms. On the basis of chest computed tomography findings, she was diagnosed with nivolumab-induced radiation recall pneumonitis and treated with prednisolone (1 mg/kg). The condition resolved rapidly, and chest computed tomography 4 months after nivolumab cessation revealed interval resolution of the lung consolidation and persistent tumor shrinkage.

Conclusion

Physicians should consider the risk of radiation recall pneumonitis during treatment with immune checkpoint inhibitors in patients who have received previous thoracic radiotherapy.

Docetaxel-induced radiation recall dermatitis with atypical features: A case report

INTRODUCTION

Radiation recall dermatitis (RRD) associated with actinomycin D was first described by in 1959, followed by the reporting of several RRD-inducing drugs. In 1994, a study demonstrated docetaxel-induced RRD for the first time; however, despite some case studies reporting RRD, a little has been reported on it since then. Here we present a rare case of atypical docetaxel-induced RRD.

CASE PRESENTATION

The patient in his 60s was administered radiotherapy for high-risk prostate cancer. He continued receiving hormonal therapy for 2 years because of being in a high-risk group and became nadir. Six months since the completion of hormonal therapy, his prostate-specific antigen (PSA) level increased again. Based on the radiological examination, he was diagnosed with multiple lung, bone, and lymph node metastases. Accordingly, we started docetaxel (75 mg/m) every 5 weeks in consideration of myelosuppression for hormone-resistant multiple metastases. Although lung metastasis shrunk by one cycle docetaxel, radiotherapy for the thoracic and lumbar vertebrae was performed for back pain and lumbago. On day 21, at the end of radiotherapy, the same dose of docetaxel was administrated for the third time. On day 7, after third docetaxel administration, erythema appeared in a irradiated field of the thoracic and lumbar vertebra. Erythema primarily appeared on the anterior side of the body, and no skin reaction was noted on the posterior part of the thoracic irradiated area. Notably, no skin reaction was observed in the previously irradiated field for prostate cancer.

CONCLUSIONS

This case report draws attention to the development of atypical RRD after administration of docetaxel and advises careful follow-up even if RRD does not appear after the first docetaxel administration.

Gemcitabine-Induced Radiation Recall Myositis: Case Report and Review of the Literature

Gemcitabine-induced radiation recall (GIRR) is a phenomenon wherein the administration of gemcitabine induces an inflammatory reaction within an area of prior radiation. We present the case of a 39-year-old female patient with metastatic breast cancer who experienced GIRR myositis 3 months following postoperative radiotherapy, with additional potential paraspinal myositis following ablative radiotherapy to the thoracic spine. A review of previously published cases of GIRR myositis was performed. The case and literature review describe the clinical course and presentation of GIRR, and highlight the importance of including radiation recall as part of a differential diagnosis when a patient undergoing chemotherapy experiences an inflammatory reaction at a prior site of radiation.

Baseline neutrophil-to-lymphocyte ratio predicts the prognosis of castration-resistant prostate cancer treated with abiraterone acetate

Abiraterone acetate (AA), a CYP17 inhibitor, now has a crucial role in the treatment of castration-resistant prostate cancer (CRPC), and previous studies have reported several prognostic clinical factors for AA treatment. The neutrophil-to-lymphocyte ratio (NLR) has also been investigated for a CRPC treatments in a few reports, however it has not been identified to be a prognostic factor for AA treatment in Japanese patients. The present study aimed to assess the association of the baseline NLR with the overall survival (OS) in CPRC patients treated by AA. The present study retrospectively reviewed a total of 90 consecutive patients with CRPC treated with AA from 2011 to 2016 at Yokohama City University Medical Center and National Cancer Center Hospital East. The primary endpoint of the study was the OS, which was defined as the survival from the start of AA administration. The secondary endpoint was the prostate-specific antigen (PSA) response. PSA response was defined as a reduction in antigen levels of >50%. Complete blood cell counts were performed, and the NLR was calculated using the neutrophil and lymphocyte counts obtained on the same day or a few days prior to the initiation of AA therapy. The NLR cut-off point was determined to be 3.76 for the OS, and divided into the high NLR group of 34 patients and the low NLR group of 56 patients. A PSA response was obtained in 8 patients (23.5%) in the high NLR group and in 24 (42.9%) in the low NLR group. The difference of PSA response between the two groups was significant (P=0.037). Kaplan-Meier curves demonstrated that a high NLR [NLR ≥3.76; median OS: 8.4 months; 95% confidence interval (CI): 6.325-10.475 months] was correlated with a risk of mortality compared with a low NLR (NLR <3.76; median OS not reached). A multivariate analysis demonstrated that the NLR was an independent predictor for the OS (hazard ratio: 2.682; 95% CI: 1.143-6.293; P=0.023). The findings suggest that the NLR may be a useful novel biomarker for predicting the prognosis of CRPC patients treated with AA.

Radiation Recall Dermatitis in Patients Treated with Sorafenib

Introduction

Radiation recall dermatitis (RRD) is a phenomenon that occurs in previously irradiated areas shortly after administration of a chemotherapeutic agent. As the use of sorafenib expands, the incidence of radiation recall dermatitis induced by sorafenib will likely increase. Here, we report on a patient who developed RRD and describe his clinical characteristics along with a review of the literature.

Case Presentation

Our patient was treated with palliative radiation therapy (RT) to a painful metastatic hepatocellular carcinoma lesion in the right forearm. He completed his radiation course with grade 1 dermatitis, which had resolved by the time he was started on sorafenib 400 mg twice daily 7 days afterwards. On the 21st day after RT, he presented with desquamation and erythema in the previously irradiated area of the right forearm, consistent with RRD. The sorafenib was discontinued and his symptoms subsequently resolved with conservative topical management.

Conclusions

Although the pathophysiologic mechanism of sorafenib-related radiation recall dermatitis remains to be investigated, practitioners should be aware of its presence and management in order to improve clinical outcomes.

The incidence and management of cutaneous adverse events of the epidermal growth factor receptor inhibitors

Overexpression of the epidermal growth factor receptor (EGFR) is found in many cancers, including those of the head and neck area, non-small-cell lung cancer, and colorectal, cervical, prostate, breast, ovary, stomach, and pancreatic cancer. The EGFR inhibitors are used at present in the treatment of such cancers. Skin lesions that develop during and after cancer treatment may be due to specific cytostatics, molecular-targeted drugs, radiation therapy, complementary therapy, or the cancer itself, and hence knowledge is essential to distinguish between them. The mechanism through which skin toxicity arises during treatment with EGFR inhibitors is not well known, but seems to be due to the modification of the RAS/RAF/MEK/ERK signal path associated with its activation, which results in the similarity between the adverse effects of EGFR inhibitors and the treatment of melanoma with BRAF and MEK inhibitors. The most common side effects are pruritus, xerosis, papulopustular rash, hand-foot skin reaction, alopecia and dystrophy of the hair, and paronychia. This work presents options for prevention and suggestions for managing these adverse events, which are of importance in the care of patients undergoing oncological treatment.

Management of Radiation Side Effects to the Skin

Radiation therapy (RT) is an essential component for management of many cancers. Veterinary health care professionals must counsel owners about the potential side effects of RT, the anticipated management plan, and associated costs. For most veterinary patients treated with RT, acute radiation side effects are mild; however, careful radiation treatment planning and appropriate management of acute side effects are essential to try to prevent chronic sequelae and the need for ongoing wound care. This article reviews acute and late side effects to the skin and their management.

CT findings in patients with Cabazitaxel induced pelvic pain and haematuria: a case series

Background

Haematuria and pelvic pain are recognized and documented adverse reactions related to Cabazitaxel use. To date there has not been any documentation of imaging findings in patients with this presentation.

Cases

We report a case series of five patients who experienced these symptoms while on Cabazitaxel and were all found to have very similar urothelial changes on CT. The patients were noted to have ureteric and renal pelvic dilatation along with urothelial enhancement (in those who had post contrast imaging). All of these changes were noted to be reversible in those who had follow up imaging after cessation of Cabazitaxel and initiation of a short course of steroids.

Conclusion

This case series helps demonstrate the pathological reversible urothelial inflammatory changes that may be occurring in patients experiencing haematuria and pelvic pain on Cabazitaxel therapy. These changes may relate to direct toxic effect of drug metabolites, a radiation recall type phenomenon or a combination of both.

Inflammatory Skin Conditions Associated With Radiotherapy

Radiotherapy for cancer is used increasingly. Because skin cells undergo rapid turnover, the ionizing radiation of radiotherapy has collateral effects that are often expressed in inflammatory reactions. Some of these reactions-radiodermatitis and recall phenomenon, for example-are very familiar to dermatologists. Other, less common radiotherapy-associated skin conditions are often underdiagnosed but must also be recognized.

Radiation recall after capecitabine in a patient with recurrent nasopharyngeal carcinoma: a case report

Background

Capecitabine has been commonly used in recurrent or metastatic nasopharyngeal carcinoma. However, radiation recall after capecitabine for nasopharyngeal carcinoma has not been reported.

Case presentation

We report the case of a 64-year-old Chinese woman with locoregionally advanced nasopharyngeal carcinoma previously treated with induction chemotherapy followed by concurrent chemoradiation 6 years ago. She developed cervical, mediastinal, and abdominal nodal relapses 14 months later. She then received capecitabine with initial excellent tumor response for 1 year but disease recurrence was noticed at the peripancreatic nodal region, which was successfully treated with concurrent chemoradiation with capecitabine. Unfortunately, she developed progressive erythema of the face and neck region at exactly the previous irradiation site for her initial nasopharyngeal carcinoma, 2 months after taking capecitabine. She initially ignored it, but it became more confluent and serious. Eventually, a facial skin biopsy was performed showing nonspecific chronic inflammation only. The diagnosis was most likely radiation recall phenomenon since capecitabine was the only drug she received before development of this dermatological manifestation on her previously irradiated face and neck. Treatment was conservative and supportive albeit with no significant clinical improvement.

Conclusions

Radiation oncologists should be aware of this potential risk of capecitabine, especially when it is administered for a long period of time.

Radiation Recall Dermatitis Secondary to Dactinomycin

Radiation recall dermatitis (RRD) is an uncommon reaction typically triggered by the use of chemotherapeutic agents in the months after treatment with radiation therapy. It usually presents as dermatitis in the irradiated field with prominent intertriginous involvement, and because internal involvement occurs in up to one-third of cases, early recognition is important. RRD has rarely been reported in the pediatric literature. We report the case of a 15-month-old boy with RRD to dactinomycin.

Radiation Recall Pneumonitis During Systemic Treatment With Everolimus

Radiation recall syndrome is an acute inflammatory reaction developing at anatomical sites of previously irradiated tissue, weeks to months after the completion of radiation therapy. The distribution pattern of inflammation typically involves, and remains limited to, the boundaries of prior radiation treatment fields. Several classical chemotherapy drugs have been reported to have the potential for causing radiation recall syndrome. With the increasing availability and expanding use of novel biologic and targeted therapy anticancer drugs, isolated reports of radiation recall syndrome secondary to this class of agents are starting to appear in the literature. We describe a case of everolimus-induced radiation recall pneumonitis in a patient with metastatic renal cell cancer.

Delayed radiation-induced inflammation accompanying a marked carbohydrate antigen 19-9 elevation in a patient with resected pancreatic cancer

Although carbohydrate antigen (CA) 19-9 is a useful tumor marker for pancreatic cancer, it can also become elevated from a variety of benign and malignant conditions. Herein we describe an unusual presentation of elevated CA 19-9 in an asymptomatic patient who had previously undergone adjuvant chemotherapy and radiation therapy for resected early stage pancreatic cancer. The rise in CA 19-9 might be due to delayed radiation-induced inflammation related to previous intra-abdominal radiation therapy with or without radiation recall induced by gemcitabine. After treatment with corticosteroids the CA 19-9 level decreased to normal, and the patient has not developed any evidence of recurrent cancer to date.

Avoiding Severe Toxicity From Combined BRAF Inhibitor and Radiation Treatment: Consensus Guidelines from the Eastern Cooperative Oncology Group (ECOG)

BRAF kinase gene V600 point mutations drive approximately 40% to 50% of all melanomas, and BRAF inhibitors (BRAFi) have been found to significantly improve survival outcomes. Although radiation therapy (RT) provides effective symptom palliation, there is a lack of toxicity and efficacy data when RT is combined with BRAFi, including vemurafenib and dabrafenib. This literature review provides a detailed analysis of potential increased dermatologic, pulmonary, neurologic, hepatic, esophageal, and bowel toxicity from the combination of BRAFi and RT for melanoma patients described in 27 publications. Despite 7 publications noting potential intracranial neurotoxicity, the rates of radionecrosis and hemorrhage from whole brain RT (WBRT), stereotactic radiosurgery (SRS), or both do not appear increased with concurrent or sequential administration of BRAFis. Almost all grade 3 dermatitis reactions occurred when RT and BRAFi were administered concurrently. Painful, disfiguring nondermatitis cutaneous reactions have been described from concurrent or sequential RT and BRAFi administration, which improved with topical steroids and time. Visceral toxicity has been reported with RT and BRAFi, with deaths possibly related to bowel perforation and liver hemorrhage. Increased severity of radiation pneumonitis with BRAFi is rare, but more concerning was a potentially related fatal pulmonary hemorrhage. Conversely, encouraging reports have described patients with leptomeningeal spread and unresectable lymphadenopathy rendered disease free from combined RT and BRAFi. Based on our review, the authors recommend holding BRAFi and/or MEK inhibitors ≥3 days before and after fractionated RT and ≥1 day before and after SRS. No fatal reactions have been described with a dose <4 Gy per fraction, and time off systemic treatment should be minimized. Future prospective data will serve to refine these recommendations.

A Case of Severe Rectal Hemorrhage Possibly Caused by Radiation Recall after Administration of Gemcitabine

Radiation recall is an acute inflammatory reaction that can be triggered when systemic agents are administered long time after radiotherapy. Because radiotherapy is now indicated for many types of cancer, care should be taken regarding possible toxic events relating to radiotherapy in combination with radio-sensitizing agents. Gemcitabine, one such anti-cancer agent, is widely used, especially for urologic cancers. We report an intriguing case of possible radiation recall in the rectum caused by gemcitabine administration 37 years after radiation therapy. From a review of the literature, it appears that there have been no reported cases of radiation recall in the rectum with such a long interval between radiation therapy and chemotherapy. Here, we describe the case and provide a literature review.

Grade 3 Radiation Recall Sigmoiditis after Treatment for Locally Advanced Cervical Cancer: A Case Report

We report a case of Grade 3 radiation recall sigmoiditis after administration of a combination of carboplatin, paclitaxel, and bevacizumab, following irradiation for a locally advanced cervical cancer. A 50-year-old woman was diagnosed with an FIGO Stage IIIb squamous cell carcinoma of the cervix with bilateral pelvic and para-aortic lymph nodes. She underwent concurrent chemoradiation followed by high dose rate (HDR) intracavitary brachytherapy. She had a complete loco-regional response. A supraclavicular recurrence was diagnosed three months after completing treatment and two cycles of carboplatin, docetaxel, and bevacizumab were given in April 2014. Shortly after the second cycle, she was admitted to the hospital for significant abdominal pain, diarrhea followed by symptoms of bowel subocclusion. The CT scan and endoscopic images revealed thickening of the sigmoid wall with important edema and telangiectasia. The biopsy was consistent with acute radiation-induced colitis. Because of persistent digestive symptoms, a diverting ileostomy was done few months later. The location, timing, pathology, and its association with a high-dose region are analyzed in this case report.

Radiation recall dermatitis and radiation pneumonitis during treatment with vemurafenib

The basis of radiation recall reactions (RRR) is a subclinical radiation damage that is uncovered later by treatment with anticancer agents. Several drugs have been associated with RRR, in particular taxanes and anthracyclines. Recently, a few cases were reported concerning radiation recall dermatitis caused by vemurafenib. Up to now, there have been no reports of RRR in the lung induced by vemurafenib. We describe the occurrence of RRR in three melanoma patients who had undergone radiotherapy for metastases followed by systemic treatment with the BRAF inhibitor vemurafenib. Two patients developed radiation recall pneumonitis (RRP) and one patient developed radiation recall dermatitis (RRD) 5-7 weeks after the radiation treatment was finished and 2-4 weeks after vemurafenib was started. The early application of systemic (RRP) and topical corticosteroids (RRD) enabled us to continue the treatment with vemurafenib without dose reduction. Caution is needed when vemurafenib is planned for patients who have undergone previous radiotherapy, and RRR of the skin and the lung have to be taken into account.

Gemcitabine-induced radiation recall myositis

Radiation recall is an uncommon phenomenon in which administration of a chemotherapeutic agent induces an acute inflammatory reaction in previously irradiated tissues, often weeks to years after completion of radiotherapy. This entity is well known to medical and radiation oncologists, however only three cases have been reported in radiology journals. We present a case of gemcitabine-induced radiation recall that manifested as myositis with associated dermatitis in the posterior thigh of a patient with remote history of localized radiotherapy for biopsy-proven breast cancer metastasis. We also present a brief literature review to update the topic of radiation recall in imaging, and emphasize the importance of knowledge of this phenomenon when considering the differential diagnosis of myositis/dermatitis in a patient who has received cancer treatment.

Radiation recall reaction causing cardiotoxicity

Radiation recall phenomenon is a tissue reaction that develops within a previously irradiated area, precipitated by the subsequent administration of certain chemotherapeutic agents. It commonly affects the skin, but can also involve internal organs with functional consequences. To our best knowledge, this phenomenon has never been reported as a complication on the heart and should be consider as a potential cause of cardiotoxicity.

Case report of cold-weather-induced radiation recall dermatitis after chemoradiotherapy with cisplatin

BACKGROUND

The radiation recall reaction (RRR) is an inflammatory reaction that occurs in previously irradiated areas. The phenomenon is probably due to an idiosyncratic hypersensitivity reaction, in which a second agent can recall the inflammatory reaction.

CASE REPORT

This case report documents a cold-weather-induced radiation recall dermatitis (RRD). We observed a severe RRD in a patient after chemoradiotherapy treatment with cisplatin for a nasopharyngeal carcinoma, precipitated by cold temperatures, which developed 9 days after completion of therapy. In the medical literature, RRD following extreme cold temperatures seems to be a peculiar event.

CONCLUSION

Until further information on the interaction is available, future studies on combined chemotherapy with cisplatin should be carefully monitored and any side effects clearly documented. This case suggests that environmental conditions may play a contributing role in the development of RRD. This case also implies that neither fraction size nor total radiation dose is a determining factor in the development of the dermatologic reaction.

Sorafenib-triggered radiation recall dermatitis with a disseminated exanthematous reaction

Sorafenib is a multi-targeted kinase inhibitor, which is the current standard treatment for advanced hepatocellular carcinoma (HCC). Only one case of radiation recall dermatitis (RRD) associated with sorafenib has been reported so far. Our patient with recurrent HCC was treated with palliative radiotherapy (RT) for the chest wall mass. Sorafenib at 400 mg twice daily was begun on the day following RT. On the 14th day post-RT, an erythematous patch was observed on right chest wall which matched area previously irradiated. It was consistent with RRD. Ten days later, a disseminated exanthematous rash and severe pruritus occurred. Sorafenib was stopped and an oral antihistamine was prescribed to relieve symptoms. At the 1-week follow-up after the cessation of sorafenib, all symptoms were resolved. Physicians should be alert to this recall phenomenon as it can occur both in the skin and elsewhere and the occurrence of RRD may be unpredictable.

Radiation-induced esophagitis exacerbated by everolimus

Background

Everolimus, a potent mammalian target of rapamycin (mTOR) inhibitor, has shown anticancer activity against various types of cancer, including renal cell carcinoma (RCC); however, little information is available on the efficacy and safety of the combination of everolimus and radiotherapy. We report a case of radiation-induced esophagitis that might have been exacerbated by the sequential administration of everolimus.

Case Presentation

A 63-year-old Japanese man with RCC complained of back pain, and magnetic resonance imaging revealed vertebral metastases. He received radiotherapy (30 Gy/10 fractions) to the T6–10 vertebrae. Everolimus was administered immediately after the completion of radiotherapy. One week later, he complained of dysphagia, nausea and vomiting. An endoscopic examination of the esophagus showed erosive esophagitis in the middle to lower portions of his thoracic esophagus, corresponding to the irradiation field.

Conclusion

Clinicians should be aware that everolimus might lead to the unexpected exacerbation of radiation toxicities.

Radiation recall reaction: two case studies illustrating an uncommon phenomenon secondary to anti-cancer agents

Radiation recall phenomenon is a tissue reaction that develops throughout a previously irradiated area, precipitated by the administration of certain drugs. Radiation recall is uncommon and easily neglected by physicians; hence, this phenomenon is underreported in literature. This manuscript reports two cases of radiation recall. First, a 44-year-old man with nasopharyngeal carcinoma was treated with radiotherapy in 2010 and subsequently developed multi-site bone metastases. A few days after the docetaxel-based chemotherapy, erythema and papules manifested dermatitis, as well as swallowing pain due to pharyngeal mucositis, developed on the head and neck that strictly corresponded to the previously irradiated areas. Second, a 19-year-old man with recurrent nasal NK/T cell lymphoma initially underwent radiotherapy followed by chemotherapy after five weeks. Erythema and edema appeared only at the irradiated skin. Both cases were considered chemotherapeutic agents that incurred radiation recall reactions. Clinicians should be knowledgeable of and pay attention to such rare phenomenon.

[Interstitial lung disease associated with lung cancer treatment]

Interstitial lung disease is one of the most serious side effects caused by lung cancer treatment. Due to the complexity diagnosis and variability of the disease, it is often not diagnosied and treated in time, even endanger the patient's life and affect the patient's prognosis. The mechanism of interstitial pneumonia caused by radiotherapy, chemotherapy and targeted therapy is still not fully known. Therefore, it become a problem that how to early detection, diagnosis and treat the interstitial lung disease caused by lung cancer treatment and it should not be ignored in the future.

Radiation recall dermatitis induced by trastuzumab

We report a case of radiation recall dermatitis caused by trastuzumab. A 55-year-old woman with metastatic breast cancer received palliative first-line trastuzumab/paclitaxel and a salvage partial mastectomy with lymph node dissection was subsequently performed. In spite of the palliative setting, the pathology report indicated that no residual carcinoma was present, and then she underwent locoregional radiotherapy to ensure a definitive response. After radiotherapy, she has maintained trastuzumab monotherapy. Nine days after the fifth cycle of trastuzumab monotherapy, dermatitis in previously irradiated skin developed, with fever. Radiation recall dermatitis triggered by trastuzumab is extremely rare. A high fever developed abruptly with a skin rash. This may be the first case of this sort to be reported.

A child with gemcitabine-induced severe radiation recall myositis resulting in a compartment syndrome

Chemotherapeutic induction of radiation recall (RR) is a rare event in which a chemotherapeutic agent given days to years after radiation therapy causes an inflammation reaction of the tissues within the irradiated area-"recalling" increased radiation effects to that area. In this unique case, a 14-year-old girl with a synovial sarcoma of the forearm was treated with neoadjuvant chemotherapy and radiation therapy. Gemcitabine was administered in an adjuvant setting inducing a RR reaction. The severity of the inflammation resulted in a forearm myositis secondarily causing a compartment syndrome that was treated with several prolonged courses of corticosteroids. The symptoms of RR and compartment syndrome have resolved 1 year postonset, although magnetic resonance imaging continues to show myositis and soft-tissue edema. This case highlights the need to maintain a heightened awareness to recognizing the signs and symptoms of RR and the potential severity of RR in pediatric cancer patients in conjunction with chemotherapeutic agents used more frequently in adults.

Locoregional interaction of ixabepilone (ixempra) after breast cancer radiation

BACKGROUND

Radiation recall is an acute inflammatory reaction within a previously irradiated field triggered by chemotherapy administration. We observed a series of patients with unexpectedly severe reactions that included radiation recall and delayed healing when patients received the microtubule stabilizer ixabepilone (Ixempra; Bristol-Myers Squibb, Princeton, NJ) after radiation. We therefore decided to evaluate our experience in patients receiving ixabepilone following radiotherapy.

METHODS

We performed a retrospective chart review of all patients treated with curative intent in the Department of Radiation Oncology at the MD Anderson Cancer Center from 2008-2011 who received any ixabepilone after completion of external-beam radiation therapy. These patients received adjuvant ixabepilone on one of two protocols, either for locally advanced breast cancer or for metastatic breast cancer. In total, 19 patients were identified and their charts were subsequently reviewed for evidence of ixabepilone-related toxicity.

RESULTS

Of the 19 patients identified who received ixabepilone following radiation therapy, three (15.8%) had unexpectedly serious reactions in the months following radiation therapy. Complications included delayed wound closure and drain placement into the seroma, intense erythema, and delayed wound closure and grade 4 chest wall necrosis requiring latissimus flap and skin grafting. The average number of days between the end of radiation therapy and documentation of reaction was 99.

CONCLUSIONS

Ixabepilone chemotherapy may induce radiation recall and delayed wound healing when used shortly after the completion of external-beam radiotherapy. Significant clinical interactions have not been previously reported and merit further evaluation.

Targeted therapy-induced radiation recall

INTRODUCTION

Radiation recall (RR) is an acute inflammatory reaction confined to previously irradiated areas after the administration of various pharmacological agents. A diverse range of chemotherapies has been associated with RR but no case series with targeted therapies (TT) has been reported.

PATIENTS AND METHODS

From a database of 346,933 cancer patients ≥18 years treated at Institut Gustave Roussy between June 1986 and August 2012, clinical data and the pattern of treatment of TT-induced RR were collected. Results were compared with those of prior TT-induced RR publications.

RESULTS

Sixteen patients with different tumour types were diagnosed with RR observed in the heart, bladder, salivary glands, skin and gastrointestinal tract. The median duration of RR was 1.7 weeks (range: 0.1-13.7) and median time to onset from TT to RR was 16.9 weeks (range: 1-86.9). TT consisted of inhibitors of the mammalian target of rapamycin (mTOR) (n=5), endothelial growth factor receptor (EGFR) (n=2), integrin (n=2), histone deacetylase (HDAC) (n=2), cell division cycle 7 (CDC7) (n=1), insulin-like growth factor 1 receptor (IGFR1) (n=1), cyclin-dependent kinase (CDK) (n=1), BRAF (n=1) and a vascular disrupting agent (VDA) (n=1). Thirteen incriminated TT (81%) were evaluated during early clinical trials and RR led to discontinuation of TT in six patients. All patients had previously received radiotherapy at a median biologically effective dose (BED) of 47 Gy (range: 20-70). The median interval from radiation to TT was 30 months (range: 0.3-363). Immunohistochemical analysis of skin biopsy specimens did not show any transforming growth factor-beta (TGF-β) activation. TT-induced RR characteristics in our population were comparable to those of the nine other cases previously reported in the literature.

CONCLUSION

This is the largest case series ever reported on TT-induced RR. RR could be a potential dose-limiting toxicity in early clinical trials. Research is warranted to further understand the exact pathophysiology of this rare but clinically relevant phenomenon.