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Rieken S, Kronziel LL, Langer T, Rades D, Boppel T, Trillenberg P, Gebauer J. Proposal of a diagnostic algorithm for radiation-induced dropped head syndrome in long-term childhood cancer survivors based on a prospective study in a specialized clinical setting and a review of the literature. J Cancer Res Clin Oncol 2023; 149:17865-17879. [PMID: 37947868 PMCID: PMC10725355 DOI: 10.1007/s00432-023-05480-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/14/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE To prospectively assess the incidence of Dropped Head Syndrome (DHS) in childhood cancer survivors (CCS) and to develop and evaluate a diagnostic algorithm for DHS. METHODS A systematic literature search for DHS in combination with neck radiotherapy (RT) exposure was performed. Analyses and a combination of the most common examination methods were integrated into a diagnostic algorithm. Almost all CCSs visiting the local late effects clinic between May 2020 and April 2022 were included in the study. CCS exposed to neck RT with doses ≥ 19 Gy received standardized clinical and neurological assessment and, in case of abnormal results, an MRI scan to confirm muscle atrophy. RESULTS Two hundred and five CCS were included of whom 41 received RT to the neck with ≥ 19 Gy. In the entire cohort and in the subgroup receiving RT, 2.4% and 12% of CCS were affected by DHS, respectively. Results of clinical and neurological assessment correlated well with MRI results. Neck circumference and neck/thigh ratio were lower after neck RT. Over 50% of CCS experienced neck disability and pain. CONCLUSIONS A relevant proportion of CCS exposed to neck RT is affected by DHS. High concordance of MRI results with the neurological examination supports the clinical value of the diagnostic algorithm. Measurement of neck circumference might be an easy tool for assessment of neck muscle atrophy in survivors at risk. IMPLICATIONS FOR CANCER SURVIVORS Integration of a diagnostic algorithm for DHS in standard long-term follow-up care facilitates diagnosis as well as initiation of early treatment and obviates the need for invasive examinations.
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Affiliation(s)
- Sarah Rieken
- Department of Oncology and Hematology, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Lea Louisa Kronziel
- Institute of Medical Biometry and Statistics, University of Luebeck, Luebeck, Germany
| | - Thorsten Langer
- Department of Pediatric Oncology and Hematology, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Tobias Boppel
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Peter Trillenberg
- Department of Neurology, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Judith Gebauer
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.
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Felong TJ, Balos LL, Silvestri NJ. Testosterone Therapy for Dropped Head Syndrome: A Case Report. J Clin Neuromuscul Dis 2022; 24:98-102. [PMID: 36409341 DOI: 10.1097/cnd.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Dropped head syndrome (DHS) is an impairment of neck extension resulting in a chin-on-chest deformity. DHS is rarely seen but a major hindrance to daily function in affected patients. DHS has been associated with movement disorders, neuromuscular disorders, and electrolyte and endocrine abnormalities. DHS has also been seen in survivors of Hodgkin lymphoma (HL) years after irradiation. HL survivors are also at risk for endocrine hypogonadism after chemotherapy. We present the case of a 58-year-old male HL survivor with dropped head and limited strength in his atrophic neck extensor muscles. Laboratory testing and imaging, nerve conduction studies, electromyography, and muscle biopsy of the neck extensors revealed myopathic and neurogenic changes. Conservative management was unsuccessful. With a desire to avoid surgical fixation, he asked his primary care physician to check his testosterone levels, which returned as low normal. Within 4 months of starting testosterone therapy, he no longer experienced dropped head.
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Affiliation(s)
| | - Lucia L Balos
- Pathology and Anatomical Sciences, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
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3
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Inoue R, Sawamura M, Yoshimura M, Takahashi R. Dropped head syndrome due to chemoradiotherapy for nasal lymphoma, characterised by short tau inversion recovery high signal intensity in the cervical paraspinal muscles. BMJ Case Rep 2022; 15:e252446. [PMID: 36368727 PMCID: PMC9660595 DOI: 10.1136/bcr-2022-252446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ryoichi Inoue
- Department of Neurology, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Masanori Sawamura
- Department of Neurology, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
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4
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Shields LB, Iyer VG, Liang J, Zhang YP, Shields CB. Early-Onset Dropped Head Syndrome and Person-in-the-Barrel Syndrome After Radiation Therapy: Clinical, Electromyographic, and MRI Findings. Cureus 2022; 14:e28279. [PMID: 36158382 PMCID: PMC9492447 DOI: 10.7759/cureus.28279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 11/05/2022] Open
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Saha BK, Chong WH. Rare and underappreciated complication following mantle field radiation 45 years ago. Intern Med J 2021; 51:1553-1554. [PMID: 34541768 DOI: 10.1111/imj.15477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/06/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Biplab K Saha
- Division of Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri, USA
| | - Woon H Chong
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York, USA
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Verla T, Huang AT, Sandulache VC, Ropper AE. Combined anterior cervical spine fusion and total laryngopharyngectomy with free flap reconstruction: A technical note. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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7
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Farshad M, Burkhard MD, Spirig JM. Occipitopexy as a Fusionless Solution for Dropped Head Syndrome: A Case Report. JBJS Case Connect 2021; 11:01709767-202109000-00080. [PMID: 34398850 DOI: 10.2106/jbjs.cc.21.00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 68-year-old woman suffered from an irradiation-induced dropped head syndrome (DHS). Fusion surgery was vehemently rejected by the patient. A new surgical method, avoiding fusion, was invented and performed to treat her DHS. This novel surgical technique of "occipitopexy"-a ligamentous fixation of the occiput to the upper thoracic spine-is described in detail. One year postoperatively, the patient was very satisfied, able to maintain a horizontal gaze, and rotate her head 20° to each side. CONCLUSION This is the first report describing "occipitopexy" as an alternative to cervicothoracic fusion for patients with flexible DHS.
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Affiliation(s)
- Mazda Farshad
- Department of Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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8
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Hutcheson K, McMillan H, Warneke C, Porsche C, Savage K, Buoy S, Wang J, Woodman K, Lai S, Fuller C. Manual Therapy for Fibrosis-Related Late Effect Dysphagia in head and neck cancer survivors: the pilot MANTLE trial. BMJ Open 2021; 11:e047830. [PMID: 34348950 PMCID: PMC8340274 DOI: 10.1136/bmjopen-2020-047830] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Late dysphagia that develops or persists years after head and neck cancer (HNC) is a disabling survivorship issue. Fibrosis is thought to stiffen connective tissues and compress peripheral nerve tracts, thereby contributing to diminished strength, flexibility, and in some cases denervation of swallowing muscles. Manual therapy (MT) is used in cancer survivors for pain and other indications, but it is unknown if increasing blood flow, flexibility and cervical range of motion (CROM) in the head and neck may improve late dysphagia. METHODS AND ANALYSIS Manual Therapy for Fibrosis-Related Late Effect Dysphagia (MANTLE) is a National Cancer Institute-funded prospective single-arm pilot trial evaluating the feasibility, safety and therapeutic potential of MT in patients with late dysphagia after radiotherapy (RT) for HNC. Disease-free survivors ≥2 years after curative-intent RT for HNC with at least moderate dysphagia and grade ≥2 Common Terminology Criteria for Adverse Events version 4.0 fibrosis are eligible. The target sample size is 24 participants who begin the MANTLE programme. MANTLE is delivered in 10 MT sessions over 6 weeks with an accompanying home exercise programme (HEP). Patients then transition to a 6-week post-washout period during which they complete the HEP and then return for a final post-washout evaluation. Feasibility (primary endpoint) and safety will be examined. Serial assessments include CROM, modified barium swallow studies, quantitative MRI, electromyography (optional) and patient-reported outcomes as secondary, tertiary and exploratory endpoints. ETHICS AND DISSEMINATION The research protocol and informed consent document was approved by the Institutional Review Board at the University of Texas MD Anderson Cancer Center. Findings will be disseminated through peer-reviewed publication that will be made publicly available on PubMed Central on acceptance for publication, in compliance with NIH public access policy. TRIAL REGISTRATION NUMBER NCT03612531.
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Affiliation(s)
- Katherine Hutcheson
- Head and Neck Surgery, Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Holly McMillan
- Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carla Warneke
- Biostatics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christine Porsche
- Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kiara Savage
- Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sheila Buoy
- Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jihong Wang
- Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Karin Woodman
- Neurology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen Lai
- Head and Neck Surgery, Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Clifton Fuller
- Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Verla T, Vedantam A, North RY, Xu DS, Raber MR, Fuentes A, Liou NE, Ropper AE. Surgical Management of Post-Radiation, Dropped Head Spinal Deformity in Head and Neck Cancer Patients. World Neurosurg 2021; 156:e1-e8. [PMID: 34245881 DOI: 10.1016/j.wneu.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dropped head syndrome is a morbid condition, which affects daily functionality, causing pain and dysphagia and respiratory compromise. Reported causes of dropped head syndrome include neuromuscular disorders, iatrogenic from cervical spine surgery, idiopathic and post-radiation for head and neck cancers. Management of this spinal disorder remains challenging, as the complication rates are high. We present our series of 7 patients who underwent surgical correction of dropped head syndrome, all resulting from radiation for head and neck cancers. METHODS Retrospective review of 7 patients who underwent surgery between 2016 and 2019 for dropped head syndrome secondary to post-radiation cervical spine deformity. Clinical variables were obtained from medical records. Radiographic parameters pre- and post-surgery including T1 slope, sagittal vertical axis, and C2-7 cervical lordosis were examined. RESULTS Seven patients were included in the study, with an average age 69 years. Two patients underwent traction pre-operatively. Five patients had posterior fixation and fusion only and two patients had a combined anterior and posterior fixation and fusion. Overall, there was improvement in average pre/post-op SVA (6.96cm to 3.04cm), T1 slope (33.61o to 24.34o) and C2-7 lordosis (-21.65o to -0.03o). CONCLUSION Surgical correction of post-radiation dropped head spinal deformity involving anterior and posterior fixation with osteotomies provides improvement in functional and radiographic outcomes as shown in our series. These cases are technically challenging and have a high rate of peri-operative complications. Approaches must be tailored to the patient with attention to their specific surgical and radiation history.
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Affiliation(s)
- Terence Verla
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA.
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Robert Y North
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - David S Xu
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Michael R Raber
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Alfonso Fuentes
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
| | - Nelson Eddie Liou
- Bobby R. Alford Department of Otolaryngology, Baylor College of Medicine, 1977 Butler Blvd. Suite E5.200. Houston, TX 77030
| | - Alexander E Ropper
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge St, Suite 9A, Houston, TX 77030 USA
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10
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Saha B, Saha S, Chong WH. Middle-aged woman with dropped head syndrome due to remote exposure to mantle field radiation. BMJ Case Rep 2021; 14:14/5/e243725. [PMID: 33947683 PMCID: PMC8098936 DOI: 10.1136/bcr-2021-243725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Biplab Saha
- Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri, USA
| | - Santu Saha
- Internal Medicine, Bangladesh Medical College, Dhaka, Dhaka District, Bangladesh
| | - Woon Hean Chong
- Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York, USA
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11
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Ando J, Ueno Y, Yasuda H, Ando M, Edahiro Y, Honda T, Takanashi M, Taniguchi D, Hattori N, Komatsu N. Radiation-Induced Myopathy Developing in a Hodgkin Lymphoma Patient: An Autopsy Case with Systemic Muscle Sampling. Case Rep Oncol 2021; 14:338-342. [PMID: 33776726 PMCID: PMC7983573 DOI: 10.1159/000512070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022] Open
Abstract
Radiation-induced myopathy (RIM) is a rare complication occurring years after radiotherapy. RIM basically occurs within the irradiation field, but some cases have been reported to be accommodated by myopathy outside the irradiation field, and the actual extent of RIM is obscure. The presented case also showed decreased MMT scores and abnormal needle electromyography results in the muscles outside the irradiated field, and the patient was initially thought to have RIM both within and outside the irradiated field. However, while systemic postmortem muscle sampling revealed prominent myopathy in line with RIM in the irradiated muscles, only mild myogenic changes that could be explained by other causes such as age-related sarcopenia, radiculopathy, and disuse atrophy were observed in the non-irradiated muscles. The number of biopsy sites in live patients is limited due to the invasive nature of the procedure, but we were privileged to systemically evaluate the extent of myopathy through multiple muscle sampling including muscles both inside and outside of the irradiation field because this was an autopsy case. Through the presented case, we conclude that RIM is a phenomenon most probably limited to the muscles within the irradiated field, and myopathy outside the irradiation is due to other causes.
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Affiliation(s)
- Jun Ando
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hajime Yasuda
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Miki Ando
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoko Edahiro
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Tadahiro Honda
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Masashi Takanashi
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Daisuke Taniguchi
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
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Brodell JD, Sulovari A, Bernstein DN, Mongiovi PC, Ciafaloni E, Rubery PT, Mesfin A. Dropped Head Syndrome: An Update on Etiology and Surgical Management. JBJS Rev 2021; 8:e0068. [PMID: 32105239 DOI: 10.2106/jbjs.rvw.19.00068] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
» Dropped head syndrome is a group of disorders with diverse etiologies involving different anatomical components of the neck, ultimately resulting in a debilitating, flexible, anterior curvature of the cervical spine.
» Causes of dropped head syndrome include myasthenia gravis, amyotrophic lateral sclerosis, Parkinson disease, radiation therapy, and cumulative age-related changes. Idiopathic cases have also been reported.
» Nonoperative treatment of dropped head syndrome includes orthotic bracing and physical therapy.
» Surgical treatment of dropped head syndrome consists of cervical spine fusion to correct the deformity.
» The limited data available examining the clinical and radiographic outcomes of surgical intervention indicate a higher rate of complications with the majority having favorable outcomes in the long term.
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Affiliation(s)
- James D Brodell
- Departments of Orthopaedics and Rehabilitation (J.D.B., A.S., D.N.B., P.T.R., and A.M.) and Neurology (P.C.M. and E.C.), University of Rochester, Rochester, New York
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13
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Knowlton SE, Zheng M, Diamond Y, Yakaboski M, Ruppert LM. Bracing to treat dropped head syndrome in cancer patients: A retrospective review. JOURNAL OF PROSTHETICS AND ORTHOTICS : JPO 2021; 33:20-25. [PMID: 36186001 PMCID: PMC9524241 DOI: 10.1097/jpo.0000000000000285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Sasha E. Knowlton
- Rehabilitation Medicine Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mimi Zheng
- Department of Rehabilitation Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
- Department of Rehabilitation Medicine, New York-Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Yoni Diamond
- Hanger Clinic, Prosthetics and Orthotics, New York, NY
| | | | - Lisa M. Ruppert
- Rehabilitation Medicine Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY
- Department of Rehabilitation Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
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14
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Oishi T, Kogelschatz CJ, Young NP, Hoffmann EM, Staff NP, Visscher SL, Borah BJ, Krauss WE, Arumaithurai K, Shelly S, Ansell SM, Klein CJ. Expanded neuromuscular morbidity in Hodgkin lymphoma after radiotherapy. Brain Commun 2020; 2:fcaa050. [PMID: 32954302 PMCID: PMC7425393 DOI: 10.1093/braincomms/fcaa050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/26/2020] [Accepted: 04/02/2020] [Indexed: 12/30/2022] Open
Abstract
Our study aims to quantitate neuromuscular morbidity from radiotherapy in Hodgkin lymphoma including: (i) frequency and (ii) time of onsets for neurological localizations; (iii) degree of disabilities and (iv) number of clinical visits compared to cardiopulmonary Hodgkin lymphoma-radiation complications. Medical records from Mayo Health systems were retrieved; identifying neuromuscular radiation treated Hodgkin lymphoma-complications from 1 January 1994 to 31 December 2016. Of an estimated 4100 post-radiotherapy Hodgkin lymphoma patients, 4.6% (189) were identified with complications. Mean latency to physician visit for symptoms was 23.7 years (range: 1-50). Most commonly identified complications included: head drop 10% (19) with or without myopathy, myopathy 39% (73), plexopathy 29% (54), myelopathy 27% (51) and polyradiculopathy 13% (24). Other findings included benign and malignant nerve sheath tumours 5% (9), phrenic and long thoracic mononeuropathies 7% (14) and compressive spinal meningioma 2% (4). Patients frequently had multiple coexisting complications (single = 76% [144], double = 17% [33], triple = 4% [8], quadruple = 2% [4]). Cardiac 28% (53) and pulmonary 15% (29) complications were also seen in these patients. History of Hodgkin lymphoma was initially overlooked by neurologists (14.3%, 48/336 clinical notes). Hospital and outpatient visits for complications were frequent: neuromuscular 19% (77/411) versus cardiopulmonary 30% (125/411). Testing was largely exclusionary, except when imaging identified secondary malignancy. Modified Rankin score at diagnosis varied: 0-1 (55.8%), 2-3 (5.8%) and 4-5 (38.3%). Neuromuscular complications among post-radiation Hodgkin lymphoma are diverse, occurring in ∼1 of 20 having markedly delayed onsets often eluding diagnosis. Frequent care visits and major morbidity are common. Survivorship recommendations should recognize the diverse neurological complications.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Cory J Kogelschatz
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.,Intermountain Neurosciences Institute, Murray, UT 84107, USA
| | - Nathan P Young
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Nathan P Staff
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Sue L Visscher
- Center of the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Bijan J Borah
- Center of the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - William E Krauss
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
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15
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Witvoet EH, Wirtz PW. Dropped Head 30 Years After Mantle Field Radiation for Hodgkin Lymphoma: A Case Report. J Clin Neuromuscul Dis 2019; 21:121-122. [PMID: 31743259 DOI: 10.1097/cnd.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Elbert H Witvoet
- Department of Neurology, Hagaziekenhuis, Haga Teaching Hospital, the Hague, the Netherlands
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16
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Burakgazi AZ, Richardson PK, Abu-Rub M. Dropped head syndrome due to neuromuscular disorders: Clinical manifestation and evaluation. Neurol Int 2019; 11:8198. [PMID: 31579150 PMCID: PMC6763751 DOI: 10.4081/ni.2019.8198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 01/02/2023] Open
Abstract
In this article, we discuss the clinical approach to patients with dropped head syndrome and identify the various neuromuscular causes of dropped head syndrome including muscle, neuromuscular junction, peripheral nerve and motor neuron etiologies. We aim to increase awareness of recognition the entity of dropped head syndrome and factors that may predict response to immunomodulating therapy in dropped head syndrome.
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17
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Kim A, Stubblefield MD. The Role of the Headmaster Collar (Cervical) for Dropped Head Syndrome in Hodgkin Lymphoma Survivors. PM R 2019; 11:939-943. [PMID: 30801942 DOI: 10.1002/pmrj.12010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 11/04/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dropped head syndrome is a potential late neurologic complication of radiation therapy in survivors of Hodgkin lymphoma. There is limited evidence for conservative management of this condition. OBJECTIVE To discover patient utilization patterns of the commonly prescribed Headmaster Collar (cervical) in Hodgkin lymphoma survivors with radiation-induced dropped head syndrome. DESIGN Questionnaire-based retrospective observational study. SETTING Single-site academic cancer center. PATIENTS Twenty-six Hodgkin lymphoma survivors treated with radiation therapy involving the mantle who were prescribed a Headmaster Collar for dropped head syndrome. METHODS OR INTERVENTIONS Patients were interviewed by phone with a structured set of questions. MAIN OUTCOME MEASUREMENTS Compliance, patterns of use, individual modifications, and side effects of collar use. RESULTS Although 58% of patients who were prescribed a Headmaster Collar eventually discontinued its use, 62% of all patients used the collar for more than 6 months. The majority of users wore the collar for up to 3 hours per day, usually for static seated activities. Thirty-eight percent of patients made personal modifications to their collar, most commonly the addition of extra padding. All but one patient had complaints about the collar, most commonly discomfort, rigidity, and confinement. CONCLUSIONS The Headmaster Collar (cervical) is often utilized for a few hours a day, for longer than 6 months, to help with static seated activities. Insights from this study might help to improve future orthotic designs with better long-term compliance rates for the treatment of radiation-induced dropped head syndrome. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Arum Kim
- Clinical Instructor of Hematology-Oncology, Geriatric-Palliative Medicine, and Rehabilitation Medicine New York University School of Medicine, New York University Langone Medical Center, New York University Perlmutter Cancer Center, Rusk Institute of Rehabilitation Medicine, 160 East 34th Street, New York, NY, 10016
| | - Michael D Stubblefield
- Medical Director of Cancer Rehabilitation, Kessler Institute for Rehabilitation National Medical Director, ReVital Cancer Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ, 07052
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Briani C, Visentin A, Campagnolo M, Salvalaggio A, Ferrari S, Cavallaro T, Manara R, Gasparotti R, Piazza F. Peripheral nervous system involvement in lymphomas. J Peripher Nerv Syst 2019; 24:5-18. [PMID: 30556258 DOI: 10.1111/jns.12295] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/01/2018] [Accepted: 12/08/2018] [Indexed: 12/11/2022]
Abstract
The peripheral nervous system may be involved at any stage in the course of lymphoproliferative diseases. The different underlying mechanisms include neurotoxicity secondary to chemotherapy, direct nerve infiltration (neurolymphomatosis), infections, immune-mediated, paraneoplastic or metabolic processes and nutritional deficiencies. Accordingly, the clinical features are heterogeneous and depend on the localization of the damage (ganglia, roots, plexi, and peripheral nerves) and on the involved structures (myelin, axon, and cell body). Some clinical findings, such a focal or diffuse involvement, symmetric or asymmetric pattern, presence of pain may point to the correct diagnosis. Besides a thorough medical history and neurological examination, neurophysiological studies, cerebrospinal fluid analysis, nerve biopsy (in selected patients with suspected lymphomatous infiltration) and neuroimaging techniques (magnetic resonance neurography and nerve ultrasound) may be crucial for a proper diagnostic workup.
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Affiliation(s)
- Chiara Briani
- Department of Neuroscience, University of Padova, Padova, Italy
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Sergio Ferrari
- Department of Neurology, Azienda Ospedaliera Universitaria Integrata, University Hospital G.B. Rossi, Verona, Italy
| | - Tiziana Cavallaro
- Department of Neurology, Azienda Ospedaliera Universitaria Integrata, University Hospital G.B. Rossi, Verona, Italy
| | - Renzo Manara
- Neuroradiology, Department of Medicine and Surgery, University of Salerno, Fisciano, Italy
| | - Roberto Gasparotti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
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Di Stefano V, Attanasi C, Ferrante C, Di Muzio A. Late onset of dropped head syndrome following mantle radiation therapy for Hodgkin lymphoma. BMJ Case Rep 2018; 11:11/1/e226822. [PMID: 30567263 DOI: 10.1136/bcr-2018-226822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Dropped head syndrome (DHS) is a rare condition, characterised by weakness of the cervical paraspinal muscles with sagging of the head. It is usually seen in association with neurological disorders and rarely can follow radiotherapy. We report a case of a 54-year-old man survivor of Hodgkin lymphoma (HL), who developed DHS 28 years after radiotherapy. He was referred to our department due to progressive weakness and atrophy of cervical paraspinal and shoulder girdle musculature. Physical and neurophysiological examination, electromyography and MRI confirmed the diagnosis of DHS. In the following years, there was no progression of symptoms.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical sciences, "G. d' Annunzio" University, Chieti, Italy
| | - Carmine Attanasi
- Centro regionale Sant'Alessio - "Margherita di Savoia per i ciechi", Roma, Italy
| | - Camilla Ferrante
- Department of Neuroscience, Imaging and Clinical sciences, "G. d' Annunzio" University, Chieti, Italy
| | - Antonio Di Muzio
- Department of Neurology, "SS Annunziata" hospital, Chieti, Italy
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20
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The Changing Role of Electrodiagnostic Testing in Cancer Rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0180-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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21
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Kaido M, Yuasa Y, Ikeda H. [A survivor of Hodgkin lymphoma manifesting dropped head syndrome as a late-onset complication of radiotherapy: a case report]. Rinsho Shinkeigaku 2018; 58:308-313. [PMID: 29710025 DOI: 10.5692/clinicalneurol.cn-001158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 50-year-old female survivor of Hodgkin lymphoma (HL), who developed dropped head syndrome (DHS). The patient was diagnosed with HL at 20 years of age, and underwent chemo-radiotherapy, which led to complete remission. Undergoing supplemental therapy for post-radiation hypothyroidism, she had twin babies. She noticed white stains on her neck at the age of 30, and the decolored area gradually expanded. Sixteen years after the radiotherapy (RT), her posterior neck muscle strength began to decline. She had to make considerable efforts to keep her neck straight, and came to experience a severe pain in the neck and shoulders. The patient visited our department due to DHS at the age of 50. She had leukoderma, muscle weakness, and muscle atrophy in the neck and para-spinal region, which were consistent with the area of RT. The strength was preserved in the other parts of the muscle, including the proximal upper limbs. Sensory nerve disorder was not detected. The serum creatine kinase level was slightly elevated. Cervical spine or cervical cord disease that can cause DHS was not detected by MRI examination. The MRI and CT images revealed marked atrophy in the posterior neck and para-spinal muscles. The electromyogram revealed myopathic changes, and the cause of her DHS was diagnosed as radiation-induced myopathy. DHS is a well-known late-onset radiation injury, and Japanese cases have been reported in elderly persons with laryngeal or lung cancer. However, there have been no Japanese case reports of radiation-induced DHS due to RT against HL in younger persons. The patient had visited several clinics and hospitals before she came to our hospital, but RT-induced DHS had been overlooked. Greater recognition and consideration is required for DHS as one of the various issues arising after long passage of HL survivors.
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Affiliation(s)
- Misako Kaido
- Department of Neurology, Sakai City Medical Center
| | | | - Hiroshi Ikeda
- Department of Radiotherapy, Sakai City Medical Center
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22
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Dropped head syndrome with proximal myopathy revealing AL amyloidosis. Joint Bone Spine 2018; 85:779-781. [PMID: 29653282 DOI: 10.1016/j.jbspin.2018.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 03/04/2018] [Indexed: 11/22/2022]
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23
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Myofascial Release and Muscle Retraining for Dropped Head Syndrome Attributed to Radiation Fibrosis in Hodgkin Lymphoma: A Case Series. REHABILITATION ONCOLOGY 2017. [DOI: 10.1097/01.reo.0000000000000065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Abstract
With numerous advancements in early detection and multimodal therapy, cancer has become a chronic disease. As the number of cancer survivors continues to increase, physiatrists and other neuromuscular disease specialists are more likely to encounter individuals with residual impairments, disabilities, and/or handicaps resulting from cancer or related treatments. The patient with cancer is especially prone to injury directed at the peripheral nervous system at multiple anatomic levels. Electrodiagnosis is an invaluable tool in the evaluation of neuromuscular disorders in this patient population.
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25
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Cauchi M, Marsh E. A practical approach to the patient presenting with dropped head. Pract Neurol 2016; 16:445-451. [DOI: 10.1136/practneurol-2016-001450] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 11/04/2022]
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26
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Grisold W, Grisold A, Löscher WN. Neuromuscular complications in cancer. J Neurol Sci 2016; 367:184-202. [PMID: 27423586 DOI: 10.1016/j.jns.2016.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/08/2016] [Accepted: 06/01/2016] [Indexed: 12/11/2022]
Abstract
Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.
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Affiliation(s)
- W Grisold
- Department of Neurology, Kaiser Franz Josef Hospital, Vienna, Austria.
| | - A Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - W N Löscher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Florczynski MM, Sanatani MS, Mai L, Fisher B, Moulin DE, Cao J, Louie AV, Pope JE, Leung E. Severe myositis of the hip flexors after pre-operative chemoradiation therapy for locally advanced rectal cancer: case report. BMC Cancer 2016; 16:243. [PMID: 27000107 PMCID: PMC4802822 DOI: 10.1186/s12885-016-2269-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/10/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The use of neoadjuvant radiation therapy and chemotherapy in the treatment of locally advanced rectal adenocarcinoma has been shown to reduce disease recurrence when combined with surgery and adjuvant chemotherapy. We report a case of a patient who developed a debilitating bilateral myopathy of the hip flexors after successful treatment for rectal cancer. To the best of our knowledge, this is the first such complication from radiation therapy reported in a patient with colorectal cancer. The disproportionate severity of our patient's myopathy relative to the dose of radiation used also makes this case unique among reports of neuromuscular complications from radiation therapy. CASE PRESENTATION The patient is a 65-year-old male with node negative, high-grade adenocarcinoma of the rectum penetrating through the distal rectal wall. He underwent neoadjuvant concurrent pelvic radiation therapy and capecitabine-based chemotherapy, followed by abdominoperineal resection and post-operative FOLFOX chemotherapy. Five months post-completion of pelvic radiotherapy and 2 months after the completion of adjuvant chemotherapy, he presented with bilateral weakness of the iliopsoas muscles and severe pain radiating to the groin. The patient improved with 40 mg/d of prednisone, which was gradually tapered to 2 mg/d over 6 months, with substantial recovery of muscle strength and elimination of pain. CONCLUSIONS The timing, presentation and response of our patient's symptoms to corticosteroids are most consistent with a radiation recall reaction. Radiation recall is a phenomenon whereby previously irradiated tissue becomes vulnerable to toxicity by subsequent systemic therapy and is rarely associated with myopathies. Radiation recall should be considered a potential complication of neoadjuvant radiation therapy for rectal cancer, and for ongoing research into the optimization of treatment for these patients. Severe myopathies caused by radiation recall may be fully reversible with corticosteroid treatment.
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Affiliation(s)
- Matthew M Florczynski
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael S Sanatani
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lauren Mai
- Departments of Neurology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Barbara Fisher
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Dwight E Moulin
- Departments of Neurology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jeffrey Cao
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Alexander V Louie
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Janet E Pope
- Departments of Rheumatology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Eric Leung
- Departments of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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Inaba K, Nakamura S, Okamoto H, Kashihara T, Kobayashi K, Harada K, Kitaguchi M, Sekii S, Takahashi K, Murakami N, Ito Y, Igaki H, Uno T, Itami J. Early-onset dropped head syndrome after radiotherapy for head and neck cancer: dose constraints for neck extensor muscles. JOURNAL OF RADIATION RESEARCH 2016; 57:169-173. [PMID: 26684338 PMCID: PMC4795943 DOI: 10.1093/jrr/rrv055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/23/2015] [Accepted: 08/15/2015] [Indexed: 06/05/2023]
Abstract
Dropped head syndrome (DHS) is a famous but unusual late complication of multimodality treatment for head and neck carcinoma. We reported this early-onset complication and analyzed the dose to the neck extensor muscles. We examined the records of three patients with DHS after radiotherapy. The doses to the neck extensor muscles were compared between three patients with DHS and nine patients without DHS. The mean dose to the neck extensor muscles of the three patients with DHS were 58.5 Gy, 42.3 Gy and 60.9 Gy, while the dose was <50 Gy in all nine patients in the control group. The onset of this syndrome was 5 months, 6 months and 15 months. The early-onset DHS may have something to do with dose to the neck extensor muscles. The proposed dose to the neck extensor muscles might be <46 Gy (or at least <50 Gy).
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Affiliation(s)
- Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Satoshi Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Hiroyuki Okamoto
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Kazuma Kobayashi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Ken Harada
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Mayuka Kitaguchi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Shuhei Sekii
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8670, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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Stone JB, DeAngelis LM. Cancer-treatment-induced neurotoxicity--focus on newer treatments. Nat Rev Clin Oncol 2015; 13:92-105. [PMID: 26391778 DOI: 10.1038/nrclinonc.2015.152] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neurotoxicity caused by traditional chemotherapy and radiotherapy is widely recognized in patients with cancer. The adverse effects of newer therapeutics, such as biological and immunotherapeutic agents, are less well established, and are associated with considerable neurotoxicity in the central and peripheral nervous systems. This Review addresses the main neurotoxicities of cancer treatment with a focus on the newer therapeutics. Recognition of these patterns of toxicity is important because drug discontinuation or dose adjustment might prevent further neurological injury. Knowledge of these toxicities also helps to differentiate treatment-related symptoms from progression of cancer or its involvement of the nervous system. Familiarity with the neurological syndromes associated with cancer treatments enables clinicians to use the appropriate treatment for the underlying malignancy while minimizing the risk of neurological damage, which might preserve patients' quality of life.
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Affiliation(s)
- Jacqueline B Stone
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Seidel C, Kuhnt T, Kortmann RD, Hering K. Radiation-induced camptocormia and dropped head syndrome: Review and case report of radiation-induced movement disorders. Strahlenther Onkol 2015; 191:765-70. [PMID: 26072168 DOI: 10.1007/s00066-015-0857-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/13/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND In recent years, camptocormia and dropped head syndrome (DHS) have gained attention as particular forms of movement disorders. Camptocormia presents with involuntary forward flexion of the thoracolumbar spine that typically increases during walking or standing and may severely impede walking ability. DHS is characterized by weakness of the neck extensors and a consecutive inability to extend the neck; in severe cases the head is fixed in a "chin to chest position." Many diseases may underlie these conditions, and there have been some reports about radiation-induced camptocormia and DHS. METHODS A PubMed search with the keywords "camptocormia," "dropped head syndrome," "radiation-induced myopathy," "radiation-induced neuropathy," and "radiation-induced movement disorder" was carried out to better characterize radiation-induced movement disorders and the radiation techniques involved. In addition, the case of a patient developing camptocormia 23 years after radiation therapy of a non-Hodgkin's lymphoma of the abdomen is described. RESULTS In total, nine case series of radiation-induced DHS (n = 45 patients) and-including our case-three case reports (n = 3 patients) about radiogenic camptocormia were retrieved. Most cases (40/45 patients) occurred less than 15 years after radiotherapy involving extended fields for Hodgkin's disease. CONCLUSION The use of wide radiation fields including many spinal segments with paraspinal muscles may lead to radiation-induced movement disorders. If paraspinal muscles and the thoracolumbar spine are involved, the clinical presentation can be that of camptocormia. DHS may result if there is involvement of the cervical spine. To prevent these disorders, sparing of the spine and paraspinal muscles is desirable.
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Affiliation(s)
- Clemens Seidel
- Department of Radiotherapy and Radiation Oncology, Leipzig University, Stephanstrasse 9a, 04103, Leipzig, Germany.
| | - Thomas Kuhnt
- Department of Radiotherapy and Radiation Oncology, Leipzig University, Stephanstrasse 9a, 04103, Leipzig, Germany
| | - Rolf-Dieter Kortmann
- Department of Radiotherapy and Radiation Oncology, Leipzig University, Stephanstrasse 9a, 04103, Leipzig, Germany
| | - Kathrin Hering
- Department of Radiotherapy and Radiation Oncology, Leipzig University, Stephanstrasse 9a, 04103, Leipzig, Germany
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Ghosh PS, Milone M. Clinical and laboratory findings of 21 patients with radiation-induced myopathy. J Neurol Neurosurg Psychiatry 2015; 86:152-8. [PMID: 24838910 DOI: 10.1136/jnnp-2013-307447] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Limited data are available on radiation-induced myopathy (RIM) in adult cancer survivors. METHODS We retrospectively reviewed the clinical, electrophysiological, serological, radiological and pathological findings of patients with RIM seen in the neurology clinic over a 11-year period (2002-2013). RESULTS Out of 251 patients with radiotherapy-induced neuromuscular complications, 21 had RIM (11 men and 10 women). Cancers included: Hodgkin's lymphoma (13), non-Hodgkin's lymphoma (one), pinealoblastoma (one), tongue (two), nasopharyngeal (one), thyroid (one) and testicular cancer (two). Various radiotherapy protocols were used but all patients received neck and upper torso radiation. The mean latency between radiation exposure and onset of RIM was 15 years (range 2-45 years). The most common presentation was head drop (43%) followed by neck pain (38%). Axial (86%) and periscapular (81%) muscle weakness and atrophy were frequent findings. Two patients died in follow-up from hypercapnic respiratory failure secondary to neuromuscular weakness. Serum creatine kinase values were usually normal or slightly elevated. EMG revealed predominantly myopathic changes in the axial and periscapular muscles. Half of the muscle biopsies (6/12) showed myopathic changes; increased connective tissue elements were observed in seven of eight muscle biopsies performed in the irradiated field; and mitochondrial dysfunction in two. CONCLUSIONS RIM is a potential long-term neuromuscular adverse effect of radiation exposure in Hodgkin's disease and other types of cancer manifesting predominantly as head drop and can be fatal due to neuromuscular respiratory failure. Improved radiotherapy protocols might reduce the risk of RIM and other radiation-induced neuromuscular complications.
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Affiliation(s)
- Partha S Ghosh
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Wilson CL, Gawade PL, Ness KK. Impairments that influence physical function among survivors of childhood cancer. CHILDREN (BASEL, SWITZERLAND) 2015; 2:1-36. [PMID: 25692094 PMCID: PMC4327873 DOI: 10.3390/children2010001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/18/2014] [Indexed: 11/29/2022]
Abstract
Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.
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Affiliation(s)
- Carmen L. Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MS-735 Memphis, TN 38105, USA; E-Mails: (P.L.G.); (K.K.N.)
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Pedicle subtraction osteotomy for the treatment of chin-on-chest deformity in a post-radiotherapy dropped head syndrome: a case report and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 6:634-43. [PMID: 25217239 DOI: 10.1007/s00586-014-3544-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/03/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Chin-on-chest deformity is a rare and severe condition mostly related with ankylosing spondylitis, traumas and/or cervical spine surgery. We present a case of 69 years old woman with a rare form of chin-on-chest secondary to dropped head syndrome (DHS), developed after radiotherapy for Hodgkin disease. In addition, we reviewed the few publications about this specific condition; management and surgical treatment of DHS are discussed. METHODS We performed a pedicle subtraction osteotomy (PSO) and stabilization through a posterior approach. Intraoperative monitoring using motor and somatosensory evoked potentials and wake-up test were carried out. RESULTS At 19th month follow-up, the patient reported a significant improvement of cervical pain, dysphagia and respiratory difficulty and a complete restoration of the neurological impairment. The achieved correction was successful and the patient was very satisfied by the restoration of forward gaze. CONCLUSIONS DHS is a very rare post-radiotherapy complication; there is lack of evidences in literature about its management. The only definitive treatment seems to be surgical intervention. PSO is a valid therapeutic option when fixed chin-on-chest deformity occurs; although it is a demanding technique and it presents high rate of complications, the actual neurological monitoring methods provide more intraoperative safety.
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Bevevino AJ, Helgeson MD, Albert TJ. Iatrogenic spinal instability: Cervical and thoracic spine. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.semss.2013.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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35
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Head drop syndrome secondary to multimodality treatments for head and neck cancer. Laryngoscope 2013; 123:938-41. [DOI: 10.1002/lary.23857] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/26/2012] [Accepted: 10/08/2012] [Indexed: 11/07/2022]
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Abstract
Although the peripheral nerve has often been considered as radioresistant, clinical practice demonstrates the occurrence of radiation-induced peripheral neuropathies. Because these complications appear late, usually several years after the course of radiotherapy, their occurrence is explained by improvement in the prognosis of several cancers. Their physiopathology is not fully understood. Compression by radio-induced fibrosis probably plays a central role but direct injury to nerves and blood vessels is probably also involved. The most frequent and best known form of postradiation neuropathy is brachial plexopathy, which may follow irradiation for breast cancer. Recent reports demonstrate that postradiation neuropathies show a great heterogeneity, particularly in the anatomical sites, but also in the clinical, electrophysiological, and neuroimaging features. The link with radiotherapy may be difficult for the clinician to establish. Patients with radiation-induced lumbosacral radiculoplexopathy may be misdiagnosed with amyotrophic lateral sclerosis as they often present with pure lower motor neuron syndrome, or with leptomeningeal metastases since nodular MRI enhancement of the nerve roots of the cauda equina and increased CSF protein content can be observed. From a pathophysiological perspective, radiation-induced neuropathy offers an interesting model for deciphering the mechanisms of peripheral neuropathies due to environmental factors. Recent developments show promising strategies for the prevention and treatment of these complications, which have a considerable impact on a patient's quality of life.
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Schlienger M, Ferroir JP, Huguet F, Deluen F, Pène F, Marseguerra R, Touboul E. [Dropped Head Syndrome after whiplash injury in a patient treated for a Hodgkin's lymphoma by mantle field radiotherapy]. Cancer Radiother 2012; 17:44-9. [PMID: 23219138 DOI: 10.1016/j.canrad.2012.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 10/13/2012] [Accepted: 10/18/2012] [Indexed: 10/27/2022]
Abstract
The authors report a case of Dropped Head Syndrome with an unusually rapid onset after an accident in a patient with a history of Hodgkin's lymphoma cured by chemotherapy and mantle field radiotherapy and compare this case to the rare published cases of chronic Dropped Head Syndrome occurring after this type of treatment. A 56-year-old man was treated at the age 36 years for supra-diaphragmatic Hodgkin's lymphoma by chemotherapy and mantle field radiotherapy according to a standard technique and standard doses (40Gy, 20 fractions, 27 days). Seventeen years after the end of treatment, he experienced a violent whiplash injury, rapidly followed by a Dropped Head Syndrome, similar to the cases of chronic Dropped Head Syndrome already described in the context of Hodgkin's lymphoma (permanent flexion of the head, only reduced in the supine position). Physical and neurophysiological examination, electromyogram, and magnetic resonance imaging confirmed the diagnosis of Dropped Head Syndrome. Very few treatment options are available for the major disability related to Dropped Head Syndrome. This type of subacute onset of Dropped Head Syndrome has not been previously described. The good results of radiation therapy after chemotherapy allow a dose reduction to 30Gy in the involved regions. This, together with recent progress in treatment planning, should allow eradication of these complications.
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Affiliation(s)
- M Schlienger
- Service d'oncologie radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
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Hashimoto Y, Maebayashi K, Izumi S, Motegi A, Mitsuhashi N. Dropped Head Syndrome Induced by Chemoradiotherapy for Nasopharyngeal Carcinoma: A Case Report. Jpn J Clin Oncol 2012; 42:1091-3. [DOI: 10.1093/jjco/hys135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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[Radiation-induced neuropathies: collateral damage of improved cancer prognosis]. Rev Neurol (Paris) 2012; 168:939-50. [PMID: 22742890 DOI: 10.1016/j.neurol.2011.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 10/28/2011] [Accepted: 11/28/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Because of the improvement of cancer prognosis, long-term damages of treatments become a medical and public health problem. Among the iatrogenic complications, neurological impairment is crucial to consider since motor disability and pain have a considerable impact on quality of life of long cancer survivors. However, radiation-induced neuropathies have not been the focus of great attention. The objective of this paper is to provide an updated review about the radiation-induced lesions of the peripheral nerve system. STATE OF THE ART Radiation-induced neuropathies are characterized by their heterogeneity in both symptoms and disease course. Signs and symptoms depend on the affected structures of the peripheral nerve system (nerve roots, nerve plexus or nerve trunks). Early-onset complications are often transient and late complications are usually progressive and associated with a poor prognosis. The most frequent and well known is delayed radiation-induced brachial plexopathy, which may follow breast cancer irradiation. Radiation-induced lumbosacral radiculoplexopathy is characterized by pure or predominant lower motor neuron signs. They can be misdiagnosed, confused with amyotrophic lateral sclerosis (ALS) or with leptomeningeal metastases since nodular MRI enhancement of the nerve roots of the cauda equina and increased cerebrospinal fluid protein content can be observed. In the absence of specific markers of the link with radiotherapy, the diagnosis of post-radiation neuropathy may be difficult. Recently, a posteriori conformal radiotherapy with 3D dosimetric reconstitution has been developed to link a precise anatomical site to unexpected excess irradiation. PERSPECTIVES AND CONCLUSION The importance of early diagnosis of radiation-induced neuropathies is underscored by the emergence of new disease-modifying treatments. Although the pathophysiology is not fully understood, it is already possible to target radiation-induced fibrosis but also associated factors such as ischemia, oxidative stress and inflammation. A phase III trial evaluating the association of pentoxifylline, tocopherol and clodronate (PENTOCLO, NCT01291433) in radiation-induced neuropathies is now recruiting.
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Chen AB, Feng Y, Neuberg D, Recklitis C, Diller LR, Mauch PN, Ng AK. Employment and insurance in survivors of Hodgkin lymphoma and their siblings: a questionnaire study. Leuk Lymphoma 2012; 53:1474-80. [DOI: 10.3109/10428194.2012.660629] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Progressive Muscle Atrophy and Weakness After Treatment by Mantle Field Radiotherapy in Hodgkin Lymphoma Survivors. Int J Radiat Oncol Biol Phys 2012; 82:612-8. [DOI: 10.1016/j.ijrobp.2010.11.064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 11/01/2010] [Accepted: 11/02/2010] [Indexed: 12/14/2022]
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Abstract
Although direct neoplastic involvement of muscle tis-sue is surprisingly rare, considering the large amount of body mass that is represented by muscle tissue, the most important and unresolved muscle effect is muscle cachexia.Other associations, such as inflammatory, paraneo-plastic, toxic, and several extremely rare associations,have been described. Drug-induced toxicity and radiation recall syndrome need to be taken into consideration when muscle symptoms appear in patients with cancer.
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Radiation Fibrosis Syndrome: Neuromuscular and Musculoskeletal Complications in Cancer Survivors. PM R 2011; 3:1041-54. [DOI: 10.1016/j.pmrj.2011.08.535] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 07/13/2011] [Accepted: 08/18/2011] [Indexed: 11/16/2022]
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Chuquilin M, Al-Lozi M. Primary amyloidosis presenting as "dropped head syndrome". Muscle Nerve 2011; 43:905-9. [PMID: 21607974 DOI: 10.1002/mus.22049] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A 77-year-old man, with a history of lymphoma, presented with isolated neck extensor weakness and a 2-year history of bilateral carpal tunnel syndrome (CTS). Needle electromyography showed myopathic changes, and biopsy of cervical paraspinal muscles showed amyloid deposition in blood vessels. Amyloidosis should be considered in the differential diagnosis of dropped head syndrome.
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Affiliation(s)
- Miguel Chuquilin
- Department of Neurology, Washington University, 660 South Euclid Avenue, Box 8111, St. Louis, Missouri 63110, USA
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Late onset radiation-induced camptocormia. J Neurol 2011; 258:1723-5. [PMID: 21431379 DOI: 10.1007/s00415-011-5997-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 03/02/2011] [Accepted: 03/03/2011] [Indexed: 10/18/2022]
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Hodgkin's Lymphoma: A Review of Neurologic Complications. Adv Hematol 2010; 2011:624578. [PMID: 20975772 PMCID: PMC2957132 DOI: 10.1155/2011/624578] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 08/26/2010] [Indexed: 12/18/2022] Open
Abstract
Hodgkin's lymphoma is a hematolymphoid neoplasm, primarily of B cell lineage, that has unique histologic, immunophenotypic, and clinical features. Neurologic complications of Hodgkin's Lymphoma can be separated into those that result directly from the disease, indirectly from the disease, or from its treatment. Direct neurologic dysfunction from Hodgkin's Lymphoma results from metastatic intracranial spinal disease, epidural metastases causing spinal cord/cauda equina compression, leptomeningeal metastases, or intradural intramedullary spinal cord metastases. Indirect neurologic dysfunction may be caused by paraneoplastic disorders (such as paraneoplastic cerebellar degeneration or limbic encephalitis) and primary angiitis of the central nervous system. Hodgkin's lymphoma treatment typically includes chemotherapy or radiotherapy with potential treatment-related complications affecting the nervous system. Neurologic complications resulting from mantle-field radiotherapy include the “dropped head syndrome,” acute brachial plexopathy, and transient ischemic attacks/cerebral infarcts. Chemotherapy for Hodgkin's lymphoma may cause cerebral infarction (due to emboli from anthracycline-induced cardiomyopathy) and peripheral neuropathy.
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APPELS CATHELIJNE, GOEKOOP ROBBERT. Dropped-head Syndrome Due to High-dose Irradiation: Figure 1. J Rheumatol 2009; 36:2316. [DOI: 10.3899/jrheum.090175] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW To conduct a critical review of recent data pertaining to the clinical and therapeutic aspects of peripheral neuropathies in the setting of malignancies, with the exception of paraproteinemic neuropathies. Our search extended to the past 2 years, using a PubMed search strategy. RECENT FINDINGS In the field of neuropathies linked with the development of the cancer, recent works have focused on lymphoma and cancer-associated vasculitides. In paraneoplastic syndromes, the major fact of the past 2 years is the issue of guidelines for diagnosis and treatment of these disorders, under the aegis of the paraneoplastic syndromes Euronetwork and of the European Federation of Neurological Sciences. When considering chemotherapy, neurotoxicity is becoming increasingly better known. Finally, the spectrum of late-delayed complications of irradiation further increases with a better clinical characterization of radiotherapy-induced dropped head syndrome. SUMMARY This article successively reviews the results of the recent studies in these various fields. In the field of chemotherapy, we will particularly focus on some new data concerning oxaliplatin, bortezomib, the albumin-bound form of paclitaxel and lenalidomide.
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