Radiation Recall Phenomenon Following COVID-19 Vaccination

AGIHO guideline on evidence-based management of COVID-19 in cancer patients: 2022 update on vaccination, pharmacological prophylaxis and therapy in light of the omicron variants

The novel coronavirus SARS-CoV-2 and the associated infectious disease COVID-19 pose a significant challenge to healthcare systems worldwide. Patients with cancer have been identified as a high-risk population for severe infections, rendering prophylaxis and treatment strategies for these patients particularly important. Rapidly evolving clinical research, resulting in the recent advent of various vaccines and therapeutic agents against COVID-19, offers new options to improve care and protection of cancer patients. However, ongoing epidemiological changes and rise of new virus variants require repeated revisions and adaptations of prophylaxis and treatment strategies to meet these new challenges. Therefore, this guideline provides an update on evidence-based recommendations with regard to vaccination, pharmacological prophylaxis and treatment of COVID-19 in cancer patients in light of the currently dominant omicron variants. It was developed by an expert panel of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) based on a critical review of the most recent available data.

Drug-induced radiation recall reactions and non-anticancer drugs: A descriptive analysis from VigiBase®

Radiation recall reactions are inflammatory reactions confined to previously irradiated tissues, often of drug-induced etiology, particularly with anticancer therapies. Other drugs, in particular COVID-19 vaccines, may also be involved. To describe radiation recall reactions under non-anticancer drugs more precisely, we extracted the cases of radiation recall reactions associated with non-anticancer drugs from WHO pharmacovigilance database VigiBase®. We performed two analyses from this extraction: a global analysis and an analysis focusing on vaccination-related issues. We extracted 120 cases corresponding to 269 drugs, of which 130 were non-anticancer (22 vaccines). Among the non-anticancer drugs, tozinameran was the most reported treatment (4.46% of cases), followed by levofloxacin (2.97%) and folinic acid (2.60%), dexamethasone (2.23), and ChAdOx1 nCoV-19 vaccine and prednisone (1.86% each). Among vaccines, tozinameran (54.55% of cases) was the most reported, followed by ChAdOx1 nCoV-19 (22.73%), HPV and inactivated influenza vaccine (9.09% each), and elasomeran (4.55%). Our study first describes the occurrence of radiation recall reactions during non-anticancer treatment. It also highlights a potential safety signal with COVID-19 vaccines.

The Interplay of Lung Cancer, COVID-19, and Vaccines

Patients with cancer are more susceptible to a higher risk of coronavirus infection and its severe complications than the general population. In addition, these patients were not included in the pivotal clinical trials for COVID-19 vaccines. Therefore, considerable uncertainty remains regarding the management of cancer patients during the COVID-19 pandemic and the safety of COVID-19 vaccinations in cancer patients. In this review, we summarize the current knowledge generated from the beginning of the COVID-19 pandemic on the vulnerability of cancer patients to the coronavirus disease, as well as the effectiveness of COVID-19 vaccines in this population. We also discuss the available data on the effects of anticancer treatment with immune checkpoint inhibitors on the immune responses to SARS-CoV-2 in cancer patients. Special attention in this review will be given to patients with lung cancer, as such patients are at an increased risk for severe effects from COVID-19.

Global prevalence and clinical manifestations of cutaneous adverse reactions following COVID-19 vaccination: A systematic review and meta-analysis

Although vaccination is widely accepted as an effective method of preventing and controlling the COVID-19 pandemic, many people are concerned about possible cutaneous side-effects, which can delay or prevent them from being vaccinated. The objectives of this systematic review were to assess the global prevalence and clinical manifestations of cutaneous adverse reactions following COVID-19 vaccination. PubMed and Scopus databases were searched for articles published from 1 January 2019 to 31 December 2021, and reference lists for each selected article were screened. Case reports, case series, observational studies and randomized controlled trials that provided information on cutaneous adverse reactions following COVID-19 vaccines were included. A total of 300 studies were included in a systematic review of which 32 studies with 946 366 participants were included in the meta-analysis. The pooled prevalence of cutaneous manifestations following COVID-19 vaccination was 3.8% (95% CI, 2.7%-5.3%). COVID-19 vaccines based on the mRNA platform had a higher prevalence than other platforms at 6.9% (95% CI, 3.8%-12.3%). Various cutaneous manifestations have been reported from injection site reactions, which were the most common (72.16%) to uncommon adverse reactions such as delayed inflammatory reactions to tissue filler (0.07%) and flares of pre-existing dermatoses (0.07%). Severe cutaneous reactions such as anaphylaxis have also been reported, but in rare cases (0.05%). In conclusion, cutaneous adverse reactions are common, especially in those receiving mRNA vaccines. Most reactions are mild and are not contraindications to subsequent vaccination except for anaphylaxis, which rarely occurs. COVID-19 vaccination may also be associated with flares of pre-existing dermatoses and delayed inflammatory reactions to tissue filler. Patients with a history of allergies, pre-existing skin conditions or scheduled for filler injections should receive additional precounselling and monitoring. A better understanding of potential side-effects may strengthen public confidence in those wary of new vaccine technologies.

SARS-CoV-2 Infection and Vaccination Cutaneous Manifestations for the Inpatient Dermatologist

Purpose of Review

The overall purpose of this review was to characterize and summarize cutaneous eruptions associated with coronavirus disease 2019 (COVID-19) as well as COVID-19 vaccination.

Recent Findings

Cutaneous eruptions associated with COVID-19 infection have a reported frequency of 1-20%. Increased COVID-19 disease severity has been associated with morbilliform exanthems, urticaria, retiform purpura, and livedo racemosa. Papulovesicular eruptions were associated with a milder COVID-19 disease course. A range of dermatoses have also been reported with COVID-19 vaccination but have rarely prevented subsequent vaccination.

Summary

Dermatologists should be aware of the associations between COVID-19 disease severity and cutaneous eruptions. Livedo racemosa and retiform purpura are particularly associated with increased disease severity and death. In the setting of COVID-19 vaccination, cutaneous eruptions can largely be managed symptomatically and very rarely do these reactions prevent subsequent vaccination.

Strategies for Cardio-Oncology Care During the COVID-19 Pandemic

Purpose of review

The COVID-19 pandemic has disrupted healthcare and has disproportionately affected the marginalized populations. Patients with cancer and cardiovascular disease (cardio-oncology population) are uniquely affected. In this review, we explore the current data on COVID-19 vulnerability and outcomes in these patients and discuss strategies for cardio-oncology care with a focus on healthcare innovation, health equity, and inclusion.

Recent findings

The growing evidence suggest increased morbidity and mortality from COVID-19 in patients with comorbid cancer and cardiovascular disease. Additionally, de novo cardiovascular complications such as myocarditis, myocardial infarction, arrhythmia, heart failure, and thromboembolic events have increasingly emerged, possibly due to an accentuated host immune response and cytokine release syndrome.

Summary

Patient-centric policies are helpful for cardio-oncology surveillance like remote monitoring, increased use of biomarker-based surveillance, imaging modalities like CT scan, and point-of-care ultrasound to minimize the exposure for high-risk patients. Abundant prior experience in cancer therapy scaffolded the repurposed use of corticosteroids, IL-6 inhibitors, and Janus kinase inhibitors in the treatment of COVID-19 infection. COVID-19 vaccine timing and dose frequency present a challenge due to overlapping toxicities and immune cell depletion in patients receiving cancer therapies. The SARS-CoV-2 pandemic laid bare social and ethnic disparities in healthcare but also steered in innovation to combat problems of patient outreach, particularly with virtual care. In the recovery phase, the backlog in cardio-oncology care, interplay of cancer therapy-related side effects, and long COVID-19 syndrome are crucial issues to address.

COVID-19 vaccine-induced recurrence of the radiation recall phenomenon in the laryngeal mucosa due to a VEGF inhibitor

Purpose

The radiation recall phenomenon (RRP) is a rare and unexpected late complication of radiation therapy (RT). Although predominantly in the skin, RRP of the upper respiratory tract has also been reported. In general, RRP is caused by anticancer agents, and the COVID-19 vaccine has also been reported to cause RRP in recent years.

Methods and Materials

A 50-year-old woman who had received RT around the larynx 3 years prior and was receiving a docetaxel + ramucirumab (RAM) regimen experienced recurrent sore throat. The administration of RAM was discontinued after a gastroscopic examination revealed mucosal bleeding from around the larynx, which was thought to be RRP caused by RAM, a vascular endothelial growth factor inhibitor.

Results

After the remission of the RRP, the patient received a COVID-19 vaccine (Pfizer-BioNTech). Five days later, the appearance of cough and recurrence of sore throat worsened with time, and marked stridor was observed. The patient was admitted, and steroid pulse therapy was administered for 3 days starting on day 18 after vaccination. On day 50 after vaccination, edema of the vocal cords improved.

Conclusions

When administering COVID-19 vaccines, considering that these vaccines may cause RRP is important, because RRP can be fatal in patients with a history of RT in the laryngeal region and treated with vascular endothelial growth factor inhibitors.

Radiation recall dermatitis induced by COVID-19 vaccination in breast cancer patients treated with postoperative radiation therapy

Background

and purpose: Radiation recall dermatitis is an adverse event predominantly due to systemic therapy administration after a previous radiation therapy course. Few case reports describe radiation recall dermatitis in breast cancer patients treated with postoperative radiation therapy following COVID-19 vaccination. In this study we investigated the incidence and severity of radiation recall dermatitis after COVID-19 vaccination in irradiated breast cancer patients.

Methods

Patients that received at least one COVID-19 vaccination dose during the year after the end of postoperative breast radiation therapy were included in this observational monocentric study. Local symptoms occurring inside the radiation field after vaccination were patient-reported and scored according to the PRO-CTCAE questionnaire. Descriptive data of radiation recall dermatitis incidence and severity, and potential risk factors were evaluated.

Results

A cohort of 361 patients with 756 administered COVID-19 vaccinations was analyzed. Breast symptoms were reported by 7.5% of patients, while radiation recall dermatitis was considered for 5.5%. The incidence of radiation recall dermatitis per single dose of vaccine was 2.6%, with a higher risk for the first dose compared to the second/third (4.4% vs 1%, p = 0.003), especially when administered within the first month after the end of irradiation (12.5% vs 2.2%, p = 0.0004). Local symptoms were generally self-limited and a few cases required anti-inflammatory drugs.

Conclusions

Radiation recall dermatitis is an uncommon but not rare phenomenon in breast cancer patients that received COVID-19 vaccination within one year after breast irradiation. However, symptoms severity were generally low/mild and reversible. These findings can be useful for patient counseling.

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First study that reported the incidence of radiation recall dermatitis after COVID-19 vaccination in breast cancer patients.

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Radiation recall dermatitis after COVID-19 vaccination was not a rare event in breast cancer patients.

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Symptom severity of radiation recall dermatitis after COVID-19 vaccination was low/moderate and self-limiting.

COVID-19 vaccines in patients with cancer: immunogenicity, efficacy and safety

Patients with cancer have a higher risk of severe coronavirus disease (COVID-19) and associated mortality than the general population. Owing to this increased risk, patients with cancer have been prioritized for COVID-19 vaccination globally, for both primary and booster vaccinations. However, given that these patients were not included in the pivotal clinical trials, considerable uncertainty remains regarding vaccine efficacy, and the extent of humoral and cellular immune responses in these patients, as well as the risks of vaccine-related adverse events. In this Review, we summarize the current knowledge generated in studies conducted since COVID-19 vaccines first became available. We also highlight critical points that might affect vaccine efficacy in patients with cancer in the future.

COVID-19 vaccine-induced Radiation Recall Dermatitis: Report of a case

Radiation Recall Dermatitis (RRD) is an inflammatory process in the site of irradiation, induced by physical and medical agents. Few cases of RRD in the skin and lung have been reported after COVID-19 vaccination. Here, we report radiation recall dermatitis after both doses of inactivated SARS-CoV-2 vaccine (Sinopharm, China).

Radiation recall phenomenon after administration of the mRNA-1273 SARS-CoV-2 vaccine

Several types of SARS-CoV-2 vaccine have been developed. However, the relationship between SARS-CoV-2 vaccine and radiation therapy (RT) is unclear. Recently, there have been some reports of radiation recall phenomenon (RRP) caused by a SARS-CoV-2 vaccine. We report a case of RRP after administration of the mRNA-1273 SARS-CoV-2 vaccine. A 51-year-old female was diagnosed with breast cancer (cT4N1M0, cStage IIIB) and underwent breast total mastectomy with axillary lymph node dissection after neoadjuvant chemotherapy. After mastectomy, the patient received RT with 50 Gy in 25 fractions. An acute side effect of grade 2 dermatitis according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. occurred after RT. The patient had not started any new systemic medication after RT; however, the patient received the mRNA-1273 SARS-CoV-2 vaccine (Moderna) 1 month after the end of the initial RT. Seven days after vaccination, the patient had a skin reaction with burning sensation and redness. This skin reaction was induced in an area corresponding to the irradiation field of the chest wall. There was no skin reaction in areas other than that described. The reaction was cured within 1 week with topical hydrocortisone. This report is an interesting case report with a RPP after administration of the mRNA-1273 SARS-CoV-2 vaccine.

Breast Radiation Recall Phenomenon After Astra-Zeneca COVID-19 Vaccine: A Case Series

We report three cases of AstraZeneca vaccine (AZV)-induced radiation recall phenomenon (RRP) in three women who had previously undergone radiotherapy for breast cancer. RRP is a rare complication of vaccination that can mimic the more common pathology of breast cellulitis. Emergency physicians, primary care specialists, and surgeons should be aware of RRP when treating patients in the current coronavirus disease 2019 (COVID-19) climate.

Cutaneous Adverse Reactions Associated with SARS-CoV-2 Vaccines

Many patients are receiving SARS-CoV-2 vaccinations, which have been associated with a variety of adverse effects. Cutaneous adverse reactions to SARS-CoV-2 vaccinations have been progressively reported, but they have not been reviewed according to their morphological clinical patterns. The objective of this review was to summarize the existing data concerning the cutaneous adverse reactions following SARS-CoV-2 vaccines and group them according to common morphological and pathogenetic patterns. We reviewed the English language literature up to 15 August 2021, using predefined keywords to identify the relevant studies evaluating cutaneous adverse reactions associated with SARS-CoV-2 vaccines. We search for recurrent morphological patterns sharing clinical signs and symptoms and physio-pathological mechanisms. Timing to onset following the first or booster dose of the vaccine, predisposing conditions, therapeutic management, and outcome were also collected. Among the dermatological manifestations associated with SARS-CoV-2 vaccinations, we distinguished: (1) new onset reactions and (2) flares of preexisting dermatoses. The most common were injection site reactions, affecting 30–70% and generally mild or moderate. Small case series or single case reports included filler reactions, exanthemas, vascular lesions, urticaria, eczematous dermatitis, autoimmune bullous reactions, and severe cutaneous adverse reactions. In addition, the exacerbation of chronic immuno-mediated dermatoses (mainly psoriasis and atopic dermatitis) and reactivations of herpes infection were reported. The cutaneous reactions were generally mild, self-limiting, and resembled common cutaneous drug eruptions and/or COVID-19 skin manifestations.