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Guimond E, Tsai CJ, Hosni A, O'Kane G, Yang J, Barry A. Safety and Tolerability of Metastasis Directed Radiotherapy in the Era of Evolving Systemic, Immune and Targeted Therapies. Adv Radiat Oncol 2022; 7:101022. [PMID: 36177487 PMCID: PMC9513086 DOI: 10.1016/j.adro.2022.101022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/02/2022] [Indexed: 11/17/2022] Open
Abstract
AbstractPurpose Systemic, immune, and target therapies are growing in use in the management of metastatic cancers. The aim of this review was to describe up-to-date published data on the safety and tolerability of metastasis-directed hypofractionated radiation therapy (RT) when combined with newer systemic, immune, and targeted therapies and to provide suggested strategies to mitigate potential toxicities in the clinical setting. Methods and Materials A comprehensive search was performed for the time period between 1946 and August 2021 using predetermined keywords describing the use of noncentral nervous system palliative RT with commonly used targeted systemic therapies on PubMed and Medline databases. A total of 1022 articles were screened, and 130 met prespecified criteria to be included in this review. Results BRAF and MEK inhibitors are reported to be toxic when given concurrently with RT; suspension 3 days and 1 to 2 days, respectively, prior and post-RT is suggested. Cetuximab, erlotinib/gefitinib, and osimertinib were generally safe to use concomitantly with conventional radiation. But in a palliative/hypofractionated RT setting, suspending cetuximab during radiation week, erlotinib/gefitinib 1 to 2 days, and osimertinib ≥2 days pre- and post-RT is suggested. Vascular endothelial growth factor inhibitors such as bevacizumab reported substantial toxicities, and the suggestion is to suspend 4 weeks before and after radiation. Less data exist on sorafenib and sunitinib; 5 to 10 days suspension before and after RT should be considered. As a precaution, until further data are available, for cyclin-dependent kinase 4-6 inhibitors, consideration of suspending treatment 1 to 2 days before and after RT should be given. Ipilimumab should be suspended 2 days before and after RT, and insufficient data exist for other immunotherapy agents. Trastuzumab and pertuzumab are generally safe to use in combination with RT, but insufficient data exist for other HER2 target therapy. Conclusions Suggested approaches are described, using up-to-date literature, to aid clinicians in navigating the integration of newer targeted agents with hypofractionated palliative and/or ablative metastatic RT. Further prospective studies are required.
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Affiliation(s)
- Elizabeth Guimond
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
- Corresponding author: Elizabeth Guimond, MD, FRCPC
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
| | - Grainne O'Kane
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
| | - Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
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Burnett LR, Hughes RT, Rejeski AF, Moffatt LT, Shupp JW, Christy RJ, Winkfield KM. Review of the Terminology Describing Ionizing Radiation-Induced Skin Injury: A Case for Standardization. Technol Cancer Res Treat 2021; 20:15330338211039681. [PMID: 34613833 PMCID: PMC8504211 DOI: 10.1177/15330338211039681] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Ionizing radiation causes injury to the skin that produces a complex clinical presentation that is managed by various paradigms without clear standards. The situation is further complicated by the fact that clinicians and researchers often use different terms and billing codes to describe the spectrum of cutaneous injury. There is, however, general agreement between the two most commonly-used diagnostic scales, the Radiation Therapy Oncology Group and the Common Terminology Criteria for Adverse Events, and in their use to describe skin injury following radiation therapy. These scales are typically used by radiation oncologists to quantify radiation dermatitis, a component of the radiation-related disorders of the skin and subcutaneous tissue family of diagnoses. In rare cases, patients with severe injury may require treatment by wound care or burn specialists, in which case the disease is described as a “radiation burn” and coded as a burn or corrosion. Further compounding the issue, most US government agencies use the term Cutaneous Radiation Injury to indicate skin damage resulting from large, whole-body exposures. In contrast, the US Food and Drug Administration approves products for radiation dermatitis or “burns caused by radiation oncology procedures.” A review of the literature and comparison of clinical presentations shows that each of these terms represents a similar injury, and can be used interchangeably. Herein we provide a comparative review of the commonly used terminology for radiation-induced skin injury. Further, we recommend standardization across clinicians, providers, and researchers involved in the diagnosis, care, and investigation of radiation-induced skin injury. This will facilitate collaboration and broader inclusion criteria for grant-research and clinical trials and will assist in assessing therapeutic options particularly relevant to patient skin pigmentation response differences.
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Affiliation(s)
| | - Ryan T Hughes
- 12279Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Lauren T Moffatt
- 121577MedStar Health Research Institute, Washington, DC, USA.,12230Georgetown University School of Medicine, Washington, DC, USA
| | - Jeffrey W Shupp
- 121577MedStar Health Research Institute, Washington, DC, USA.,12230Georgetown University School of Medicine, Washington, DC, USA.,8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Robert J Christy
- 110230US Army Institute for Surgical Research, San Antonio Texas, USA
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Billena C, Padia S, O'Brien B, Knoble J, Gokhale A, Rajagopalan M. Radiation recall dermatitis after treatment of stage IV breast cancer with nivolumab: a case report. Immunotherapy 2020; 12:123-130. [PMID: 31992119 DOI: 10.2217/imt-2019-0020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Radiation recall dermatitis (RRD) is an uncommon dermatologic reaction provoked notably by chemotherapy in an area of skin irradiated weeks to years prior. We report a case of RRD with nivolumab in a woman with breast cancer. The patient was diagnosed with invasive ductal carcinoma of the left breast with an isolated spinal metastasis approached in an oligometastatic fashion with neoadjuvant chemotherapy, modified radical mastectomy and adjuvant radiotherapy. Unfortunately, after progression of bony metastases treated with radiotherapy, the patient received nivolumab and subsequently developed a rash corresponding to the adjuvant radiation field. This case highlights the unpredictable nature and characteristic rash of RRD. It is an important differential diagnosis for multidisciplinary teams who also see chemotherapy-induced dermatitis and immune-related adverse events.
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Affiliation(s)
- Cole Billena
- Department of Surgery, Mount Carmel Health System, Columbus, OH 43081, USA
| | - Shilpa Padia
- Department of Surgery, Mount Carmel Health System, Columbus, OH 43081, USA
| | - Bridget O'Brien
- Department of Surgery, Mount Carmel Health System, Columbus, OH 43081, USA
| | - Jeanna Knoble
- Department of Hematology, Oncology Zangmeister Cancer Center, Columbus, OH 43219, USA
| | - Abhay Gokhale
- Department of Radiation Oncology, Mount Carmel Health System, Columbus, OH 43081, USA
| | - Malolan Rajagopalan
- Department of Radiation Oncology, Mount Carmel Health System, Columbus, OH 43081, USA
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Couty E, Vallard A, Sotton S, Ouni S, Garcia MA, Espenel S, Rancoule C, Ben Mrad M, Biron AC, Perrot JL, Langrand-Escure J, Magné N. Safety assessment of anticancer drugs in association with radiotherapy in metastatic malignant melanoma: a real-life report : Radiation/systemic drug combo in metastatic melanoma. Cancer Chemother Pharmacol 2019; 83:881-892. [PMID: 30806760 DOI: 10.1007/s00280-019-03806-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/22/2019] [Indexed: 12/23/2022]
Abstract
PURPOSE To assess the safety of the association of radiotherapy (RT) and systemic treatments for patients with metastatic malignant melanoma (mMM). METHODS A retrospective analysis included consecutive patients treated with palliative RT, and at least one line of systemic therapy for mMM between 2001 and 2016. Treatments were defined as sequential or concomitant when RT and the systemic drug were administered, respectively, at more or less than five half-lives from each other. RESULTS 92 patients were included. They had 110 palliative RT treatments. RT was delivered with a "conventional" chemotherapy (mainly fotemustine and/or dacarbazine) and a "modern" systemic therapy (BRAF inhibitors, association of BRAF and MEK inhibitors, immunotherapy), respectively, in 88 (80%) and 22 (20%) cases. Systemic treatments and RT were mainly concurrently performed (n = 61, 55.5%). Regarding acute grade ≥ 3 toxicity, no difference was reported between sequential and concomitant groups either in the whole cohort (p = 1) or in the subgroup of patients receiving "modern" systemic therapies (p = 1). Acute and late grade ≥ 3 toxicities only occurred with vemurafenib. BRAF inhibitors and RT produced more severe infield adverse events than other associations (p = 0.001) with two deaths. CONCLUSION In our series, compared to sequential administration, concomitant association of systemic anticancer drugs and palliative RT did not increase toxicity in mMM patients. BRAF inhibitors and RT produced severe infield toxicities. Prospective studies are needed to better characterize the toxicity of each association.
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Affiliation(s)
- Emmanuelle Couty
- Dermatology Department, University Hospital Nord Saint Etienne, 42270, St Priest en Jarez, France
| | - Alexis Vallard
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
| | - Sandrine Sotton
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
| | - Sarra Ouni
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
| | - Max-Adrien Garcia
- Public Health Department, Lucien Neuwirth Cancer Institute, 42270, St Priest en Jarez, France
| | - Sophie Espenel
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
- Cellular and Molecular Radiobiology Laboratory, CNRS UMR 5822, IPNL, 69622, Villeurbanne, France
| | - Chloe Rancoule
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
- Cellular and Molecular Radiobiology Laboratory, CNRS UMR 5822, IPNL, 69622, Villeurbanne, France
| | - Majed Ben Mrad
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
| | - Anne-Catherine Biron
- Dermatology Department, University Hospital Nord Saint Etienne, 42270, St Priest en Jarez, France
| | - Jean-Luc Perrot
- Dermatology Department, University Hospital Nord Saint Etienne, 42270, St Priest en Jarez, France
| | - Julien Langrand-Escure
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France
| | - Nicolas Magné
- Institut de Cancérologie Lucien Neuwirth, 108 bis Avenue Albert Raimond, BP 60008, 42271, St Priest en Jarez cedex, France.
- Cellular and Molecular Radiobiology Laboratory, CNRS UMR 5822, IPNL, 69622, Villeurbanne, France.
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Anker CJ, Grossmann KF, Atkins MB, Suneja G, Tarhini AA, Kirkwood JM. Avoiding Severe Toxicity From Combined BRAF Inhibitor and Radiation Treatment: Consensus Guidelines from the Eastern Cooperative Oncology Group (ECOG). Int J Radiat Oncol Biol Phys 2016; 95:632-46. [PMID: 27131079 PMCID: PMC5102246 DOI: 10.1016/j.ijrobp.2016.01.038] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 01/12/2016] [Accepted: 01/20/2016] [Indexed: 12/25/2022]
Abstract
BRAF kinase gene V600 point mutations drive approximately 40% to 50% of all melanomas, and BRAF inhibitors (BRAFi) have been found to significantly improve survival outcomes. Although radiation therapy (RT) provides effective symptom palliation, there is a lack of toxicity and efficacy data when RT is combined with BRAFi, including vemurafenib and dabrafenib. This literature review provides a detailed analysis of potential increased dermatologic, pulmonary, neurologic, hepatic, esophageal, and bowel toxicity from the combination of BRAFi and RT for melanoma patients described in 27 publications. Despite 7 publications noting potential intracranial neurotoxicity, the rates of radionecrosis and hemorrhage from whole brain RT (WBRT), stereotactic radiosurgery (SRS), or both do not appear increased with concurrent or sequential administration of BRAFis. Almost all grade 3 dermatitis reactions occurred when RT and BRAFi were administered concurrently. Painful, disfiguring nondermatitis cutaneous reactions have been described from concurrent or sequential RT and BRAFi administration, which improved with topical steroids and time. Visceral toxicity has been reported with RT and BRAFi, with deaths possibly related to bowel perforation and liver hemorrhage. Increased severity of radiation pneumonitis with BRAFi is rare, but more concerning was a potentially related fatal pulmonary hemorrhage. Conversely, encouraging reports have described patients with leptomeningeal spread and unresectable lymphadenopathy rendered disease free from combined RT and BRAFi. Based on our review, the authors recommend holding BRAFi and/or MEK inhibitors ≥3 days before and after fractionated RT and ≥1 day before and after SRS. No fatal reactions have been described with a dose <4 Gy per fraction, and time off systemic treatment should be minimized. Future prospective data will serve to refine these recommendations.
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Affiliation(s)
- Christopher J Anker
- Division of Radiation Oncology, University of Vermont Cancer Center, Burlington, Vermont.
| | - Kenneth F Grossmann
- Division of Medical Oncology, Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Michael B Atkins
- Department of Oncology, Georgetown-Lombardi Comprehensive Cancer Center, Georgetown University School of Medicine, Washington, District of Columbia
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ahmad A Tarhini
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John M Kirkwood
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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