1
|
Naghavi S, Motahharynia A, Fatemi F, Ahmadi E, Mokhtari F, Adibi I. The benefit of intravenous immune globulin in the treatment of delayed radiation myelopathy. Strahlenther Onkol 2023:10.1007/s00066-023-02150-1. [PMID: 37726423 DOI: 10.1007/s00066-023-02150-1] [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: 01/24/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023]
Abstract
Delayed radiation myelopathy (DRM) is a rare yet severe complication of radiotherapy. This condition has a progressive pattern that is often irreversible. Several therapeutic strategies have been introduced to alleviate disease complications, including corticosteroids, hyperbaric oxygen, anticoagulants, and antivascular endothelial growth factor (VEGF) agents. However, despite their beneficial effect, they have not been the definitive treatments for DRM. Here we present the case of a 55-year-old woman with a history of multiple myeloma who developed neurological complications 11 months after radiation therapy. As her radiologic findings demonstrated transverse myelitis, based on the DRM diagnostic criteria, the diagnosis of delayed radiation myelitis was reached. Therefore, methylprednisolone pulse therapy was initiated, resulting in the complete resolution of her neurological symptoms. However, on her follow-up examination, although she did not have new neurological complications, magnetic resonance imaging (MRI) demonstrated a residual enhancement in the thoracic spinal cord area. Hence, due to the possibility of myelitis progression and spinal cord atrophy, intravenous immune globulin (IVIG) was administered, resulting in the resolution of lesion enhancement. Considering this outcome and the immunomodulatory properties of IVIG, it could be regarded as a potential therapeutic option in the case of DRM activity.
Collapse
Affiliation(s)
- Saba Naghavi
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Motahharynia
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farnaz Fatemi
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elaheh Ahmadi
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Faezeh Mokhtari
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Iman Adibi
- Isfahan Neuroscience Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
- Center for Translational Neuroscience, Isfahan University of Medical Sciences, Isfahan, Iran.
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
| |
Collapse
|
2
|
Karri J, Lachman L, Hanania A, Marathe A, Singh M, Zacharias N, Orhurhu V, Gulati A, Abd-Elsayed A. Radiotherapy-Specific Chronic Pain Syndromes in the Cancer Population: An Evidence-Based Narrative Review. Adv Ther 2021; 38:1425-1446. [PMID: 33570737 DOI: 10.1007/s12325-021-01640-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/27/2021] [Indexed: 12/25/2022]
Abstract
While radiation therapy is increasingly utilized in the treatment paradigm of many solid cancers, the chronic effects of radiation therapies are poorly characterized. Notably, understanding radiation-specific chronic pain syndromes is paramount given that the diagnosis and management of these conditions can serve to prevent long-standing functional impairments, optimize quality of life, and even allow for continued radiotherapy candidacy. These radiation-specific chronic pain phenomena include dermatitis, mucositis, enteritis, connective tissue fibrosis, lymphedema, and neuropathic pain syndromes. It is necessary to maintain a low threshold of suspicion for appropriately diagnosing these conditions as there exists a variance in when these symptoms arise after radiation. However, we present key epidemiological data delineating vulnerable cancer populations for each pain syndrome along with the available evidence for the management for each specific condition.
Collapse
Affiliation(s)
- Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Laura Lachman
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Alex Hanania
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Anuj Marathe
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Mani Singh
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | - Nicholas Zacharias
- Division of Pain Medicine, Department of Anesthesia, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Vwaire Orhurhu
- Division of Pain Medicine, Department of Anesthesia, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA
| | - Amitabh Gulati
- Division of Pain Medicine, Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Alaa Abd-Elsayed
- Division of Pain Medicine, Department of Anesthesia, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
| |
Collapse
|
3
|
Peyraga G, Ducassou A, Arnaud FX, Lizée T, Pouédras J, Moyal É. [Radiotherapy and spinal toxicity: News and perspectives]. Cancer Radiother 2020; 25:55-61. [PMID: 33303351 DOI: 10.1016/j.canrad.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/26/2020] [Accepted: 05/01/2020] [Indexed: 01/21/2023]
Abstract
Radiation-induced myelopathy is a devastating late effect of radiotherapy. Fortunately, this late effect is exceptional. The clinical presentation of radiation myelopathy is aspecific, typically occurring between 6 to 24 months after radiotherapy, and radiation-induced myelopathy remains a diagnosis of exclusion. Magnetic resonance imaging is the most commonly used imaging tool. Radiation oncologists must be extremely cautious to the spinal cord dose, particularly in stereotactic radiotherapy and reirradiation. Conventionally, a maximum dose of 50Gy is tolerated in normofractionated radiotherapy (1.8 to 2Gy per fraction). Repeat radiotherapies lead to consider cumulative doses above this recommendation to offer individualized reirradiation. Several factors increase the risk of radiation-induced myelopathy, such as concomitant or neurotoxic chemotherapy. The development of predictive algorithms to prevent the risk of radiation-induced myelopathy is promising. However, radiotherapy prescription should be cautious, regarding to ALARA principle (as low as reasonably achievable). As the advent of immunotherapy has improved patient survival data and the concept of oligometastatic cancer is increasing in daily practice, stereotactic treatments and reirradiations will be increasingly frequent indications. Predict the risk of radiation-induced myelopathy is therefore a major issue in the following years, and remains a daily challenge for radiation oncologists.
Collapse
Affiliation(s)
- G Peyraga
- Service de radiothérapie, groupe de radiothérapie et d'oncologie des Pyrénées (Grop), chemin de l'Ormeau, 65000 Tarbes, France.
| | - A Ducassou
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - F-X Arnaud
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - T Lizée
- Service de radiothérapie, Institut cancérologique de l'ouest, centre Paul-Papin, 15, rue André-Bocquel, 49055 Angers, France
| | - J Pouédras
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| | - É Moyal
- Service de radiothérapie, Institut universitaire du cancer de Toulouse (Oncopole), 1, avenue Irène-Joliot-Curie, 31000 Toulouse, France
| |
Collapse
|
4
|
Omuro AMP, Martin-Duverneuil N, Delattre JY. Complications of radiotherapy to the central nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:887-901. [PMID: 22230540 DOI: 10.1016/b978-0-444-53502-3.00030-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Antonio M P Omuro
- Service de Neurologie Mazarin, Université Paris VI Pierre et Marie Curie, Paris, France.
| | | | | |
Collapse
|
5
|
McMullen KP, Shaw EG, Stieber VW. Central Nervous System Emergencies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
6
|
Mathis S, Dumas P, Neau JP, Gil R. La neuropathie motrice pure, une complication rare de la radiothérapie: trois observations et une revue de la littérature. Rev Med Interne 2007; 28:377-87. [PMID: 17337314 DOI: 10.1016/j.revmed.2007.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 01/22/2007] [Accepted: 01/31/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early or late neurological symptoms with lesions of peripheral or central nervous system can originated from radiotherapy. METHODS We report three cases of pure motor neuropathy in patients, which were treated by X-ray treatment several years ago. RESULTS Three patients (35-65 years old) have been presenting a pure motor neuropathy between 8.5 and 21 years after radiotherapy for Hodgkin disease (two cases) or testicular seminoma (one case). In each case, a proximodistal weakness with proximal predominance was observed and confirmed by the electromyographic findings. After a gradual worsening, we observed a clinical stability in patients treated by anticoagulant (one case) or pentoxifylline (two cases). CONCLUSION Pure motor neuropathy is a rare and late complication of the radiotherapy. A treatment with anticoagulant or pentoxifylline, with or without tocopherol, has been suggested.
Collapse
Affiliation(s)
- S Mathis
- Clinique Neurologique, CHU de Poitiers, Université de Poitiers, 2, rue de la Milétrie, 86021 Poitiers cedex 05, France.
| | | | | | | |
Collapse
|
7
|
Butler JM, Rapp SR, Shaw EG. Managing the cognitive effects of brain tumor radiation therapy. Curr Treat Options Oncol 2006; 7:517-23. [PMID: 17032563 DOI: 10.1007/s11864-006-0026-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative radiation therapy (RT), either alone or in combination with chemotherapy, is the mainstay of treatment for primary and/or metastatic brain tumors. The majority of patients with brain tumors will have significant symptoms of their disease and of RT that will have a negative impact on their quality of life and neurocognitive function. The symptoms of brain tumors depend on tumor location. Radiation-induced brain injury is a complex and dynamic process involving all cells in the brain, including endothelial and oligodendroglial cells, astrocytes, microglia, neurons, and neuronal stem cells. The symptoms of radiation-induced brain injury may be acute, subacute, or chronic, occurring hours, days, weeks, months, and even years after exposure to radiation, the pathogenesis of which is oxidative stress and inflammation. At present, there are no effective preventive approaches for radiation-induced brain injury. Rather, the management of radiation-induced fatigue, changes in mood, and cognitive dysfunction involves a multidisciplinary approach using pharmacologic, behavioral, and rehabilitative therapies. Given the prevalence of brain neoplasms and the high incidence of the radiation-induced symptom cluster and brain injury, clinical research to address these important clinical problems is critical.
Collapse
Affiliation(s)
- Jerome M Butler
- Department of Radiation Oncology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | | | | |
Collapse
|
8
|
Abstract
BACKGROUND Acute myelopathies represent a heterogeneous group of disorders with distinct etiologies, clinical and radiologic features, and prognoses. Transverse myelitis (TM) is a prototype member of this group in which an immune-mediated process causes neural injury to the spinal cord, resulting in varying degrees of weakness, sensory alterations, and autonomic dysfunction. TM may exist as part of a multifocal CNS disease (eg, MS), multisystemic disease (eg, systemic lupus erythematosus), or as an isolated, idiopathic entity. REVIEW SUMMARY In this article, we summarize recent classification and diagnostic schemes, which provide a framework for the diagnosis and management of patients with acute myelopathy. Additionally, we review the state of current knowledge about the epidemiology, natural history, immunopathogenesis, and treatment strategies for patients with TM. CONCLUSIONS Our understanding of the classification, diagnosis, pathogenesis, and treatment of TM has recently begun to expand dramatically. With more rigorous criteria applied to distinguish acute myelopathies and with an emerging understanding of immunopathogenic events that underlie TM, it may now be possible to effectively initiate treatments in many of these disorders. Through the investigation of TM, we are also gaining a broader appreciation of the mechanisms that lead to autoimmune neurologic diseases in general.
Collapse
Affiliation(s)
- Adam I Kaplin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Osler 320, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | | | | | | | | |
Collapse
|