Radiation recall dermatitis: case report and review of the literature

Radiation recall reaction induced by gemcitabine/docetaxel in children: A retrospective study on risk factors and outcomes

INTRODUCTION

Radiation recall reaction (RRR) is a rare inflammatory reaction developing in a previously irradiated field after a triggering agent. In pediatric patients, it is poorly understood and deficiently studied. Gemcitabine-docetaxel (G/D) in childhood cancer is mainly used as a salvage regimen for sarcomas. We aim to describe RRR triggered by G/D in children.

PATIENTS AND METHODS

Retrospective review of 21 patients receiving G/D along with radiotherapy at two hospitals from 2010 until 2022. RRR was considered as any toxicity occurring after G/D administration in a previously irradiated field. RRR features were described. Fisher's and Mann-Whitney tests were utilized to analyze the risk factors involved.

RESULTS

Sixteen episodes of RRR developed in 16 (76.2%) patients. RRR mainly involved deep layers of the skin (58%) and occurred predominantly after two G/D cycles. The mean time between radiotherapy and chemotherapy was 28.5 days (0-1359 days), and the mean radiation volume 391 mL (157-1810 mL) for RRR. RRR treatment was mainly systemic steroids, with partial responses in six of 11 (58%) patients. Re-exposure to G/D was associated with a high rate of recurrence in nine of 15 (56.2%), prompting drug discontinuation. The major risk factors for RRR after G/D include, without statistical significance, a larger volume of the irradiated field and a shorter interval between chemotherapy and radiotherapy.

CONCLUSIONS

The incidence of RRR after G/D in the pediatric population is higher than previously reported. Drug re-exposure is usually followed by recurrence. Higher irradiated volumes and a shorter time to the start of chemotherapy could be related with an increased risk of RRR.

The Completion of Postoperative Radiotherapy After Breast-Conserving Surgery in a Patient With Recurrent Erythema Multiforme: A Case Report

Radiotherapy (RT) can induce dermatitis and exacerbate a patient's preexisting skin conditions. We present a case of RT in a 61-year-old Japanese woman with a history of erythema multiforme (EM). She was diagnosed with a nodule on her right breast during therapy for EM. EM was noticed on the anterior chest and upper and lower extremities. RT was initially postponed due to exacerbation of EM before postoperative RT for right breast cancer. However, considering that EM tends to recur every one to two months, RT was commenced during a period of less active dermatitis, and a total dose of 50 Gy of conventional irradiation was successfully administered. One year after RT, there was no EM recurrence, dermatitis development, obvious late effects, or radiation pneumonitis. Our experience suggests that RT can be administered relatively safely to patients with recurrent EM but should be administered with caution.

Radiotherapy of orbital metastases: a systematic review of management and treatment outcomes on behalf of palliative care study group of Italian association of radiotherapy and clinical oncology (AIRO)

OBJECTIVES

We search the current literature on data regarding the role of RT in OM treatment, focusing on the improvement of symptoms and patient quality of life.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations.

RESULTS

From 340 citations, 60 papers were finally selected: 45 case reports and 15 case series. The case reports accounted for 47 patients. In 37/39 cases (95%), EBRT was done. Patients were mainly treated with 3DCRT, IMRT, and with SBRT. The most used RT regimens were 30 Gy in 10 fractions (23%) and 20-25 Gy in 5 fx (13%). No sever toxicity was reported. A median LC of 11 months (range 1-54 months) and a median OS of 12 months (range 1-54 months) were registered. Among the case series, a total of 457 patients were examined, 227 of whom underwent RT. The main used techniques were 3DCRT, CK, GK, SBRT, and BRT. RT doses could vary from 30 Gy/10 fractions to 60 Gy/30 fractions, 50 Gy/5 fractions, or 16.5-21 Gy in single fraction. No toxicity above G2 was reported. ORR could vary between 75 and 100%. Only two study provided information on response duration: a mean LC time of 22.8 months and a mean time to local progression of 5 months (range: 3-7). Regarding OS, the data were heterogeneous, ranging between 1 and 54 months.

CONCLUSIONS

RT for OM seems to be a safe and feasible option. More information on the RT ideal techniques and dose are still needed.

ADVANCES IN KNOWLEDGE

This paper tried to sum up the few and fragmented data on the use of radiotherapy for orbital metastases: the possible option ranged from 3D- and 2D-CRT to SBRT, CK, and GK, with different possible fractionations (30Gy in 10 fractions, 60 Gy/30 fractions, 20-50 Gy/5 fractions, or 16.5-21 Gy in single fraction). Regardless of the chosen approach, almost all treated patients experienced a benefit after RT in terms of OM-related symptom intensity reduction and a good acute and late toxicity profile.

Patient follow-up for possible radiation injury from fluoroscopically-guided interventions: Need to consider high cumulative exposure from multiple procedures

PURPOSE

Patient skin dose from interventional fluoroscopy procedures may exceed the threshold of tissue injuries and established guidelines recommend patient follow-up for air kerma at reference point (K_a,r) ≥ 5 Gy for individual procedures. Patients may undergo multiple procedures and skin injuries may be possible by cumulative exposure, even when individually insufficient to cause injury. This study sought to quantify the frequency of patients whose individual procedure doses are below 5 Gy but whose cumulative K_a,r is ≥ 5 Gy.

METHODS

This retrospective study analyzed 37,917 consecutive procedures in interventional radiology and vascular surgery at a tertiary-care hospital between January 2016 and June 2021. Radiation dosage was retrieved from the fluoroscopy acquisition systems. For a patient receiving multiple procedures, but each with K_a,r < 5 Gy, cumulative K_a,r within 2, 7, 14, 30, 183, and 365 days was assessed.

RESULTS

Nearly 1/3rd (37.4 %) patients underwent multiple procedures. With individual procedures of K_a,r < 5 Gy exclusively, 1.9, 4.4, and 5.6 in 1000 patients received cumulative K_a,r of 5-14.1 Gy from the procedures within 30, 183, and 365 days, respectively. From the procedures within 14 days, 1.3 in 1000 patients received cumulative K_a,r of 5-11.4 Gy; and from those within 7 days, 0.87 in 1000 patients received 5-9.1 Gy. In comparison, 4.3 in 1000 patients received K_a,r of 5-12 Gy from a single procedure.

CONCLUSIONS

In the absence of guidelines on patient follow-up for multiple procedures, our study may provide good material for setting up such guidelines.

Emerging Skin Toxicities in Patients with Breast Cancer Treated with New Cyclin-Dependent Kinase 4/6 Inhibitors: A Systematic Review

Three cyclin-dependent kinases 4/6, including palbociclib, ribociclib, and abemaciclib, have been approved for the treatment of patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative advanced breast cancer. The objective of this study was to evaluate the occurrence and clinical spectrum of cutaneous adverse events in patients with breast cancer following therapy with cyclin-dependent kinase 4/6 inhibitors. A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases up to November 2020 to evaluate studies published from 2015 to 2020. Articles were selected by title, abstract, and full text as required. In addition, a manual search was performed from among the references of articles included. Forty-one articles were included with a total of 13 reported dermatologic reactions including alopecia, bullous skin rash, Stevens-Johnson syndrome, toxic epidermal necrolysis, radiation recall and radiation dermatitis, Henoch-Schonlein purpura, cutaneous leukocytoclastic vasculitis, subacute and chronic cutaneous lupus erythematosus, histiocytoid Sweet syndrome, vitiligo-like lesions, and erythema dyschromicum perstans. Skin toxicity is an important issue because it usually affects a patient's quality of life and could lead to a discontinuation of therapies; therefore, it is of fundamental importance to recognize and adequately manage the adverse skin reactions associated with these types of drugs.

Selection of Appropriate Wound Dressing for Various Wounds

There are many factors involved in wound healing, and the healing process is not static. The therapeutic effect of modern wound dressings in the clinical management of wounds is documented. However, there are few reports regarding the reasonable selection of dressings for certain types of wounds in the clinic. In this article, we retrospect the history of wound dressing development and the classification of modern wound dressings. In addition, the pros and cons of mainstream modern wound dressings for the healing of different wounds, such as diabetic foot ulcers, pressure ulcers, burns and scalds, and chronic leg ulcers, as well as the physiological mechanisms involved in wound healing are summarized. This article provides a clinical guideline for selecting suitable wound dressings according to the types of wounds.

Radiation recall dermatitis after treatment of stage IV breast cancer with nivolumab: a case report

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.

Occurrence of an Abscopal Radiation Recall Phenomenon in a Glioblastoma Patient Treated with Nivolumab and Re-Irradiation

Glioblastoma multiforme is the most frequent primary brain tumor. The clinical course of glioblastoma is almost invariably fatal. Combined chemo-irradiation with temozolomide is currently the standard of care for newly diagnosed glioblastoma and concurrent Nivolumab, an anti-PD-1 monoclonal antibody is being studied for de novo glioblastoma. We present a 62-year old patient with glioblastoma, which was discovered during evaluation of sudden-onset moderate ataxia. Following craniotomy of the glial tumour he received chemo radiation. During this first-line treatment the patient participated in the CA209-548 phase III placebo controlled study investigating the addition of concurrent nivolumab. One month after the last administration of nivolumab after 60 weeks of study participation, magnetic resonance imaging scan showed progressive disease. Therefore stereotactic re-irradiation was given. Five days after completing radiation therapy and 50 days after his last nivolumab course he developed a mild diffuse generalized pruritic maculopapular exanthema. Skin biopsy was very indicative for a drug hypersensitivity reaction. The maculopapular rash and pruritus was successfully treated with moderate potency topical corticosteroids and prednisone. With the introduction of PD1/PD-L1 inhibitors and other immunotherapies tweaking the immune system to target cancer cells one can argue that once local radiation triggers a local immune mediated hypersensitivity reaction as seen in radiation recall dermatitis, the subsequent hypersensitivity reaction which would traditionally only be a local reaction is now possible to advance to more pronounced (systemic) reactions as seen in an abscopal effect. Therefore, we propose a combined name to coin this effect, the abscopal radiation recall phenomenon.

Skin diseases of the breast and nipple: Inflammatory and infectious diseases

Certain dermatologic conditions are unique to the breast and nipple, whereas others may incidentally involve these structures. All require a nuanced approach to diagnosis and treatment because of the functional, sexual, and aesthetic importance of this area. The lactating patient requires special management because certain treatment options are contraindicated. All dermatologic conditions involving the breast and nipple require careful evaluation because malignancy of the breast can be mistaken for a benign condition or may trigger the development of certain dermatologic conditions. The second article in this continuing medical education series reviews common and uncommon inflammatory and infectious conditions of the breast and nipple and provides insight into both the diagnosis and the treatment of this heterogeneous group of diseases. For the purposes of this article, these conditions are divided into 4 distinct categories: 1) dermatitis; 2) radiation-induced changes; 3) mastitis; and 4) miscellaneous dermatologic conditions of the breast and nipple.

Recurrent radiation recall dermatitis triggered by radiological procedures in a patient with breast cancer

Radiation recall dermatitis is an acute inflammatory reaction that occurs on previously irradiated skin by usage of chemotherapeutic agents and other triggering drugs. The recall reaction is usually associated with drugs but may also occur following ultraviolet radiation. We report a patient with radiation recall dermatitis, triggered after imaging procedures that involved radiation.

Recall erythema phenomenon following Er:YAG laser treatment: two case studies and literature review

Recall erythema is a phenomenon occurring when an area of epidermis treated with laser is later exposed to a trigger, most often sunlight or hot water, causing erythema in the zone of laser treatment after post-treatment erythema has already resolved. Radiation recall dermatitis is a more specific subtype of recall erythema in which an area treated with radiation is subjected to another exposure causing erythema in the area of previous radiation. Cases of recall dermatitis after laser treatment are extremely rare and have only been reported with diode neodymium-doped yttrium aluminum garnet lasers. We report two cases of recall dermatitis following erbium-doped yttrium aluminum garnet resurfacing laser triggered by exposure to either hot water or direct sunlight, and in one case, radioablation of the thyroid gland. We will also provide a brief literature review of recall dermatitis in the setting of laser surgery.

Disease- and Treatment-related Complication on F-18-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Oncology Practice: A Pictorial Review

F-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is routinely performed in oncology patients for various indications including staging, restaging, recurrence detection, and treatment response evaluation. Many disease- and treatment-related complications can be incidentally detected on PET/CT, which may be due to the complication of radiotherapy, chemotherapy, intervention, or primary tumor itself. Some of these complications could be life threatening and need urgent intervention. Therefore, these incidental findings should be recognized on PET/CT and immediately informed to the treating physicians if required urgent intervention.

A Case of Radiation Recall Dermatitis of Scalp in Acute Lymphoblastic Leukemia After Prophylactic Cranial Radiotherapy

The radiation recall dermatitis (RRD) phenomenon is defined as the “recalling” of the skin following the administration of drugs; this induces a response or flare-like reaction over the skin that is exposed to radiation. In this case report, a young female developed RRD on Day 18 after the completion of cranial radiotherapy, that is, four days after the restart of the chemotherapy with doxorubicin. It is a self-limiting condition with supportive care as the treatment. When encountered in hematological malignancies, undue treatment breaks can delay definitive treatment and can eventually cause a relapse. 

Pemetrexed-induced radiation recall dermatitis in a patient with lung adenocarcinoma: case report and literature review

Radiation recall dermatitis (RRD) is an inflammatory reaction in a previously irradiated field subsequent to the administration of pharmacologic or promoting agents. Herein, we describe a 47-year-old man with NSCLC who was treated with radiotherapy and pemetrexed-based chemotherapy three years prior to developing RRD upon resumption of pemetrexed-based chemotherapy. RRD with pemetrexed is rare and consists of five cases reported thus far. Although RRD is a rare phenomenon, it should be considered in any patient with dermatologic reactions that occur at the site of previous exposure to radiation therapy. When severe, RRD can pose a significant, and possibly life-threatening, impediment to the treatment and care of oncology patients. We discuss the time course, natural history, and management of this condition, as well as a connection to internal organ involvement, such as pneumonitis in thoracic oncology patients.

Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy

Ionizing radiation is an important treatment modality for a variety of malignant conditions. However, development of radiation-induced skin changes is a significant adverse effect of radiation therapy (RT). Cutaneous repercussions of RT vary considerably in severity, course, and prognosis. When they do occur, cutaneous changes to RT are commonly graded as acute, consequential-late, or chronic. Acute reactions can have severe sequelae that impact quality of life as well as cancer treatment. Thus, dermatologists should be informed about these adverse reactions, know how to assess their severity and be able to determine course of management. The majority of measures currently available to prevent these acute reactions are proper skin hygiene and topical steroids, which limit the severity and decrease symptoms. Once acute cutaneous reactions develop, they are treated according to their severity. Treatments are similar to those used in prevention, but incorporate wound care management that maintains a moist environment to hasten recovery. Chronic changes are a unique subset of adverse reactions to RT that may develop months to years following treatment. Chronic radiation dermatitis is often permanent, progressive, and potentially irreversible with substantial impact on quality of life. Here, we also review the etiology, clinical manifestations, pathogenesis, prevention, and management of late-stage cutaneous reactions to radiotherapy, including chronic radiation dermatitis and radiation-induced fibrosis.

Severe myositis of the hip flexors after pre-operative chemoradiation therapy for locally advanced rectal cancer: case report

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.

Radiation recall dermatitis occurring 6 years and 4 months after breast-conserving surgery: A case report

Currently in Japan, breast-conserving therapy, consisting of breast-conserving surgery and post-operative radiation therapy, is performed frequently for the treatment of invasive breast cancer. It has been demonstrated that radiation therapy not only prevents recurrence in the preserved breast, but that it also contributes to improved patient survival. The present study describes the case of a 37-year-old woman with radiation recall dermatitis that occurred 6 years and 4 months after breast-conserving surgery. Erythema with a relatively distinct border was observed at the irradiated site on the left breast; eczema was diagnosed by a dermatologist. Inflammatory breast cancer was ruled out, since chest X-ray, abdominal ultrasound and bone scintigraphy were negative. Following ~1 month of topical corticosteroid application and oral second generation antihistamine treatment, the erythema was alleviated and the subjective symptoms also disappeared. Only a few cases of radiation recall dermatitis have been described in the fields of radiology and dermatology, but not yet in the surgical field. In the future, the incidence of radiation recall dermatitis is predicted to increase due to the increasing number of patients undergoing breast-conserving therapy. Whether in the surgical, radiological or dermatological field, if erythema is detected at the irradiated site during post-operative follow-up, routine care should be provided, keeping in mind the possibility of radiation recall dermatitis and inflammatory breast cancer.

Radiation recall dermatitis and radiation pneumonitis during treatment with vemurafenib

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

Radiation recall dermatitis induced by tamoxifen during adjuvant breast cancer treatment

Tamoxifen and radiotherapy are used in breast cancer treatment worldwide. Radiation recall dermatitis (RRD), induced by tamoxifen, has been rarely reported. Herein, we report a RRD case induced by tamoxifen. A 47-year-old woman had a right quadrantectomy and an axillary lymph node dissection due to breast cancer. The tumor was staged pT2N0; it was hormone receptor positive, and human epidermal growth factor receptor 2 negative. The patient received adjuvant chemotherapy followed by tamoxifen and radiotherapy. After 22 months of tamoxifen, the patient developed a localized heating sensation, tenderness, edema, and redness at the irradiated area of the right breast. The symptoms improved within 1 week without treatment. Three weeks later, however, the patient developed similar symptoms in the same area of the breast. She continued tamoxifen before and during dermatitis, and symptoms resolved within 1 week.

Erythema multiforme, Stevens Johnson syndrome, and toxic epidermal necrolysis syndrome in patients undergoing radiation therapy: a literature review

OBJECTIVE

Erythema multiforme (EM), Stevens Johnson syndrome (SJS), and toxic epidermal necrolysis syndrome (TENS) are exfoliative disorders that may present as complications in some patients undergoing radiotherapy. The purpose of this literature review was to determine the reported frequency of these exanthemata in irradiated patients.

METHODS

A comprehensive search from 1903 to 2011, identified 89 articles with 165 cases.

RESULTS

Of 151 evaluable cases, 57 (38%) described EM; 46 (30.5%) SJS; 14 (9%) SJS/TENS overlap; and 34 (22.5%) TENS. Ninety-three percent underwent radiotherapy for either a primary or metastatic malignancy. A majority of patients were simultaneously treated with medications known to precipitate these exanthemata. Of the 61 patients receiving antiepileptic medications during radiotherapy, 48 were treated prophylactically and 13 for seizures, most frequently with phenytoin or phenobarbital. Amifostine was the second most common medication associated with radiotherapy and these reactions. Fourteen (23%) patients on anticonvulsant medication, and 11 (38%) on other medications died compared with 3 (8%) patients treated with radiotherapy alone (P = 0.002). No deaths occurred among irradiated patients receiving amifostine.

CONCLUSIONS

EM, SJS, and TENS were rarely reported in patients undergoing radiotherapy alone. The majority of SJS and TENS occurred in irradiated patients with concomitant prescribed medications.

Radiation recall after a transarterial hepatic chemoembolization

Radiation recall is a rare side effect observed in patients treated with certain medications after radiation therapy. This effect mimics a radiation-induced tissue reaction in expression; however, it occurs outside of the traditional time course and only in the presence of a catalyzing agent. The authors report a case of radiation recall resulting from an interaction between radiation delivered during a fluoroscopically guided hepatic chemoembolization for treatment of metastatic carcinoid tumor and the oral chemotherapeutic agents capecitabine and temozolomide administered 7 weeks later.

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

BACKGROUND

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

CASE REPORT

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

CONCLUSION

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

Sorafenib-triggered radiation recall dermatitis with a disseminated exanthematous reaction

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

Radiation recall dermatitis induced by trastuzumab

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

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

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

Locoregional interaction of ixabepilone (ixempra) after breast cancer radiation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Helical tomotherapy for spine oligometastases from gastrointestinal malignancies

Purpose

This study evaluated the treatment effectiveness and proper radiation dose of helical tomotherapy (HT) in spine oligometastases from gastrointestinal cancers.

Materials and Methods

From 2006 to 2010, 20 gastrointestinal cancer patients were treated with HT for spine oligometastases (31 spine lesions). The gross tumor volume (GTV) was the tumor evident from magnetic resonance imaging images fused with simulation computed tomography images. Clinical target volume (CTV) encompassed involved vertebral bodies or dorsal elements. We assumed that the planning target volume was equal to the CTV. We assessed local control rate after HT for 31 spine metastases. Pain response was scored by using a numeric pain intensity scale (NPIS, from 0 to 10).

Results

Spine metastatic lesions were treated with median dose of 40 Gy (range, 24 to 51 Gy) and median 5 Gy per fraction (range, 2.5 to 8 Gy) to GTV with median 8 fractions (range, 3 to 20 fraction). Median biologically equivalent dose (BED, α/β = 10 Gy) was 52 Gy₁₀ (range, 37.5 to 76.8 Gy₁₀) to GTV. Six month local control rate for spine metastasis was 90.3%. Overall infield failure rate was 15% and outfield failure rate was 75%. Most patients showed pain relief after HT (93.8%). Median local recurrence free survival was 3 months. BED over 57 Gy₁₀ and oligometastases were identified as prognostic factors associated with improved local progression free survival (p = 0.012, p = 0.041).

Conclusion

HT was capable of delivering higher BED to metastatic lesions in close proximity of the spinal cord. Spine metastases from gastrointestinal tumors were sensitive to high dose radiation, and BED (α/β = 10 Gy) higher than 57 Gy₁₀ could improve local control.

Drug-induced photosensitivity: culprit drugs, management and prevention

Photo-induced drug eruptions are cutaneous adverse events due to exposure to a drug and either ultraviolet or visible radiation. Based on their pathogenesis, they can be classified as phototoxic or photoallergic drug eruptions, although in many cases it is not possible to determine whether a particular eruption is due to a phototoxic or photoallergic mechanism. In this review, the diagnosis, prevention and management of drug-induced photosensitivity are discussed. Diagnosis is based primarily on the history of drug intake and the clinical appearance of the eruption, primarily affecting sun-exposed areas of the skin. Phototesting and photopatch testing can be useful adjuncts in making a diagnosis. The mainstay of management is prevention, including informing patients of the possibility of increased sun sensitivity and the use of sun protective measures. However, once the eruption has occurred, it may be necessary to discontinue the culprit medication and treat the eruption with a potent topical corticosteroid. Drugs that have been implicated in causing photosensitive eruptions are reviewed. Tetracycline, doxycycline, nalidixic acid, voriconazole, amiodarone, hydrochlorothiazide, naproxen, piroxicam, chlorpromazine and thioridazine are among the most commonly implicated medications. We review the medical literature regarding evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing.

Radiation recall dermatitis due to gemcitabine does not suggest the need to discontinue chemotherapy

Radiation recall is common following treatment with certain chemotherapy drugs and presents frequently as a skin reaction. With gemcitabine, such a recall phenomenon may affect internal tissues and presents itself as myositis. Although such reactions have previously been reported in the literature, whether or not to continue chemotherapy during such reactions remains controversial. We reported a case of radiation recall in a patient treated with gemcitabine and radiation therapy that presented as myositis. We were able to continue palliative chemotherapy and manage the side effects with supportive care treatment. This case report provides partial support for the continuation of chemotherapy when required even when a recall reaction is encountered.

Sorafenib induced radiation recall dermatitis after spine radiosurgery

Radiation recall dermatitis has been documented to occur in previously irradiated skin (within the radiation port) the administration of some chemotherapeutic agents. Clinically, it can occur weeks or months after radiation therapy, and resembles the appearance of acute radiation skin reaction. The patterns of the reaction correspond with radiation fields and skin doses. We report a case of recall dermatitis 8 weeks after of spine radiosurgery initiated by the use of a multi-targeted tyrosine kinase inhibitor, Sorafenib, used for treatment of hepatocellular carcinoma.

Radiation recall with anticancer agents

There is still much that needs to be understood about radiation recall, and it is not currently possible to predict which patients will be affected and to which drugs they will react. Furthermore, there are no clearly defined characteristics of drugs that cause radiation recall, and thus, it is a possibility that must be kept in mind with use of any drug after radiotherapy, including those from new drug classes. Although it is not yet possible to design treatment regimens to eliminate the risk of radiation recall, it seems likely that risks can be minimized by prolonging the interval between completion of radiotherapy and initiation of full-dose chemotherapy.

Radiation recall is an acute inflammatory reaction confined to previously irradiated areas that can be triggered when chemotherapy agents are administered after radiotherapy. It remains a poorly understood phenomenon, but increased awareness may aid early diagnosis and appropriate management. A diverse range of drugs used in the treatment of cancer has been associated with radiation recall. As most data come from case reports, it is not possible to determine the true incidence, but to date the antineoplastic drugs for which radiation recall reactions have been most commonly reported include the anthracycline doxorubicin, the taxanes docetaxel and paclitaxel, and the antimetabolites gemcitabine and capecitabine. Radiation recall is drug-specific for any individual patient; it is not possible to predict which patients will react to which drugs, and rechallenge does not uniformly induce a reaction. There are no identifiable characteristics of drugs that cause radiation recall, and thus, it is a possibility that must be kept in mind with use of any drug after radiotherapy, including those from new drug classes. Although it is not yet possible to design treatment regimens to eliminate the risk of radiation recall, it seems likely that risks can be minimized by prolonging the interval between completion of radiotherapy and initiation of chemotherapy.

Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair

Most advice currently available with regard to fluoroscopic skin reactions is based on a table published in 1994. Many caveats in that report were not included in later reproductions, and subsequent research has yielded additional insights. This review is a consensus report of current scientific data. Expected skin reactions for an average patient are presented in tabular form as a function of peak skin dose and time after irradiation. The text and table indicate the variability of reactions in different patients. Images of injuries to skin and underlying tissues in patients and animals are provided and are categorized according to the National Cancer Institute skin toxicity scale, offering a basis for describing cutaneous radiation reactions in interventional fluoroscopy and quantifying their clinical severity. For a single procedure performed in most individuals, noticeable skin changes are observed approximately 1 month after a peak skin dose exceeding several grays. The degree of injury to skin and subcutaneous tissue increases with dose. Specialized wound care may be needed when irradiation exceeds 10 Gy. Residual effects from radiation therapy and from previous procedures influence the response of skin and subcutaneous tissues to subsequent procedures. Skin irradiated to a dose higher than 3-5 Gy often looks normal but reacts abnormally when irradiation is repeated. If the same area of skin is likely to be exposed to levels higher than a few grays, the effects of previous irradiation should be included when estimating the expected tissue reaction from the additional procedure.

Patch-test-induced "flare-up" reactions to neomycin at prior biopsy sites

"Recall dermatitis" classically refers to the uncommon phenomenon of chemotherapy-induced reactivation of skin damage originally induced by radiotherapy months or years earlier. We compare this condition to ectopic flare-up reactions presenting as dermatitis at existing or previous sites by an inducing agent. Enhanced sensitization of an existent allergen by patch testing is rarely described. We describe a case of a 61-year-old man's developing localized allergic contact dermatitis at previous neomycin-treated sites following the diagnosis of neomycin sensitivity on patch testing, which we attribute to a "flare-up" phenomenon.