Radiation myelitis: a complication of concurrent cisplatin and 5-fluorouracil chemotherapy with extended field radiotherapy for carcinoma of the uterine cervix

Stereotactic Body Radiation Therapy for Spinal Metastases: Benefits and Limitations

Progress in biological cancer characterization, targeted systemic therapies and multimodality treatment strategies have shifted the goals of radiotherapy for spinal metastases from short-term palliation to long-term symptom control and prevention of compilations. This article gives an overview of the spine stereotactic body radiotherapy (SBRT) methodology and clinical results of SBRT in cancer patients with painful vertebral metastases, metastatic spinal cord compression, oligometastatic disease and in a reirradiation situation. Outcomes after dose-intensified SBRT are compared with results of conventional radiotherapy and patient selection criteria will be discussed. Though rates of severe toxicity after spinal SBRT are low, strategies to minimize the risk of vertebral compression fracture, radiation induced myelopathy, plexopathy and myositis are summarized, to optimize the use of SBRT in multidisciplinary management of vertebral metastases.

[Radiotherapy and spinal toxicity: News and perspectives]

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.

Radiation myelitis after durvalumab administration following chemoradiotherapy for locally advanced non-small cell lung cancer: an illustrative case report and review of the literature

A 69-year-old man with stage IIIB lung adenocarcinoma received durvalumab following chemoradiotherapy. The prescribed dose was 50 Gy in 2 Gy fractions, and the maximum spinal cord dose was 40 Gy. After three cycles of durvalumab, he experienced bladder and rectal disturbance, muscle weakness in the lower limbs, and sensory loss in the lower body. Magnetic resonance imaging revealed T2 signal hyperintensity involving the thoracic spinal cord. As the thoracic spinal cord with T2 signal hyperintensity matched with the irradiated site, the patient was diagnosed with radiation myelitis. This case report shows the clinical and radiographic features of a case of locally advanced non-small cell lung cancer that demonstrated radiation myelitis following durvalumab administration. The time of onset was very early and the influence of durvalumab was suspected as the cause of myelitis.

Transplantation of mesenchymal stem cells in a laryngeal carcinoma patient with radiation myelitis

Radiation myelitis is a rather rare but devastating complication following therapeutic irradiation to neoplasms when the spinal cord is included within the radiation field. Symptoms of radiation myelitis with the therapeutic doses of radiation commonly employed are usually delayed and most often appear about 6 to 24 months following irradiation. So far, no treatment has proved satisfactory.

Transplantation of allogeneic mesenchymal stem cells has been a promising therapy strategy for many disorders in the central nervous system, such as multiple sclerosis, neuromyelitis optica, and autoimmune encephalomyelitis. The cell-base therapy has shown to act to limit inflammation of central nervous system, stimulate neurogenesis, protect axons and promote remyelination. But it has not been established as a therapeutic option for radiation myelitis.

In this report, we describe the outcome of allogeneic umbilical cord-derived mesenchymal stem cell transplantation in a patient with laryngeal carcinoma who developed radiation-induced myelitis of his spinal cord with characteristic magnetic resonance imaging changes.

Lumbosacral plexopathy: A rare long term complication of concomitant chemo-radiation for cervical cancer

Radiation induced Lumbosacral plexophaty (RILP) is a rare but severe complication that has a considerable impact on quality of life. Its occurrence is rare but increasing with improved long-term cancer survival. This entity commonly results in different degrees of sensory and motor deficits. The pathophysiological mechanisms are not yet fully understood. Diagnosis of radiation myelopathy in women with gynecologic malignancies may increase with the use of concomitant chemo-radiation. This report describes the effect of this combination therapy in a 64-year-old woman with cervical carcinoma.

Physical models and simpler dosimetric descriptors of radiation late toxicity

Predicting radiation damage to specific organs is becoming ever more challenging with the use of intensity-modulated beams, nonuniform dose distributions, partial organ irradiation, and interpatient and even intraorgan variations in radiation sensitivity. Data-based physical models can be of use in summarizing complicated dose-volume data to help describe clinical outcomes and ultimately aid in the prediction of clinical toxicity. This article attempts to provide a brief overview of the use of normal tissue complication probability (NTCP) models and other simple dose/volume metrics to describe a few clinically significant complications (either frequent or serious) associated with radiation therapy of the head and neck, thorax, and abdominal-pelvic regions. Specifically, it reviews the application of these methods for late toxicities of the parotid, lung, heart, spinal cord, liver, and rectum. It focuses on organ-specific NTCP parameters as well as simple dosimetric descriptors that might be used to help treatment plan evaluation in clinical practice.

Fatal radiation myelopathy after high-dose busulfan and melphalan chemotherapy and radiotherapy for Ewing's sarcoma: a review of the literature and implications for practice

Radiation myelopathy is a rare, devastating, late effect of radiotherapy to the spinal cord. Spinal cord tolerance is currently accepted as about 50 Gy in 1.8-2 Gy fractions. However, the effect of chemotherapy on cord tolerance is unclear. This issue is important, given the increasing use of chemotherapy in combination with radiotherapy. We describe the case of a 17-year-old boy with a right apical paraspinal Ewing's tumour in the neck treated with induction chemotherapy, high-dose chemotherapy (busulfan and melphalan) with peripheral stem-cell rescue and, 4 months later, radiotherapy to the primary tumour site (cervical cord received 50 Gy in 30 fractions). After a latent period of 4 months, he developed a progressive, severe and ultimately fatal radiation myelopathy, which we suggest was due to a synergistic interaction between the high-dose chemotherapy and the radiotherapy. The use of such chemotherapy regimens in Ewing's tumours should be carefully considered, particularly when radiotherapy encompassing the spinal cord is an essential component of management.

Concurrent and Adjuvant Chemotherapy for Nasopharyngeal Carcinoma: A Factorial Study

Purpose

To study the efficacy of concurrent chemoradiotherapy (CRT) and adjuvant chemotherapy (AC) for nasopharyngeal carcinoma (NPC).

Patients and Methods

Patients with Ho's stage T3 or N2/N3 NPC or neck node ≥ 4 cm were eligible. Patients were randomly assigned to have radiotherapy (RT) or CRT with uracil and tegafur and to have AC or no AC after RT/CRT. AC comprised alternating cisplatin, fluorouracil, vincristine, bleomycin, and methotrexate for six cycles. There were four treatment groups: A, RT; B, CRT; C, RT and AC; D, CRT and AC. For CRT versus RT, groups B and D were compared with groups A and C. For AC versus no AC, groups C and D were compared with groups A and B.

Results

Three-year failure-free survival (FFS) and overall survival (OS) for CRT versus RT were 69.3% versus 57.8% and 86.5% versus 76.8%, respectively (P = .14 and .06; n = 110 v 109). Distant metastases rate (DMR) was significantly reduced with CRT (14.8% v 29.4%; P = .026). Locoregional failure rates (LRFR) were similar (20% v 27.6%; P = .39). Three-year FFS and OS for AC versus no AC were 62.5% versus 65% and 80.4% versus 83.1%, respectively (P = .83 and .69; n = 111 v 108). DMR and LRFR were not reduced with AC (P = .34 and .15, respectively). Cox model showed CRT to be a favorable prognostic factor for OS (hazard ratio, 0.42; P = .009).

Conclusion

An improvement in OS with CRT was observed but did not achieve statistical significance. The improvement seemed to be associated with a significant reduction in DMR. AC did not improve outcome.

[Late post-irradiation cervical spinal cord disease. A case]

A case of delayed progressive radiation myelitis (DPRM) which begin 11 months after naso pharyngeal carcinoma radiation, in a young man, is reported. The initial manifestation is often a Brown-Sequard's syndrome progressing to complete and permanent myelopathy, with notable absence of localized or radicular pain. The parenchymal change of the spinal cord in radiation myelopathy can be easily visualized with magnetic resonance imaging (MRI) however there may be cases in which MRI appearance alone does not distinguish specially between tumor and radiation necrosis with absolute confidence: therefore, DPRM is by necessity a diagnosis of exclusion, based on clinical, paraclinical results and course of disease. Corticosteroid therapy is accompanied by a significant remission of symptoms. The evolution is characterized by a worse prognosis, prevention is absolutely necessary based on perfect radiation technic, knowledge on tolerance of spinal cord to irradiation (time-dose-volume factors) and other risks factors (chemotherapy, age and vascular disease).