Radiation recall reactions: An oncologic enigma

Palliative radiation therapy for locally advanced breast cancer

PURPOSE OF REVIEW

Globally, breast cancer is the most commonly diagnosed cancer in women. Locally advanced breast cancers (LABCs) may necessitate palliative radiation therapy (RT) due to the severity of the patients' symptoms, inoperability, or other reasons precluding curative-intent treatment such as poor performance status and patient comorbidities. This review aims to discuss current evidence on palliative RT in LABC.

RECENT FINDINGS

Advanced targeted RT techniques have led to improvements in local control with reduced treatment-related toxicities. Emerging short-course palliative RT prescriptions offer feasible options that avoid delay in systemic therapy. Additionally, recent studies also highlight approaches for integrating palliative RT with systemic therapies.

SUMMARY

Palliative RT plays a vital role in managing symptoms and enhancing quality of life for LABC patients. However, there is currently no consensus on the optimal prescriptions for palliative RT in these patients. Standardized reporting of palliative RT studies is needed for robust comparison of efficacy and toxicity between various treatment regimens. Furthermore, future research on the optimal integration of RT with novel systemic agents is needed.

Potential radiotherapy-related reactivation of immune checkpoint inhibitor hepatitis

This report details the reactivation of immune checkpoint inhibitor (ICI)-related autoimmune hepatitis triggered by stereotactic body radiation therapy (SBRT) in a 55-year-old male with hilar cholangiocellular carcinoma. Initially diagnosed in December 2021, the patient underwent successful resection and subsequent adjuvant therapy. Despite stable disease following chemotherapy augmented with durvalumab, he developed grade 3 acute hepatitis after seven cycles of durvalumab. Following a brief prednisolone regimen and normalization of liver tests, SBRT targeting para-aortic lymph nodes was initiated. Remarkably, severe hepatitis reoccurred 7 days after starting SBRT, 88 days following the last durvalumab infusion, necessitating resumed and escalated prednisolone treatment. Another course of SBRT for a newly diagnosed metastatic liver lesion was administered in September 2023, with ongoing prednisolone adjustment. By February 2024, liver tests normalized, but subsequent radiological assessments indicated tumor progression, leading to the reintroduction of chemotherapy. This case underscores the potential of SBRT for activating severe immune-mediated hepatotoxicity in patients treated with ICIs, highlighting the need for careful monitoring and management of such patients. Further, this report highlights the possible survival benefit of the strategic application of SBRT in addition to systematic treatment in recurrent and metastatic cholangiocellular carcinoma.

A case of cetuximab-induced radiation recall skin dermatitis and review of the literature

Radiation recall presents as an acute inflammatory reaction triggered by systemic therapy, usually chemotherapy, and is typically limited to an area that was previously irradiated. Radiation recall reactions are generally self-limiting and most commonly occur in the skin. Many systemic agents have been described to elicit a radiation recall reaction, but the exact pathogenesis is largely unknown. Here, we describe the first reported case of radiation recall dermatitis following cetuximab. While cetuximab is associated with other skin reactions, oncologists should not exclude radiation recall dermatitis as a potential complication of cetuximab infusion in patients with prior radiation, and special attention should be paid to the pattern of skin changes both in terms of location and chronology.

Radiation recall pneumonitis from immune checkpoint inhibitors after extra pulmonary radiation

Radiation recall is an unpredictable, poorly understood inflammatory reaction within the confines of previously irradiated tissue that occurs following exposure to a systemic agent. In this article, we will focus on a subcategory of radiation recall, called radiation recall pneumonitis (RRP), precipitated by immune checkpoint inhibitors (ICI). Historically, RRP can develop weeks to years after radiation treatment to the lung, most commonly after receiving certain chemotherapeutic agents, but more recently has been recognized in association with immunotherapy agents (ICIs). Up until now, RRP following exposure to ICIs has been described in patients who have received radiation to the lung itself. Here we present three cases of RRP in patients who received radiation to areas adjacent to the lung parenchyma, and developed pulmonary infiltrates in an area adjacent to the radiation field while on ICI therapy. Since ICI induced RRP is treatable and steroid sensitive, early recognition and treatment are important.

Radiation recall dermatitis during treatment of endometrial cancer with pembrolizumab plus lenvatinib: A case report

Radiation Recall encompasses an array of inflammatory reactions, most commonly dermatitis, that occurs in response to a systemic medication with distribution in a previously irradiated field. While historically cytotoxic chemotherapy was a major culprit, this case report describes radiation recall dermatitis in response to pembrolizumab and lenvatinib in a 62-year old female with ongoing advanced endometrial cancer and history of breast cancer. Discontinuation of lenvatinib alone lead to complete resolution of the dermatitis, and she ultimately resumed her previous lenvatinib dose without recurrent symptoms. This case represents an important possible adverse effect of a commonly used targeted therapy, particularly in a population likely to have a history of prior radiation exposure.

Gemcitabine-Induced Radiation Recall Phenomenon in Cervical Cancer: A Case Report

The radiation recall phenomenon is a rare, massive inflammatory reaction induced by some chemotherapeutic agents in previously irradiated areas. When it occurs in the pelvis it looks like a recurrence. Recognizing this phenomenon is paramount to avoiding unnecessary surgical intervention and complications. Symptoms manifest as dermatitis, mucositis, myositis, esophagitis, colitis, proctitis, and pneumonitis in areas within the irradiation field. Most patients respond to clinical treatment with corticosteroids. Here, we describe a 47-year-old patient with cervical carcinoma, FIGO stage IIB, submitted to external beam radiotherapy and concomitant chemotherapy with cisplatin (40 mg/m² weekly), followed by intracavitary brachytherapy. One month after the end of radiotherapy and chemotherapy, the patient underwent laparoscopic completion hysterectomy plus bilateral salpingo-oophorectomy, followed by three cycles of cisplatin 50 mg/m² D1 and gemcitabine 1,000 mg/m² D1 and D8. Four months after the surgery, she presented with a suspicious mass in the vaginal dome that proved to be an exuberant inflammatory reaction that regressed after treatment with corticosteroids.

Recognizing cisplatin as a potential radiation recall trigger: case report and focused systematic review

We present a case of mild radiation recall dermatitis triggered by cisplatin chemotherapy given simultaneously to re-irradiation. The dermatitis area correlated to skin exposure of the previous radiation therapy, characterizing the reaction clearly as a recall. Cisplatin has not yet been recognized as a potential trigger for recall reactions. Although it was part of several reported multidrug trigger combinations, all review works referred to cisplatin as not suspicious, suggesting the combination partner as the effector. We performed a focused systematic literature review aiming to re-evaluate the real role of cisplatin as a (co-)triggering factor. In total, 30 reported cases were found, 90% triggered by multidrug combinations. The latter tended to cause more severe symptoms. Besides findings supporting the 20 Gy-threshold theory, no correlation between radiation dose and severity or prevalence was found. Recognition of cisplatin as a trigger of the recall phenomenon and its supportive management may prevent unnecessary cessation of systemic chemotherapy. Systematic reporting of recall events as a secondary endpoint of prospective clinical trials applying radiation therapy could support understanding the recall phenomenon.

Radiation Recall Pneumonitis: The Open Challenge in Differential Diagnosis of Pneumonia Induced by Oncological Treatments

The treatment of primary and secondary lung neoplasms now sees the fundamental role of radiotherapy, associated with surgery and systemic therapies. The improvement in survival outcomes has also increased attention to the quality of life, treatment compliance and the management of side effects. The role of imaging is not only limited to recognizing the efficacy of treatment but also to identifying, as soon as possible, the uncommon effects, especially when more treatments, such as chemotherapy, immunotherapy and radiotherapy, are associated. Radiation recall pneumonitis is an uncommon treatment complication that should be correctly characterized, and it is essential to recognize the mechanisms of radiation recall pneumonitis pathogenesis and diagnostic features in order to promptly identify them and adopt the best therapeutic strategy, with the shortest possible withdrawal of the current oncological drug. In this setting, artificial intelligence could have a critical role, although a larger patient data set is required.

Radiation Recall Pneumonitis Anticipates Bilateral Immune-Induced Pneumonitis in Non-Small Cell Lung Cancer

Radiation recall pneumonitis (RRP) is a rare inflammatory reaction that occurs in previously irradiated fields, and it may be caused by various triggering agents. Immunotherapy has been reported to potentially be one of these triggers. However, precise mechanisms and specific treatments have not been explored yet due to a lack of data in this setting. Here, we report a case of a patient who received radiation therapy and immune checkpoint inhibitor therapy for non-small cell lung cancer. He developed first radiation recall pneumonitis and subsequently immune-checkpoint inhibitor-induced pneumonitis (IIP). After presenting the case, we discuss the currently available literature on RRP and the challenges of differential diagnosis between RRP, IIP, and other forms of pneumonitis. We believe that this case is of particular clinical value since it highlights the importance of including RRP in a differential diagnosis of lung consolidation during immunotherapy. Furthermore, it suggests that RRP might anticipate more extensive ICI-induced pneumonitis.

Immunotherapy Assessment: A New Paradigm for Radiologists

Immunotherapy denotes an exemplar change in an oncological setting. Despite the effective application of these treatments across a broad range of tumors, only a minority of patients have beneficial effects. The efficacy of immunotherapy is affected by several factors, including human immunity, which is strongly correlated to genetic features, such as intra-tumor heterogeneity. Classic imaging assessment, based on computed tomography (CT) or magnetic resonance imaging (MRI), which is useful for conventional treatments, has a limited role in immunotherapy. The reason is due to different patterns of response and/or progression during this kind of treatment which differs from those seen during other treatments, such as the possibility to assess the wide spectrum of immunotherapy-correlated toxic effects (ir-AEs) as soon as possible. In addition, considering the unusual response patterns, the limits of conventional response criteria and the necessity of using related immune-response criteria are clear. Radiomics analysis is a recent field of great interest in a radiological setting and recently it has grown the idea that we could identify patients who will be fit for this treatment or who will develop ir-AEs.

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.

Radiation recall myositis with pazopanib in a patient with soft tissue sarcoma

Introduction

Radiation recall reaction is an acute inflammatory reaction confined to previously irradiated areas that are most commonly triggered by the administration of anti-cancer agents after radiotherapy. Radiation recall myositis is a relatively rare form of radiation recall reaction.

Case report

Here we report a 29-year-old female patient who suffered from metastatic monophasic synovial sarcoma. 8.5 months after post-operative radiotherapy of the right thigh region, the patient suffered pain, edema, redness, and increased temperature locally on the right thigh. Physical exam showed red fixed skin, rigidity and severe tenderness of region, and thigh magnetic resonance imaging revealed dense edema areas at the addiction, semimembranous-semitendinous muscle, and superior part of the biceps femoris and vastus lateralis isointense on T1AG, hyperintense T2AG images. Based on these findings, the patient was diagnosed with pazopanib-induced radiation recall myositis.

Management & outcome

Pazopanib was stopped and pentoxifylline (2  × 400 mg), Vitamin E (3  × 400 mg), and methylprednisolone (2  × 8 mg) were prescribed. After 1 month, complete relief of thigh pain and marked recovery of rigidity, as well as erythema, were achieved and no recurrence of radiation recall reaction-related symptoms was observed after the pazopanib rechallenge.

Discussion

Myositis is a relatively rare presentation of radiation recall reaction and physicians must be aware of the symptoms of the patients who are treated by radiotherapy and pazopanib.

Radiation Recall Pneumonitis COVID-19 Infection Induced After Adjuvant Breast Cancer Radiotherapy. A Known Phenomenon in an Unknown Pandemic Disease: A Case Report

The COVID-19 pandemic has opened several new disease scenarios, yielding novel syndromes that have never been seen before and resurrecting old inflammatory phenomena that are no longer recorded, such as radiation recall (RR) syndromes. Radiation recall syndrome is a limited field inflammatory reaction that occurs in a volume that was irradiated several months or years previously before being induced by a triggering factor. The most frequently reported phenomena are skin reactions; however, other organs could be involved, such as the lungs in radiation recall pneumonitis (RRP). It is a well-described inflammatory reaction that occurs within a pulmonary volume that was irradiated several months or years previously via radiotherapy (RT), triggered by factors such as drugs, including chemotherapy agents, immunotherapy, or vaccination. Indeed, during the COVID-19 pandemic, RRP following anti-COVID-19 vaccination or SARS-CoV2 infection was recently reported. ACE receptor-rich tissues such as lung or skin tissues were mainly involved. Herein, we present a case of RRP triggered by COVID-19 pulmonary infection in a woman who previously underwent adjuvant breast cancer radiotherapy. Although symptoms were typical, pulmonary CT findings depicted a unique distribution of ground-glass opacities (GGOs) throughout the previous radiation portals and mirror-like the radiation fields. Anamnesis and radiation plan evaluation were crucial in the diagnosis of RRP.

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.

Pulmonary Lymphangitis Poses a Major Challenge for Radiologists in an Oncological Setting during the COVID-19 Pandemic

Due to the increasing number of COVID-19-infected and vaccinated individuals, radiologists continue to see patients with COVID-19 pneumonitis and recall pneumonitis, which could result in additional workups and false-positive results. Moreover, cancer patients undergoing immunotherapy may show therapy-related pneumonitis during imaging management. This is otherwise known as immune checkpoint inhibitor-related pneumonitis. Following on from this background, radiologists should seek to know their patients' COVID-19 infection and vaccination history. Knowing the imaging features related to COVID-19 infection and vaccination is critical to avoiding misleading results and alarmism in patients and clinicians.