Anal Canal Cancer and Chemoradiation Treatment in Two Patients with Systemic Lupus Erythematosus treated by Chronic Therapeutic Immunosuppression

[Radiotherapy and immune suppression: A short review]

The management of patients undergoing immunosuppressive agents is really challenging. Based on precaution principle, it seems mandatory to stop immunosuppressive (or immunomodulating) agents during radiation. Yet, it is impossible in grafted patients. It is possible in patients with autoimmune disease, but in this case, the autoimmune disease might modify patient's radio-sensitivity. We provide a short review about the safety of radiotherapy in grafted/auto-immune patients. The literature is limited with data coming from outdated case-report or case-control studies. It seems that radiotherapy is feasible in grafted patients, but special dose-constraints limitations must probably be considered for the transplant and the other organs at risk. There is very little data about the safety of radiotherapy, when associated with immunomodulating agents. The most studied drug is the methotrexate but only its prescription as a chemotherapy (high doses for a short period of time) was reported. When used as an immunomodulator, it should probably be stopped 4 months before and after radiation. Apart from rheumatoid arthritis, it seems that collagen vascular diseases and especially systemic scleroderma and systemic lupus erythematous feature increased radio-sensitivity with increased severe late toxicities. Transplanted patients and collagen vascular disease patients should be informed that there is very little data about safety of radiation in their case.

When rectal bleeding is serious: anal squamous cell carcinoma in two intravenous cyclophosphamide treated systemic lupus erythematosus patients with human papilloma virus infection

Anal squamous cell carcinoma is a potentially fatal disease. Human papilloma virus (HPV) is the most common sexually transmitted disease worldwide and is responsible for almost all cases of anal cancer. Immunocompromised patients are at increased risk of developing anal dysplasia and malignancies. A lack of awareness of HPV-associated anal malignancies in the immunocompromised may lead to a delay in diagnosis and confer a poor prognosis.

Influence of connective tissue diseases on the expression of radiation side effects: a systematic review

BACKGROUND AND PURPOSE

Patient related co-factors may increase the risk of radiation morbidity. Connective tissue diseases (CTD) are among the co-morbidities that are relatively well studied and have been shown to be of potential clinical relevance for radiotherapy. The aim of this systematic review is to quantify the contribution of CTD to the risk of radiation related side effects.

PATIENTS AND METHODS

Relevant publications reporting the outcome of radiotherapy in patients with CTD were retrieved according to a standardized query and evaluated for their methodology and quality of reporting, using defined quality criteria. A quantitative estimate of the relative risk of developing side effects in patients with CTD was derived from the observed proportions of responders in patients with or without CTD. Risk estimates were synthesized across studies.

RESULTS

Eight studies which include data of 9-209 patients who had CTD and were treated with radiotherapy were identified and reviewed. Three of these studies included data suited for further quantitative analysis. The test of the uni-directional hypothesis that patients with CTD had an increased risk of late effects after radiotherapy reached statistical significance, the one-tailed P-value being 0.03. The pooled relative risk was 2.0 with 95% confidence interval (0.99, 4.1).

CONCLUSIONS

CTD is associated with an increased risk of late radiation induced normal tissue reaction. The literature published to date provides some support for this assertion although most of the reports are plagued by methodological weaknesses, thus calling for a large coordinated study.