Gemcitabine-induced Radiation Recall Dermatitis: Case Report

Toxic Epidermal Necrolysis Associated with Gemcitabine Therapy in a Patient with Metastatic Transitional Cell Carcinoma of the Bladder

The authors report on a case of treatment-related toxic epidermal necrolysis in an elderly man receiving chemotherapy (gemcitabine) for transitional cell carcinoma of bladder and discuss the implications of the case.

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.

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.

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.

Chemotherapeutic agents and the skin: An update

Chemotherapeutic agents give rise to numerous well described adverse effects that may affect the skin, hair, mucous membranes, or nails. The mucocutaneous effects of longstanding agents have been extensively studied and reviewed. Over the last 2 decades, a number of new molecular entities for the treatment of cancer have been approved by the United States Food and Drug Administration (FDA). This article reviews the cutaneous toxicity patterns of these agents. It also reviews one drug that has not received FDA approval but is in use outside the United States and is important dermatologically. Particular emphasis is placed on the novel signal transduction inhibitors as well as on newer literature pertaining to previously described reactions.

LEARNING OBJECTIVES

At the completion of this learning activity, participants should able to list the newer chemotherapeutic agents that possess significant mucocutaneous side effects and describe the range of reactions that are seen with each drug. In addition, they should be able to formulate appropriate management strategies for these reactions.

Gemcitabine-related "pseudocellulitis": report of 2 cases and review of the literature

Gemcitabine is a chemotherapeutic agent whose cutaneous toxicities are easily mistaken for infections. We describe 2 patients, 1 with gemcitabine-induced radiation recall dermatitis and 1 with gemcitabine-related erysipeloid reaction, who received misdiagnoses of infectious cellulitis and were given empirical antibiotics. Recognition of these syndromes is important to avoid unnecessary antibiotic use.

Gemcitabine-related radiation recall in a patient with pancreatic cancer

Radiation recall refers to inflammatory reactions triggered by chemotherapeutic agents and develops cutaneously in the previously irradiated areas. Such agents include anthracyclines, taxanes and capecitabine. Radiation recall related to gemcitabine has been reported in lung and breast cancer. Similar phenomenon associated with gemcitabine, the only FDA-approved drug for pancreatic cancer, is rarely reported. We report a patient with inoperable pancreatic cancer who developed gastrointestinal bleeding secondary to radiation-recall related to gemcitabine and review literature. A 57-year-old white male with unresectable pancreatic cancer received capecitabine in combination with radiation therapy followed by capecitabine alone given over approximately a 3-month time period. Computed tomography re-evaluation demonstrated a new liver lesion. The patient was then treated with gemcitabine and irinotecan. On day 15 of cycle 1, he reported progressive worsening of weakness and fatigue, and melena. Physical examination revealed hypotension (84/47 mmHg) and heme-positive stool on rectal examination. He denied aspirin or non-steroidal anti-inflammatory drug use. Chemotherapy was held. Hematocrit was 20% (previously 33%). He was transfused with 3 units of packed red blood cells. An esophago-gastro-duodenal examination was performed which showed antritis and duodenitis consistent with radiation therapy. A single site of oozing was injected with epinephrine. The diffuse gastritis was aggressively treated with proton pump inhibitors. The patient's hematocrit eventually stabilized and was 30% at discharge. Gemcitabine was not resumed. Radiation recall from gemcitabine is rare, but can potentially arise in any site that has been previously irradiated. Gemcitabine should be added to the list of drugs known to cause radiation recall. Treating physicians must be aware of this potential toxicity from gemcitabine either given concomitantly or followed by radiation. We suggest discontinuing gemcitabine if radiation recall is observed. Further studies are warranted into the pathogenesis of this unique phenomenon.

Radiation recall: A well recognized but neglected phenomenon

INTRODUCTION

Radiation recall is an inflammatory skin reaction at a previously irradiated field subsequent to the administration of a variety of pharmacologic agents. Although skin has been the major site of radiation recall toxicity, instances involving other organ have been reported.

MATERIALS AND METHODS

Data for this review were identified by searches of Medline and Cancerlit. The search terms "radiation", "recall", and "toxicity" were used. References identified from within retrieved articles were also used. There was no limitation on year of publication and no abstract forms were included. Only articles published in English were taken into consideration.

RESULTS

Idiosyncratic drug hypersensitivity phenomenon is a recent hypothesis which correlates best with the available facts at this moment. The phenomenon may occur days to years after radiotherapy has been completed. The majority of the drugs commonly used in cancer therapy have been involved in the radiation recall phenomenon. A mixed non-specific inflammatory infiltrate seems to be the common histopathologic criteria in previous published reports. Universally, corticosteroids or the use of non-steroidal anti-inflammatory agents, in conjunction with withdrawal of the offending agent, produce prompt improvement.

CONCLUSION

We propose to collect all future radiation recall phenomenon in a Rare Cancer Network database in order to augment our understanding of this rare reaction.

Retrospective analysis of adverse drug reactions induced by gemcitabine treatment in patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the leading cause of cancer death in the world. Traditional chemotherapy for advanced NSCLC is often considered excessively toxic. Recent clinical trials documented that gemcitabine may represent a good therapeutical option in patients with NSCLC. Aim of our research was to retrospectively evaluate the adverse effects induced by gemcitabine in patients with NSCLC from 1 January 1997 to 31 December 2002, in clinical records of Oncology Divisions of "S. Giovanni di Dio" Hospital of Crotone, "Ospedali Riuniti" Hospital of Reggio Calabria, Hospital of Paola, and in Pneumological Oncology Division of "Mariano Santo" Hospital of Cosenza, Italy. Clinical records of patients treated with gemcitabine (1000mgm(-2) on days 1 and 8) were reviewed and following data were obtained: sex and age of the patients, histologic diagnosis and disease stage, World Health Organisation (WHO) performance status and toxic effects induced by gemcitabine. We reported that 71.6% of NSCLC patients (age range 48-77 years; 135 males, 27 females; performance status 0=53, 1=109) were eligible for our study. Side effect of gemcitabine involved gastrointestinal system (nausea, vomiting and diarrhoea) and only in the last cycles (VIII-XI) emopoiethic system (leukopenia, neutropenia, thrombocytopenia and anemia). Grade IV vomiting occurred in three patients, thrombocytopenia in two. Grade III leukopenia was observed in three patients. Other toxicities were mild. None of the patients died during chemotherapy. In conclusion, these data showed that gemcitabine present a very good tolerability in patients with NSCLC. Therefore, it could be considered as a new therapeutic agents to use as first line therapy for this disease.

Gemcitabine-related radiation recall preferentially involves internal tissue and organs

Radiation recall refers to inflammatory reactions triggered by cytotoxic agents and develops in previously irradiated areas. Most reactions develop cutaneously. The most common chemotherapeutic agents implicated are anthracyclines and taxanes. Gemcitabine, a nucleotide analog, recently was implicated in several cases. The authors performed a literature search using PubMed and the search terms "gemcitabine" and "radiation recall" to find prior cases of radiation recall attributed to gemcitabine. These cases were compared with those attributed to anthracyclines and taxanes. The literature search found 12 cases of radiation recall caused by gemcitabine. The authors also determined that their case of myositis developing in the rectus abdominus muscle of a patient with pancreatic adenocarcinoma was the manifestation of radiation recall, thereby bringing the number of patients who developed radiation recall to gemcitabine and were discussed in the current study to 13. Approximately 70% of the cases manifested as inflammation of internal organs or tissues and 30% manifested as a dermatitis or mucositis. This finding differs from other common agents, in which 63% of the radiation recall events are reported to manifest as a dermatitis. Compared with anthracyclines and taxanes, the interval from the completion of radiation therapy to the initiation of chemotherapy is less for gemcitabine (median time of 56 days for gemcitabine, compared with 218 days for the taxanes and 646 days for doxorubicin). The majority of radiation recall reactions attributed to gemcitabine are reported to affect internal tissue or organs. In contrast, other common agents for the most part trigger cutaneous inflammation. The development of internal tissue inflammation is reportedly correlated with a shorter interval from the time of completion of radiation therapy to the initiation of chemotherapy.