Steroid-withdrawal radiation pneumonitis in cancer patients

Unexpected Symptomatic Pneumonitis Following Breast Tangent Radiation: A Case Report

Symptomatic radiation pneumonitis (RP) following radiation therapy (RT) to the breast alone is very uncommon. We report a case of an 80-year-old female who presented with fatigue, exertional dyspnea, fever, and cough 11.5 weeks following adjuvant breast RT with tangent fields alone. Imaging was consistent with RP, and she responded to a tapering course of steroids.

Role of sphingolipids in murine radiation-induced lung injury: protection by sphingosine 1-phosphate analogs

Clinically significant radiation-induced lung injury (RILI) is a common toxicity in patients administered thoracic radiotherapy. Although the molecular etiology is poorly understood, we previously characterized a murine model of RILI in which alterations in lung barrier integrity surfaced as a potentially important pathobiological event and genome-wide lung gene mRNA levels identified dysregulation of sphingolipid metabolic pathway genes. We hypothesized that sphingolipid signaling components serve as modulators and novel therapeutic targets of RILI. Sphingolipid involvement in murine RILI was confirmed by radiation-induced increases in lung expression of sphingosine kinase (SphK) isoforms 1 and 2 and increases in the ratio of ceramide to sphingosine 1-phosphate (S1P) and dihydro-S1P (DHS1P) levels in plasma, bronchoalveolar lavage fluid, and lung tissue. Mice with a targeted deletion of SphK1 (SphK1(-/-)) or with reduced expression of S1P receptors (S1PR1(+/-), S1PR2(-/-), and S1PR3(-/-)) exhibited marked RILI susceptibility. Finally, studies of 3 potent vascular barrier-protective S1P analogs, FTY720, (S)-FTY720-phosphonate (fTyS), and SEW-2871, identified significant RILI attenuation and radiation-induced gene dysregulation by the phosphonate analog, fTyS (0.1 and 1 mg/kg i.p., 2×/wk) and to a lesser degree by SEW-2871 (1 mg/kg i.p., 2×/wk), compared with those in controls. These results support the targeting of S1P signaling as a novel therapeutic strategy in RILI.

Retrospective analysis of steroid therapy for radiation-induced lung injury in lung cancer patients

PURPOSE

To disclose characteristics of lung cancer patients developing radiation-induced lung injury treated with or without corticosteroid therapy.

METHODS AND MATERIALS

Radiographic changes, symptoms, history of corticosteroid prescription, and clinical course after 50-70 Gy of thoracic radiotherapy were retrospectively evaluated in 385 lung cancer patients.

RESULTS

Radiation-induced lung injury was stable without corticosteroid in 307 patients (Group 1), stable with corticosteroid in 64 patients (Group 2), and progressive to death despite corticosteroid in 14 patients (Group 3). Fever and dyspnea were noted in 11%, 50% and 86% (p<0.001), and in 13%, 44% and 57% (p<0.001) patients in Groups 1-3, respectively. Median weeks between the end of radiotherapy and the first radiographic change were 9.9, 6.7 and 2.4 for Groups 1-3, respectively (p<0.001). The initial prednisolone equivalent dose was 30-40 mg daily in 52 (67%) patients. A total of 16 (4.2%) patients died of radiation pneumonitis or steroid complication with a median survival of 45 (range, 8-107) days.

CONCLUSION

Development of fever and dyspnea, and short interval between the end of radiotherapy and the first radiographic change were associated with fatal radiation-induced lung injury. Prednisolone 30-40 mg daily was selected for the treatment in many patients.

Brain metastases: treatment options to improve outcomes

In recent years, a broader base of treatment options has evolved to improve the outcome for patients with brain metastases. The selection of the most appropriate intervention for the individual patient is dependent on a careful evaluation of the extent of intracranial tumour, as well as an understanding of patient and tumour characteristics that are important determinants of prognosis. Recent analyses have confirmed good performance status, control of the primary tumour, absence of extracranial metastases and age less than 65 years to be predictors for longer survival. Medical therapy typically includes the use of corticosteroids, and some advances have been made in optimising the use of these agents. Prophylactic use of antiepileptic drugs in patients with brain metastases is generally discouraged. Chemotherapy was previously not considered to have a role in treating brain metastases, but has increasingly become an accepted treatment option. Recent clinical studies have evaluated the integration of chemotherapy with conventional treatments such as radiotherapy and the addition of biological response modifiers. In the past, radiotherapy has been the mainstay of treatment for brain metastases. A number of randomised controlled trials have explored external beam radiation therapy, radiation sensitisers, postoperative whole brain irradiation and prophylactic cranial irradiation. Significant improvements in survival have been demonstrated as a result of prophylactic cranial irradiation in patients with small-cell lung cancer, and improved local control of brain metastases has been achieved with postoperative whole brain irradiation. A number of studies have helped define a more efficient use of external beam irradiation. Radiosurgery in particular has been identified as an important advance in radiation treatment delivery and may provide an acceptable alternative to surgical resection in many patients. Conventional surgery has long had a role to play in establishing the diagnosis, guiding the choice of subsequent therapies and reversing life-threatening complications from brain metastases. The risks of surgery have been reduced with recent improvements in anaesthesia and intraoperative tumour localisation. Recent clinical studies have addressed the role of surgical resection in the management of patients with a single brain metastasis. Survival benefits have been demonstrated in patients undergoing surgical resection in addition to external beam radiation therapy. Despite the improvements achieved in the treatment of patients with brain metastases at first diagnosis, the question of retreatment may arise in due course. The therapeutic options available in this situation include re-operation, radiosurgery and brachytherapy.

Risk of pneumonitis in breast cancer patients treated with radiation therapy and combination chemotherapy with paclitaxel

BACKGROUND

Some chemotherapy (CT) drugs, including taxanes, may enhance the effectiveness of radiation therapy (RT). However, combining these therapies may increase the incidence of radiation pneumonitis, a lung inflammation. In a retrospective cohort study, we evaluated the incidence of radiation pneumonitis in breast cancer patients treated with RT and standard adjuvant CT by use of doxorubicin (Adriamycin) and cyclophosphamide, with and without paclitaxel.

METHODS

Forty-one patients with breast cancer were treated with RT and adjuvant CT, including paclitaxel. Paclitaxel and RT (to breast-chest wall in all and lymph nodes in some) were delivered sequentially in 20 patients and concurrently in 21 patients. Paclitaxel was given weekly in some patients and every 3 weeks in other patients. The incidence of radiation pneumonitis was compared with that among patients in our database whose treatments did not include paclitaxel (n = 1286). The percentage of the lung volume irradiated was estimated. The Cox proportional hazards model was used to find covariates that may be associated with the observed outcomes. All P values were two-sided.

RESULTS

Radiation pneumonitis developed in six of the 41 patients. Three patients received paclitaxel concurrently with RT, and three received it sequentially (P =.95). The mean percentage of lung volume irradiated was 20% in patients who developed radiation pneumonitis and 22% in those who did not (P =.6). For patients treated with CT including paclitaxel, the crude rate of developing radiation pneumonitis was 14.6% (95% confidence interval [CI] = 5.6% to 29.2%). For patients treated with CT without paclitaxel, the crude rate of pneumonitis was 1.1% (95% CI = 0.2% to 2.3%). The difference between the crude rates with or without paclitaxel is highly statistically significant (P<.0001). The mean time to develop radiation pneumonitis in patients treated concurrently with RT and paclitaxel was statistically significantly shorter in patients receiving paclitaxel weekly than in those receiving it every 3 weeks (P =.002).

CONCLUSIONS

The use of paclitaxel and RT in the primary treatment of breast cancer should be undertaken with caution. Clinical trials with the use of combination CT, including paclitaxel plus RT, whether concurrent or sequential, must evaluate carefully the incidence of radiation pneumonitis.

Risk factors for severe radiation pneumonitis in lung cancer

BACKGROUND

Risk factors for severe radiation pneumonitis, which often spreads beyond treatment portals and may even be bilateral, have not been fully investigated. The purpose of this study was to identify important factors associated with severe radiation pneumonitis.

METHODS

111 cases of primary lung cancer, treated with radiotherapy or chemoradiotherapy, were retrospectively analyzed.

RESULTS

Severe radiation pneumonitis occurred in 17 cases (15.3%). The ratio of interstitial change in lungs before radiotherapy and radiotherapy to the contralateral mediastinum with > 40 Gy in the radiation pneumonitis group (RP group) was significantly higher than in patients without radiation pneumonitis (control group) (47.1% vs 5.3%; P < 0.001 and 58.8% vs 27.7%; P = 0.037, respectively). Using logistic regression analysis, interstitial changes before radiotherapy and radiotherapy to the contralateral mediastinum of > 40 Gy were significant risk factors associated with severe radiation pneumonitis.

CONCLUSIONS

These data suggest that pre-existing interstitial changes detected by chest radiography or computed tomography and radiotherapy to the contralateral mediastinum (> 40 Gy) may predict the development of severe radiation pneumonitis.

Azathioprine as a steroid-sparing agent in radiation pneumonitis

Radiation therapy is commonly used for treatment of neoplastic disease involving the thorax. Treatment complications include radiation pneumonitis that may require therapy with corticosteroids which possess significant side effects. We report the use of azathioprine as a steroid-sparing agent in a patient with severe radiation pneumonitis and steroid-induced myopathy.

The reverse hockey stick technique: postmastectomy radiation therapy for breast cancer patients with locally advanced tumor presentation or extensive loco-regional recurrence

A combination of photon and electron radiation therapy (RT) fields was devised to treat patients with initial or recurrent breast cancer presentations which extensively involved the chest wall (CW) and/or the axilla. The ipsilateral supraclavicular, infraclavicular, axillary, and lateral CW regions are treated in continuity by anterior and posterior opposed photon beam "reverse hockey stick" fields. The internal mammary and medial chest wall regions are treated by an anterior electron beam field which is tightly junctioned to the photon beam fields. Electron beam energy and thickness of applied bolus are selected so that the electron beam 80% depth isodose curve matches the anterior pleural surface and/or deepest extent of tumor. The goal of treatment is to deliver 4400-5000 cGy to regions at risk of microscopic tumor with local boosts to 6000-7500 cGy to sites of gross disease. Between January 1977, and June 1985, this technique was selectively used in 46 patients, 31 patients with loco-regional tumor recurrence and 15 post-mastectomy patients who initially presented with locally advanced disease. A minimum tumor dose of 4400 cGy was delivered in all except five patients. A diffuse moist skin reaction developed in 31 of the 44 (70%) patients who received at least 3800 cGy. This healed in less than 1 month in all except seven. Frequency of CW diffuse moist skin reaction within the electron beam field was related to the daily applied RT dose. Diffuse moist skin reactions were also noted to be more frequent among patients who had received prior or concurrent Adriamycin. Significant complications included symptomatic arm lymphedema in seven; CW ulcer in two; and acute radiation pneumonitis; steroid-withdrawal radiation pneumonitis, pleuritis, and marked thrombocytopenia in one patient each. With a follow-up of 36-100 months, there was no evidence of loco-regional tumor relapse in 55% of patients treated for recurrent disease and in 73% treated following mastectomy for locally advanced presentations. In summary, we find the reverse hockey stick technique to be a simple, highly reproducible and effective RT approach for postmastectomy breast cancer patients with extensive initial presentation or recurrent disease.