|Year : 2014 | Volume
| Issue : 4 | Page : 1093-1097
Radiation recall phenomenon presenting as myositis triggered by carboplatin plus paclitaxel and related literature review
Chi Hoon Maeng1, Jun Sang Park2, Seung Ah Lee2, Dong Hwan Kim2, Dong Hwan Yun2, Seung-Don Yoo2, Hee-Sang Kim2, Jinmann Chon2
1 Department of Internal Medicine, Division of Hemato-Oncology, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
2 Department of Physical Medicine and Rehabilitation, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
|Date of Web Publication||9-Jan-2015|
Department of Physical Medicine and Rehabilitation, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, 23 Kyungheedae ro, Dongdaemun gu, Seoul - 30 701
Source of Support: None, Conflict of Interest: None
While most case reports to date are radiation recall dermatitis, radiation recall myositis, which is a distinct form of radiation recall phenomenon caused by carboplatin plus paclitaxel, has not been reported. We treated a 57-year-old female patient who suffered from recurrent cervical cancer. When the patient developed a new left sacral metastasis, salvage radiotherapy (total dose 60 Gy) was administered. Four weeks later, chemotherapy using carboplatin plus paclitaxel was initiated. Four months after chemotherapy, the patient complained of severe pain in her left buttock. On magnetic resonance imaging (MRI), edematous changes and increased signal densities of left gluteus maximus and medius muscles were noted suggesting myositis. The border of the high signal intensity territory of the muscles was sharp and clearly corresponded with the recent irradiation field. We concluded that the patient had radiation recall myositis triggered by paclitaxel-carboplatin. Symptoms were controlled by analgesics, and there was no recurrence.
Keywords: Carboplatin, myositis, paclitaxel, radiation recall
|How to cite this article:|
Maeng CH, Park JS, Lee SA, Kim DH, Yun DH, Yoo SD, Kim HS, Chon J. Radiation recall phenomenon presenting as myositis triggered by carboplatin plus paclitaxel and related literature review. J Can Res Ther 2014;10:1093-7
|How to cite this URL:|
Maeng CH, Park JS, Lee SA, Kim DH, Yun DH, Yoo SD, Kim HS, Chon J. Radiation recall phenomenon presenting as myositis triggered by carboplatin plus paclitaxel and related literature review. J Can Res Ther [serial online] 2014 [cited 2021 Jun 24];10:1093-7. Available from: https://www.cancerjournal.net/text.asp?2014/10/4/1093/146090
| > Introduction|| |
Radiation recall is a rare phenomenon, which is defined as acute inflammation, triggered by subsequent chemotherapy that develops in a previously irradiated field. The first case of radiation recall was reported in 1959, and numerous cases have been diagnosed to date.  Radiation recall has been linked to a variety of chemotherapeutic agents, including 5-fluorouracil, capecitabine, anthracycline, gemcitabine, taxanes, oxaliplatin, vinorelbine, and cisplatin. ,,,,,, In addition, various antimicrobial agents have been considered as causative agents, , and some investigators have reported radiation recall following molecular targeted therapy. ,, Radiation recall frequently presents as acute dermatitis  and differentiates from radiation-induced skin sensitization when chemotherapeutic agents are administrated more than 7 days after completion of radiotherapy. ,
While acute dermatitis is a common feature of radiation recall, some cases involve internal organs or tissues, particularly those treated with gemcitabine. ,,, However, radiation recall myositis is rarer than dermatitis, and this report describes a unique case of radiation recall myositis associated with chemotherapeutic agents other than gemcitabine.
| > Case report|| |
A 57-year-old female was diagnosed with cervical cancer and underwent laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy in March 2006. The tumor was histologically confirmed as a squamous cell carcinoma. The surgery was performed with curative intent, and the surgical resection margin was negative; however, locoregional recurrent disease in pelvic cavity was found in 2010. Because there was no distant metastasis, the patient received cisplatin-based concurrent chemoradiotherapy. In April 2011, a newly developed metastasis of left side sacrum was found. A sacral laminectomy was performed to decrease the tumor burden because the patient still had no distant metastasis. Salvage radiotherapy was administered subsequently. The total irradiation dose was 60 Gy in 42 fractions. Four weeks after the completion of radiotherapy, salvage chemotherapy using carboplatin plus paclitaxel was initiated for six cycles from October 2011 to January 2012.
Approximately four months after chemotherapy was initiated, the patient complained of severe pain in her left buttock and lower extremity. Physical examination revealed local tenderness around the affected area, although there was no sensory deficit. Subsequently, we performed lumbosacral spine magnetic resonance imaging (MRI) to evaluate possible etiologies. We observed that the left gluteus maximus and gluteus medius muscles had diffusely increased signal densities [Figure 1]. Furthermore, edematous changes in the affected muscles were noted on the high short TI inversion recovery signal density. These findings were suggestive of myositis. Interestingly, the affected area clearly corresponded with the recent irradiation field. Other muscle disease or metastatic lesions could be excluded because the border of the high signal intensity territory was sharp and the intensity was diffuse in pattern. Because the myositis appeared 4 months after completion of radiotherapy, we concluded that the patient had radiation recall myositis triggered by paclitaxel-carboplatin. Symptoms were controlled by analgesics, and there was no recurrence.
|Figure 1: An MRI image with high short TI inversion recovery signal density of the gluteus muscle with diffuse enhancement of the involved area on the lumbar spine (A, transverse and B, sagittal view). The area matched a prior irradiated field|
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| > Discussion|| |
Radiation recall is a well-known phenomenon, although the detailed pathophysiology remains to be elucidated. There are many potential causative agents triggering radiation recall, and the phenomenon is drug-specific with a clinical presentation that varies among individuals. Predicting the development of radiation recall is not possible, even though a prior episode of radiation recall does not preclude patients from challenging the drug again. , Most cases of radiation recall report the phenomena as acute inflammation involving cutaneous tissue, and the related drugs are often anticancer agents.  Acute dermatitis of radiation recall is probably caused by a hypersensitivity reaction with idiosyncrasy.  Histological findings characterized by epidermal dysplasia, necrotizing keratinocytes, increased mitotic figures, and local inflammatory infiltration are typical pathological changes, suggesting an important role for radiation.  Chemotherapeutic agents can potentiate the inflammatory process, resulting in dermatitis.  Although most cases of radiation recall are dermatitis, some investigators also report other rare forms, such as myositis.
We reviewed the available literature reporting radiation recall myositis by searching PubMed with the keywords "radiation recall" and "myositis," and the related articles were checked and reviewed [Table 1]. The time intervals between completion of radiotherapy and initiation of chemotherapy did not exceed 5 months, although the statistical relevance could not be determined. The reported symptoms were primarily pain of the involved muscles and edematous changes noted on computed tomography (CT) or MRI. Painful muscles were well controlled by corticosteroid and/or non-steroidal anti-inflammatory drugs (NSAIDs) or by discontinuation of the causative drug. There was no recurring phenomenon among the patients who received the culprit drug again after symptoms were relieved, with the exception of one case.  The most commonly reported causative drug was gemcitabine. Interestingly, there were no cases driven by paclitaxel or carboplatin, which were the triggering agents in our case. It is not clear which of these two drugs was directly responsible for the phenomenon. To the best of our knowledge, this is the first report of radiation recall myositis induced by paclitaxel and carboplatin. In the literature review, there was one report of a patient treated with gemcitabine plus carboplatin.  However, the authors concluded that gemcitabine, and not carboplatin, was the triggering drug, although there was no definite explanation. There have been several published cases of radiation recall dermatitis induced by paclitaxel, ,,, and another report of paclitaxel and carboplatin-caused radiation recall colitis.  In that case, colitis-related symptoms started the day after administration of chemotherapy. In our case, the time interval between the end of radiotherapy and the beginning of chemotherapy was approximately 1 month, whereas radiation recall myositis developed 4 months after chemotherapy, which was not a significantly different trend from previous reports. Even though we did not re-administer the chemotherapeutic agents, based on previous reports, it was possible to administer chemotherapy safely, but with caution, if the patient recovered from recall phenomenon and the response to chemotherapy remained. A limitation of this case report was a lack of pathological confirmation of the involved soft tissue. However, a biopsy was not possible because the patient complained of severe buttock pain, and we treated her symptoms promptly and successfully. A biopsy was not essential in our case because radiation recall is generally diagnosed with consideration of the relevant patient history, related symptoms, and typical images from a radiological study, such as CT or MRI. 
|Table 1: Reported cases of radiation recall myositis induced by chemotherapeutic agents|
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| > Conclusions|| |
Radiation recall induced by chemotherapy can comprise myositis, as well skin inflammation. It is triggered by various agents, including gemcitabine, which is one of the most commonly reported anticancer drugs associated with radiation recall myositis. However, as we report here, paclitaxel plus carboplatin can also cause radiation recall myositis. Physicians should be educated about this disease in order to manage this idiosyncratic phenomenon whenever patients receive chemotherapy followed by radiotherapy.
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