Radiation recall dermatitis: A review of the literature.

PURPOSE/OBJECTIVES: Radiation recall dermatitis (RRD) is a skin reaction limited to an area of prior radiation triggered by the subsequent introduction of systemic therapy. To characterize RRD, we conducted a literature search, summarized RRD features, and compared the most common drug classes implicated in this phenomenon. MATERIALS/METHODS: PubMed, Embase, Scopus, Web of Science, and Cochrane DBSR databases were queried through July 1, 2019 using key words: radiation recall, RRD, and radiodermatitis (limited to humans and English language). Studies included case reports in which patients treated with radiotherapy were initiated on a new line of systemic therapy and subsequently developed a skin reaction in the irradiated area. RRD cases were organized by whether RRD occurred after a single drug or multiple drug administration. RESULTS: One-hundred fifteen studies representing 129 RRD cases (96 single-drug RRD, 33 multi-drug) were included. Sixty-three drugs were associated with RRD. Docetaxel (22) and gemcitabine (18) were the two drugs most commonly associated with RRD. Breast cancer (69 cases) was the most commonly associated tumor type. For single-drug RRD, the median radiotherapy dose was 45.0 Gy (range, 30.0-63.2 Gy). The median time from radiotherapy to drug exposure, time from drug exposure to RRD and time to significant improvement was 8 weeks (range, 2-132 weeks), 5 days (range, 2-56 days), and 14 days (range, 7-49 days), respectively. Variables significantly associated with grade ≥2 toxicity were docetaxel (P = 0.04) and non-antifolate antimetabolite (P = 0.05). The only variable significantly associated with grade ≥3 toxicity was capecitabine (P = 0.04). CONCLUSIONS: RRD is a complex toxicity that can occur after a wide range of radiotherapy doses and many different systemic agents. Most commonly, it presents in patients diagnosed with breast cancer and after administration of a taxane or antimetabolite medication. RRD treatment generally consists of corticosteroids with consideration of antibiotics if superinfection is suspected. Drug re-challenge may be considered after RRD if the initial reaction was of mild intensity.

Patient-reported outcomes version of the common terminology criteria for adverse events and quality-of-life linear analogue self-assessment in breast cancer patients receiving radiation therapy: single-institution prospective registry.

PURPOSE/OBJECTIVES: We sought to investigate the impact of patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE) on overall quality-of-life (QOL) employing linear analogue self-assessment (LASA) in breast cancer (BC) patients undergoing radiation therapy (RT). MATERIALS/METHODS: All patients treated with RT for BC with curative intent from 2015 to 2019 at our institution were included. Breast specific PRO-CTCAE and overall QOL LASA questionnaires were administered at baseline, end-of-treatment, 3, 6, 12 months, and then annually. Minimal clinically important difference in overall QOL was a 10-point change in LASA. Hypofractionation was any treatment > 2 Gy per fraction. Mixed models for repeated measures were used to determine the association of PRO-CTCAE and overall QOL LASA. RESULTS: Three hundred thirty-one (331) patients with a median follow-up of 3.1 years (range 0.4-4.9) were included. Average overall QOL LASA scores were 78.5 at baseline, 79.8 at end-of-treatment, 79.8 at 3 months, 77.1 at 6 months, 79.4 at 12 months, and 79.7 at 24 months. On univariate analysis, patients reporting a grade ≥ 3 PRO-CTCAE had, on average, a 10.4-point reduction in overall LASA QOL (p < 0.0001). On multivariate analysis, not being treated with hypofractionation and higher BMI were predictive for worse overall LASA QOL with a 10-point reduction in LASA for patients reporting a grade ≥ 3 PRO-CTCAE (p < 0.0001). CONCLUSIONS: Patients reporting a grade ≥ 3 PRO-CTCAE experienced statistically significant and clinically meaningful deterioration in overall QOL LASA. Hypofractionation improved QOL while higher BMI predicted for worse QOL. PRO-CTCAE should be integrated into future clinical trials.

The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature.

OBJECTIVE: The purpose of this paper is to summarize the best evidence regarding the impact of providing patient-reported outcomes (PRO) information to health care professionals in daily clinical practice. METHODS: Systematic review of randomized clinical trials (Medline, Cochrane Library; reference lists of previous systematic reviews; and requests to authors and experts in the field). RESULTS: Out of 1,861 identified references published between 1978 and 2007, 34 articles corresponding to 28 original studies proved eligible. Most trials (19) were conducted in primary care settings performed in the USA (21) and assessed adult patients (25). Information provided to professionals included generic health status (10), mental health (14), and other (6). Most studies suffered from methodologic limitations, including analysis that did not correspond with the unit of allocation. In most trials, the impact of PRO was limited. Fifteen of 23 studies (65%) measuring process of care observed at least one significant result favoring the intervention, as did eight of 17 (47%) that measured outcomes of care. CONCLUSIONS: Methodological concerns limit the strength of inference regarding the impact of providing PRO information to clinicians. Results suggest great heterogeneity of impact; contexts and interventions that will yield important benefits remain to be clearly defined.

Accelerated hyperfractionation radiation therapy after lumpectomy and axillary lymph node dissection in patients with stage I or II breast cancer: pilot study.

PURPOSE: To prospectively assess tolerance to accelerated hyperfractionation radiation therapy in patients undergoing breast-conservation therapy and to exclude, with 90% confidence, a 20% or greater risk of an acute toxic reaction of at least grade 3 (severe). MATERIALS AND METHODS: Thirty-seven patients (aged 33-80 years) with evaluatable cases received 48 Gy in twice-daily 1.6-Gy fractions to the breast and regional lymph nodes (if three or more lymph nodes were involved) and a boost of 9.6 Gy in twice-daily 1.6-Gy fractions. Acute and late effects were scored by using the Radiation Therapy Oncology Group and European Organization for the Research and Treatment of Cancer radiation morbidity criteria. RESULTS: One patient developed a grade 3 acute skin toxic reaction and another grade 3 (continuous) acute edema. There have been no grade 4 (life-threatening) acute toxic reactions, local recurrences, or cancer- or treatment-related deaths. CONCLUSION: This breast-conservation accelerated hyperfractionation radiation therapy schedule is tolerable. Additional follow-up is necessary to determine long-term morbidity and cosmesis, and further study in a larger patient group is necessary to confirm efficacy.

Malignant fibrous histiocytoma of the lung. Report of four cases and review of the literature.

BACKGROUND: Primary malignant fibrous histiocytoma (MFH) of the lung is a rare clinical entity. Only 23 reports of 49 cases have been reported in the literature. Surgery was the primary mode of therapy, with high rates of local and distant recurrence reported. The role of radiation therapy and chemotherapy has never been clearly defined. METHODS: The records of the Mayo Clinic in Scottsdale and Rochester from 1970 to 1990 were reviewed for cases of primary pulmonary MFH. A review of the literature was also undertaken. RESULTS: Four cases from the Mayo records and 49 cases from a review of the literature were identified. Eight patients were alive at 5 years from diagnosis; all had been treated with surgery as the primary modality. No definite relationship between histologic subtype of MFH and survival could be identified and no definite role of radiation therapy or chemotherapy could be defined. CONCLUSIONS: MFH of the lung should be treated by surgical resection if technically feasible. The role of adjuvant therapy remains undefined.

The use of radiotherapy for patients with isolated elevation of serum prostate specific antigen following radical prostatectomy.

PURPOSE: An analysis was performed to assess the outcome of patients who received radiotherapy for isolated elevation of serum prostate specific antigen (PSA) levels following radical retropubic prostatectomy. MATERIALS AND METHODS: Forty-six patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymphadenectomy. These patients had detectable serum PSA 6 or more months postoperatively. No patient had other clinical evidence of recurrent disease as determined by history, physical examination, bone scan, computerized tomography of the abdomen and pelvis, chest radiographs, complete blood cell counts and serum chemistry profiles. The patients received prostate bed irradiation using 10 MV. x-rays and a 4-field approach. Doses ranged from 60.0 to 67.0 Gy. in 1.8 to 2.0 Gy. fractions. Freedom from failure after radiotherapy was defined as maintaining a PSA of 0.3 ng./ml. or less without hormonal intervention. RESULTS: In 27 of the 46 patients (59%) PSA had decreased to 0.3 ng./ml. or less at last measurement without hormonal intervention. The freedom from failure rate was 50% at 3 and 5 years. More favorable responses to salvage radiotherapy occurred in patients with low grade tumors and serum PSA 1.1 ng./ml. or less at initiation of radiotherapy. Patients, receiving radiation doses of 64 Gy. or more had more favorable response rates than those receiving lesser doses. CONCLUSIONS: Isolated elevations of serum PSA following prostatectomy reflect residual disease. Radiotherapy administered to the prostate bed effectively decreased serum PSA in approximately half of the cases. This effect appears to be accomplished by eradicating tumor cells in the prostate bed.

Conservative therapy of breast cancer. The Mayo Clinic experience.

PURPOSE: A retrospective analysis of patients with intraductal and early-stage invasive breast cancer treated with breast-conserving surgery and radiation was conducted to determine the local recurrence and survival rates. Between January 1979 and December 1989, 181 patients were treated with breast-conserving surgery and definitive radiation. Nine of these patients also had either synchronous or metachronous bilateral breast cancers also treated with breast conservation. Fourteen cases were intraductal cancer, while the remaining were invasive carcinomas. With a median length of patient follow-up of 4.9 years following initiation of radiation, the overall survival at 5 and 8 years was 93% and 83%, respectively. The local recurrence-free survival at both 5 and 8 years for all patients was 96%. The overall and recurrence-free survival of the intraductal patients alone was 100% at 5 years. Lymph node status and grade were identified as variables associated with time until recurrence based on a stepwise Cox proportional hazards model analysis. Physician assessment of cosmesis was ranked as good to excellent in 82% of patients. This study further substantiates the role of breast-conserving surgery and definitive radiation in the treatment of early-stage breast cancer.

Prolonged amenorrhea associated with total nodal irradiation for Hodgkin's disease.

Pelvic irradiation in the treatment of Hodgkin's disease, including total nodal irradiation, may result in substantial radiation to the ovaries unless oophoropexy and central pelvic shielding is used. Despite such precautions, temporary or permanent amenorrhea may result due to direct or scattered radiation. This article describes a 32-year-old patient who underwent oophoropexy followed by total nodal irradiation for Hodgkin's disease. The patient became amenorrheic for 14 consecutive months. Spontaneous recovery of ovarian function with resumption of menses then occurred and has remained normal to date. The occurrence of prolonged but temporary amenorrhea should be recognized after pelvic radiotherapy for the treatment of Hodgkin's disease.

The result of radical retropubic prostatectomy and adjuvant therapy for pathologic stage C prostate cancer.

PURPOSE: The results of therapy in 288 men with pathologic Stage C prostate cancer who underwent radical retropubic prostatectomy (RRP) were analyzed to determine the effects of adjuvant therapy. METHODS AND MATERIALS: Twenty-seven of the 288 patients received preoperative neoadjuvant hormonal therapy (leuprolide acetate). Postoperatively, 60 patients received adjuvant radiotherapy (RT) to the prostate bed. Follow-up ranged from 3 to 83 months (median = 32 months). Freedom from failure (FFF) was defined as maintaining a serum PSA level of < or = 0.3 ng/ml. RESULTS: The FFF was 61% at 3 years and 45% at 5 years for the entire group. The FFF following RRP plus RT was 75% at 3 years and 57% at 5 years as compared to 56% at 3 years and 40% at 5 years for RRP without RT (p=0.049). The FFF following RRP plus neoadjuvant hormonal therapy was 58% at 3 years and 40% at 5 years as compared to 60% at 3 years and 45% at 5 years following RRP without hormonal therapy (p=0.3). In patients without seminal vesicle (SV) invasion, the FFF was 81% at 3 years and 5 years for RRP plus RT as compared to 61% at 3 years and 50% at 5 years for RRP without RT (p=0.01). In patients with SV invasion, the FFF was 61% at 3 years and 36% at 5 years for RRP plus RT as compared to 44% at 3 years and 23% at 5 years for RRP without RT (p=0.23). The projected local control rate was 83% at 5 years for those with RRP alone as compared to 100% for RRP plus RT (p=0.02). Survival at 5 years was projected to be 92% and was not significantly altered by the administration of adjuvant therapies. CONCLUSIONS: Postoperative RT was associated with significantly improved local control and FFF rates, especially in patients with tumors which did not involve the seminal vesicles.

Breast conservation therapy for invasive breast cancer: a review of prior trials and the Mayo Clinic experience.

OBJECTIVE: To assess the role of breast conservation therapy in the management of early-stage invasive breast cancer. DESIGN: We reviewed the results of previously published trials and summarized 165 cases of breast conservation surgical procedures and irradiation at the Mayo Clinic between January 1979 and September 1989. MATERIAL AND METHODS: From the prior clinical trials, the criteria for selection of patients, the surgical and radiation techniques used, the complications of treatment, the cosmetic results, and the follow-up assessment and survival were analyzed. The 165 Mayo patients were also characterized, and their results were described. RESULTS: Breast conservation therapy consists of excision of the primary tumor followed by irradiation. A coordinated multidisciplinary approach should be used for selection of patients. Several large-scale clinical trials have demonstrated that breast conservation therapy is an appropriate option for most women with early-stage breast cancer and provides tumor control and survival rates equivalent to mastectomy. With a collaborative treatment program and judicious application of contemporary standards of practice, a good-to-excellent cosmetic outcome can be achieved in most patients, and the risk of treatment-related sequelae is minimal. The Mayo Clinic experience with breast conservation therapy is consistent with these observations and compares favorably with other institutional and clinical trial results. CONCLUSION: Patients should be fully educated about the options for primary management of early-stage breast cancer because the selection of therapy may profoundly influence psychologic adjustment and acceptance of the treatment program.