Radiation recall dermatitis with soft tissue necrosis following pemetrexed therapy: a case report

Abstract

IntroductionRadiation recall dermatitis is a well known but still poorly understood inflammatory reaction. It can develop in previously irradiated areas and has been shown to be triggered by a variety of different drugs, including cytostatic agents. Pemetrexed may cause radiation recall dermatitis in pre-irradiated patients.Case presentationWe present the case of a 49-year-old Caucasian woman with non-small cell lung cancer who was initially treated with carboplatin and paclitaxel concomitant with radiotherapy after suffering a painful plexus brachialis infiltration. Due to disease progression, a second-line treatment with pemetrexed was started. A severe soft tissue necrosis developed despite steroid treatment and plastic surgery.ConclusionTo the best of our knowledge, we present the first case of a patient with severe soft tissue necrosis in a pre-irradiated area after pemetrexed therapy. We believe that physicians treating patients with pemetrexed should be aware of the severe, possibly life-threatening effects that may be induced by pemetrexed after previous radiation therapy.

Epidemiology of Infections in Cancer Patients

“…Radiation reactions such as radiation enhancement and radiation recall predispose to infection due to local tissue inflammation and breakdown [120][121][122][123][124]. Radiation enhancement, also called radiation sensitization or radiosensitization, is defined as occurring within seven days of radiation exposure and is postulated to be due to the effect of medications that either enhance the initial radiation tissue damage or hinder repair of the tissues after exposure.…”

Pemetrexed-induced radiation recall dermatitis in a patient with lung adenocarcinoma: case report and literature review

“…Interestingly, the patient did not have a recall reaction on the anterior chest wall, where the maximum dosage was 34.0 Gy. Spirig et al also showed a minimal threshold dose that manifested in the RRD localizing to the patient's back and sparing the front side of the radiation portal (7).…”

“…Cutaneous adverse reactions, however, are commonly referred to as "rash" in clinical trials, without any specifics of the actual pathology or etiology. In case reports, pemetrexed-related cutaneous adverse events have been described as acute generalized exanthematous pustulosis (10), toxic epidermal necrolysis (11), and RRD (4)(5)(6)(7)(8).…”

“…Although RRD affects the skin, the radiation recall phenomenon can affect internal soft tissues and organs, including the lungs. RRD precipitated by pemetrexed, a third-generation multitargeted antifolate compound approved and used in the treatment of malignant pleural mesothelioma and NSCLC (1)(2)(3), is a rarely reported phenomenon (4)(5)(6)(7)(8). We describe a 47-year-old man with NSCLC who was treated with radiotherapy and pemetrexed-based chemotherapy 3 years prior to developing RRD upon resumption of pemetrexed-based chemotherapy.…”

Revisiting cutaneous adverse reactions to pemetrexed

“…In some instances, however, CAR identification was more clearly supported (24)(25)(26)(27)(28)(29)(30)(31)(32). The specific diseases associated with these events were reported to be alopecia (22), acute generalized exanthematous pustulosis (AGEP) (24), urticarial vasculitis (25), radiation recall dermatitis (RRD) (26)(27)(28), toxic epidermal necrolysis (TEN) (29,30), eyelid edema (31) and PL-like dermatitis (32).…”