40 yo WF

1

• 40 y/o WF
• h/o breast CA Dxd in 2001 with liver (2002) and
  bone metastasis (2003) s/p chemotherapy
• had radiation 4 months PTA
• had gemcitabine before and after radiation
• Was admitted at OSH 2 weeks PTA for Lt femur, hip
  pain, and fever
• Received multiple ATBs without any improvement

2

• Over the first week of her hospitalization at
  OSH, pain was constant and the area of pain
  became red and swollen and spread across her
  whole rear Lt buttock.
• On admissionpt noted that her whole Lt leg was
  swollen, her buttock and upper thigh were
  markedly re and painful.

3

• Pt was transferred to Baptist Medical Center for
  concerns with necrotizing fasciitis.
• Allergy None
• Meds Vancomycin, Zosyn, Clindamycin, Meropenem,
  Levaquin, Rocephin

4
Physical Examination

• VS T 101.7 P 107 RR 22 BP 140/80
• PO 98 RA
• GA well-nourished WF in pain, laying on
  Rt side
• HEENT WNL
• Neck supple
• Chest CTA bilaterally
• Heart RSR, no murmur

5
Physical Examination

• Abd benign
• Ext Lt leg- swollen, erythema and induration at
  Lt buttock, very tender
• NS no focal deficit
• LN no lymphadenopathy

6
Laboratory Data

• CBC
• WBC 16.7 Hb 10.1 Hct 29.5 Plt 472
• N 83 , E 0
• CMP
• BMP WNL , Cr 0.8
• AST 54 ALT 34 ALP 181 TB 1.1
• Alb 2.4
• ESR 82 CRP 29.56

7

• CT LLE one week PTA from OSH
• Marked inflammatory changes involving the
  subcutaneous tissues
• and muscles of the left gluteal region and
  proximal, anterior left thigh. consistent with
  myositis and adjacent fasciitis. No evidence of
  osteomyelitis.

8

• Pt was placed on nafcillin and clindamycin
• ID was consulted.
• Recs
• - MRI LLE
• - To change ATBs to Vancomycin and
• Meropenem
• - Consult Rad-Onc
• - Consider deep skin biopsy

9

• CT both LE 2 days after admission
• Pyomyositis involving the left gluteus maximus
  muscle, as well as
• the adductor and extensor musculature about the
  left hip.
• No evidence of subcutaneous air to suggest
  necrotizing fasciitis.

10

• Aspiration was attempted with no return of fluid.
  
• Core Bx of the left gluteus maximus muscle was
  done and sent to micro for culture as well as
  pathology for
• evaluation.

11
CULTURE

• TISSUE from Lt gluteus
• -NO GROWTH
• Blood culture
• - NO GROWTH

12
PATHOLOGY

• Necrosis of adipose tissue and fascia consistent
  with radiation-induced necrosis.
• Stains for bacteria and fungi are negative
• The morphology of the lesion with acute and
  chronic diffuse inflammation and fibrosis as well
  as lack of a wall of an abscess favor
  radiation-induced necrosis over a primary
  infectious process.

13
Radiation recall dermatitis

• An inflammatory skin reaction that develops in a
  previously irradiated body part after
  administration of certain promoting agents.
• Most cases have been associated with
  chemotherapy.
• was originally described with dactinomycin
• Since then, a number of drugs have been
  associated with this phenomenon , particularly
  the anthracyclines

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• not limited to the skin
• can extend to unirradiated skin
• Erythema - most common sign
• may be painful
• Vesiculation, desquamation, and ulceration

16

• Histologically, epidermal dysplasia, necrotic
  keratinocytes, and a mixed inflammatory reaction
• Some cases - psoriasiform dermatitis
• Additional dermal changes
• - dermal fibrosis
• - vasodilatation
• - atypical fibroblasts

17

• Most often, RRD occurs with the first dose of a
  chemotherapeutic agent
• Sometimes depends on drug dose
• IV chemotherapy agents usually produce RRD more
  rapidly (several minutes to 14 days) than oral
  agents, (3 days to 2 months)

18

• The duration of symptoms also differs with drugs
  administered IV or orally.
• RRD caused by IV drugs - resolves within two
  weeks
• Oral medications - symptoms may last for several
  months

19

• To prevent recurrence
• Dose reduction
• Corticosteroids
• Rechallenge with the same agent will not
• always lead to recrudescence.
• The pathogenesis of this local
• phenomenon is not well understood.

20
GEMCITABINE-INDUCED RADIATION RECALL

• MELENDA D. JETER, M.D., M.P.H.,et al
• Int. J. Radiation Oncology Biol. Phys., Vol. 53,
  No. 2, pp. 394400, 2002
• 6 patients with radiation recall secondary to
  gemcitabine
• central nervous system, skin, GI tract, and in
  the lymphatic and musculoskeletal systems.

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• The time between initiation of radiation and
  recall of the radiation phenomenon ranged from 3
  weeks to 8 months from the time gemcitabine was
  initiated.
• The usual dosage of gemcitabine in these cases
  was 1000 mg/m2 q week.

22

• Treatment of the recall reaction
• - discontinuing gemcitabine
• - steroid therapy
• - supportive therapy
• - and/or nonsteroidal anti-inflammatory
• agents
• Minimal improvement was seen in 3 out of 6
  patients, and resolution was seen in 3 out of 6
  patients.

23
Gemcitabine

• Antimetabolites
• A potent radiation enhancer
• The exact mechanism of its enhancement is not
  known.
• ? lower threshold for radiation-induced apoptosis

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• In 2 patients, the recall reaction was observed
  in only one area of prior irradiation and not in
  the others.
• Could be caused by variations in tissue tolerance
  or differing levels of tissue repair over time.
• Doses of 600 mg/m2 and higher may cause a
  radiation recall phenomenon.

25

• Gemcitabines ability to penetrate the CNS may be
  responsible for the radiation recall phenomena
• Radiation recall from gemcitabine chemotherapy is
  rare.