Gemicitabine-Induced Radiation Recall Phenomenon in Two Distinctive Sites on the Same Patient Lulu Zhang, MD, MPH1, Raina Patel, MD2, Syed Mehdi, MD3

1 Department of Internal Medicine, Albany Medical Center, Albany NY; 2 Department of Pathology, 3Division of Hematology-Oncology, Department of Internal Medicine, Stratton Veterans Affairs Medical Center, Albany, NY

• Radiation recall phenomenon is an acute inflammatory reaction developing in previously irradiated areas after administration of inciting agents systemically.

• The most common agents are anticancer drugs. Most agents cause radiation recall dermatitis.

• Gemcitabine is a widely used chemotherapy medication by blocking DNA synthesis and repair. It seems to cause more internal organ damage than dermatitis.

• There has been no report of both myositis and pseudocellulitis induced by gemcitabine on the same patient.

• A 66-year-old male with stage IIIa squamous cell carcinoma of the right upper lung and stage I squamous cell carcinoma of the left supraglottic larynx, was treated with chemoradiation after Right anterior axillary thoracotomy with bilobectomy and En-bloc chest wall resection.

• He received concurrent radiation, carboplatin and paclitaxel. One month later, he received cisplatin and gemcitabine as adjunct therapy.

• One week after finishing all therapies, which was 104 days from last radiation therapy, patient developed severe neck, throat and right shoulder pain, accompanied by neck soft tissue erythema and swelling. He was having a lot of brown-greenish thick secretions in his throat with dysphagia and onydophagia. There was no superficial change of right shoulder, but he did have exquisitely tenderness with about 10 degree passive range of motion in all directions, no active range of motion. Sensations were intact. He also had fever, with temperature max 100.8 F.

• Positive lab findings include WBC 14.2 K/mm3 (4.4-10.7), Neutrophil 81%, CPK peak 683 units/L (21-232), ESR 120 mm/hr (0-20), CRP 16.72 mg/dl (0-0.8).

• CT of the chest showed diffuse stranding of the fat in the right chest wall extending to the axilla, no focal fluid collection. Duplex of right upper extremity showed no evidence of DVT.

• Patient was diagnosed of aspiration pneumonia and was started on zosyn. His fever and leukocytosis resolved, but the pain in his right shoulder with decreased range of motion did not improve at all after 4-day zosyn.

• Gemicitabine-induced radiation recall pseudocellulitis and myositis were entertained as the diagnosis. Patient received naproxen followed by prednisone taper, which resolved his neck pain, swelling and frozen shoulder.

• Repeated CT of the chest also showed improved soft tissue inflammation after 2 weeks steroid tapering treatment.

• Gemcitabine-induced radiation recall phenomenon is a rare but real disease entity.

• It may mimic many other inflammatory or infectious diseases.

• It is important to bear this diagnosis in mind when a patient develops symptoms in a previously irradiated area.

• Anti-inflammatory/corticosteroid treatments still remain the mainstay therapy with good responses.

1) Philip F, Roopa B, et al. Gemcitabine-related radiation recall preferentially involves internal tissue and organs. Cancer 2004;100(9):1793-99. 2) Katzung et al. (2012) Basic and clinical pharmacology, 12 e, chapter 54. McGraw-Hill. 3) Fogarty et al. Radiation recall reaction following gemcitabine. Lung Cancer. 2001;33:299-302. 4) Jeter et al. Gemcitabine-induced radiation recall. Int. J. Radiation Oncology Biol Phys. 2002;53(2): 394-400. 5) Eckardt et al. A child with gemcitabine-induced severe radiation recall myositis resulting in a compartment syndrome. J Pediatr Hematol Oncol. 2013; 35(2): 156-61. 6) Squire et al. An Unusual Case of Gemcitabine-Induced Radiation Recall. Am J Clin Oncol. 2006;29: 636. 7) Lock et al. Radiation recall dermatitis due to gemcitabine does not suggest the need to discontinue chemotherapy. Oncology Letters. 2011;2:85-90. 8) Biswas et al. Gemcitabine-induced radiation recall phenomenon in a post-operative and post-radiotherapy case of peri-ampullary carcinoma during adjuvant chemotherapy. J of Cancer Res and Ther. 2012;8(3):439-41. 9) Burris et al. Radiation recall with anticancer agents. The Oncologist. 2010;15:1227-37.

Poorly differentiation tumor invading chest Wall cortical bone (HE, 200x).

Neck and anterior chest wall skin erythema and soft tissue swelling after chemotherapy.

CT of the chest: diffuse stranding of the fat in the right chest wall extending to the axilla during initial presentation;

CT chest: improved inflammation after steroid treatment.