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Clinical Challenge

Lower Back Pain in a Patient With Sarcoma

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Oncology

Published Online: March 25, 2021

JAMA Oncology Clinical Challenge

Article Information and Disclosures

Sebastian Mönch, MD¹;

Gabriel Scheubeck, MD²;

Wolfgang G. Kunz, MD¹

Author Affiliations

¹Department of Radiology, University Hospital, LMU Munich, Munich, Germany
²Department of Medicine III, University Hospital, LMU Munich, Munich, Germany

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A 39-year-old female patient with alveolar rhabdomyosarcoma and bone metastases presented in April 2020 with lower back pain, which was aggravated while standing and walking. She reported no known trauma, and no motor or sensory deficits were noted during clinical examination. She had no fever.

After the initial sarcoma diagnosis in September 2018, the patient received 8 cycles of doxorubicin hydrochloride and ifosfamide along with regional hyperthermia, followed by good tumor response. The patient had a history of a pathological fracture of L4, which had been treated with radiotherapy and vertebroplasty in November 2019 and remained unchanged on imaging obtained in April 2020. The treatment regimen recently had been switched to gemcitabine hydrochloride and docetaxel in January 2020 following osseous progression during maintenance chemotherapy with trofosfamide, idarubicin hydrochloride, and etoposide.

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C. Radiation recall myositis

Radiation recall is a rare diagnosis in which inflammatory reactions are induced by chemotherapeutic agents in previously irradiated tissues. D’Angio et al¹ were the first to describe this phenomenon in 1959. In pediatric and adult patients treated first with radiotherapy and then with intravenous administration of actinomycin D, development of erythema was observed and was sharply limited to prior irradiation fields in the course of actinomycin D treatment.

Since publication of the study by D’Angio et al,¹ many cytotoxic agents have been identified as potential triggers for radiation recall events. Among the most frequent drugs associated with these events are anthracyclines and taxanes, such as docetaxel.² In recent years, gemcitabine also was implicated in several cases.³ Although radiation recall was initially and most often reported to affect the skin, such reactions associated with use of gemcitabine predominantly seem to be associated with inflammation of internal tissues, especially muscles, triggering radiation recall myositis.⁴^- 6

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Article Information

Corresponding Author: Wolfgang G. Kunz, MD, Department of Radiology, University Hospital, LMU Munich, Marchioninistr 15, 81377 Munich, Germany (wolfgang.kunz@med.lmu.de).

Published Online: March 25, 2021. doi:10.1001/jamaoncol.2020.8080

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Lars H. Lindner, MD; Nina-Sophie Schmidt-Hegemann, MD; and Marcus Unterrainer, MD, PhD, MHBA, all of LMU Munich, for their contributions in data collection and their thoughtful comments on the manuscript. They were not compensated for their contributions.

References

D’Angio GJ , Farber S , Maddock CL . Potentiation of x-ray effects by actinomycin D. Radiology. 1959;73:175-177. doi:10.1148/73.2.175 PubMed Google Scholar Crossref

Friedlander PA , Bansal R , Schwartz L , Wagman R , Posner J , Kemeny N . Gemcitabine-related radiation recall preferentially involves internal tissue and organs. Cancer. 2004;100(9):1793-1799. doi:10.1002/cncr.20229 PubMed Google Scholar Crossref

Welsh JS , Torre TG , DeWeese TL , O’Reilly S . Radiation myositis. Ann Oncol. 1999;10(9):1105-1108. doi:10.1023/A:1008365221440 PubMed Google Scholar Crossref

Lock M , Sinclair K , Welch S , Younus J , Salim M . Radiation recall dermatitis due to gemcitabine does not suggest the need to discontinue chemotherapy. Oncol Lett. 2011;2(1):85-90. doi:10.3892/ol.2010.195 PubMed Google Scholar Crossref

Pentsova E , Liu A , Rosenblum M , O’Reilly E , Chen X , Hormigo A . Gemcitabine induced myositis in patients with pancreatic cancer: case reports and topic review. J Neurooncol. 2012;106(1):15-21. doi:10.1007/s11060-011-0672-8 PubMed Google Scholar Crossref

Squire S , Chan M , Feller E , Mega A , Gold R . An unusual case of gemcitabine-induced radiation recall. Am J Clin Oncol. 2006;29(6):636. doi:10.1097/01.coc.0000182426.43595.25 PubMed Google Scholar Crossref

Indinnimeo M , Cicchini C , Kanakaki S , Larcinese A , Mingazzini PL . Chemotherapy-induced radiation recall myositis. Oncol Rep. 2003;10(5):1401-1403.PubMed Google Scholar

Jeter MD , Jänne PA , Brooks S , et al. Gemcitabine-induced radiation recall. Int J Radiat Oncol Biol Phys. 2002;53(2):394-400. doi:10.1016/S0360-3016(02)02773-6 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.