Abstract
The spine is the most common site for bone metastases. Radiation therapy is a common treatment for palliation of pain and for prevention or treatment of spinal cord compression. Helical tomotherapy (HT), a new image-guided intensity modulated radiotherapy (IMRT), delivers highly conformal dose distributions and provides an impressive ability to spare adjacent organs at risk, thus increasing the local control of spinal column metastases and decreasing the potential risk of critical organs under treatment. However, there are a lot of non-target organs at risk (OARs) occupied by low dose with underestimate in this modern rotational IMRT treatment. Herein, we report a case of a pathologic compression fracture of the T9 vertebra in a 55-year-old patient with cholangiocarcinoma. The patient underwent HT at a dose of 30 Gy/10 fractions delivered to T8-T10 for symptom relief. Two weeks after the radiotherapy had been completed, the first course of chemotherapy comprising gemcitabine, fluorouracil, and leucovorin was administered. After two weeks of chemotherapy, however, the patient developed progressive dyspnea. A computed tomography scan of the chest revealed an interstitial pattern with traction bronchiectasis, diffuse ground-glass opacities, and cystic change with fibrosis. Acute radiation pneumonitis was diagnosed. Oncologists should be alert to the potential risk of radiation toxicities caused by low dose off-targets and abscopal effects even with highly conformal radiotherapy.
Highlights
Intensity-modulated radiotherapy (IMRT) is a powerful tool which enabled us to achieve desired dose to tumor and reducing radiation doses to critical structures simultaneously
Radiation pneumonitis in patients undergoing treatment for lung cancer has been shown to be associated with a V20 > 20%, where V20 represents the percentage of lung volume receiving at least 20 Gy [11], and a mean lung dose > 13.6 Gy [12]
The opacities with ground-glass pattern and bleb formation in the transverse views of chest computed tomography (CT) (Figure 2) confined in the previous low dose non-target organs at risk (OARs) field (Figure 3) indicate radiation pneumonitis recalled by gemcitabine
Summary
Intensity-modulated radiotherapy (IMRT) is a powerful tool which enabled us to achieve desired dose to tumor and reducing radiation doses to critical structures simultaneously. Radiation Oncology 2009, 4:71 http://www.ro-journal.com/content/4/1/71 image-guided intensity modulated radiotherapy (IGIMRT) is a safe and effective treatment for cancer spinal metastasis [2]. Helical tomotherapy (HT) is a new CT-based rotational intensity modulated radiotherapy that can deliver highly conformal dose distributions with an ability to spare critical organs from radiation exposure [3]. Gemcitabine chemotherapy, can cause radiation recall followed by standard radiation therapy [8]. We present a case of radiation recall pneumonitis with simultaneous abscopal effects following highly conformal HT and gencitabine-based chemotherapy for metastatic spine lesion in a patient with metastatic cholangiocarcinoma. After one month in the intensive care unit, the patient stabilized and was transferred to the hematology ward for further care
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