Severe myositis of the hip flexors after pre-operative chemoradiation therapy for locally advanced rectal cancer: case report

Abstract

BackgroundThe use of neoadjuvant radiation therapy and chemotherapy in the treatment of locally advanced rectal adenocarcinoma has been shown to reduce disease recurrence when combined with surgery and adjuvant chemotherapy. We report a case of a patient who developed a debilitating bilateral myopathy of the hip flexors after successful treatment for rectal cancer. To the best of our knowledge, this is the first such complication from radiation therapy reported in a patient with colorectal cancer. The disproportionate severity of our patient’s myopathy relative to the dose of radiation used also makes this case unique among reports of neuromuscular complications from radiation therapy.Case presentationThe patient is a 65-year-old male with node negative, high-grade adenocarcinoma of the rectum penetrating through the distal rectal wall. He underwent neoadjuvant concurrent pelvic radiation therapy and capecitabine-based chemotherapy, followed by abdominoperineal resection and post-operative FOLFOX chemotherapy. Five months post-completion of pelvic radiotherapy and 2 months after the completion of adjuvant chemotherapy, he presented with bilateral weakness of the iliopsoas muscles and severe pain radiating to the groin. The patient improved with 40 mg/d of prednisone, which was gradually tapered to 2 mg/d over 6 months, with substantial recovery of muscle strength and elimination of pain.ConclusionsThe timing, presentation and response of our patient’s symptoms to corticosteroids are most consistent with a radiation recall reaction. Radiation recall is a phenomenon whereby previously irradiated tissue becomes vulnerable to toxicity by subsequent systemic therapy and is rarely associated with myopathies. Radiation recall should be considered a potential complication of neoadjuvant radiation therapy for rectal cancer, and for ongoing research into the optimization of treatment for these patients. Severe myopathies caused by radiation recall may be fully reversible with corticosteroid treatment.

Multidisciplinary approach to L3/L4 lumbar disc prolapse masquerading as focal limb myositis-a radiological challenge

“…No evidence of infection was found in our case with a normal range of inflammatory markers. Chemoradiation causing myopathy of hip muscles was reported by Florczynski et al 6 in a case of adenocarcinoma of the rectum. That happened 5 month post-radiotherapy and 2 month post-chemotherapy completion in their case.…”

A Case of Radiation Recall Myositis and Neuropathy in Locally Advanced Rectal Cancer

“…Proposed mechanisms include lowering of the inflammatory threshold in radiated tissues, and enhanced drug hypersensitivity [13,14]. Subclinical inflammatory processes and tissue damage caused by RT presenting clinically only after additional toxicity caused by chemotherapy is another possibility [15].…”

“…Few reports exist of RRR associated with 5FU and oxaliplatin, and myositis is even more rare. Specifically, only one other publication has described RRR myositis following administration of 5FU and oxaliplatin [15].…”

Disease- and treatment-related complication on F-18-Fluorodeoxyglucose positron emission tomography/computed tomography in oncology practice: A pictorial review

“…[ 63 ] Furthermore, chemotherapy has potential to exacerbate tissue injury caused by radiation therapy, phenomenon known as radiation recall. [ 64 ] In such cases, previously irradiated tissue becomes more vulnerable to toxic effect of subsequent systemic therapy. Radiation recall most commonly occurs as dermatitis but could also leads to myositis, pneumonitis, or enterocolitis.…”

“…Radiation recall most commonly occurs as dermatitis but could also leads to myositis, pneumonitis, or enterocolitis. [ 64 65 66 67 ] Time interval between radiation treatment and radiographic appearance of radiation-induced muscle changes have been studied with both photon and neutron therapy. MR imaging showed that muscle edema following radiation therapy with neutrons peaks at about 6 months compared to 12–18 months after treatment with photons.…”