From the Guidelines
Radiation recall pneumonitis, also known as radiation-induced lung injury, can be caused by certain chemotherapeutic drugs, such as paclitaxel, in combination with radiation therapy. The evidence suggests that the risk of radiation pneumonitis is correlated with the dose-volume histogram parameters, including the mean lung dose (MLD) and the percentage volume of both lungs minus the planning target volume (PTV) receiving 20 Gy (V20) 1.
Risk Factors
Some of the key risk factors for radiation pneumonitis include:
- High doses of radiation to the lungs
- Certain chemotherapeutic drugs, such as paclitaxel, platinum, etoposide, taxanes, and vinorelbine
- Concurrent radiotherapy and chemotherapy
- Pre-existing lung conditions, such as idiopathic interstitial pneumonitis
Prevention and Management
Prevention and management strategies for radiation pneumonitis include:
- Limiting the dose of radiation to the lungs
- Using intensity-modulated radiotherapy (IMRT) to reduce the dose to normal tissues
- Administering corticosteroids to reduce inflammation
- Avoiding certain chemotherapeutic drugs that are known to increase the risk of radiation pneumonitis
Chemotherapeutic Drugs
Some chemotherapeutic drugs that have been associated with an increased risk of radiation pneumonitis include:
- Paclitaxel
- Platinum
- Etoposide
- Taxanes
- Vinorelbine
- Gemcitabine (although the evidence is limited)
It's worth noting that the evidence is not very strong for some of these drugs, and the risk of radiation pneumonitis may depend on various factors, including the dose and schedule of the drug, as well as the individual patient's underlying health conditions 1.
In terms of management, corticosteroids are recommended for patients with troublesome cough attributed to chemotherapy or radiation-induced pneumonitis 1. Additionally, proton beam therapy may be considered as an alternative to traditional radiation therapy to reduce the risk of radiation pneumonitis 1.
From the FDA Drug Label
Pediatric patients receiving concomitant doxorubicin and actinomycin-D have manifested acute "recall" pneumonitis at variable times after local radiation therapy.
- Radiation recall pneumonitis can be caused by the combination of doxorubicin and actinomycin-D in pediatric patients after local radiation therapy 2.
From the Research
Causes of Radiation Recall Pneumonitis
Radiation recall pneumonitis (RRP) is an unpredictable inflammatory reaction that occurs within previously irradiated tissue after exposure to a systemic agent. The following are some causes of RRP:
- Immune checkpoint inhibitors (ICIs) such as pembrolizumab 3 and anti-PD-1 blockade Camrelizumab 4
- Chemotherapeutic agents such as erlotinib 5 and cisplatin 4
- Targeted therapy agents such as everolimus 6
- Molecular-target agents 4
Systemic Agents Triggering RRP
Systemic agents can trigger RRP in previously irradiated fields, including:
- Immune checkpoint inhibitors (ICIs) 7, 4, 3
- Chemotherapy drugs 5, 4
- Targeted therapy anticancer drugs 6
- Biologic agents 6
Timing and Risk Factors
RRP can develop weeks to years after radiation treatment to the lung 7, 5, and the risk may be increased in patients undergoing immunotherapy after prior irradiation 3. The use of a tyrosine kinase inhibitor (TKI) after radiation therapy may also trigger radiation pneumonitis 5.