Radiation Oncology/Contraindications

Contraindications to Radiation Therapy

Collagen vascular diseases

It is a commonly held notion that collagen vascular diseases--such as lupus, scleroderma, Sjogren's, etc.--are an absolute contraindication to radiotherapy since the effects on normal tissue would be greater, and even severe.

Collagen vascular diseases include: rheumatoid arthritis, scleroderma, Raynaud's, lupus erythematosus, Sjogren's, polymyositis.

Several studies, however, claim that it is safe to give high dose radiation in these patients:

• Mayo Clinic; 2012 (1980-2005) PMID 22340665 -- "Acute and late toxicities of radiotherapy for patients with discoid lupus erythematosus: a retrospective case-control study." (Patel AB, Radiat Oncol. 2012 Feb 16;7:22. doi: 10.1186/1748-717X-7-22.)
  • Retrospective review and matched case control. 12 patients with discoid lupus erythematosus, 15 RT courses. Median F/U 2.6 years (0 - 15 years)
  • Acute toxicity: 67% any grade, 13% grade 3+. Acute dermatological toxicity 53%.
  • Late toxicity: 58% any grade, 23% grade 3+. Late dermatological toxicity 42% grade 1-2, no grade 3+. No difference between DLE and control treatments
  • Conclusion: Findings do not suggest increased risk of toxicity to skin or other organs in patients with DLE

• Mayo Clinic, 2008 PMID 18164848 -- "Systemic lupus erythematosus, radiotherapy, and the risk of acute and chronic toxicity: the Mayo Clinic Experience." (Pinn ME, Int J Radiat Oncol Biol Phys. 2008 Jun 1;71(2):498-506. doi: 10.1016/j.ijrobp.2007.10.014. Epub 2007 Dec 31.)
  • Retrospective. 21 patients with SLE, 34 courses of EBRT and 1 prostate implant. Discoid lupus excluded. Median F/U 5.6 years
  • Outcome: 5- year chronic toxicity grade 1+ was 45%; 10-year was 56%. 5-year grade 3+ was 28%; 10-year was 40%. Toxicity correlated with SLE renal involvement, absence of photosensitivity, absence of arthritis, and presence of malar rash
  • Conclusion: Risk of toxicity was moderate but not prohibitive of the use of RT. More advanced SLE may be at increased risk for chronic toxicity

• Review; 2007 PMID 18035210 -- "Radiotherapy in setting of collagen vascular disease." (Wo J, Int J Radiat Oncol Biol Phys. 2007 Dec 1;69(5):1347-53.)
  • Published results remain controversial
  • Close involvement of rheumatologists. Consider initiating NSAID prior to treatment

• Yale; 2001 PMID 11769860 — "Breast-conserving therapy in the setting of collagen vascular disease." (Chen AM, Cancer J. 2001 Nov-Dec;7(6):480-91.)
  • 36 pts (17-RA, 4-SD, 4-Raynaud, 5-Lupus, 2-Sjogren, 4-polymyositis). Median total dose 64 Gy.
  • Matched to control patients. Median f/u 12.5 yrs. No significant difference in acute complications (14% vs 8%). A significant difference was noted for late complications (17% vs 3%). When analyzed by specific disease, the difference disappeared in all but the scleroderma group.
  • Conclusion:Higher incidence of complications for scleroderma but not other collagen vascular diseases.

• U.Pittsburgh; 1998 PMID 9499258 — "Radiotherapy for malignancies associated with lupus: case reports of acute and late reactions." (Rakfal SM, Am J Clin Oncol. 1998 Feb;21(1):54-7.)
  • 6 pts with Lupus (5-SLE, 1-discoid) treated with RT (4-breast, 1-Hodgkin's, 1-thymoma). With f/u of 7-121 months, none of the patients had severe acute or late skin or subcutaneous complications.
  • Conclusion: No severe acute or late reactions in patients with Lupus after radiotherapy

• Iowa; 1993 PMID 8490925 -- "Acute and late reactions to radiation therapy in patients with collagen vascular diseases." (Ross JG, Cancer. 1993 Jun 1;71(11):3744-52.)
  • 61 pts with CVD (39-RA, 13-Lupus, 4-scleroderma, 4-dermatomyositis, 1-polymyositis). Matched to control patients.
  • No significant difference in acute (11% vs 7%) or late (10% vs 7%) complications. 3 pts with CVD had fatal complications vs none in the control group. RA was associated with a slight increase in late complications; SLE was associated with a slight increase in acute reactions. No significant acute or late reactions were noted in patients with scleroderma, dermato- or poly-myositis.
  • Conclusion: there was no increase in complications for patients with CVD

Inherited Hypersensitivity Syndromes

• Some patients with these syndromes may exhibit abnormally severe normal tissue reactions
• Ataxia-Telangiectasia is the most striking example
• RT doses may need to be adjusted accordingly

• Ataxia-Telangiectasia: profound sensitivity
• Ataxia-Telangiectasia-Like Disorder
• Nijmegen Breakage Syndrome
• Fanconi Anemia
• Nevoid Basal Cell Carcinoma Syndrome / Gorlin Syndrome: marked skin sensitivity
• Cockayne Syndrome: slight hypersensitivity
• Down's Syndrome
• Gardner's Syndrome
• Usher's Syndrome