Radiation recall

Definition

Radiation recall is an erythematous or inflammatory skin reaction (resembles severe sunburn, and can include vesiculation, desquamation, and ulceration) that can occur at the site of previous radiation when certain anti-cancer drugs are given.

Onset/duration

Onset of radiation recall can be more rapid following intravenous (IV) administration of chemotherapy (several minutes to two weeks) than with orally administered agents (where the average onset is days to weeks). Duration is similarly different - IV related reactions usually resolve within about two weeks, while reactions following PO drug administration can last for several months.

Risk factors

Drugs that are associated with radiation recall include:

• capecitabine
• cyclophosphamide
• fluorouracil
• doxorubicin (free and liposomal)
• dactinomycin
• etoposide
• gemcitabine
• idarubicin
• oxaliplatin
• paclitaxel
• nab-paclitaxel
• pemetrexed
• procarbazine
• tamoxifen.

Investigations and diagnosis

• assess patient for previous history of radiation therapy
• perform skin assessment
• monitor skin for signs of radiation recall.

Grading

Grade	Radiation recall reaction (dermatologic)
1	Faint erythema or dry desquamation
2	Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate oedema
3	Moist desquamation in areas other than skin folds and creases; bleeding induced by minor trauma or abrasion
4	Life-threatening consequences; skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site; skin graft indicated
5	Death

Common Terminology Criteria for Adverse Events (CTCAE) v5.0, 27 November, 2017

Treatment

• Care for skin depending on type of reaction.

Educate patient:

• about the possibility of radiation recall
• to report any changes in their skin
• to apply sunscreen (SPF 50+, UVA and UVB protection) to skin before going outdoors and repeated during prolonged exposure 
• to wear loose protective clothing e.g. long sleeve shirt, hat when outside
• to avoid extremes of temperatures.

Version 4

Date	Summary of changes
14/12/2022	Internal review. Idarubicin and procarbazine added to drugs that may cause radiation recall. Patient education section updated. Moved to clinical resources section. Version increased to V.4. Review in 4 years.
11/05/2023	Patient information updated with more detail around sunscreen.

Version 3

Date	Summary of changes
20/09/2010	First approved on eviQ. Version 1.
30/06/2015	Reviewed and reformatted. Version 2.
31/05/2017	Transferred to new eviQ website. Version 3.
27/04/2018	CTCAE information updated to v5.0 published November 27, 2017.