Cases J. 2009; 2: 25.
Published online 2009 January 7. doi: 10.1186/1757-1626-2-25. PMCID: PMC2628867
Copyright © 2009 Azad; licensee BioMed Central Ltd.
Severe cutaneous toxicity following treatment with radiotherapy and cetuximab: a case report
Arun Azad1
SEVERE EDIT
Two weeks after commencing treatment he developed a severe painful skin reaction within the radiotherapy field. This progressively worsened, necessitating hospitalisation one week after completing radiotherapy. On examination, he had a moist, desquamating, circumferential, erythematous rash on the lower half of his face and upper neck. He was dehydrated and febrile at 38.5°C. He had oral mucositis but no candidiasis. There was a mild acneiform rash over the upper torso and arms. Other vital signs and the remaining physical examination were unremarkable.
Swabs were taken from the desquamating rash and cytomegalovirus DNA was detected on polymerase chain reaction. He was given a three-month course of valganciclovir (900 mg twice daily for three weeks, followed by 900 mg daily). The rash was treated with twice daily dressings and silver sulphadiazine cream and he was discharged home after three weeks. FDG-PET performed three months later showed complete metabolic remission.
Cetuximab is a chimeric monoclonal antibody against epidermal growth factor receptor (EGFR), a receptor tyrosine kinase that is up-regulated in more than 90% of HNSCCs[1]. In a pivotal phase III study of 424 patients with locoregionally advanced HNSCCs[2], the addition of cetuximab to radiotherapy significantly improved locoregional control (50% versus 41%), three-year survival (55% vs. 45%) and median survival (49 months versus 29 months). The only grade 3 toxicities more common in the cetuximab group were infusional reactions and acneiform rash (17% versus 1%).
Interestingly, there was no significant increase in grade 3 radiation dermatitis for the cetuximab group (23% versus 18%) in this study. However, multiple reports have subsequently emerged of severe radiation dermatitis complicating treatment with concurrent cetuximab and radiotherapy for HNSCCs [3-5]. Radiation dermatitis must be distinguished from the acneiform rash of the face, neck and upper torso that affects up to 2/3 of patients receiving anti-EGFR agents[6,7].
It should also be noted that most patients receiving radiotherapy alone for HNSCCs experience some degree of radiation dermatitis[8]. Nonetheless, consensus guidelines have now been developed for the prevention and management of cutaneous toxicity in patients with HNSCCs treated with cetuximab and radiotherapy[8]. These guidelines emphasise the need for adequate hygiene and hydration of the skin. More severe reactions may require dressings, topical anti-inflammatory agents and antimicrobials for secondary infections.
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