title: Fatal radiation myelopathy after high-dose busulfan and melphalan chemotherapy and radiotherapy for Ewing's sarcoma: a review of the literature and implications for practice.
abstract: Radiation myelopathy is a rare, devastating, late effect of radiotherapy to the spinal cord. Spinal cord tolerance is currently accepted as about 50 Gy in 1.8-2 Gy fractions. However, the effect of chemotherapy on cord tolerance is unclear. This issue is important, given the increasing use of chemotherapy in combination with radiotherapy. We describe the case of a 17-year-old boy with a right apical paraspinal Ewing's tumour in the neck treated with induction chemotherapy, high-dose chemotherapy (busulfan and melphalan) with peripheral stem-cell rescue and, 4 months later, radiotherapy to the primary tumour site (cervical cord received 50 Gy in 30 fractions). After a latent period of 4 months, he developed a progressive, severe and ultimately fatal radiation myelopathy, which we suggest was due to a synergistic interaction between the high-dose chemotherapy and the radiotherapy. The use of such chemotherapy regimens in Ewing's tumours should be carefully considered, particularly when radiotherapy encompassing the spinal cord is an essential component of management.
authors.affiliation: The London Bone and Soft Tissue Tumour Service, Meyerstein Institute of Oncology, The Middlesex Hospital, UCL Hospitals NHS Trust, Mortimer St, London W1T 3AA, UK. beatrice.seddon@uclh.org
authors.forename: B M
authors.initials: BM
authors.lastname: Seddon
authors.forename: A M
authors.initials: AM
authors.lastname: Cassoni
authors.forename: M J
authors.initials: MJ
authors.lastname: Galloway
authors.forename: J H
authors.initials: JH
authors.lastname: Rees
authors.forename: J S
authors.initials: JS
authors.lastname: Whelan
mesh_terms: D000293:Adolescent; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001859:Bone Neoplasms / Q000188:drug therapy / Q000532:radiotherapy; D002066:Busulfan / Q000008:administration & dosage / Q000009:adverse effects*; D003131:Combined Modality Therapy; D017809:Fatal Outcome; D006801:Humans; D008297:Male; D008558:Melphalan / Q000008:administration & dosage* / Q000009:adverse effects*; D011878:Radiotherapy / Q000009:adverse effects*; D012512:Sarcoma, Ewing / Q000188:drug therapy* / Q000532:radiotherapy*; D013116:Spinal Cord / Q000528:radiation effects; D013118:Spinal Cord Diseases / Q000209:etiology*
chemical_list: D002066:Busulfan; D008558:Melphalan