Recall Those Thrilling Days of Yesteryear …

The blaring theme of the William Tell Overture, with trumpet fanfare, and its “off-to-the-races” tempo harkens one of my favorite TV shows: The Lone Ranger. In fact, the stirring theme song was known to me only as “The Lone Ranger,” knowing nothing about Gioacchino Rossini or opera. The Lone Ranger, a masked man played by Clayton Moore, somewhat of a paradox and a mystery because only bandits wore masks hiding their identity. He only used silver bullets, and had a trusted friend named Tonto (played by Jay Silverheels), an Indian who referred to him as “Kemosabe.” What an unlikely pairing. As The Lone Ranger galloped to rear his steed at the same dessert rock each week, the announcer would intone something about: “Recall those thrilling days of yesteryear . . .” and we were enthralled by another episode of a single righteous man doing deeds that righted wrongs and there was never a hint of impropriety or dirty backhanded tactics. Corny, huh? Surely it would not make it today. Howard (Skip) Burris brings back some other thrills about the subject of combined modality use and the curious phenomenon of “radiation recall.” Talk about odd pairings, chemotherapy was the “chemo-sabe” to the lone ranger of radiotherapy, but unlike Jay Silverheels and Clayton Moore, this couple has not always gotten along, retreating to opposite camps rather than celebrating their small steps of success. Skip Burris brings to light a new drug, ixabepilone, from a new class, epothilones, which stabilize microtubules. It is approved for use in the second line of refractory breast cancer. It purports a new interaction with radiotherapy characterized as “radiation recall.” It is a case report and review of the literature [1]. Skip’s review relies heavily on the Camidge and Price treatise from 9 years ago [2], and adds the case reports and other agents causing “recall” reported in the interim years. Timing may greatly influence these phenomena. “Recall versus radiosensitization” is a key concept from the Camidge and Price essay that Burris picks up and adopts. In “sensitization,” the drugs and chemotherapy are used together so that the chemotherapy tees up the cells for the damage by the radiotherapy. The classic use of fluorouracil and cisplatin fit the bill here. On the other hand, Camidge and Price distinguished “recall versus impaired healing,” and caution that “all radiation reactions in the skin [need to] have completely recovered before a reaction can be said to produce radiation recall dermatitis” [2]. If radiotherapy has so injured tissue, bringing chemotherapy in too soon can exacerbate the toxicity and make a subliminal toxicity overt. Dr. Burris, in this case report, didn’t seem to accept this concept. The case report describes such an exacerbation of the damage produced by the radiotherapy more than radiation recall. But radiation recall is hard to explain in the first place. Both the Burris and Camidge and Price papers try to bring reason to what is mysterious and enigmatic. Although they each take pains to describe the dermatologic phenomena, both admit that there are visceral aspects (pneumonitis/lung scar, enteritis/bowel obstruction?) that