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Radiation Pneumonitis

Radiation Pneumonia

Radiation pneumonitis is a term describing the injury and inflammatory changes of the lungs as a result of radiation exposure, principally from radiotherapy for an underlying thoracic malignancy. Depending on the dose received and the extent of radiation, symptoms range from a mild cough to chronic respiratory insufficiency and pulmonary hypertension. The diagnosis mandates a thorough clinical and imaging workup in order to confirm the diagnosis.


Presentation

Radiation pneumonitis (often described as the initial event in radiation-induced lung injury) is not uncommon after the use of radiotherapy for treatment of malignant diseases located in the thorax [1] [2] [3]. The clinical presentation, although possessing a very wide spectrum of symptoms, depends on three main factors - the amount of radiation received by the patient (rare cases have been described after receiving < 20 Gy, while 40 Gy virtually always causes symptoms), the volume of the irradiated lung and the dose fractionation [1] [4]. Certain cytotoxic drugs, when combined with radiotherapy, have also been implicated in the pathogenesis of radiation pneumonitis, such as bleomycin [5] [6]. In milder cases, radiation pneumonitis is manifested as a subtle cough accompanied by chest discomfort that may spontaneously resolve after some time [3]. On the other hand, dyspnea, a prominent nonproductive cough, and fever that progress to severe respiratory decline and cyanosis are typical for more severe cases [4] [6]. Symptoms can appear after only 1 month in the case of profound radiation injury, whereas up to 6 months might pass before first symptoms are observed in individuals who were exposed to lower doses [1] [6] [7]. Regardless of the severity, the vast majority of patients develop progressive fibrosis of the lungs, which may lead to chronic respiratory insufficiency, portal hypertension (as a result of congestion), hepatomegaly, orthopnea, and a significant impairment in the overall quality of life [4] [7].

Cough
  • Depending on the dose received and the extent of radiation, symptoms range from a mild cough to chronic respiratory insufficiency and pulmonary hypertension.[symptoma.com]
  • An 80-year-old man was admitted to our division because of hemosputum, cough, and chest pain for three months.[ncbi.nlm.nih.gov]
  • A 59-year-old woman suffering from dry cough and dyspnea was admitted to our hospital. She had undergone concurrent chemo-radiotherapy five months earlier.[ncbi.nlm.nih.gov]
  • Characteristics include fever, fatigue, chills, unproductive cough, tachycardia, and tachypnea; in the chronic form there is interstitial fibrosis with collagenous thickening of the alveolar septa.[medical-dictionary.thefreedictionary.com]
  • If it occurs, acute SRP usually develops 4-12 weeks after completion of radiotherapy and presents as a dry cough, dyspnea and low-grade fever.[ncbi.nlm.nih.gov]
Dry Cough
  • A 59-year-old woman suffering from dry cough and dyspnea was admitted to our hospital. She had undergone concurrent chemo-radiotherapy five months earlier.[ncbi.nlm.nih.gov]
  • If it occurs, acute SRP usually develops 4-12 weeks after completion of radiotherapy and presents as a dry cough, dyspnea and low-grade fever.[ncbi.nlm.nih.gov]
  • Radiation pneumonitis may also cause: Persistent dry cough, which may range from mild to severe Chest pain Increasing amounts of sputum, which may or not have blood Fever Muscle aches Increasing weakness The doctor will ask about any symptoms and medical[health.cvs.com]
  • Pulmonary (lung) fibrosis involves inflammation and scarring of the lungs causing patients to feel short of breath, have a chronic dry cough, feel fatigue and pain in the chest, and suffer loss of appetite and weight loss.[inspire.com]
  • Soon after the treatment, you might have a dry cough or shortness of breath. This is called acute radiation pneumonitis (pronounced new-mon-eye-tiss). It usually only lasts for a few days or weeks and gradually gets better.[cancerresearchuk.org]
Pleural Effusion
  • Pleural effusions or atelectasis are also sometimes seen 1,5 . CT CT is not only better able to delineate parenchymal changes, but often demonstrates changes localised to the irradiated field, making the diagnosis easier.[radiopaedia.org]
  • . • Dullness to percussion from a small pleural effusion is occasionally noted. These effusions rarely increase in size, however, and often spontaneously remit. 12.[slideshare.net]
Rales
  • Shortness of breath and right chest rales developed in a 15-year-old boy within 12 hours of the resumption of chemotherapy 6 weeks after radiation therapy was completed.[ncbi.nlm.nih.gov]
  • The patient had a history of COPD and showed evident symptoms of dyspnea and Velcro rales from the two lungs.[alliedacademies.org]
Hepatomegaly
  • Regardless of the severity, the vast majority of patients develop progressive fibrosis of the lungs, which may lead to chronic respiratory insufficiency, portal hypertension (as a result of congestion), hepatomegaly, orthopnea, and a significant impairment[symptoma.com]
Liver Tenderness
  • Furthermore, a detailed physical examination, with an emphasis on lung auscultation and palpation of the abdomen (as liver tenderness is observed in severe cases), may provide additional evidence to pursue the diagnosis.[symptoma.com]
Suggestibility
  • Our analysis suggested that TGF-β1 T869C rs1982073 polymorphism was associated with lower RP risk for CT combined CC versus TT model (OR 0.58, 95% CI 0.43-0.77).[ncbi.nlm.nih.gov]
  • ROC analysis suggested that SPECT-based DFH parameters outperformed standard DVH parameters as predictors of RP.[ncbi.nlm.nih.gov]
  • Fluorine-18 fluorodeoxyglucose (FDG) imaging with a dual-head coincidence gamma camera system (Co-PET) diagnosed radiation pneumonitis 1 month after completion of radiotherapy, when the clinical and radiographic signs were atypical and more suggestive[ncbi.nlm.nih.gov]
  • A chest roentgenogram taken when the atelectasis had improved revealed the absence of pneumonitis shadows in the right upper lobe, suggesting that the atelectatic lung escaped radiation pneumonitis.[ncbi.nlm.nih.gov]
  • Taken together these reports suggest that radiosensitivity of normal tissues and tumors may be strongly linked in a proportion of patients with lung cancer.[ncbi.nlm.nih.gov]

Workup

The initial signs of radiation pneumonitis, particularly in milder cases, have often been misinterpreted or misdiagnosed [4]. For this reason, a thorough clinical investigation is mandatory in order to make a correct diagnosis. Physicians must obtain a meticulous patient history that will reveal an underlying malignant disease for which radiation therapy was recently used, and such findings must point toward radiation pneumonitis. Furthermore, a detailed physical examination, with an emphasis on lung auscultation and palpation of the abdomen (as liver tenderness is observed in severe cases) [4], may provide additional evidence to pursue the diagnosis. In addition to lung-function tests and evaluation of pulse oximetry, imaging studies should be employed. In the acute setting, plain radiography of the lungs can detect ground-glass opacities or lung consolidation at the site of irradiation as early as few weeks after radiotherapy [4] [6]. Less common, but still important findings are the presence of a crazy paving pattern (opacities located at the ground-glass appearing areas), a reversed halo sign (a central opacity encircled by dense consolidation), pleural and pericardial effusions, as well as bronchiectasis [1] [4] [6]. Atelectasis and fibrosis, as well as their extension beyond the field of radiation, is seen in profound radiation injury [3] [8]. Because the radiographic signs are not uniform across all individuals, computed tomography (CT), particularly contrast-enhanced CT, is often recommended over chest X-rays, as it provided a better view of the structural changes of the lungs [1] [3] [6]. Fluorodeoxyglucose-positron emission tomography (FDG-PET) is also recommended by some authors [3].

Pulmonary Infiltrate
  • Pneumonia carcinomatosa, occurring after lung irradiation, can therefore be added to the differential diagnosis of radiographic peripheral pulmonary infiltrates.[ncbi.nlm.nih.gov]
  • Abstract The onset of fever and pulmonary infiltrates in patients who have been treated with thoracic irradiation is a relatively common occurrence. Radiation pneumonitis and infectious pneumonitis share many clinical features.[ncbi.nlm.nih.gov]
  • Diagnosis • Bronchoalveolar lavage and transbronchial biopsy can exclude other causes of pulmonary infiltrates, but these techniques are less helpful for diagnosing radiation-induced lung injury. • Transbronchial biopsy specimens are too small for diagnosing[slideshare.net]
  • NCI Common Terminology Criteria for Adverse Events(CTCAE) V3.0 肺/上気道 Page 50 No: 22019 肺臓炎/肺浸潤 Pneumonitis/ pulmonary infiltrates Grade1 症状がなく, 画像所見のみ Grade2 症状あり, 日常生活に支障がない Grade3 症状があり, 日常生活に支障あり;酸素吸入を要する Grade4 生命を脅かす;人工呼吸を要する Grade5 死亡 注:成人呼吸促迫症候群[osaka-med.ac.jp]
Mediastinal Shift
  • Chest computed tomography in the postpneumonectomy patient may be helpful to evaluate the degree of pulmonary-mediastinal shift and optimization of the radiotherapy field.[ncbi.nlm.nih.gov]
Ground Glass Appearance
  • Less common, but still important findings are the presence of a crazy paving pattern (opacities located at the ground-glass appearing areas), a reversed halo sign (a central opacity encircled by dense consolidation), pleural and pericardial effusions,[symptoma.com]
Pleural Effusion
  • Pleural effusions or atelectasis are also sometimes seen 1,5 . CT CT is not only better able to delineate parenchymal changes, but often demonstrates changes localised to the irradiated field, making the diagnosis easier.[radiopaedia.org]
  • . • Dullness to percussion from a small pleural effusion is occasionally noted. These effusions rarely increase in size, however, and often spontaneously remit. 12.[slideshare.net]
Pleural Rub
  • . • Many patients have no abnormal chest findings,while others have crackles or a pleural rub over the area of irradiation. • Dullness to percussion from a small pleural effusion is occasionally noted.[slideshare.net]

Treatment

  • Although corticosteroids are widely used for the treatment of radiation pneumonitis, they are not always effective. In this report, we used cyclosporin A in the treatment of a patient suffering from steroid-refractory radiation pneumonitis.[ncbi.nlm.nih.gov]
  • The median follow-up after IS treatment initiation was 18 months (range: 4-66 months). The median duration of IS treatment and prednisolone treatment was 8.2 months (range: 3.0-48.3 months) and 11.4 months (range: 5.0-44.0 months), respectively.[ncbi.nlm.nih.gov]
  • The early application of systemic (RRP) and topical corticosteroids (RRD) enabled us to continue the treatment with vemurafenib without dose reduction.[ncbi.nlm.nih.gov]
  • We present a case of an asymptomatic woman in complete remission of Hodgkin's disease after treatment with chemotherapy and radiotherapy where a focal uptake of Gallium-67 was discovered two months after finishing treatment.[ncbi.nlm.nih.gov]
  • The treatment plan was reviewed for critical structure delineation and dose delivered. Treatment planning data were analyzed using Computational Environment for Radiotherapy Research (V3.3).[ncbi.nlm.nih.gov]

Prognosis

  • As regards effects of PPI on prognosis of two groups, remission rate of radiation pneumonia in PPI group was significantly less than that of the control group.[ncbi.nlm.nih.gov]
  • OBJECTIVES: To identify the factors that predict the progression of radiological radiation pneumonitis (RP) to symptomatic RP, and to evaluate the usefulness of the neutrophil-lymphocyte ratio (NLR) as a marker of RP severity and prognosis in stage III[ncbi.nlm.nih.gov]
  • […] attenuation (2-4 months after therapy) Patchy consolidation (1-12 months after therapy) Non-uniform discrete consolidation (most common; 3 months to 10 years after therapy) Sequential transverse images through lung showing radiation pneumonitis in right lung Prognosis[learningradiology.com]
  • Treatment and prognosis Steroids can reduce the severity of acute radiation pneumonitis.[radiopaedia.org]

Etiology

  • Applicable To Radiation pneumonitis Use Additional Use Additional Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • RP and OP are suspected to belong in another etiological category. The goal of the present study is to investigate the relationship between RP and OP.[ro-journal.biomedcentral.com]

Epidemiology

  • For discussion of epidemiology of radiation induced lung disease please refer to the parent article: radiation induced lung disease .[radiopaedia.org]
  • Epidemiology It is common, if all causes of pneumonitis are considered.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • Improvements in radiation technique, as well as the understanding of the pathophysiology of radiation injury, have led to lower rates of pneumonitis and improved symptom control.[ncbi.nlm.nih.gov]
  • Literature dealing with clinical, pathological, pathophysiological, and radiographic manifestations of radiation pneumonitis is shortly reviewed.[ncbi.nlm.nih.gov]
  • Pathophysiology, clinical aspects, outcome, and treatment are reported. Clinical RP is related to different factors, the most important being irradiated lung volume and radiotherapy dose.[journals.lww.com]
  • Pathophysiology: Two separate and distinct mechanisms are involved in the pathogenesis of acute radiation pneumonitis.The first, classical radiation pneumonitis, involves direct toxic injury to endothelial and epithelial cells from the radiation, resulting[aboutcancer.com]

Prevention

  • METHODS: Fourty rats were randomly divided into control group, radiation group, stem cell prevention group, stem cell treatment group and prednisone treatment group.[ncbi.nlm.nih.gov]
  • INTRODUCTION: The purpose of the present study was to evaluate the role of renin-angiotensin system (RAS) inhibitors in preventing symptomatic radiation pneumonitis (RP) after stereotactic body radiotherapy (SBRT).[ncbi.nlm.nih.gov]
  • So, to prevent symptomatic RP, it is recommended that the V5 be limited to[ncbi.nlm.nih.gov]
  • If further studies conclude that this drug can indeed prevent fibrosis in lung cancer patients, I believe researchers are a huge step closer to curing this disease, said Dr. Cheng.[inspire.com]
  • It is potential to be a therapeutic molecular to attenuate or prevent radiation pneumonitis. Note: This abstract was not presented at the meeting. Citation Format: Szu-Yuan Wu.[cancerres.aacrjournals.org]

References

Article

  1. Choi YW, Munden RF, Erasmus JJ, et al. Effects of radiation therapy on the lung: radiologic appearances and differential diagnosis. Radiographics. 2004;24(4):985-997.
  2. Mehta V. Radiation pneumonitis and pulmonary fibrosis in non-small-cell lung cancer: pulmonary function, prediction, and prevention. Int J Radiat Oncol Biol Phys. 2005;63:5–24.
  3. Giridhar P, Mallick S, Rath GK, Julka PK. Radiation induced lung injury: prediction, assessment and management. Asian Pac J Cancer Prev. 2015;16(7):2613-2617.
  4. Williams JP, Johnston CJ, Finkelstein JN. Treatment for Radiation-Induced Pulmonary Late Effects: Spoiled for Choice or Looking in the Wrong Direction? Curr Drug Targets. 2010;11(11):1386-1394.
  5. Sostman HD, Putnam CE, Gamsu G. Diagnosis of chemotherapy lung. AJR Am J Roentgenol. 1981;136:33-40.
  6. Benveniste MFK, Welsh J, Godoy MCB, Betancourt SL, Mawlawi OR, Munden RF. New era of radiotherapy: an update in radiation-induced lung disease. Clin Radiol. 2013;68(6):e275-e290.
  7. Trott KD, Herrmann T, Kasper M. Target cells in radiation pneumopathy. Int J Radiat Oncol Biol Phys. 2004;58:463–469.
  8. Kouloulias V, Zygogianni A, Efstathopoulos E, et al. Suggestion for a new grading scale for radiation induced pneumonitis based on radiological findings of computerized tomography: correlation with clinical and radiotherapeutic parameters in lung cancer patients. Asian Pac J Cancer Prev. 2013;14(5):2717-2722.

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Last updated: 2019-07-11 21:02