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Radiation Pneumonitis 大里仁愛醫院核子醫學科  林文玉醫師
Effects of Radiation Therapy on the Lung: Radiologic Appearance  ,[object Object],[object Object],[object Object],[object Object],[object Object]
60 y/o F with stage IIIb non-small cell lung cancer Before 2 months after completion of R/T 9 months after completion of R/T
Differentiation diagnosis ,[object Object],[object Object],[object Object],[object Object]
HRCT findings in Lymphangitic Carcinomatosis Interlobular septal thickening, thickening of fissures and thickening of the peribronchovascular interstitium (bronchial cuffing). Depending on filling with fluid or with tumor cells, septal thickening is irregular or smooth.
Subacute hypersensitivity pneumonitis The key findings in the subacute hypersensitivity pneumonitis are: ill-defined centrilobular nodules of ground-glass opacity (80% of cases) or  mosaic pattern of a combination of patchy ground-glass opacity due to lung infiltration and patchy lucency due to bronchiolitis with air trapping
Histopathologic Features of RP ,[object Object],[object Object],[object Object],[object Object]
LLL lung mass
Various Factors Influence the Degree of Lung Injury  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Factors predicting radiation pneumonitis in lung cancer patients a retrospective study Radiotherapy and Oncology 67 (2003) 275–283 Tiziana Rancatia, Giovanni Luca Ceresolib, Giovanna Gagliardic, Stefano Schipanib, Giovanni Mauro Cattaneod, *  Physics Department, University of Milano, Via Celoria 16, 20133, Milan, Italy; Radiochemotherapy Department, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132 Milan, Italy; Department of Hospital Physics, Karolinska Hospital, Stockholm, Sweden ; Medical Physics Department, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132 Milan, Italy Purpose:  To evaluate clinical and lung dose–volume histogram based  factors as predictors  of radiation pneumonitis (RP) in lung cancer patients (PTs) treated with thoracic irradiation
Methods and Material ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
The goal of radiotherapy ,[object Object],[object Object]
Probit model (Lyman) TD 50 (1) : the tolerance dose  for reference volume  irradiation m : the steepness slope of the dose response curve V ref  : the reference volume n : tissue-specific parameter
 
 
 
Radiation therapy technique  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
洋紅 , 藍寶石
53 y/0 woman, adeno. LLL,(a) before RT, (b) 1mon after RT and (c) 5mon after RT
 
 
 
Mantle field: all the major lymph node regions above the diaphragm
Epidemiology Ref.: UpToDate: Radiation-induced lung injury Clinical pneumonitis Radiographic abnormalities Breast ca. 0 ~ 10 % 27 ~ 40 % Lung ca. 5 ~ 15 % 66%
Radiation Pneumonitis vs Radiation Fibrosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ref.: Semin Oncol 32(Suppl 3): S42-S54.
Capillary lumen Type I pneumocyte Type I pneumocyte Type II pneumocyte Endothelium Alveolar space Type II pneumocyte secreting surfactant: lower surface tension
Histopathologic grading ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Role of type II pneumocytes : dose response of radiation-induced lung changes in the transient high vascular permeability period  ,[object Object],[object Object],Experimental and Toxicologic Pathology Volume 56, Issue 3 ,  3 December 2004, Pages 181-187
Radiation pneumonitis in mice: A severe injury model for pneumocyte engraftment from bone marrow ,[object Object],Experimental Hematology 30 (2002) 1333–1338
Clinical manifestation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ref.: UpToDate: Radiation-induced lung injury. Semin Oncol 32(Suppl 3): S42-S54.
Grading of Acute Pneumonitis Ref.: Semin Oncol 32(Suppl 3): S42-S54. Int j Radiation Oncology biol Phys 63(1):5-24. ADL: activities of daily living Radiation Therapy Oncology Group South-West Oncology Group National Cancer Institute
Grading of Late Lung Toxicity Ref.: Semin Oncol 32(Suppl 3): S42-S54.
Incidence and RT protocol ,[object Object],[object Object],[object Object],[object Object],[object Object],Ref.: Semin Oncol 32(Suppl 3): S42-S54.
Radiation Pneumonitis Ref.: Semin Oncol 32(Suppl 3): S42-S54.
FDG PET Demonstrates Radiation-Induced Changes to Nonirradiated Lungs .. ,[object Object],[object Object],[object Object],CHEST 2005; 128:1448–1452 To determine whether acute changes in shielded lungs can be detected by PET after RT..  ( single center from 1995 to 1999, C/T + R/T + op/ biopsy, 3/16 small cell, 13/16 NSCLC )
Results ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Most RP occurs in RT tx field but why bilateral ? ,[object Object],[object Object],[object Object],[object Object]
Radiation Pneumonitis: Pulmonary Metabolic Response to Radiation ( PMRR)  in Lung Cancer Patients ,[object Object],Matthew McCurdy1,2, Josue Martinez3, Rick Castillo4, Nicolas Zouain2, and Thomas Guerrero4 1.Baylor College of Medicine, Houston, TX, 2. University of North Dakota School of Medicine & Health Sciences, Fargo and Grand Forks, ND 3. Texas A&M University, College Station, TX, 4. The University of Texas M.D. Anderson Cancer Center, Houston, TX
Purpose ,[object Object],[object Object]
 
RESULTS:  The median time between radiotherapy completion and FDG-PET imaging was 47 days (range, 34-71 days). The  removal of the tumor volume  from analysis was possible using a  threshold planning dose . The median of the mean standard uptake value in the lung that received 0-5 Gy was 0.51 (range, 0.35-1.15), 5-10 Gy was 0.77 (range, 0.40-1.36), 10-20 Gy was 0.80 (range, 0.40-1.69), and >20 Gy was 1.08 (range, 0.55-2.70).  A hierarchical linear regression model of the radiation dose and normalized FDG uptake per case found an adequate fit with the linear model .  The 18 cases had a posterior mean of slopes range of 0.0011-0.064. The slope of this relationship varied over an order of magnitude,  reflecting the range of the underlying pulmonary biological response to radiation among the study population .
 
 
Conclusion: ,[object Object],[object Object],[object Object],[object Object]
Local dose vs. FDG uptake response in irradiated lung ,[object Object],[object Object],Thomas Guerrero, et al Division of Radiation Oncology, and Department of Biostatistics and Applied Mathematics I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
The Slope I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
FDG uptake  not related  to time and volume I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
FDG PET in predicting RP  SONG Hao, YU Jin-ming, Feng-ming Kong, LU Jie, BAI Tong, MA Li and FU Zheng Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital,  Tianjin 360060, China (Song H);  Department of Radiation Oncology (Yu JM). ,[object Object],[object Object],[object Object]
Conclusion ,[object Object],[object Object]
 
 
Conclusion ,[object Object],[object Object]
Radiation Pneumonitis: correlation of Toxicity with PMRR ,[object Object],[object Object],I. J. Radiation Oncology Biology Physics  Volume 71, Number 4, 2008 Justin P. Hart, MD., PH.D.,  Mathew R. McCurDy, PH.D. et al. Department of Radiation Oncology, Quantitative Sciences, and Diagnostic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX..
 
 
Take home messages (1) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Take home messages (2) ,[object Object]

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Radiation pneumonitis and ddx

  • 2.
  • 3. 60 y/o F with stage IIIb non-small cell lung cancer Before 2 months after completion of R/T 9 months after completion of R/T
  • 4.
  • 5. HRCT findings in Lymphangitic Carcinomatosis Interlobular septal thickening, thickening of fissures and thickening of the peribronchovascular interstitium (bronchial cuffing). Depending on filling with fluid or with tumor cells, septal thickening is irregular or smooth.
  • 6. Subacute hypersensitivity pneumonitis The key findings in the subacute hypersensitivity pneumonitis are: ill-defined centrilobular nodules of ground-glass opacity (80% of cases) or mosaic pattern of a combination of patchy ground-glass opacity due to lung infiltration and patchy lucency due to bronchiolitis with air trapping
  • 7.
  • 9.
  • 10. Factors predicting radiation pneumonitis in lung cancer patients a retrospective study Radiotherapy and Oncology 67 (2003) 275–283 Tiziana Rancatia, Giovanni Luca Ceresolib, Giovanna Gagliardic, Stefano Schipanib, Giovanni Mauro Cattaneod, * Physics Department, University of Milano, Via Celoria 16, 20133, Milan, Italy; Radiochemotherapy Department, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132 Milan, Italy; Department of Hospital Physics, Karolinska Hospital, Stockholm, Sweden ; Medical Physics Department, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132 Milan, Italy Purpose: To evaluate clinical and lung dose–volume histogram based factors as predictors of radiation pneumonitis (RP) in lung cancer patients (PTs) treated with thoracic irradiation
  • 11.
  • 12.
  • 13. Probit model (Lyman) TD 50 (1) : the tolerance dose for reference volume irradiation m : the steepness slope of the dose response curve V ref : the reference volume n : tissue-specific parameter
  • 14.  
  • 15.  
  • 16.  
  • 17.
  • 19. 53 y/0 woman, adeno. LLL,(a) before RT, (b) 1mon after RT and (c) 5mon after RT
  • 20.  
  • 21.  
  • 22.  
  • 23. Mantle field: all the major lymph node regions above the diaphragm
  • 24. Epidemiology Ref.: UpToDate: Radiation-induced lung injury Clinical pneumonitis Radiographic abnormalities Breast ca. 0 ~ 10 % 27 ~ 40 % Lung ca. 5 ~ 15 % 66%
  • 25.
  • 26. Capillary lumen Type I pneumocyte Type I pneumocyte Type II pneumocyte Endothelium Alveolar space Type II pneumocyte secreting surfactant: lower surface tension
  • 27.
  • 28.
  • 29.
  • 30.
  • 31. Grading of Acute Pneumonitis Ref.: Semin Oncol 32(Suppl 3): S42-S54. Int j Radiation Oncology biol Phys 63(1):5-24. ADL: activities of daily living Radiation Therapy Oncology Group South-West Oncology Group National Cancer Institute
  • 32. Grading of Late Lung Toxicity Ref.: Semin Oncol 32(Suppl 3): S42-S54.
  • 33.
  • 34. Radiation Pneumonitis Ref.: Semin Oncol 32(Suppl 3): S42-S54.
  • 35.
  • 36.
  • 37.
  • 38.
  • 39.
  • 40.  
  • 41. RESULTS: The median time between radiotherapy completion and FDG-PET imaging was 47 days (range, 34-71 days). The removal of the tumor volume from analysis was possible using a threshold planning dose . The median of the mean standard uptake value in the lung that received 0-5 Gy was 0.51 (range, 0.35-1.15), 5-10 Gy was 0.77 (range, 0.40-1.36), 10-20 Gy was 0.80 (range, 0.40-1.69), and >20 Gy was 1.08 (range, 0.55-2.70). A hierarchical linear regression model of the radiation dose and normalized FDG uptake per case found an adequate fit with the linear model . The 18 cases had a posterior mean of slopes range of 0.0011-0.064. The slope of this relationship varied over an order of magnitude, reflecting the range of the underlying pulmonary biological response to radiation among the study population .
  • 42.  
  • 43.  
  • 44.
  • 45.
  • 46. The Slope I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
  • 47. FDG uptake not related to time and volume I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
  • 48. I.J. Radiation Oncology Bio. Phys. Vol. 68 No.4 pp.1030-35
  • 49.
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