Effects of Radiation Therapy

on the Lung :
Radiologic Appearances and
Differential Diagnosis

RadioGraphics 2004; 24:985-998

พญ.ปั ญรส คงปั ญญา

 Radiation-induced lung disease
(RILD)
• Histopathologic features
• Factors influencing the radiologic appearance
• Radiologic manifestations
• Radiation therapy techniques
• Differential diagnosis
 Histopathologic features
• 4-12 weeks : Radiation pneumonitis
 Diffuse alveolar damage
 Intra-alveolar proteinaceous exudate
• 6-12 months : Radiation fibrosis
• 2 years : Stable
 Factors influencing the radiologic
appearance
• Age
• Volume of lung irradiated
• Shape of the radiation fields
• Total dose of radiation : > 40 Gy
• Number of fractions of radiation
• Prior or concomitant chemotherapy
• Withdrawal of corticosteroid treatment
Radiologic manifestations
• Radiation pneumonitis
 Homogeneous or patchy ground-glass
opacity or consolidation
 Ipsilateral pleural effusion, atelectasis
 Edges correspond to radiation ports
 Abnormalities outside of ports in 20%
 Radiation pneumonitis
2 months

F 60 yrs. Stage IIIB non-small cell lung cancer

 F 53 yrs Adeoncarcinoma

1 months 5 months
 Radiation pneumonitis and fibrosis

5 months 9 months
 Radiologic manifestations
• Radiation fibrosis
 Linear scarring
 Ipsilateral volume loss
 Dense consolidation
 Traction bronchiectasis
 Pleural thickening
 Sharp demarcation
12 months
Squamous cell carcinoma Poorly differentiated
non-small cell lung cancer

14 months 5 years
Radiation therapy techniques
• Non small cell lung cancer
- Primary tumor
- 2 cm. margin around the visualized edge
of the tumor
- 1 cm. margin around treated regional
lymph nodes
- Extensive mediastinal component of tumor 
ipsilateral supraclavicular area
Radiation therapy techniques
• Small cell lung cancer
Two types of radiation portals
- Extensive portals encompassing : hila,
mediastinum, both supraclavicular areas
- Limited portals encompassing : primary
tumor and adjacent nodal stations
Radiation therapy techniques
• Breast cancer
- RILD at the periphery of the lung
- Supraclavicular portal Apical RILD
 Radiation pneumonitis and fibrosis
F 42 yrs Adenocarcinoma of the right breast

4 months 26 months
 Radiation pneumonitis and fibrosis

Adenocarcinoma of the right breast

4 months 16 months
Radiation therapy techniques
Esophageal cancer
- 5-6 cm. margin above and below tumor
- Paramediastinal opacities in lower lobes

Adenocarcinoma of distal
esophagus
3 months
Radiation therapy techniques
• Head and neck cancer
- Apical aspect of the thorax  bilateral apical
RILD
Radiation therapy techniques
HL or NHL
- Paramediastinal and apical RILD

4 months 11 months
Differential diagnosis
• Infection
• Local tumor recurrent
• Lymphangitic carcinomatosis
• Radiation-induced neoplasm
 Pulmonary infection
Poorly differentiated non-small cell lung cancer

3 months
 Recurrent tumor
Adenocarcinoma of the right upper lobe

15 months 20 months
 Recurrent tumor
Large cell carcinoma of the right upper lobe

7 months 11 months
The End.