Chest
Recent Advances in Chest MedicineRadiation-Induced Lung Injury: Assessment and Management
Section snippets
Pathophysiology
The effect of radiation on the lung was originally described in 1925 by Evans and Leucutia,15 who categorized RILI into an acute injury stage, radiation pneumonitis (RP), and the ensuing chronic injury stage, radiation pulmonary fibrosis (RPF). Although the two stages are interdependent, they can be clearly separated in time: RP occurs within 6 months of therapy (most often within 12 weeks), whereas RPF occurs > 1 year following therapy.2, 16, 17 A temporal biological phenomenon exists, with
Risk Factors
Although most patients receiving thoracic irradiation are at risk for RILI, the presence or absence of several factors may modify their risk (Table 1). For all patients, history of smoking, COPD, and interstitial lung disease are all associated with increased risk.32, 33, 34, 35, 36, 37, 38 In patients with breast cancer, concurrent use of chemotherapy or tamoxifen, older age, chest wall irradiation with electrons, and supraclavicular field treatment are correlated with increased risk.39, 40 In
Clinical Assessment
The severity of RP varies from radiographic findings with no clinical symptoms to life-threatening disease requiring hospitalization.18 Two widely used radiation toxicity grading systems, the Radiation Therapy Oncology Group and the Common Terminology Criteria for Adverse Events, categorize patients based on the severity of their pneumonitis (Table 2).66 The most common symptoms are dyspnea, which can be mild to severe, and a dry, nonproductive cough. Low-grade fevers present in < 10% of cases,
Management Strategies
No controlled studies have been conducted to evaluate the role of various therapies in treating RILI in humans. For very mild symptoms, clinical observation can be considered. However, most experts recommend systemic glucocorticoids to treat significantly symptomatic RP,72 provided that lung infection has been ruled out. For example, a treatment course of 1 mg/kg per day of prednisone can be given for 2 to 4 weeks, followed by a slow tapering of the medication for an additional 6 to 12 weeks.
Future Directions
Irradiated volumes continue to decrease as external beam radiation planning becomes increasingly conformal and spares healthy tissue while maximizing dose delivery to target. In addition, emerging clinical, serologic, and radiographic predictors of lung injury may lead to further personalized and risk-adaptive radiation planning.11 Several promising immunomodulating agents targeting interleukins such as IL-1β, IL-13, and IL-17α and the transcription factor STAT3 have shown promising efficacy in
Conclusions
Although it is important to recognize RILI as a possible etiology in the appropriate patient, it should only be considered after other possibilities have been fully exhausted. With modern treatment techniques, the incidence of adverse effects from radiation have declined immensely,103 and it is important to realize that the vast majority of patients receiving thoracic RT may not have significant pulmonary toxicity requiring medical intervention. Furthermore, patients undergoing RT outside the
Acknowledgments
Financial/nonfinancial disclosures: None declared.
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