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Case history

image A 75-year-old man with a background of severe chronic obstructive pulmonary disease (COPD) diagnosed radiologically, and right upper lobe lung cancer (T1N0M0), received stereotactic ablative body radiotherapy. He presented 6 weeks later with increasing shortness of breath on exertion and dry cough. He had already received two courses of antibiotics and steroids after his radiotherapy.

He was started on prednisolone 40 mg/day, with a plan to reduce the dose by 5 mg every 5 days, along with prophylactic co-trimoxazole. He was referred to the respiratory team for formal assessment including repeating his pulmonary function test (PFT), optimizing his inhaler therapy and checking his usage technique.

Three weeks later a CT scan showed good partial response to radiotherapy with distortion of adjacent lung parenchyma in keeping with radiotherapy changes (Figure 19.1). He was clinically improved, so he had his prednisolone dose reduced by 5 mg every week until he reached a dose of 10 mg/day, after which it was reduced by 1 mg every week. The dose of his budesonideā€“formoterol inhaler was increased. The respiratory team arranged for his PFT to be repeated, which showed a similar obstructive pattern to that of his pre-radiotherapy PFT.

The patient continues under follow-up. Six months later he is well and has a WHO performance status of 1; he is currently on prednisolone 3 mg/day and has discontinued the prophylactic co-trimoxazole. A CT scan showed further response of his cancer and resolution of radiotherapy changes without the development of fibrosis. He continues to reduce his dose of prednisolone.

What is radiation pneumonitis and how does it develop?

What are the risk factors for radiation pneumonitis?

What are the clinical manifestations of radiation pneumonitis?

How is radiation pneumonitis diagnosed?

What is the management of radiation pneumonitis?

Figure 19.1

CT scan 2 months after radiotherapy shows changes in the right lung parenchyma surrounding the tumour, in keeping with radiotherapy changes.

What is radiation pneumonitis and how does it develop?

Patients who receive radiotherapy to their lungs may experience different forms of toxicity, known collectively as radiation-induced lung injury (RILI). It can manifest itself acutely as radiation pneumonitis, which happens most commonly within the first 12 weeks following treatment but may occur up to 6 months after radiotherapy. The chronic manifestation of RILI is radiation pulmonary fibrosis, which may occur more than a year after treatment.1 RILI is a major limiting factor for the dose of radiation any patient can receive to treat chest tumours.

The pathogenesis of radiation pneumonitis may be summarized as follows: the ionizing radiation passing through the lung tissue has a direct cytotoxic effect on its cells, starting with increasing capillary permeability and resulting in pulmonary oedema. The damage to type I and II pneumocytes leads to loss of surfactant and transudation of plasma proteins ...

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