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Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 19-20

Clinical relevance of radiation pneumonitis in breast cancers

Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication11-Jan-2013

Correspondence Address:
Sushma Agrawal
Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-330X.105885

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How to cite this article:
Agrawal S. Clinical relevance of radiation pneumonitis in breast cancers. South Asian J Cancer 2013;2:19-20

How to cite this URL:
Agrawal S. Clinical relevance of radiation pneumonitis in breast cancers. South Asian J Cancer [serial online] 2013 [cited 2020 Jul 13];2:19-20. Available from:

Presently, it is well established that post-operative radiation therapy (RT) reduces both the risk of local recurrence and extends overall survival in patients with breast cancer (BC). [1],[2],[3],[4] However, concerns have been raised about the risk of acute and chronic RT-induced side effects as there are number of treated individuals and their expected survival is longer compared to most patients with other malignant diseases. Radiation pneumonitis, cardiac toxicity, arm lymphedema, neuropathy, and skin changes are examples of the wide range of complications that have been associated with adjuvant radiotherapy. [5],[6] The present article by Bhadra et al. in this issue of South Asian Journal of Cancer, focuses on one aspect of the first mentioned RT-related complication, viz. lung density changes measured by computed tomography (CT) and their relation to clinical symptoms. [7] Since the data on toxicity after RT in BC in high-risk and advanced BC is lacking from developing countries, this work by Bhadra et al. is worth admiring.

Patients with radiation pneumonitis may present with symptoms, i.e., dyspnea, non-productive cough, and/or low-grade fever. Only grade 2 or greater pneumonitis, which requires steroids is considered clinically significant. Radiologic lung injury is more common than symptomatic pneumonitis. On the chest radiograph, this is classically manifested as an area of consolidation confined to the treatment portal, so-called straight-line pneumonia. The use of CT scans for follow-up has permitted a much more detailed description of the changes seen in the acute phase of radiation lung injury. These radiologic features include ground-glass opacities, patchy consolidation, pleural reactions, and lung fibrosis. [8] This prospective study by Bhadra et al. on 53 patients have reported 28% incidence of radiation pneumonitis, which is comparable to the literature. They have found a positive correlation of symptomatic pneumonitis with increasing CT scores, which has been described in the literature. [9] It would have been useful to evaluate the radiological changes in a chest X-ray as well, since it has been found that the incidence of chest X-ray abnormalities were 35% as compared to 15% in CT in a cohort of 87 patients of BC. [10] The diagnosis of radiation pneumonitis can be established on a chest X-ray rather than on a CT scan, especially in the context of the developing countries. The addition of a CT exam should be considered in patients with respiratory distress following RT, where the chest X-ray does not reveal the cause for the symptoms, e.g., radiation pneumonitis (structural changes in agreement with the beam arrangement), infection, or disseminated malignant disease, and pulmonary embolism should be excluded.

Though the authors have mentioned the division of CT thorax into three divisions: Apical-lateral, central-parahilar, and basal-lateral segments, the prevalence of CT scan abnormalities in these segments has not been mentioned. Radiological abnormalities in the central-parahilar and apical-lateral regions have been significantly correlated to pulmonary complications by Lind et al. [9] The positive correlation of decrease in FVC in patients with CT scores 4-9 have been reported by other authors as well. The time course of pulmonary function test (PFT) changes after locoregional RT for BC follows a biphasic pattern. An early reduction in PFTs at 3-6 months with a partial recovery at 12 months after RT is followed by a late, more important PFT reduction up to 8-10 years after RT. Tamoxifen use may have an impact on this late decline in PFTs. At 8-10 years after RT, mean reductions in Forced expiratory volume at 1 second (FEV1) of 4% and in Vital Capacity, Diffusion lung capacity for carbon monoxide (VC, DLCO), and Total Lung Capacity (TLC) of 5%, 9%, and 11%, respectively, were observed compared with pre-RT values. For FEV1 and DLCO, an early decrease was predictive for a late decrease. [11]

Radiation pneumonitis after RT for BC has been reported to be related to the following factors: The amount of lung irradiated within the tangential fields, the use of an additional supraclavicular (SC) field, prior exposure to chemotherapy (anthracyclines, taxanes), high-dose chemotherapy, and concurrent tamoxifen medication and smoking habits. Concurrent use of tamoxifen results in higher incidence of radiation pneumonitis. [12] The sequential use of chemotherapy was found to result in an actuarial rate of radiation pneumonitis in the paclitaxel-treated group as 15.4% compared with 0.9% with non-paclitaxel-containing chemotherapy. [13] Concurrent paclitaxel increases the incidence of RP to 20%. [14] RT to the chest wall results in <1% incidence of radiation pneumonitis, and with locoregional RT this increases to 11%. [15] The authors did not find a significant difference in change in FVC with or without inclusion of internal mammary chain (IM) of lymphnodes. Recently European Organisation for Research and Treatment of Cancer (EORTC) reported the incidence of radiation pneumonitis as 4% as compared to 1.3% with or without inclusion of IM in the irradiation field, where IM was treated with a combination of photons and electrons. [16]

A correlation between increasing irradiated lung volumes and pulmonary complications needs to be mentioned. A correlation between increasing irradiated lung volumes >20 Gy-level (V20), and pulmonary complications has been found. Other dosimetric factors like V13, V20, V30 and mean lung dose have also been found to correlate with radiation pneumonitis. [17] Use of CT scans to help beam design can avoid the thickness of lung being irradiated in the tangential fields. Individualized cerrobend blocks designed for each patient to define the deep border of the tangential fields when there is a need of IM irradiation can avoid lung irradiation. Use of partial wide tangential fields (PWTF) designed to selectively irradiate only the superior IMN and block the inferior portion of the field by shaped cerrobend blocks or multi-leaf collimators are used by certain centers to reduce incidental cardiac and lung irradiation. Use of 3D conformal radiotherapy (3D-CRT) can minimize the percent of incidentally irradiated lung volume and only 2% radiation pneumonitis has been reported. [18] Even with hypofractionated regimes, the incidence of RP is 1.4%. [19]

In conclusion, data on pulmonary toxicity in high-risk and advanced BC after RT from developing countries is lacking. Implementation of 3D-CRT reduces this toxicity significantly.

  References Top

1.Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11.  Back to cited text no. 1
2.Overgaard M, Christensen JJ, Johansen H, Nybo-Rasmussen A, Brincker H, van der Kooy P, et al. Postmastectomy irradiation in high-risk breast cancer patients. Present status of the Danish Breast Cancer Cooperative Group trials. Acta Oncol 1988;27:707-14.  Back to cited text no. 2
3.Ragaz J, Jackson SM, Le N, Plenderleith IH, Spinelli JJ, Basco VE, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997;337:956-62.  Back to cited text no. 3
4.Overgaard M, Jensen MB, Overgaard J, Hansen PS, Rose C, Andersson M, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999;353:1641-8.  Back to cited text no. 4
5.Paszat LF, Mackillop WJ, Groome PA, Boyd C, Schulze K, Holowaty E. Mortality from myocardial infarction after adjuvant radiotherapy for breast cancer in the surveillance, epidemiology, and end-results cancer registries. J Clin Oncol 1998;16:2625-31.  Back to cited text no. 5
6.White J, Joiner MC. Toxicity from radiation in breast cancer. Cancer Treat Res 2006;128:65-109.  Back to cited text no. 6
7.Bhadra K, Patra NB, Manna A, Kabasi A, Pal J, Sarkar SK. Abnormalities by pulmonary regions studied with computer tomography and clinical correlation following local-regional radiotherapy for breast cancer. South Asian J Cancer 2013;2:21-4.  Back to cited text no. 7
  Medknow Journal  
8.Choi YW, Munden RF, Erasmus JJ, Park KJ, Chung WK, Jeon SC, et al. Effects of radiation therapy on the lung: Radiologic appearances and differential diagnosis. Radiographics 2004;24:985-97.  Back to cited text no. 8
9.Lind PA, Svane G, Gagliardi G, Svensson C. Abnormalities by pulmonary regions studied with computer tomography following local or local-regional radiotherapy for breast cancer. Int J Radiat Oncol Biol Phys 1999;43:489-96.  Back to cited text no. 9
10.Rancati T, Wennberg B, Lind P, Svane G, Gagliardi G. Early clinical and radiological pulmonary complications following breast cancer radiation therapy: NTCP fit with four different models. Radiother Oncol 2007;82:308-16.  Back to cited text no. 10
11.Erven K, Weltens C, Nackaerts K, Fieuws S, Decramer M, Lievens Y. Changes in pulmonary function up to 10 years after locoregional breast irradiation. Int J Radiat Oncol Biol Phys 2012;82:701-7.  Back to cited text no. 11
12.Bentzen SM, Skoczylas JZ, Overgaard M, Overgaard J. Radiotherapy-related lung fibrosis enhanced by tamoxifen. J Natl Cancer Inst 1996;88:918-22.  Back to cited text no. 12
13.Beal K, Hudis C, Norton L, Wagman R, McCormick B. Radiation pneumonitis in breast cancer patients treated with taxanes: Does sequential radiation therapy lower the risk? Breast J 2005;11:317-20.  Back to cited text no. 13
14.Hanna YM, Baglan KL, Stromberg JS, Vicini FA, A Decker D. Acute and subacute toxicity associated with concurrent adjuvant radiation therapy and paclitaxel in primary breast cancer therapy. Breast J 2002;8:149-53.  Back to cited text no. 14
15.Lind PA, Wennberg B, Gagliardi G, Fornander T. Pulmonary complications following different radiotherapy techniques for breast cancer, and the association to irradiated lung volume and dose. Breast Cancer Res Treat 2001;68:199-210.  Back to cited text no. 15
16.Matzinger O, Heimsoth I, Poortmans P, Collette L, Struikmans H, Van Den Bogaert W, et al. Toxicity at three years with and without irradiation of the internal mammary and medial supraclavicular lymph node chain in stage I to III breast cancer (EORTC trial 22922/10925). Acta Oncol 2010;49:24-34.  Back to cited text no. 16
17.Blom-Goldman U, Svane G, Wennberg B, Lideståhl A, Lind PA. Quantitative assessment of lung density changes after 3-D radiotherapy for breast cancer. Acta Oncol 2007;46:187-93.  Back to cited text no. 17
18.Recht A, Ancukiewicz M, Alm El-Din MA, Lu XQ, Martin C, Berman SM, et al. Lung dose-volume parameters and the risk of pneumonitis for patients treated with accelerated partial-breast irradiation using three-dimensional conformal radiotherapy. J Clin Oncol 2009;27:3887-93.  Back to cited text no. 18
19.Bentzen SM, Agrawal RK, Aird EG, Barrett JM, Barrett-Lee PJ, Bentzen SM, et al. START Trialists' Group. The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: A randomised trial. Lancet 2008;371:1098-107.  Back to cited text no. 19

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