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Effects of Radiation Therapy on the Lung: Radiologic Appearances and Differential Diagnosis¹

¹ From the Department of Radiology, College of Medicine, Hanyang University, Seoul, Korea (Y.W.C., W.K.C., S.C.J., C.K.P.); the Department of Radiology, University of Texas M.D. Anderson Cancer Center, Houston (R.F.M., J.J.E.); and the Department of Radiology, Ajou University Medical Center, Suwon, Korea (K.J.P.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received July 7, 2003; revision requested August 25 and received October 9; accepted October 13. Supported in part by grant HY2002–1 from the research fund of Hanyang University. All authors have no financial relationships to disclose. Address correspondence to Y.W.C., Department of Radiology, Hanyang University Hospital, 17 Haengdang-dong, Sungdong-ku, Seoul 133–792, Korea (e-mail: ywchoi@hanyang.ac.kr).

View larger version (172K): [in a new window]   Figure 1a.  Temporal evolution of RILD in a 60-year-old woman with stage IIIb non-small cell lung cancer. (a) Chest radiograph obtained before treatment shows a nodule in the left lung (arrow) and hilar adenopathy. (b) Chest radiograph obtained 2 months after completion of radiation therapy shows radiation pneumonitis, which manifests as faint areas of increased opacity within the radiation portal. (c) Chest radiograph obtained 9 months after completion of radiation therapy shows evolution to radiation fibrosis, which manifests as increasing volume loss and consolidation. Note the sharp demarcation between the normal and irradiated lung parenchyma.

View larger version (168K): [in a new window]   Figure 1b.  Temporal evolution of RILD in a 60-year-old woman with stage IIIb non-small cell lung cancer. (a) Chest radiograph obtained before treatment shows a nodule in the left lung (arrow) and hilar adenopathy. (b) Chest radiograph obtained 2 months after completion of radiation therapy shows radiation pneumonitis, which manifests as faint areas of increased opacity within the radiation portal. (c) Chest radiograph obtained 9 months after completion of radiation therapy shows evolution to radiation fibrosis, which manifests as increasing volume loss and consolidation. Note the sharp demarcation between the normal and irradiated lung parenchyma.

View larger version (162K): [in a new window]   Figure 1c.  Temporal evolution of RILD in a 60-year-old woman with stage IIIb non-small cell lung cancer. (a) Chest radiograph obtained before treatment shows a nodule in the left lung (arrow) and hilar adenopathy. (b) Chest radiograph obtained 2 months after completion of radiation therapy shows radiation pneumonitis, which manifests as faint areas of increased opacity within the radiation portal. (c) Chest radiograph obtained 9 months after completion of radiation therapy shows evolution to radiation fibrosis, which manifests as increasing volume loss and consolidation. Note the sharp demarcation between the normal and irradiated lung parenchyma.

View larger version (144K): [in a new window]   Figure 2.  Radiation pneumonitis in a 60-year-old woman with stage IIIb non-small cell lung cancer (same patient as in Fig 1). Computed tomographic (CT) scan obtained 2 months after completion of radiation therapy shows diffuse ground-glass attenuation in the left lung, a typical appearance of radiation pneumonitis.

View larger version (143K): [in a new window]   Figure 3a.  Nodular radiation pneumonitis in a 65-year-old woman with adenocarcinoma of the left lower lobe and left hilar and mediastinal adenopathy. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 5 months after completion of radiation therapy shows a decrease in the size of the tumor and a new nodular area of increased attenuation in the left lower lobe (arrow). The nodular area of increased attenuation is due to radiation injury. (c) CT scan obtained 9 months after completion of radiation therapy shows evolution to fibrosis, with coalescence of the nodular area of increased attenuation and the residual tumor.

View larger version (145K): [in a new window]   Figure 3b.  Nodular radiation pneumonitis in a 65-year-old woman with adenocarcinoma of the left lower lobe and left hilar and mediastinal adenopathy. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 5 months after completion of radiation therapy shows a decrease in the size of the tumor and a new nodular area of increased attenuation in the left lower lobe (arrow). The nodular area of increased attenuation is due to radiation injury. (c) CT scan obtained 9 months after completion of radiation therapy shows evolution to fibrosis, with coalescence of the nodular area of increased attenuation and the residual tumor.

View larger version (139K): [in a new window]   Figure 3c.  Nodular radiation pneumonitis in a 65-year-old woman with adenocarcinoma of the left lower lobe and left hilar and mediastinal adenopathy. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 5 months after completion of radiation therapy shows a decrease in the size of the tumor and a new nodular area of increased attenuation in the left lower lobe (arrow). The nodular area of increased attenuation is due to radiation injury. (c) CT scan obtained 9 months after completion of radiation therapy shows evolution to fibrosis, with coalescence of the nodular area of increased attenuation and the residual tumor.

View larger version (138K): [in a new window]   Figure 4a.  Radiation fibrosis in a 62-year-old woman with poorly differentiated non-small cell lung cancer. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 12 months after completion of radiation therapy shows radiation fibrosis. Note the bronchiectasis and volume loss and the sharp demarcation between normal lung tissue and areas of fibrosis.

View larger version (146K): [in a new window]   Figure 4b.  Radiation fibrosis in a 62-year-old woman with poorly differentiated non-small cell lung cancer. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 12 months after completion of radiation therapy shows radiation fibrosis. Note the bronchiectasis and volume loss and the sharp demarcation between normal lung tissue and areas of fibrosis.

View larger version (137K): [in a new window]   Figure 5a.  RILD due to tangential-beam irradiation in a 42-year-old woman with adenocarcinoma of the right breast. (a) CT scan obtained 4 months after completion of radiation therapy shows ground-glass attenuation and nodules, which are predominantly located in the peripheral aspect of the right upper lobe. (b) CT scan obtained 26 months after completion of radiation therapy shows the typical pattern of subpleural radiation fibrosis in lung tissue adjacent to the treated chest wall region.

View larger version (132K): [in a new window]   Figure 5b.  RILD due to tangential-beam irradiation in a 42-year-old woman with adenocarcinoma of the right breast. (a) CT scan obtained 4 months after completion of radiation therapy shows ground-glass attenuation and nodules, which are predominantly located in the peripheral aspect of the right upper lobe. (b) CT scan obtained 26 months after completion of radiation therapy shows the typical pattern of subpleural radiation fibrosis in lung tissue adjacent to the treated chest wall region.

View larger version (135K): [in a new window]   Figure 6a.  Images obtained with computed dosimetric reconstruction. (a) Isodose line image used for planning standard anteroposterior-posteroanterior radiation therapy. The area of highest radiation dose is indicated by the magenta line around the border of the right chest wall (arrows). (b) Isodose axial image used for planning 3D conformal radiation therapy in another patient. The area of highest radiation dose is indicated by the aquamarine line immediately surrounding the tumor. With 3D radiation therapy, the highest radiation dose is delivered to the tumor; with standard radiation therapy, the highest dose is at the chest wall.

View larger version (140K): [in a new window]   Figure 6b.  Images obtained with computed dosimetric reconstruction. (a) Isodose line image used for planning standard anteroposterior-posteroanterior radiation therapy. The area of highest radiation dose is indicated by the magenta line around the border of the right chest wall (arrows). (b) Isodose axial image used for planning 3D conformal radiation therapy in another patient. The area of highest radiation dose is indicated by the aquamarine line immediately surrounding the tumor. With 3D radiation therapy, the highest radiation dose is delivered to the tumor; with standard radiation therapy, the highest dose is at the chest wall.

View larger version (157K): [in a new window]   Figure 7a.  Three patterns of radiation-induced lung injury after 3D conformal radiation therapy. (a-c) Modified conventional pattern in a 53-year-old woman with adenocarcinoma. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 1 month after completion of radiation therapy shows a decrease in the size of the mass along with ground-glass attenuation, which is indicative of pneumonitis. (c) CT scan obtained 5 months after completion of radiation therapy shows organization of the pneumonitis into fibrosis. Note the volume loss, consolidation, and air bronchograms, as in conventional fibrosis; however, the fibrosis is localized to a small area of the lung. (d) Masslike pattern in a 67-year-old man with squamous cell carcinoma. CT scan obtained 14 months after completion of radiation therapy shows the consolidation and bronchiectasis of fibrosis. The fibrosis forms a masslike area of increased attenuation, which could be mistaken for a malignancy. (e) Scarlike pattern in a 60-year-old woman with poorly differentiated non-small cell carcinoma. CT scan obtained 5 years after completion of radiation therapy shows only a linear band of fibrosis, which resembles a scar.

View larger version (161K): [in a new window]   Figure 7b.  Three patterns of radiation-induced lung injury after 3D conformal radiation therapy. (a-c) Modified conventional pattern in a 53-year-old woman with adenocarcinoma. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 1 month after completion of radiation therapy shows a decrease in the size of the mass along with ground-glass attenuation, which is indicative of pneumonitis. (c) CT scan obtained 5 months after completion of radiation therapy shows organization of the pneumonitis into fibrosis. Note the volume loss, consolidation, and air bronchograms, as in conventional fibrosis; however, the fibrosis is localized to a small area of the lung. (d) Masslike pattern in a 67-year-old man with squamous cell carcinoma. CT scan obtained 14 months after completion of radiation therapy shows the consolidation and bronchiectasis of fibrosis. The fibrosis forms a masslike area of increased attenuation, which could be mistaken for a malignancy. (e) Scarlike pattern in a 60-year-old woman with poorly differentiated non-small cell carcinoma. CT scan obtained 5 years after completion of radiation therapy shows only a linear band of fibrosis, which resembles a scar.

View larger version (157K): [in a new window]   Figure 7c.  Three patterns of radiation-induced lung injury after 3D conformal radiation therapy. (a-c) Modified conventional pattern in a 53-year-old woman with adenocarcinoma. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 1 month after completion of radiation therapy shows a decrease in the size of the mass along with ground-glass attenuation, which is indicative of pneumonitis. (c) CT scan obtained 5 months after completion of radiation therapy shows organization of the pneumonitis into fibrosis. Note the volume loss, consolidation, and air bronchograms, as in conventional fibrosis; however, the fibrosis is localized to a small area of the lung. (d) Masslike pattern in a 67-year-old man with squamous cell carcinoma. CT scan obtained 14 months after completion of radiation therapy shows the consolidation and bronchiectasis of fibrosis. The fibrosis forms a masslike area of increased attenuation, which could be mistaken for a malignancy. (e) Scarlike pattern in a 60-year-old woman with poorly differentiated non-small cell carcinoma. CT scan obtained 5 years after completion of radiation therapy shows only a linear band of fibrosis, which resembles a scar.

View larger version (146K): [in a new window]   Figure 7d.  Three patterns of radiation-induced lung injury after 3D conformal radiation therapy. (a-c) Modified conventional pattern in a 53-year-old woman with adenocarcinoma. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 1 month after completion of radiation therapy shows a decrease in the size of the mass along with ground-glass attenuation, which is indicative of pneumonitis. (c) CT scan obtained 5 months after completion of radiation therapy shows organization of the pneumonitis into fibrosis. Note the volume loss, consolidation, and air bronchograms, as in conventional fibrosis; however, the fibrosis is localized to a small area of the lung. (d) Masslike pattern in a 67-year-old man with squamous cell carcinoma. CT scan obtained 14 months after completion of radiation therapy shows the consolidation and bronchiectasis of fibrosis. The fibrosis forms a masslike area of increased attenuation, which could be mistaken for a malignancy. (e) Scarlike pattern in a 60-year-old woman with poorly differentiated non-small cell carcinoma. CT scan obtained 5 years after completion of radiation therapy shows only a linear band of fibrosis, which resembles a scar.

View larger version (158K): [in a new window]   Figure 7e.  Three patterns of radiation-induced lung injury after 3D conformal radiation therapy. (a-c) Modified conventional pattern in a 53-year-old woman with adenocarcinoma. (a) CT scan obtained before treatment shows a mass in the left lower lobe. (b) CT scan obtained 1 month after completion of radiation therapy shows a decrease in the size of the mass along with ground-glass attenuation, which is indicative of pneumonitis. (c) CT scan obtained 5 months after completion of radiation therapy shows organization of the pneumonitis into fibrosis. Note the volume loss, consolidation, and air bronchograms, as in conventional fibrosis; however, the fibrosis is localized to a small area of the lung. (d) Masslike pattern in a 67-year-old man with squamous cell carcinoma. CT scan obtained 14 months after completion of radiation therapy shows the consolidation and bronchiectasis of fibrosis. The fibrosis forms a masslike area of increased attenuation, which could be mistaken for a malignancy. (e) Scarlike pattern in a 60-year-old woman with poorly differentiated non-small cell carcinoma. CT scan obtained 5 years after completion of radiation therapy shows only a linear band of fibrosis, which resembles a scar.

View larger version (120K): [in a new window]   Figure 8a.  Apical RILD due to supraclavicular radiation therapy in a 42-year-old woman with adenocarcinoma of the right breast (same patient as in Fig 5). (a) CT scan obtained 4 months after completion of radiation therapy shows ground-glass attenuation and nodular areas of increased attenuation in the right upper lobe, findings indicative of radiation pneumonitis. (b) CT scan obtained 16 months after completion of radiation therapy shows organization of the apical radiation pneumonitis into fibrosis.

View larger version (116K): [in a new window]   Figure 8b.  Apical RILD due to supraclavicular radiation therapy in a 42-year-old woman with adenocarcinoma of the right breast (same patient as in Fig 5). (a) CT scan obtained 4 months after completion of radiation therapy shows ground-glass attenuation and nodular areas of increased attenuation in the right upper lobe, findings indicative of radiation pneumonitis. (b) CT scan obtained 16 months after completion of radiation therapy shows organization of the apical radiation pneumonitis into fibrosis.

View larger version (155K): [in a new window]   Figure 9.  RILD after adjuvant chemotherapy and radiation therapy in a 53-year-old man with adenocarcinoma of the distal esophagus. CT scan obtained 3 months after completion of therapy shows areas of increased attenuation, a finding consistent with early radiation fibrosis. The RILD is more prominent in the left lower lobe but is bilateral and has the typical paramediastinal distribution.

View larger version (124K): [in a new window]   Figure 10a.  Biapical RILD in a 72-year-old woman with squamous cell carcinoma of the tonsil. (a) Chest radiograph shows bilateral apical radiation fibrosis and pleural thickening. (b) CT scan shows radiation fibrosis in the lung apices. The distribution and appearance are typical of RILD in patients with head and neck cancer.

View larger version (107K): [in a new window]   Figure 10b.  Biapical RILD in a 72-year-old woman with squamous cell carcinoma of the tonsil. (a) Chest radiograph shows bilateral apical radiation fibrosis and pleural thickening. (b) CT scan shows radiation fibrosis in the lung apices. The distribution and appearance are typical of RILD in patients with head and neck cancer.

View larger version (113K): [in a new window]   Figure 11a.  Paramediastinal RILD in a 27-year-old woman with nodular sclerosing Hodgkin lymphoma. (a) CT scan obtained with narrow window settings (level, –675 HU; width, 750 HU) 16 weeks after completion of radiation therapy shows subtle paramediastinal ground-glass attenuation in the upper lobes, a finding indicative of radiation pneumonitis. (b) CT scan obtained 11 months after completion of radiation therapy shows organization of the radiation pneumonitis into the typical paramediastinal pattern of fibrosis.

View larger version (139K): [in a new window]   Figure 11b.  Paramediastinal RILD in a 27-year-old woman with nodular sclerosing Hodgkin lymphoma. (a) CT scan obtained with narrow window settings (level, –675 HU; width, 750 HU) 16 weeks after completion of radiation therapy shows subtle paramediastinal ground-glass attenuation in the upper lobes, a finding indicative of radiation pneumonitis. (b) CT scan obtained 11 months after completion of radiation therapy shows organization of the radiation pneumonitis into the typical paramediastinal pattern of fibrosis.

View larger version (126K): [in a new window]   Figure 12a.  Pulmonary infection in a 52-year-old man with poorly differentiated non-small cell lung cancer being treated with 3D conformal radiation therapy. (a) CT scan obtained before treatment shows a large mass in the left lower lobe. (b) CT scan obtained 12 weeks after completion of radiation therapy shows numerous poorly defined nodules outside the radiation treatment port. Although the CT appearance mimics that of metastatic nodules, a unilateral distribution would be atypical.

View larger version (133K): [in a new window]   Figure 12b.  Pulmonary infection in a 52-year-old man with poorly differentiated non-small cell lung cancer being treated with 3D conformal radiation therapy. (a) CT scan obtained before treatment shows a large mass in the left lower lobe. (b) CT scan obtained 12 weeks after completion of radiation therapy shows numerous poorly defined nodules outside the radiation treatment port. Although the CT appearance mimics that of metastatic nodules, a unilateral distribution would be atypical.

View larger version (144K): [in a new window]   Figure 13a.  Recurrent tumor in a 68-year-old woman with stage IIIb adenocarcinoma of the right upper lobe. (a) CT scan obtained 15 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. (b) CT scan obtained 20 months after completion of radiation therapy shows that the fibrosis has developed a convex contour, a finding indicative of recurrent tumor.

View larger version (135K): [in a new window]   Figure 13b.  Recurrent tumor in a 68-year-old woman with stage IIIb adenocarcinoma of the right upper lobe. (a) CT scan obtained 15 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. (b) CT scan obtained 20 months after completion of radiation therapy shows that the fibrosis has developed a convex contour, a finding indicative of recurrent tumor.

View larger version (148K): [in a new window]   Figure 14a.  Recurrent tumor in a 61-year-old woman after chemotherapy and radiation therapy for a large cell carcinoma of the right upper lobe. (a) CT scan obtained 7 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. (b) CT scan obtained 11 months after completion of radiation therapy shows soft tissue filling the bronchi (arrows), a finding indicative of recurrent tumor.

View larger version (146K): [in a new window]   Figure 14b.  Recurrent tumor in a 61-year-old woman after chemotherapy and radiation therapy for a large cell carcinoma of the right upper lobe. (a) CT scan obtained 7 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. (b) CT scan obtained 11 months after completion of radiation therapy shows soft tissue filling the bronchi (arrows), a finding indicative of recurrent tumor.

View larger version (145K): [in a new window]   Figure 15a.  Radiation fibrosis in a 53-year-old man with squamous cell carcinoma of the right upper lobe. (a) Chest radiograph obtained 8 months after completion of radiation therapy shows that the right hilum has an abnormal contour. There was concern that this contour represented recurrent tumor. (b) CT scan shows a right lower lobe mass that abuts the hilum (arrow). (c) PET scan shows normal FDG uptake in the thorax. (d) Fused CT-PET scan shows normal activity in the mass, thus confirming the absence of recurrent tumor in the area of radiation fibrosis.

View larger version (108K): [in a new window]   Figure 15b.  Radiation fibrosis in a 53-year-old man with squamous cell carcinoma of the right upper lobe. (a) Chest radiograph obtained 8 months after completion of radiation therapy shows that the right hilum has an abnormal contour. There was concern that this contour represented recurrent tumor. (b) CT scan shows a right lower lobe mass that abuts the hilum (arrow). (c) PET scan shows normal FDG uptake in the thorax. (d) Fused CT-PET scan shows normal activity in the mass, thus confirming the absence of recurrent tumor in the area of radiation fibrosis.

View larger version (90K): [in a new window]   Figure 15c.  Radiation fibrosis in a 53-year-old man with squamous cell carcinoma of the right upper lobe. (a) Chest radiograph obtained 8 months after completion of radiation therapy shows that the right hilum has an abnormal contour. There was concern that this contour represented recurrent tumor. (b) CT scan shows a right lower lobe mass that abuts the hilum (arrow). (c) PET scan shows normal FDG uptake in the thorax. (d) Fused CT-PET scan shows normal activity in the mass, thus confirming the absence of recurrent tumor in the area of radiation fibrosis.

View larger version (115K): [in a new window]   Figure 15d.  Radiation fibrosis in a 53-year-old man with squamous cell carcinoma of the right upper lobe. (a) Chest radiograph obtained 8 months after completion of radiation therapy shows that the right hilum has an abnormal contour. There was concern that this contour represented recurrent tumor. (b) CT scan shows a right lower lobe mass that abuts the hilum (arrow). (c) PET scan shows normal FDG uptake in the thorax. (d) Fused CT-PET scan shows normal activity in the mass, thus confirming the absence of recurrent tumor in the area of radiation fibrosis.

View larger version (152K): [in a new window]   Figure 16a.  Recurrent tumor in a 60-year-old woman with limited small cell carcinoma. (a) CT scan obtained 27 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. Note the patent air bronchogram. (b) Fused CT-PET scan shows increased FDG uptake in the area of fibrosis. Note that the recurrent tumor does not fill in the air bronchogram.

View larger version (133K): [in a new window]   Figure 16b.  Recurrent tumor in a 60-year-old woman with limited small cell carcinoma. (a) CT scan obtained 27 months after completion of radiation therapy shows radiation fibrosis in the right upper lobe. Note the patent air bronchogram. (b) Fused CT-PET scan shows increased FDG uptake in the area of fibrosis. Note that the recurrent tumor does not fill in the air bronchogram.