Factors affecting post-treatment radiation-induced lung disease in patients receiving stereotactic body radiotherapy to lung.

The aim of the study is to investigate factors that may cause radiation-induced lung disease (RILD) in patients undergoing stereotactic body radiotherapy (SBRT) for lung tumors. Medical records of patients treated between May 2018 and June 2019 with SBRT were retrospectively evaluated. All patients should have a diagnosis of either primary non-small cell lung cancer (NSCLC) or less than three metastases to lung from another primary. The median treatment dose was 50 Gy in 4-5 fractions. Tumor response and RILD were evaluated in thoracic computer tomography (CT) using RECIST criteria. 82 patients with 97 lung lesions were treated. The median age was 68 years (IQR = 62-76). With a median follow-up of 7.2 months (3-18 months), three patients had grade 3 radiation pneumonitis (RP). RILD was observed in 52% of cases. Patients who had RILD had a higher risk of symptomatic RP (p = 0.007). In multivariate analyses older age, previous lung radiotherapy history, and median planning treatment volume (PTV) D95 value of ≥ 48 Gy were associated with RILD. Local recurrence (LR) was observed in 5.1% of cases. There was no difference in overall survival and LR with the presence of RILD. Older age, previous lung radiotherapy history, and median PTV D95 value of ≥ 48 Gy seems to be associated with post-SBRT RILD.

Wegener's granulomatosis presenting with life-threatening lung hemorrhage in a 7-year-old child.

Wegener's granulomatosis (WG) is an idiopathic systemic disease that usually onsets in adolescence and is rare in young children. Its diagnosis is usually based on the presence of fever with arthralgia and weight loss, associated with symptoms of upper and/or lower respiratory tract involvement and renal disorders. We describe the appearance of a life-threatening lung hemorrhage in the absence of hemoptysis in a 7-year-old girl with a completely negative previous clinical history, who was subsequently diagnosed as having WG. The teaching message is that immediate bronchoscopy with bronchoalveolar lavage seems to be advisable in the presence of severe respiratory distress and bilateral lung as well as renal involvement. When a diffuse alveolar hemorrhage syndrome is demonstrated, WG should be considered among the main etiologies even in a relatively young child without a clinically suggestive history.

Stereotactic body radiation therapy using CyberKnife for T1N0M0 lung cancer patients with severe pulmonary dysfunction.

We retrospectively investigated the efficacy and safety of stereotactic body radiotherapy (SBRT) for T1N0M0 lung cancer using CyberKnife (CK) among 13 patients with severe pulmonary dysfunction which was defined as forced expiratory volume in 1 s (FEV1.0) of <1 L. The prescribed dose was 54 Gy in 3 fractions but adjusted for some patients if their tumors were in close proximity to the organs at risk (54 Gy/3 fractions: n = 11; 50 Gy/5 fractions: n = 1; 60 Gy/8 fractions: n = 1). During follow up (median follow-up: 27 months), we evaluated local control, overall survival and toxicity, using diagnostic imaging and laboratory tests. The patients' median FEV1.0 was 0.84 L. Of the 13 patients, 3 were diagnosed as having lung cancer histologically and 10 diagnosed clinically. Their 2-year rates for overall survival and local control were 89 and 100%, respectively. So far, we have seen no adverse effects of grade 2 or higher. We concluded that CK-SBRT is effective and well tolerated for T1N0M0 lung cancer, even in patients with severe pulmonary dysfunction, but should be further evaluated with a larger cohort and longer follow-up periods.

Radiotherapy in the control of bleeding from primary and secondary lung tumours.

This literature review clarifies the role of radiotherapy in the management of low-volume haemoptysis. Embase and Medline were interrogated, and PRISMA guidelines were then used to select relevant articles. Seventy-eight articles were considered relevant and manually reviewed. The evidence suggests that external beam radiotherapy is more effective than endobronchial brachytherapy at controlling low-volume haemoptysis. There is no evidence to recommend a combination of the two techniques. Different doses and fractionations appear equally effective, with a potential survival advantage of higher dose regimens for fitter patients. Palliative radiotherapy is effective at controlling low-volume haemoptysis. External beam radiotherapy is the first-line treatment, with endobronchial brachytherapy recommended following external beam radiotherapy failure. Choice of dose and fractionation should take into account the patient's performance status.

Hepatic selective internal radiation therapy: how well does pretreatment 99mTc-macroaggregated albumin activity distribution and quantification agree with post-therapy bremsstrahlung imaging?

AIM: The aim of this study was to examine the agreement of pretreatment Tc-macroaggregated albumin imaging performed for selective internal radiation therapy (SIRT) workup with Y percentage lung shunt (PLS) and regional hepatic distribution in subsequent post-therapy bremsstrahlung imaging. PATIENTS AND METHODS: Planar images were used to calculate PLS. The significant Y bremsstrahlung scatter required background correction. Results using both Y lung background regions of interest (ROI) reported in previous studies and extended ROIs (reflecting lung background variation) were compared with Tc-MAA PLS. Lesion and healthy liver volumes were outlined on diagnostic computed tomography scans and registered to Tc-MAA and Y single-photon emission computed tomography/computed tomographydata. Single-photon emission computed tomography voxel values were normalized to injected Y activity. Volume mean activities were calculated, and converted into the mean absorbed dose. Agreement was quantified using Bland-Altman analysis. RESULTS: PLS: The bias using previous studies' lung background ROIs was -10.71%, with a 95% confidence interval (CI) of -18.79 to -2.64%. The extended ROI yielded a bias of 0.77% (95% CI: -2.23 to 3.70%). Liver: The healthy liver bias was 0.01 MBq/ml (0.17 Gy), with a -0.05 to 0.06 MBq/ml (95% CI:0.80 -1.93 Gy). The lesion mean activity/ml bias was -0.02 MBq/ml (3.71 Gy), with a -0.81 to 0.76 MBq/ml (95% CI: -35.49 to 28.07 Gy). CONCLUSIONS: The PLS agreement was sensitive to the Y lung background correction ROI, potentially explaining a previously published controversy. The mean activity and absorbed dose agreement for the metastatic lesions was poorer than the healthy liver volumes studied here.

Effect of low-level laser therapy on hemorrhagic lesions induced by immune complex in rat lungs.

OBJECTIVE: The aim of this study was to investigate if low-level laser therapy (LLLT) can modulate formation of hemorrhagic lesions induced by immune complex. BACKGROUND DATA: There is a lack of information on LLLT effects in hemorrhagic injuries of high perfusion organs, and the relative efficacy of LLLT compared to anti-inflammatory drugs. METHODS: A controlled animal study was undertaken with 49 male Wistar rats randomly divided into seven groups. Bovine serum albumin (BSA) i.v. was injected through the trachea to induce an immune complex lung injury. The study compared the effect of irradiation by a 650-nm Ga-Al-As laser with LLLT doses of 2.6 Joules/cm(2) to celecoxib, dexamethasone, and control groups for hemorrhagic index (HI) and myeloperoxide activity (MPO) at 24 h after injury. RESULTS: The HI for the control group was 4.0 (95% CI, 3.7-4.3). Celecoxib, LLLT, and dexamethasone all induced significantly (p < 0.01) lower HI than control animals at 2.5 (95% CI, 1.9-3.1), 1.8 (95% CI, 1.2-2.4), and 1.5 (95% CI, 0.9-2.1), respectively, for all comparisons to control. Dexamethasone, but not celecoxib, induced a slightly, but significantly lower HI than LLLT (p = 0.04). MPO activity was significantly decreased in groups receiving celecoxib at 0.87 (95% CI, 0.63-1.11), dexamethasone at 0.50 (95% CI, 0.24-0.76), and LLLT at 0.7 (95% CI, 0.44-0.96) when compared to the control group, at 1.6 (95% CI, 1.34-1.96; p < 0.01), but there were no significant differences between any of the active treatments. CONCLUSION: LLLT at a dose of 2.6 Joules/cm(2) induces a reduction of HI levels and MPO activity in hemorrhagic injury that is not significantly different from celecoxib. Dexamethasone is slightly more effective than LLLT in reducing HI, but not MPO activity.

An unintended consequence: fatal amiodarone pulmonary toxicity in an older woman.

Amiodarone pulmonary toxicity represents the most serious adverse reaction from amiodarone use. It remains underdiagnosed and can have a variable presentation. The elderly population is at increased risk for amiodarone pulmonary toxicity. Thus, clinicians should prescribe the lowest dosage possible in the elderly and have a low threshold to discontinue the amiodarone for anyone with unexplained fatigue, dyspnea, cough, or weight loss. We present the case of an 89-year-old female who presented with a several month history of fatigue and recent development of dyspnea on exertion and a dry cough. She had been taking amiodarone for 1 year secondary to atrial fibrillation. Chest x-ray and chest CT revealed multilobar airway opacities. An infectious work-up was negative and a transbronchial biopsy revealed prominent intra-alveolar foamy macrophages, consistent with amiodarone pulmonary toxicity. Despite the prompt discontinuation of her amiodarone and a trial of intravenous steroids, the patient succumbed to respiratory failure. The risk factors, clinical presentation, diagnosis, treatment, and prevention of amiodarone pulmonary toxicity are discussed.

Radiation Dose Reduction in Computed Tomography-Guided Lung Interventions using an Iterative Reconstruction Technique.

PURPOSE: To compare the radiation doses and image qualities of computed tomography (CT)-guided interventions using a standard-dose CT (SDCT) protocol with filtered back projection and a low-dose CT (LDCT) protocol with both filtered back projection and iterative reconstruction. MATERIALS AND METHODS: Image quality and radiation doses (dose-length product and CT dose index) were retrospectively reviewed for 130 patients who underwent CT-guided lung interventions. SDCT at 120 kVp and automatic mA modulation and LDCT at 100 kVp and a fixed exposure were each performed for 65 patients. Image quality was objectively evaluated as the contrast-to-noise ratio and subjectively by two radiologists for noise impression, sharpness, artifacts and diagnostic acceptability on a four-point scale. RESULTS: The groups did not significantly differ in terms of diagnostic acceptability and complication rate. LDCT yielded a median 68.6% reduction in the radiation dose relative to SDCT. In the LDCT group, iterative reconstruction was superior to filtered back projection in terms of noise reduction and subjective image quality. The groups did not differ in terms of beam hardening artifacts. CONCLUSION: LDCT was feasible for all procedures and yielded a more than two-thirds reduction in radiation exposure while maintaining overall diagnostic acceptability, safety and precision. The iterative reconstruction algorithm is preferable according to the objective and subjective image quality analyses. KEY POINTS: Implementation of a low-dose computed tomography (LDCT) protocol for lung interventions is feasible and safe. LDCT protocols yield a significant reduction (more than 2/3) in radiation exposure. Iterative reconstruction algorithms considerably improve the image quality in LDCT protocols.

Use of irradiation in lymphomatoid granulomatosis.

A middle-aged white man with lymphomatoid granulomatosis was studied over the ten-year course of his disease. Both a large subcutaneous mass in his thigh and life-threatening massive involvement of the right lung occurred on separate occasions, and each responded to therapy with irradiation after immunosuppression failed. Irradiation should be considered as one of the primary forms of treatment of lymphomatoid granulomatosis in those with localized lesions.

Pulmonary irradiation for Kaposi's sarcoma in AIDS.

A 26-year-old-old male patient with aids (acquired Immune Deficiency Syndrome) and diffuse Kaposi's sarcoma (KS) infiltration of both lungs received bilateral pulmonary irradiation. The patient received 1,600 rad in 10 treatments to the left lung, followed by a 2-week rest period, followed by 1,800 rad in 10 treatments to the right lung. He tolerated the treatments quite well, and demonstrated symptomatic improvement as well as radiographic improvement. This demonstrates both subjective and objective radioresponsiveness of Kaposi's Sarcoma in AIDS patients, and may be utilized as a consideration for palliative treatment of other patients with AIDS and KS.

Serum copper concentration as an index of experimental lung injury.

Serum copper (Cu) concentration was evaluated as an index of lung injury in two rat models of pneumotoxicity: hemithoracic irradiation and monocrotaline ingestion. In both models there was a dose- and time-dependent increase in serum Cu concentration. This hypercupremia paralleled the development of pulmonary endothelial dysfunction (decreased lung plasminogen activator activity and increased prostacyclin production) and pulmonary fibrosis (hydroxyproline accumulation). In the radiation model, lung injury and hypercupremia persisted for at least 6 months, and were spared similarly when the total dose was delivered in multiple daily fractions as compared to single doses. In irradiated rats, the elevated serum Cu concentration was accompanied by increases in plasma ceruloplasmin, lung Cu concentration, and lung Cu/Zn superoxide dismutase (SOD) activity. In monocrotaline-treated rats, lung damage and hypercupremia also were accompanied by a reduction in liver Cu concentration, and by a direct correlation between the concentrations of Cu and SGOT in the serum. In both models, some but not all modifiers of lung damage (penicillamine, angiotensin converting enzyme inhibitors, pentoxifylline) also partially prevented the insult-induced hypercupremia. In contrast, serum iron concentration was largely independent of treatment in all experiments. These data suggest that elevated serum copper concentration is an accurate and minimally invasive index of lung injury in irradiated and monocrotaline-treated rats.

[The use of contact YAG-laser in surgeries on pleura and lungs]. / Ispol'zovanie kontaktnogo AIG-lazera pri vypolnenii operatsii na legkikh i plevre.

The original sapphire scalpel and the thermal tip of quartz were used by the authors while performing interventions on lungs and pleura. High efficacy of operations and low frequency of complications were noted.

Exercise in patients with non-small cell lung cancer.

PURPOSE: This study aimed to evaluate the safety, feasibility, and effects of an 8-wk combined resistance and endurance exercise program in patients with advanced non-small cell lung cancer (NSCLC) during in- and outpatient care. METHODS: In this intervention study, 40 patients with predominantly advanced NSCLC receiving simultaneous or sequential radiochemotherapy or chemotherapy alone were enrolled. For a period of 8 wk, patients were instructed to exercise at least five times per week during the inpatient setting and at least three times per week in the outpatient setting. Physical performance status (endurance capacity: 6-min walk test; strength capacity: handheld dynamometry), quality-of-life (Functional Assessment of Cancer Therapy-Lung), fatigue (Multidimensional Fatigue Inventory), and depression (Patient Health Questionnaire) were assessed at baseline (T0), after the exercise intervention (T1), and at a follow-up time point 8 wk later (T2). The primary end point was adequate adherence (feasibility) defined as completing at least two training sessions per week during a minimum of 6 wk. RESULTS: Of 40 patients, 31 (77.5%) completed the postexercise assessment (T1) and 22 (55%) completed follow-up (T2). The stages were IIA (5%), IIIA (8%), IIIB (20%), and IV (67%), and the median age was 63 yr (range = 22-75 yr). Overall, adherence was 82% for those patients who completed T1, and 55% of the 40 participating patients fulfilled the adequate adherence criterion. Those who completed the intervention showed a significant improvement in the 6-min walk distance and in knee, elbow, and hip muscle strength after the intervention (T1). Quality of life, fatigue, and depression scores remained stable or declined slightly. Significant improvements in knee-muscle strength were also observed at T2. CONCLUSIONS: Exercise training is feasible in advanced and metastatic NSCLC patients during anticancer treatment. In this pilot study, endurance and strength capacity improved over time, indicating the rehabilitative importance of the applied intervention. To investigate the potential impact of exercise training in this patient group, a larger randomized trial is warranted.

Comparison of calculated dose by helical tomotherapy treatment planning machine and measured dose of radiophotoluminescence glass dosimeter in lung lesions using Rando Phantom.

AIM: To examine the compatibility of the measured and calculated dose for the treatment of lung lesions by helical tomotherapy. MATERIALS AND METHODS: The administered dose was measured a total of 55 times at 22 points with a radiophotoluminescence glass dosimeter (RPLGD) inserted in the position of an anthropomorphic Rando Phantom. Two Gy were prescribed and calculated with a tomotherapy planning machine for a 3-cm diameter spherical planning target volume (PTV) created in the lung area. Compatibility (measured dose/calculated dose and σ value=(D(meas)-D(calc))/D(prescribed)) × 100 (%)) was analyzed according to dosimeter location. RESULTS: Deviations between measured and calculated doses for the lung lesion were within 4% for planning target volume, indicating that adequate dose delivery to the PTV was achievable. On the other hand, we found dose deviations up to 15% for the lower prescribed dose range (64% or less) for the measured dose/calculated comparison and a 6% deviation according to the σ value in or near inhomogeneous tissue. CONCLUSION: Although the measured dose satisfied the clinical requirement in almost all areas including PTV, we should note that there may be discrepancies between expected calculated dose and irradiated dose in or near inhomogeneous area.

Usefulness of combination of pulmonary ventilation and perfusion scintigraphy on the diagnosis of children with unilateral hyperlucent lung.

OBJECTIVES: Unilateral hyperlucent lung on chest radiograph is uncommon in children. It is often found incidentally and always refers to Swyer-James syndrome, with decrease in pulmonary vascularity and air trapping during expiration. However, it may occasionally mimic other serious lung diseases such as pulmonary hypoplasia/aplasia, defect of pulmonary artery, and other primary pulmonary disorders. In this study, we hypothesized that there would be characteristic patterns in pulmonary ventilation and perfusion scintigraphy (V/Q scan) in children with unilateral hyperlucency on chest film, which could play an important role in differential diagnosis of this disease group explicitly. METHODS: Children with unilateral hyperlucency on chest radiograph had a detailed clinical examination and underwent echocardiography, chest computed tomography, selective pulmonary angiogram, flexible bronchoscopy, and pulmonary V/Q scan. RESULTS: A total of 10 cases were enrolled, including two cases of unilateral pulmonary artery agenesis, three cases of Swyer-James syndrome, two cases of agenesis of the right lung, one case of lobar emphysema, and two cases of tetralogy of fallot with left pulmonary artery stenosis. Besides, an overview of children with unilateral hyperlucent lung is provided, reviewing nine studies (171 patients), including our clinical experience, and finally an algorithm for diagnosis unilateral hyperlucent lung is proposed, based on the characteristics of V/Q scan. CONCLUSION: We chose a descriptive approach to the V/Q scan in children with unilateral hyperlucent lung on chest radiograph. This result enables us to promote the V/Q scan as a first-line tool in evaluating these patients and to avoid further unnecessary procedures.