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1.
Medicine (Baltimore) ; 98(27): e16398, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31277197

RESUMO

RATIONALE: Primary or reactivation pulmonary tuberculosis (TB) is frequent in immunocompromised patients such as those with human immunodeficiency virus (HIV) infection, chronic renal failure, poorly controlled diabetes, and hematologic malignancy. Immune system of patients with solid-organ cancer can be also altered by malignancy itself or chemotherapy. However, information on the effect of radiation on patient's immunity is scarce. Herein, we present a case of pulmonary TB occurring in a radiation field that mimics focal radiation pneumonitis in a patient who has received curative chemoradiation therapy for neck malignancy. We also performed literature review to understand the impact of radiation therapy on patients' immunity. PATIENT CONCERN: A 56-year-old male patient visited our hospital with a palpable mass in the right supraclavicular fossa which was later confirmed as metastatic squamous cell carcinoma. After completion of concurrent chemoradiation therapy, a focal consolidation was developed in the right upper lobe apex where radiation was applied. The patient did not have any symptoms or signs of infectious disease. DIAGNOSIS: Pulmonary TB was diagnosed through polymerase chain reaction (PCR) test and culture of sputum. INTERVENTION: Anti-TB medication was started. OUTCOME: The patient was tolerable to anti-TB medication and the size of TB lesion gradually decreased. LESSON: A suspicion of pulmonary TB should be given to patients with new infiltrates in radiation port due to impact of radiation therapy on local infection barriers and patients' immune system.


Assuntos
Pneumonite por Radiação/diagnóstico , Tuberculose Pulmonar/diagnóstico , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/radioterapia , Quimiorradioterapia , Diagnóstico Diferencial , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/radioterapia , Humanos , Masculino , Pessoa de Meia-Idade
2.
Radiat Oncol ; 14(1): 7, 2019 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-30642354

RESUMO

BACKGROUND: Lung dose-volume histogram (DVH) in radiotherapy could be calculated from multiple normal lung definitions. The lung dosimetric parameters generated from various approaches are significantly different. However, limited evidence shows which definition should be used to more accurately predict radiation pneumonitis (RP). We aimed to compare the RP prediction accuracy of dosimetric parameters from three lung volume methods in lung cancer patients treated with Intensity-Modulated Radiation Therapy (IMRT). METHODS: We retrospectively reviewed 183 consecutive lung cancer patients treated with IMRT from January 2014 to October 2017. The normal lungs were defined by total bilateral lung volume (Total Lung), excluding PTV (Lung-PTV) or PGTV (Lung-PGTV). V5, V20, and mean lung dose (MLD) have been extracted from three definitions. The primary endpoint was acute grade 2 or higher RP (RP2). Correlation between RP2 and dose parameters were analyzed by logistic regression. We evaluated prediction performance using area under the receiver operating characteristic curve (AUC) and normal tissue complication probability (NTCP) model. RESULTS: Twenty-six patients (14.2%) developed acute RP2 after IMRT treatment. Significant dosimetric differences were found between any 2-paired lung volumes (Ps < 0.001). To limit RP2 incidence less than 20%, the cutoff MLDs were 12.5 Gy, 14.2 Gy, and 15.0 Gy, respectively, for Lung-PTV, Lung-PGTV, and Total Lung methods. There were 54% (13% vs. 20%) and 45% (20% vs. 29%) RP2 probability variances detected at each MLD cutoff points from Lung-PTV and Lung-PGTV definitions. The best RP prediction performance was found in MLD from Lung-PTV method (AUC = 0.647), which is significantly better (P = 0.006) than the MLD from Lung-PGTV method (AUC = 0.609). CONCLUSION: There are significant differences in acute RP2 rate prediction using dosimetric parameters from various normal lung definitions. Excluding PTV from total lung volume may be more accurate and promising to predict acute symptomatic radiation pneumonitis in IMRT treated lung cancer patients.


Assuntos
Adenocarcinoma/radioterapia , Carcinoma de Células Escamosas/radioterapia , Neoplasias Pulmonares/radioterapia , Pneumonite por Radiação/diagnóstico , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia de Intensidade Modulada/efeitos adversos , Carcinoma de Pequenas Células do Pulmão/radioterapia , Adenocarcinoma/patologia , Carcinoma de Células Escamosas/patologia , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Pneumonite por Radiação/etiologia , Dosagem Radioterapêutica , Estudos Retrospectivos , Carcinoma de Pequenas Células do Pulmão/patologia
3.
Int J Radiat Oncol Biol Phys ; 103(2): 403-410, 2019 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-30291994

RESUMO

PURPOSE: To confirm the superiority of effective dose (Deff) over mean lung dose (MLD) for predicting risk of radiation pneumonitis (RP), using data from patients on a randomized trial of intensity modulated radiation therapy (IMRT) versus passively scattered proton therapy (PSPT). METHODS AND MATERIALS: The prescribed target dose for the 203 evaluated patients was 66 to 74 Gy (relative biological effectiveness) in 33 to 37 fractions with concurrent carboplatin/paclitaxel. Time to grade ≥2 RP was computed from the start of radiation therapy, with disease recurrence or death considered censoring events. Generalized Lyman models of censored time to RP were constructed with MLD or Deff as the dosimetric parameter. Smoking status (current, former, never) was also analyzed. RESULTS: Of the 203 patients, 46 experienced grade ≥2 RP (crude incidence 23%) at a median 3.7 months (range, 0.6-12.6 months). The volume parameter estimated for the Deff model was n = 0.5, confirming estimates from earlier studies. Compared with MLD (in which n = 1), the dosimetric parameter Deff, computed using n = 0.5, resulted in a better fit of the Lyman model to the clinical data (P = .010). Using Deff, the model describes RP risk for IMRT and PSPT data combined because no further improvement was found from separate fits (P = .558). Based on Deff, predicted RP risk per patient ranged from 24 percentage points lower to 19 percentage points higher than predictions based on MLD. For patients with similar MLD, Deff predicted higher risk, on average, for PSPT over IMRT. Current smokers had a lower risk of RP compared with former smokers and nonsmokers (P = .021). CONCLUSIONS: We used data from a randomized trial to validate our previous finding that Deff with n = 0.5 (corresponding to root mean squared dose) is a better predictor of RP than is MLD. Differences between Deff and MLD indicate that delivering higher doses to smaller lung volumes (vs lower doses to larger volumes) increases RP risk. We further corroborated that current smoking is associated with decreased RP risk.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Pulmão/efeitos da radiação , Pneumonite por Radiação/diagnóstico , Radioterapia de Intensidade Modulada/métodos , Fumar/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Teorema de Bayes , Carboplatina/administração & dosagem , Interpretação Estatística de Dados , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Paclitaxel/administração & dosagem , Fótons , Terapia com Prótons/métodos , Prótons , Radiometria , Radioterapia , Reprodutibilidade dos Testes , Risco , Espalhamento de Radiação , Adulto Jovem
4.
Pract Radiat Oncol ; 9(1): e74-e82, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30144583

RESUMO

PURPOSE: This study aimed to investigate the association between target volume margins and clinical outcomes for patients with inoperable non-small cell lung cancer (NSCLC) treated with concurrent chemoradiation therapy. METHODS AND MATERIALS: We reviewed the records of 82 patients with inoperable NSCLC treated between 2009 and 2016 with concurrent chemoradiation. All patients received positron emission tomography-based treatment planning, 4-dimensional computed tomography simulation to define an internal target volume, and daily cone beam computed tomography. We quantified variations in target volume margins with a margin deviation index (MDI), calculated as the percentage change in equivalent uniform dose between the original planning target volume (PTV) and a standard reference PTV 10 mm beyond the original gross tumor volume, consistent with the minimum margins mandated by recent NSCLC trials. Greater MDIs equated to smaller effective target volume margins. We dichotomized patients by the upper tercile MDI value (5.8%). Endpoints included time to locoregional progression and time to grade ≥ 3 radiation esophagitis (RE3) or radiation pneumonitis (RP3), modelled with the Fine-Gray method. RESULTS: Median follow-up was 37.8 months (range, 5.9-58.1 months). Larger MDIs correlated with smaller clinical target volume (CTV) + PTV margins, larger gross tumor volumes, later treatment year, and intensity modulated radiation therapy use. The risk of locoregional progression did not differ for MDI ≥5.8% versus <5.8% (adjusted hazard ratio: 0.88; P = .76), but the risk of RE3 or RP3 was decreased for MDI ≥5.8% (adjusted hazard ratio: 0.27; P = .027). Patients with MDI ≥5.8% were treated with smaller CTV + PTV margins (median, 5.6 vs 8 mm; P < .0001) and a marginally lower volume of esophagus receiving ≥50 Gy (median, 31.1% vs 35.3%; P = .069). CONCLUSIONS: Smaller margins were used for larger tumors but were not associated with an increase in locoregional failures. Additional studies could clarify whether smaller margins, when used alongside modern radiation therapy techniques, decrease treatment-related toxicity for inoperable NSCLC.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Quimiorradioterapia/efeitos adversos , Esofagite/etiologia , Recidiva Local de Neoplasia/diagnóstico , Pneumonite por Radiação/etiologia , Planejamento da Radioterapia Assistida por Computador/métodos , Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/patologia , Tomografia Computadorizada de Feixe Cônico , Esofagite/diagnóstico , Feminino , Seguimentos , Tomografia Computadorizada Quadridimensional , Humanos , Processamento de Imagem Assistida por Computador/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/etiologia , Tomografia por Emissão de Pósitrons , Prognóstico , Pneumonite por Radiação/diagnóstico , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada/métodos , Estudos Retrospectivos
5.
Technol Cancer Res Treat ; 17: 1533033818801323, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30286697

RESUMO

The purpose of this study was to examine the characteristics and treatment plans of patients who experienced fatal radiation pneumonitis after stereotactic body radiation therapy for primary or oligometastatic lung cancer. Records of 1789 patients treated with stereotactic body radiation therapy for primary or oligometastatic lung cancer were retrospectively reviewed to identify those who developed fatal radiation pneumonitis. Twenty-three (1.3%; 18 men and 5 women) patients developed fatal radiation pneumonitis after stereotactic body radiation therapy for lung cancer; their median age was 74 years. The mean Krebs von den Lungen-6 level and percent vital capacity were 1320 U/mL and 82%, respectively. Prestereotactic body radiation therapy computed tomography revealed pulmonary interstitial change in 14 (73.7%) of 19 patients in whom computed tomography data could be reviewed. Seven (30.4%) of 23 patients had regularly used steroids. The median time duration between stereotactic body radiation therapy commencement and pneumonia symptom appearance was 75 (range: 14-204) days. Median survival time following pneumonia symptom appearance was 53 (range: 4-802) days. The 6- and 12-month overall survival rates were 34.8% and 13.0%, respectively. The 6-month overall survival rates in patients with and without heart disease were 50.0%, 16.7%, and 46.7% for heart disease existence, respectively. There were 4 patients in whom fatal radiation pneumonitis occurred within 2 months after stereotactic body radiation therapy and who died within 1 month. Three of them had no pulmonary interstitial change before stereotactic body radiation therapy, but had heart disease. In summary, the survival time in this case series was generally short but varied widely. More than half of the patients had pulmonary interstitial change before stereotactic body radiation therapy, although immediately progressive fatal radiation pneumonitis was also observed in patients without pulmonary interstitial change. True risk factors for fatal radiation pneumonitis should be examined in a prospective study with a larger cohort.


Assuntos
Neoplasias Pulmonares/radioterapia , Pneumonite por Radiação/fisiopatologia , Radiocirurgia/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Humanos , Pulmão/patologia , Pulmão/efeitos da radiação , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/etiologia , Pneumonite por Radiação/mortalidade , Fatores de Risco
6.
Cancer Radiother ; 22(8): 826-838, 2018 Dec.
Artigo em Francês | MEDLINE | ID: mdl-30337050

RESUMO

In case of refusal or contraindication for surgical management of a stage I non-small cell lung carcinoma, the validated alternative therapy is stereotactic irradiation. This technique reaches an equivalent tumour control rate than surgery and significantly higher than conventional radiotherapy. One of the dreaded complications is radiation induced lung toxicity (radiation pneumonitis and lung fibrosis), especially when it is symptomatic, occurring in about 10 % of cases. This article is a literature review of this complication's predictive factors.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Pulmão/efeitos da radiação , Órgãos em Risco , Pneumonite por Radiação/etiologia , Radiocirurgia/efeitos adversos , Fatores Etários , Biomarcadores , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Terapia Combinada , Comorbidade , Suscetibilidade a Doenças , Relação Dose-Resposta à Radiação , Humanos , Pulmão/diagnóstico por imagem , Neoplasias Pulmonares/tratamento farmacológico , Mucina-1/análise , Proteínas de Neoplasias/análise , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/epidemiologia , Pneumonite por Radiação/prevenção & controle , Transtornos Respiratórios/complicações , Transtornos Respiratórios/epidemiologia , Fatores de Risco , Resultado do Tratamento
7.
Pract Radiat Oncol ; 8(5): e364-e368, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29730281

RESUMO

PURPOSE: The purpose of this study is to determine the incidence of radiation pneumonitis (RP) in children receiving radiation therapy (RT) for Hodgkin lymphoma (HL). METHODS AND PATIENTS: A retrospective chart review was conducted of pediatric HL patients who received multiagent chemotherapy followed by RT to any part of the chest. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03, was used to determine the RP grade. Parameters analyzed included sex; age; bleomycin dose; and RT dosimetric variables such as mean lung dose (MLD), mean individual (i; right vs left) lung dose or iMLD, V5 to V25, and individual lung V5 to V25. RESULTS: From 2008 through 2016, 54 children with HL received RT to the chest and had follow-up and dosimetry information. All patients received induction chemotherapy; the most common regimen was Adriamycin, bleomycin, vincristine, etoposide, prednisone, and cyclophosphamide-based chemotherapy (n = 48). All received a prescribed dose of 21 Gy in 14 fractions. Median follow-up from completion of RT was 39.5 months. Three of 54 patients (5.6%) or 3 of 108 (2.8%) lungs developed RP; 2 lungs had grade 1, whereas 1 had grade 2 RP. RP was seen only in patients with MLD >12.4 Gy (P = .009), V5 >66% (P = .033), V10 >55% (P =.015), V15 >45% (P =.005), and V20 >32% (P =.007). Likewise, RP was only seen in lungs with iMLD >13.8 Gy, iV5 >75% (P =.02), iV10 >64% (P =.02), iV15 >47% (P < .005), and iV20 >34% (P =.003). CONCLUSIONS: RP in pediatric HL patients is an uncommon complication. MLD, iMLD, V5-V20, and iV5-iV20 correlated with RP.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Doença de Hodgkin/terapia , Quimioterapia de Indução/métodos , Pneumonite por Radiação/epidemiologia , Adolescente , Bleomicina/uso terapêutico , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Incidência , Pulmão/diagnóstico por imagem , Pulmão/efeitos da radiação , Masculino , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/etiologia , Dosagem Radioterapêutica , Radioterapia Adjuvante/efeitos adversos , Radioterapia Adjuvante/métodos , Estudos Retrospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X
8.
Medicine (Baltimore) ; 97(21): e10681, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29794744

RESUMO

RATIONALE: This combination of fluticasone propionate (FP) and the long-acting ß2-agonist salmeterol (Salm) can control the symptoms of asthma and COPD better than FP or Salm on their own and better than the combination of inhaled corticosteroids plus montelukast. FP/Salm has been shown to control symptoms of asthma and COPD better than a double dose of inhaled steroids. The patient in our report had a history of COPD, and suffered relapse of RP when given only steroids. It is possible that COPD history helps explain this patient's more difficult treatment course. Therefore, this combination may be more effective than inhaled steroids for patients with a history of COPD. PATIENT CONCERS: This patient suffered adverse reactions triggered by methylprednisolone: weight gain, hyperglycaemia and sleep disturbance after more than two months of intravenous and oral prednisolone. These reactions disappeared when we switched the patients to FP/Salm maintenance therapy. DIAGNOSES: The patient underwent upper right lobectomy in September 2011. Immunohistochemistry indicated low squamous cell differentiation, and he was diagnosed with stage IIB disease (T2N1M0) according to the Union for International Cancer Control (UICC) (7th edition).One month after repeat radiotherapy, the patient experienced fever (37.6°C), cough, chest distress and shortness of breath. We performed serologic tests, laboratory tests for procalcitonin and C-reactive protein, as well as sputum and blood cultures to rule out bacterial infection. Chest CT showed consolidation with air bronchogram in the hilum of the right lung and ground-glass densities in the right lower lobe and left upper lobe. These radiographic signs are typical of RP. Since the patient required oxygen, he was diagnosed with grade III RP. INTERVENTIONS: After the patinet was diagnosed with grade III RP. The patient was immediately prescribed oxygen, anti-infectives for prophylaxis, treatments to facilitate expectoration and prevent asthma, and most importantly, intravenous methylprednisone at an initial dose of 60  per day. And we cut the steroid dose in half every one week when the patient's symptoms improved obviously, and the patchy shadow on the chest radiograph sharply reduced. Then we give him FP (500 mg)/Salm (50 mg) twice daily for two months. Then the dose was halved for an additional two months. OUTCOMES: The patient showed no signs of tumor or RP relapse by the last follow-up in March 2018. LESSONS: This maintenance therapy of FP/Salm for patient with grade III RP may help avoid relapse when steroid therapy is tapered, particularly for patients with a history of COPD. It may also reduce risk of steroid-associated adverse effects. Based on the results observed with our patient, we intend to design a prospective trial to assess the efficacy of FP/Salm when used as preventive treatment for patients at high risk of RP, and when used as maintenance treatment for patients with grade III RP.


Assuntos
Agonistas de Receptores Adrenérgicos beta 2/uso terapêutico , Anti-Inflamatórios/uso terapêutico , Combinação Fluticasona-Salmeterol/uso terapêutico , Neoplasias Pulmonares/terapia , Pneumonite por Radiação/tratamento farmacológico , Glucocorticoides/efeitos adversos , Glucocorticoides/uso terapêutico , Humanos , Pulmão/patologia , Pulmão/efeitos da radiação , Masculino , Metilprednisolona/efeitos adversos , Metilprednisolona/uso terapêutico , Pessoa de Meia-Idade , Pneumonectomia , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Pneumonite por Radiação/diagnóstico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
9.
Respir Res ; 19(1): 72, 2018 04 24.
Artigo em Inglês | MEDLINE | ID: mdl-29690880

RESUMO

BACKGROUND: Radiation pneumonitis (RP) is a frequent complication of concurrent chemoradiotherapy (CCRT) and is associated with severe symptoms that decrease quality of life and might result in pulmonary fibrosis or death. The aim of this study is to identify whether pulmonary function test (PFT) abnormalities may predict RP in non-small cell lung cancer (NSCLC) patients. METHODS: A prospective multi-institutional study was conducted with locally advanced and oligometastatic NSCLC patients. All participants were evaluated at baseline, end of CCRT, week 6, 12, 24, and 48 post-CCRT. They completed forced spirometry with a bronchodilator, body plethysmography, impulse oscillometry, carbon monoxide diffusing capacity (DLCO), molar mass of CO2, six-minute walk test and exhaled fraction of nitric oxide (FeNO). Radiation pneumonitis was assessed with RTOG and CTCAE. The protocol was registered in www.clinicaltrials.gov (NCT01580579), registered April 19, 2012. RESULTS: Fifty-two patients were enrolled; 37 completed one-year follow-up. RP ≥ Grade 2 was present in 11/37 (29%) for RTOG and 15/37 (40%) for CTCAE. Factors associated with RP were age over 60 years and hypofractionated dose. PFT abnormalities at baseline that correlated with the development of RP included lower forced expiratory volume in one second after bronchodilator (p = 0.02), DLCO (p = 0.02) and FeNO (p = 0.04). All PFT results decreased after CCRT and did not return to basal values at follow-up. CONCLUSIONS: FEV1, DLCO and FeNO prior to CCRT predict the development of RP in NSCLC. This study suggests that all patients under CCRT should be assessed by PFT to identify high-risk patients for close follow-up and early treatment.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Volume Expiratório Forçado/fisiologia , Neoplasias Pulmonares/radioterapia , Pneumonite por Radiação/diagnóstico , Espirometria/tendências , Fatores Etários , Carcinoma Pulmonar de Células não Pequenas/fisiopatologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/fisiopatologia , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Pneumonite por Radiação/fisiopatologia , Testes de Função Respiratória/tendências
10.
Qual Life Res ; 27(6): 1563-1570, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29549533

RESUMO

PURPOSE: Clinician ratings of concurrent chemoradiation (CRT)-induced radiation pneumonitis (RP) in patients with non-small cell lung cancer (NSCLC) are based on both imaging and patient-reported lung symptoms. We compared the value of patient-reported outcomes versus normal-lung uptake of 18F-fluoro-2-deoxyglucose in positron emission computed tomography (FDG PET/CT) during the last week of treatment, for indicating the development of grade ≥ 2 RP within 4 months of CRT completion. METHODS: 132 patients with NSCLC-reported RP-related symptoms (coughing, shortness of breath) repeatedly using the validated MD Anderson Symptom Inventory lung cancer module. Of these patients, 68 had FDG PET/CT scans that were analyzed for normal-lung mean standardized FDG uptake values (SUVmean) before, during, and up to 4 months after CRT. Clinicians rated RP using CTCAE version 3. Logistic regression models examined potential predictors for developing CTCAE RP ≥ 2. RESULTS: For the entire sample, patient-rated RP-related symptoms during the last week of CRT correlated with clinically meaningful CTCAE RP ≥ 2 post-CRT (OR 2.74, 95% CI 1.25-5.99, P = 0.012), controlled for sex, age, mean lung radiation dose, comorbidity, and baseline symptoms. Moderate/severe patient-rated RP-related symptom score (≥ 4 on a 0-10 scale, P = 0.001) and normal-lung FDG uptake (SUVmean > 0.78, P = 0.002) in last week of CRT were equally strong predictors of post-CRT CTCAE RP ≥ 2 (C-index = 0.78, 0.77). CONCLUSIONS: During the last week of CRT, routine assessment of moderate-to-severe RP-related symptoms provides a simple way to identify patients with NSCLC who may be at risk for developing significant post-CRT RP, especially when PET/CT images of normal-lung FDG uptake are not available.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/complicações , Carcinoma Pulmonar de Células não Pequenas/radioterapia , Quimiorradioterapia/efeitos adversos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/radioterapia , Medidas de Resultados Relatados pelo Paciente , Pneumonite por Radiação/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/patologia , Quimiorradioterapia/métodos , Feminino , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Pneumonite por Radiação/patologia
11.
J Radiat Res ; 59(3): 298-302, 2018 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-29415179

RESUMO

Radiation-induced organizing pneumonia (OP) reportedly occurs in ~2% of patients who receive whole-breast radiotherapy (WBRT). Though there are several reported risk factors, they remain unclear and controversial. We analyzed the incidence of and risk factors for OP after WBRT at our institution. We analyzed 665 breast cancer patients (with WBRT of 679 breasts) who underwent WBRT from October 2007 to September 2012 at our institution and were followed up for more than 1 year after completion of WBRT. Factors included in the analysis were age, the side affected, central lung distance (CLD), radiation dose, concurrent endocrine therapy, and chemotherapy. The median age was 56 years (range, 23-89 years). The sides affected were left, right and bilateral in 342, 309 and 14 patients, respectively. The median CLD was 1.1 cm (range, 0-3.0 cm). Concurrent endocrine therapy was performed in 236 patients, and chemotherapy was given in 215 patients; of these, 4 received concurrent chemotherapy. OP developed in nine patients (1.4%). The median time taken to develop OP after the completion of WBRT was 4 months (range, 2-12 months). All nine patients were treated with steroids, and symptoms promptly improved, except in two patients who relapsed. Statistical analysis revealed that only CLD (≥1.5 cm) was significantly associated with the development of OP (P = 0.004). In conclusion, the incidence of OP after WBRT was 1.4%, and CLD was a significant risk factor. In these patients, OP was controlled with steroid administration.


Assuntos
Neoplasias da Mama/radioterapia , Pneumonite por Radiação/epidemiologia , Pneumonite por Radiação/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/tratamento farmacológico , Análise Fatorial , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Pneumonite por Radiação/diagnóstico , Fatores de Risco , Adulto Jovem
12.
Strahlenther Onkol ; 194(6): 520-532, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29450591

RESUMO

AIM: of this study is to determine the temporal resolution of therapy-induced pneumonitis, and to assess promoting factors in adjuvant treated patients with unilateral mammacarcinoma. PATIENTS AND METHODS: A total of 100 post-surgery patients were recruited. The cohort was treated by 2 field radiotherapy (2FRT; breast and chest wall, N = 75), 3 field radiotherapy (3FRT; + supraclavicular lymphatic region, N = 8), or with 4 field radiotherapy (4FRT; + parasternal lymphatic region, N = 17). Ninety-one patients received various systemic treatments prior to irradiation. Following an initial screening visit post-RT, two additional visits after 12 and 25 weeks were conducted including radiographic examination. In addition, general anamnesis and the co-medication were recorded. The endpoint was reached as soon as a pneumonitis was developed or at maximum of six months post-treatment. RESULTS: A pneumonitis incidence of 13% was determined. Of 91 patients with prior systemic therapy, 11 patients developed pneumonitis. Smoking history and chronic obstructive pulmonary disease (COPD) appeared to be positive predictors, whereas past pneumonia clearly promoted pneumonitis. Further pneumonitis-promoting predictors are represented by the applied field extensions (2 field radiotherapy [2FRT] < 3 field radiotherapy [3FRT] < 4 field radiotherapy [4FRT]) and the type of combined initial systemic therapies. As a consequence, all of the three patients in the study cohort treated with 4FRT and initial chemotherapy combined with anti-hormone and antibody protocols developed pneumonitis. A combination of the hormone antagonists tamoxifen and goserelin might enhance the risk for pneumonitis. Remarkably, none of the 11 patients co-medicated with statins suffered from pneumonitis. CONCLUSIONS: The rapidly increasing use of novel systemic therapy schedules combined with radiotherapy (RT) needs more prospective studies with larger cohorts. Our results indicate that contribution to pneumonitis occurrence of various (neo)adjuvant therapy approaches followed by RT is of minor relevance, whereas mean total lung doses of >10 Gy escalate the risk of lung tissue complications. The validity of potential inhibitors of therapy-induced pneumonitis as observed for statin co-medication should further be investigated in future trials.


Assuntos
Adenocarcinoma/radioterapia , Neoplasias da Mama/radioterapia , Carcinoma in Situ/radioterapia , Pneumonite por Radiação/epidemiologia , Adenocarcinoma/cirurgia , Adulto , Idoso , Neoplasias da Mama/cirurgia , Carcinoma in Situ/cirurgia , Quimioterapia Adjuvante/efeitos adversos , Estudos de Coortes , Feminino , Gosserrelina/administração & dosagem , Gosserrelina/efeitos adversos , Humanos , Incidência , Mastectomia , Pessoa de Meia-Idade , Estudos Prospectivos , Pneumonite por Radiação/diagnóstico , Radioterapia Adjuvante , Fatores de Risco , Tamoxifeno/administração & dosagem , Tamoxifeno/efeitos adversos
13.
Clin Lung Cancer ; 19(2): e211-e217, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29017827

RESUMO

INTRODUCTION: To investigate the relationship between malnutrition and the severity of radiation pneumonitis (RP) in patients with lung cancer with normal baseline pulmonary function and lungs' V20 < 35% treated by intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy. MATERIALS AND METHODS: A total of 150 patients with lung cancer who received definitive IMRT (≥ 60 Gy) and concurrent chemotherapy were enrolled. In the condition of normal baseline pulmonary function and strict constraints of the irradiation dose to normal lung tissues, we recorded Eastern Cooperative Oncology Group score; concurrent chemotherapy; clinical stage; the level of albumin (ALB), hemoglobin, and C-reactive protein; Subjective Global Assessment (SGA) scores; radiation esophagitis grade; V20 of lungs; and mean lung dose. These factors were correlated with RP using univariate and multivariate regression analyses. RESULTS: Of 150 patients, 12 patients (8.0%) developed Grade 3 to 5 RP, 37 (24.6%) patients developed grade 3 to 5 esophageal toxicity. In univariate analysis, ALB level (P = .002), radiation esophagitis (P < .001), and SGA score (P < .001) were significantly associated with RP. Multivariate analysis revealed that SGA (P < .001) was the independent predictor of RP. CONCLUSIONS: SGA could be a predictor for RP in patients with lung cancer treated with definitive IMRT and concurrent chemotherapy.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia , Neoplasias Pulmonares/diagnóstico , Pulmão/fisiologia , Desnutrição/diagnóstico , Pneumonite por Radiação/diagnóstico , Projetos de Pesquisa , Adulto , Idoso , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Valor Preditivo dos Testes , Prognóstico , Radioterapia de Intensidade Modulada
14.
Am J Clin Oncol ; 41(6): 576-580, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27560156

RESUMO

OBJECTIVES: Angiotensin-converting enzyme inhibitors (ACEi) have demonstrated decreased rates of radiation-induced lung injury in animal models and clinical reports have demonstrated decreased pneumonitis in the setting of conventionally fractionated radiation to the lung. We tested the role of ACEi in diminishing rates of symptomatic (grade ≥2) pneumonitis in the setting of lung stereotactic body radiation therapy (SBRT). METHODS: We analyzed patients treated with thoracic SBRT to 48 to 60 Gy in 4 to 5 fractions from 2006 to 2014. We reviewed pretreatment and posttreatment medication profiles to document use of ACEi, angiotensin receptor blockers, bronchodilators, aspirin, PDE-5 inhibitors, nitrates, and endothelin receptor antagonists. Pneumonitis was graded posttreatment based on Common Terminology Criteria for Adverse Events Version 4.0. Univariate and multivariate analysis was performed and time to development of pneumonitis was evaluated by the Kaplan-Meier method. RESULTS: A total of 189 patients were evaluated with a median follow-up of 24.8 months. The overall 1-year rate of symptomatic pneumonitis was 13.2%. The 1-year rate of symptomatic pneumonitis was 4.2% for ACEi users versus 16.3% in nonusers (P=0.03). On univariate analysis, the odds of developing grade 2 or greater pneumonitis were significantly lower for patients on ACEi (P=0.03). On multivariate analysis, after controlling for clinicopathologic characteristics and dosimetric endpoints, there was a significant association between ACEi use and decreased risk of clinical pneumonitis (P=0.04). Angiotensin receptor blockers or other bronchoactive medications did not show significant associations with development of pneumonitis. CONCLUSIONS: Incidental concurrent use of ACEi demonstrated efficacy in diminishing rates of symptomatic pneumonitis in the setting of lung SBRT.


Assuntos
Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Quimiorradioterapia , Neoplasias Pulmonares/cirurgia , Lesões por Radiação/tratamento farmacológico , Pneumonite por Radiação/tratamento farmacológico , Radiocirurgia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Lesões por Radiação/diagnóstico , Lesões por Radiação/etiologia , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/etiologia , Fatores de Risco , Taxa de Sobrevida
15.
Clin Respir J ; 12(3): 1264-1273, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28618180

RESUMO

OBJECTIVES: To identify the factors that predict the progression of radiological radiation pneumonitis (RP) to symptomatic RP, and to evaluate the usefulness of the neutrophil-lymphocyte ratio (NLR) as a marker of RP severity and prognosis in stage III non-small cell lung cancer (NSCLC) patients treated with definitive concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: We retrospectively reviewed 61 patients treated between January 2010 and December 2015. Patients' demographic characteristics, clinical data, laboratory findings and treatment parameters were analyzed to determine the predictive factors associated with progression from radiological RP to symptomatic RP. RESULTS: Forty-seven patients (77%) exhibited radiological RP at a median of 78 days after radiation therapy (RT) completion, and 15 (32%) of these patients developed symptomatic RP. The interval between RT completion and radiological RP presentation was shorter in patients who progressed to symptomatic RP (P = .001); progression was highly probable if this latency period was ≤2 months (P = .002). Stage and RT technique correlated with symptomatic RP development (P = .046 and P = .046, respectively). Among dosimetric factors, a V20 (defined as the lung volume receiving ≥20 Gy) of >30% was the most significant predictor of symptomatic RP (P = .001). The NLR and C-reactive protein level at radiological RP were higher in patients who developed symptomatic RP (P = .067 and P = .012, respectively). On multivariate analysis, a V20 >30% and an NLR at radiological RP >6 were associated with symptomatic RP development. CONCLUSION: The NLR at radiological RP is a useful biomarker for predicting symptomatic RP development after CCRT in stage III NSCLC patients.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/terapia , Linfócitos/citologia , Neutrófilos/citologia , Lesões por Radiação/sangue , Pneumonite por Radiação/sangue , Planejamento da Radioterapia Assistida por Computador/métodos , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/sangue , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Quimiorradioterapia , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/sangue , Neoplasias Pulmonares/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico , Lesões por Radiação/etiologia , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/etiologia , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X
16.
Clin Lung Cancer ; 19(1): e85-e90, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28655592

RESUMO

BACKGROUND: The aim of this study was to determine the prognostic factors of radiation pneumonitis (RP) after stereotactic body radiotherapy (SBRT). PATIENTS AND METHODS: A total of 50 patients (36 male and 14 female) were treated with SBRT for 42 primary lung cancers and 8 metastatic lung cancers. SBRT was performed with 48 Gy in 4 fractions to the isocenter or with 40 Gy in 4 fractions covering 95% of the planning target volume. Percentage of low attenuation area (%LAA) was defined as percentage of the lung area with attenuation of -860 Hounsfield units (HU) or lower (%LAA-860) or of -960 HU or lower (%LAA-960). The dosimetric parameter of V20 Gy, which means percentage volume of the lung receiving 20 Gy or more, was recalculated. RP was assessed using Common Terminology Criteria for Adverse Events version 4.0. RESULTS: The median follow-up period was 39.0 months (range, 7.2-94.5 months). RP of Grade 0, Grade 1, and Grade 2 to 3 was diagnosed in 11, 29, and 10 patients, respectively. Multivariate analyses (MVA) for Grade 1 showed that higher %LAA-860 and higher %LAA-960 were significantly associated with a lower rate of Grade 1 RP. MVA for Grade 2 to 3 showed that lower Brinkman index and lower lung V20 Gy were significantly associated with a lower rate of Grade 2 to 3 RP, and, in contrast, %LAA-860 and %LAA-960 had no association with Grade 2 to 3 RP. CONCLUSION: This result suggests that high %LAA is associated with radiological changes (Grade 1) but that %LAA has no correlation with Grade 2 to 3 RP because symptomatic RP might also be affected by other factors.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Pulmão/diagnóstico por imagem , Enfisema Pulmonar/diagnóstico , Lesões por Radiação/diagnóstico , Pneumonite por Radiação/diagnóstico , Radiocirurgia/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/complicações , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Feminino , Seguimentos , Humanos , Processamento de Imagem Assistida por Computador , Pulmão/patologia , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico , Enfisema Pulmonar/patologia , Lesões por Radiação/patologia , Pneumonite por Radiação/etiologia , Pneumonite por Radiação/patologia , Tomografia Computadorizada por Raios X
17.
Curr Oncol ; 25(6): e610-e614, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30607130

RESUMO

Introduction: Radiotherapy (rt) plays an important role in the treatment of lung cancer. One of the most common comorbidities in patients with lung cancer is pulmonary emphysema. The literature offers conflicting data about whether emphysema increases the occurrence and severity of radiation pneumonitis (rp). As a result, whether high doses of rt (with curative intent) should be avoided in patients with emphysema is still unclear. Objective: We measured the documented incidence of rp in patients with and without emphysema who received curative radiation treatment. Methods: This retrospective cohort study considered patients in the lung cancer clinical database of the Peter Brojde Lung Cancer Centre. Data from the database has been used previously for research studies, including a recent publication about emphysema grading, based on the percentage of lung occupied by emphysema on computed tomography (ct) imaging. Results: Using previously published methods, chest ct imaging for 498 patients with lung cancer was scored for the presence of emphysema. The analysis considered 114 patients who received at least 30 Gy radiation. Of those 114 patients, 64 (56%) had emphysema, with approximately 23% having severe or very severe disease. The incidence of rp was 34.4% in patients with emphysema (n = 22) and 32.0% in patients with no emphysema (n = 16, p = 0.48). No difference in the incidence of rp was evident between patients with various grades of emphysema (p = 0.96). Similarly, no difference in the incidence of rp was evident between the two treatment protocols-that is, definitive rt 17 (37%) and combined chemotherapy-rt 21 (31%, p = 0.5). Conclusions: In our cohort, the presence of emphysema on chest ct imaging was not associated with an increased risk of rp. That finding suggests that patients with lung cancer and emphysema should be offered rt when clinically indicated. However, further prospective studies will be needed for confirmation.


Assuntos
Enfisema/etiologia , Enfisema/fisiopatologia , Neoplasias Pulmonares/complicações , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/etiologia , Idoso , Feminino , Humanos , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/radioterapia , Masculino , Pessoa de Meia-Idade , Pneumonite por Radiação/epidemiologia , Radioterapia/efeitos adversos , Radioterapia/métodos , Dosagem Radioterapêutica , Testes de Função Respiratória , Estudos Retrospectivos , Medição de Risco , Tomografia Computadorizada por Raios X
18.
Muscle Nerve ; 56(6): 1031-1040, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28833264

RESUMO

Neuromuscular late effects of radiation therapy (RT) result from radiation fibrosis (RF) of the treated tissues. The clinical manifestations of this dysfunction have been termed radiation fibrosis syndrome (RFS). Any segment of the central and/or peripheral nervous system can be involved, including the brain, spinal cord, nerve roots, plexus, peripheral nerves, and muscles. Often, multiple levels are damaged, resulting in a constellation of findings named for the affected structures (i.e., radiculo-plexo-neuro-myopathy). Accurately diagnosing RFS requires the clinician to understand the basics of how radiation is and has been delivered. Key parameters of RT delivery include total dose, dose per fraction, and the radiation field treated. This article describes the basic principles of RT delivery, the pathophysiology of radiation injury, and how to identify and evaluate neuromuscular late effects of radiation in cancer survivors. Muscle Nerve 56: 1031-1040, 2017.


Assuntos
Doenças Neuromusculares/diagnóstico , Lesões por Radiação/diagnóstico , Pneumonite por Radiação/diagnóstico , Radiocirurgia/efeitos adversos , Humanos , Neoplasias/epidemiologia , Neoplasias/radioterapia , Doenças Neuromusculares/epidemiologia , Lesões por Radiação/epidemiologia , Pneumonite por Radiação/epidemiologia
19.
Anticancer Res ; 37(8): 4643-4647, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28739765

RESUMO

BACKGROUND/AIM: Radiation pneumonia is a main side-effect that has limited the clinical usage of radiotherapy in locally advanced esophageal carcinoma. T helper cells 17 (Th 17) and T regulatory cells (Tregs) play an important role in inflammatory diseases. The balance between Treg and Th17 cells is a key factor in the progression of many inflammatory and autoimmune diseases. Whether Tregs and Th17 cells are predictive factors of radiation pneumonia has not yet been reported. In this study, we investigated the relationships of Treg/Th17 cells and radiation pneumonia in patients with locally advanced esophageal cancer who received radiotherapy. PATIENTS AND METHODS: One hundred and forty-eight patients with locally advanced esophageal cancer who received radical and palliative radiotherapy were enrolled. The levels of Th17 and Treg cells in the blood of patients were detected using flow cytometry at the time point of pre-radiotherapy, 1st, 2nd, 3rd, 4th, 5th and 6th week from the start of radiation and 4 weeks after completion of radiotherapy. Radiation pneumonia was evaluated according to Radiation Therapy Oncology Group's acute radiation pneumonia standards, with the endpoint being grade 2 or above radiation pneumonia. RESULTS: There were 24 cases of radiation pneumonia in 148 cases of locally advanced esophageal cancer patients who underwent radiotherapy. Th17 cells increased and, in contrast, Treg cells decreased in the radiation pneumonia group. The change in the ratio of Th17/Treg was more pronounced and the difference was statistically significant from the 5th week after irradiation compared to patients with no radiation pneumonia (p<0.05). There was no significant difference in dosimetric parameters, including V5, V20, V30 and mean lung dose (MLD) and clinical factors, such as gender, age, smoking history, history of surgery and chemotherapy. CONCLUSION: The ratio of Th17/Treg cells may be an effective predictive factor of radiation pneumonia.


Assuntos
Neoplasias Esofágicas/complicações , Neoplasias Esofágicas/imunologia , Pneumonite por Radiação/etiologia , Linfócitos T Reguladores/imunologia , Células Th17/imunologia , Adulto , Idoso , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/radioterapia , Feminino , Seguimentos , Humanos , Imunofenotipagem , Incidência , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Fenótipo , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/epidemiologia , Fatores de Risco , Linfócitos T Reguladores/metabolismo , Células Th17/metabolismo
20.
Cancer Radiother ; 21(5): 411-423, 2017 Aug.
Artigo em Francês | MEDLINE | ID: mdl-28596060

RESUMO

Radiation-induced lung injuries mainly include the (acute or sub-acute) radiation pneumonitis, the lung fibrosis and the bronchiolitis obliterans organizing pneumonia (BOOP). The present review aims at describing the diagnostic process, the current physiopathological knowledge, and the available (non dosimetric) preventive and curative treatments. Radiation-induced lung injury is a diagnosis of exclusion, since clinical, radiological, or biological pathognomonic evidences do not exist. Investigations should necessarily include a thoracic high resolution CT-scan and lung function tests with a diffusing capacity of the lung for carbon monoxide. No treatment ever really showed efficacy to prevent acute radiation-induced lung injury, or to treat radiation-induced lung fibrosis. The most promising drugs in order to prevent radiation-induced lung injury are amifostine, angiotensin-converting-enzyme inhibitors and pentoxifylline. Inhibitors of collagen synthesis are currently tested at a pre-clinical stage to limit the radiation-induced lung fibrosis. Regarding available treatments of radiation-induced pneumonitis, corticoids can be considered the cornerstone. However, no standardized program or guidelines concerning the initial dose and the gradual tapering have been scientifically established. Alternative treatments can be prescribed, based on clinical cases reporting on the efficacy of immunosuppressive drugs. Such data highlight the major role of the lung dosimetric protection in order to efficiently prevent radiation-induced lung injury.


Assuntos
Pneumonia em Organização Criptogênica/etiologia , Pneumonia em Organização Criptogênica/terapia , Fibrose Pulmonar/etiologia , Fibrose Pulmonar/terapia , Lesões por Radiação/terapia , Pneumonite por Radiação/terapia , Pneumonia em Organização Criptogênica/diagnóstico , Pneumonia em Organização Criptogênica/fisiopatologia , Pneumonia em Organização Criptogênica/prevenção & controle , Humanos , Fibrose Pulmonar/diagnóstico , Fibrose Pulmonar/fisiopatologia , Fibrose Pulmonar/prevenção & controle , Lesões por Radiação/diagnóstico , Lesões por Radiação/fisiopatologia , Lesões por Radiação/prevenção & controle , Pneumonite por Radiação/diagnóstico , Pneumonite por Radiação/fisiopatologia , Pneumonite por Radiação/prevenção & controle
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