New era of radiotherapy: an update in radiation-induced lung disease

Abstract

Over the last few decades, advances in radiotherapy (RT) technology have improved delivery of radiation therapy dramatically. Advances in treatment planning with the development of image-guided radiotherapy and in techniques such as proton therapy, allows the radiation therapist to direct high doses of radiation to the tumour. These advancements result in improved local regional control while reducing potentially damaging dosage to surrounding normal tissues. It is important for radiologists to be aware of the radiological findings from these advances in order to differentiate expected radiation-induced lung injury (RILD) from recurrence, infection, and other lung diseases. In order to understand these changes and correlate them with imaging, the radiologist should have access to the radiation therapy treatment plans.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig. 1. Planning treatment fields in different intra thoracic malignancies

(a) Patient with NSCLC with IMRT focused in the primary lung malignancy. A Total dose of 63 Gy in 27 fractions was delivered. (b) Axial CT image obtained 4 months after completion of therapy shows left lung opacities included in the treatment planning field consistent with radiation pneumonitis. (c) Patient with oesophageal malignancy extending to the gastro-oesophageal junction. IMRT permit a focused treatment to the oesophagus and positive loco-regional lymph nodes while sparing spinal cord, heart, and mediastinum. A total dose of 50.4 Gy in 28 fractions was delivered. (d) Axial CT image obtained 3 months after treatment ending in a patient with oesophageal malignancy demonstrates lung opacities in the lower lobes included in the irradiated field. (e) Patient with breast cancer treated with 3D-CRT including right lateral chest wall, supraclavicular and internal mammary regions treated with a total dose of 50 Gy in 25 fractions. (f) Axial CT image obtained 4 months after completion of therapy shows right apical lung opacities consistent with radiation pneumonitis. Treatment planning field is helpful to differentiate radiation lung injury from an infectious process. (g) Patient with malignant pleural mesothelioma located in the right side. Patient received surgical treatment with extrapleural pneumonectomy and was treated with postoperative radiotherapy. Treatment was delivered to the right thoracic cavity with a total dose of 50 Gy in 25 fractions. Note that treatment planning included the dome of the liver. (h) Axial CT image after administration of intravenous contrast medium obtained 4 months after completion of therapy shows surgical changes due to right extrapleural pneumonectomy and signs of resection/reconstruction of the right hemidiaphragm. Peripheral band of low attenuation (arrows) is seen in the right lobe of the liver which is consistent with post radiation changes.

Fig 2. Fifty-two-year-old man with adenocarcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium and prior to treatment shows a left central lung lesion (arrow) surrounding lingular bronchus. (b) Axial CT image obtained 2 months after completion of radiotherapy shows ground-glass opacities (arrow) consistent with radiation lung injury.

Fig 2. Fifty-two-year-old man with adenocarcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium and prior to treatment shows a left central lung lesion (arrow) surrounding lingular bronchus. (b) Axial CT image obtained 2 months after completion of radiotherapy shows ground-glass opacities (arrow) consistent with radiation lung injury.

Fig. 3. Seventy-five-year-old woman with adenocarcinoma of the lung

(a) 3-D conformal proton beam radiation plan utilizing a right anterior oblique and a left anterior oblique beams and a total dose of 74 Co-60 Gy in 37 fractions. (b) Axial CT image obtained 3 months after completion of radiotherapy shows ground-glass opacities with interlobular septal thickening in the right lung (arrow) consistent with a crazy-paving pattern. Note that there are focal left lung opacities outside of the radiation field consistent with post radiation changes.

Fig. 3. Seventy-five-year-old woman with adenocarcinoma of the lung

(a) 3-D conformal proton beam radiation plan utilizing a right anterior oblique and a left anterior oblique beams and a total dose of 74 Co-60 Gy in 37 fractions. (b) Axial CT image obtained 3 months after completion of radiotherapy shows ground-glass opacities with interlobular septal thickening in the right lung (arrow) consistent with a crazy-paving pattern. Note that there are focal left lung opacities outside of the radiation field consistent with post radiation changes.

Fig. 4. Sixty-eight-year-old man with a left upper lobe NSCLC

(a) Axial CT image before administration of intravenous contrast medium and prior to radiotherapy treatment shows a large central left upper lobe mass (M) and left paratracheal nodal metastatic disease (arrow). (b) 3D conformal proton beam radiation plan utilizing a right anterior oblique, left posterior oblique and right posterior oblique beams and a total dose of 74 Co-60 Gy in 37 fractions. (c) Axial CT image obtained 4 months after completion of radiotherapy demonstrating a central ground-glass opacity with a surrounding halo of consolidation (arrows) consistent with a reversed halo sign.

Fig. 4. Sixty-eight-year-old man with a left upper lobe NSCLC

(a) Axial CT image before administration of intravenous contrast medium and prior to radiotherapy treatment shows a large central left upper lobe mass (M) and left paratracheal nodal metastatic disease (arrow). (b) 3D conformal proton beam radiation plan utilizing a right anterior oblique, left posterior oblique and right posterior oblique beams and a total dose of 74 Co-60 Gy in 37 fractions. (c) Axial CT image obtained 4 months after completion of radiotherapy demonstrating a central ground-glass opacity with a surrounding halo of consolidation (arrows) consistent with a reversed halo sign.

Fig. 4. Sixty-eight-year-old man with a left upper lobe NSCLC

(a) Axial CT image before administration of intravenous contrast medium and prior to radiotherapy treatment shows a large central left upper lobe mass (M) and left paratracheal nodal metastatic disease (arrow). (b) 3D conformal proton beam radiation plan utilizing a right anterior oblique, left posterior oblique and right posterior oblique beams and a total dose of 74 Co-60 Gy in 37 fractions. (c) Axial CT image obtained 4 months after completion of radiotherapy demonstrating a central ground-glass opacity with a surrounding halo of consolidation (arrows) consistent with a reversed halo sign.

Fig 5. Thirty-six-year-old woman with a left upper lobe NSCLC

(a) Axial CT image prior to treatment show a spiculate nodule in the left upper lobe (arrow). (b) Axial CT image obtained 3 years after completion of radiotherapy shows lung opacities with traction bronchiectasis (arrow) consistent with radiation fibrosis.

Fig 5. Thirty-six-year-old woman with a left upper lobe NSCLC

(a) Axial CT image prior to treatment show a spiculate nodule in the left upper lobe (arrow). (b) Axial CT image obtained 3 years after completion of radiotherapy shows lung opacities with traction bronchiectasis (arrow) consistent with radiation fibrosis.

Fig. 6. Sixty-eight-year-old man with a left upper lobe NSCLC treated with stereotactic body radiotherapy

(a) Treatment planning field in SBRT. A total dose of 50 Gy in four fractions was delivered. (b) Axial CT image 6 months after completion of therapy shows focal lung opacities in the left lung included in the irradiated field (arrowhead) and consistent with radiation lung damage. In the right lung there are new opacities far from the radiation planning area (arrow). (c) Axial CT image obtained 8 months after completion of RT demonstrate persistence of RILD (arrowhead) with resolution of right upper lobe pneumonia.

Fig. 6. Sixty-eight-year-old man with a left upper lobe NSCLC treated with stereotactic body radiotherapy

(a) Treatment planning field in SBRT. A total dose of 50 Gy in four fractions was delivered. (b) Axial CT image 6 months after completion of therapy shows focal lung opacities in the left lung included in the irradiated field (arrowhead) and consistent with radiation lung damage. In the right lung there are new opacities far from the radiation planning area (arrow). (c) Axial CT image obtained 8 months after completion of RT demonstrate persistence of RILD (arrowhead) with resolution of right upper lobe pneumonia.

Fig. 6. Sixty-eight-year-old man with a left upper lobe NSCLC treated with stereotactic body radiotherapy

(a) Treatment planning field in SBRT. A total dose of 50 Gy in four fractions was delivered. (b) Axial CT image 6 months after completion of therapy shows focal lung opacities in the left lung included in the irradiated field (arrowhead) and consistent with radiation lung damage. In the right lung there are new opacities far from the radiation planning area (arrow). (c) Axial CT image obtained 8 months after completion of RT demonstrate persistence of RILD (arrowhead) with resolution of right upper lobe pneumonia.

Fig. 7. Sixty-six-year-old woman with left upper lobe lung cancer treated with definitive proton radiation therapy

Six months after treatment completion patient had a primary complaint of cough and shortness of breath. (a) Treatment planning field included three beams and a total dose of 87.5 Co-60 Gy. Proton therapy was chosen due to the fact that the tumour is located close to lobar bronchus and proton radiation therapy would be the optimal way of treating this tumour to reduce toxicity and possible bronchial stenosis. (b) Axial CT image obtained 6 months after completion of therapy demonstrates left lung opacities included in the irradiated filed (*) consistent with radiation lung injury. There is additional development of focal right upper lobe opacity (arrow) outside of the treatment planning field. (c) Axial CT images obtained 8 months after completion of therapy demonstrates persistent post-radiation lung injury in the left upper lobe (arrowhead) with resolution of the right upper lobe consolidative opacity. (d) Axial CT image obtained 8 months after completion of therapy at a lower anatomic level than (c), detected migratory patchy lung opacities (thin arrow). Right upper lobe opacities detected on Fig. 10b have resolved in the interval. A clinical diagnosis of organizing pneumonia was made and treatment with steroid was indicated. Patient demonstrated clinical improvement and prednisone was gradually tapered and totally discontinued. After 4 months chest CT (not shown) demonstrated completed resolution of radiological findings.

Fig. 7. Sixty-six-year-old woman with left upper lobe lung cancer treated with definitive proton radiation therapy

Six months after treatment completion patient had a primary complaint of cough and shortness of breath. (a) Treatment planning field included three beams and a total dose of 87.5 Co-60 Gy. Proton therapy was chosen due to the fact that the tumour is located close to lobar bronchus and proton radiation therapy would be the optimal way of treating this tumour to reduce toxicity and possible bronchial stenosis. (b) Axial CT image obtained 6 months after completion of therapy demonstrates left lung opacities included in the irradiated filed (*) consistent with radiation lung injury. There is additional development of focal right upper lobe opacity (arrow) outside of the treatment planning field. (c) Axial CT images obtained 8 months after completion of therapy demonstrates persistent post-radiation lung injury in the left upper lobe (arrowhead) with resolution of the right upper lobe consolidative opacity. (d) Axial CT image obtained 8 months after completion of therapy at a lower anatomic level than (c), detected migratory patchy lung opacities (thin arrow). Right upper lobe opacities detected on Fig. 10b have resolved in the interval. A clinical diagnosis of organizing pneumonia was made and treatment with steroid was indicated. Patient demonstrated clinical improvement and prednisone was gradually tapered and totally discontinued. After 4 months chest CT (not shown) demonstrated completed resolution of radiological findings.

Fig. 7. Sixty-six-year-old woman with left upper lobe lung cancer treated with definitive proton radiation therapy

Six months after treatment completion patient had a primary complaint of cough and shortness of breath. (a) Treatment planning field included three beams and a total dose of 87.5 Co-60 Gy. Proton therapy was chosen due to the fact that the tumour is located close to lobar bronchus and proton radiation therapy would be the optimal way of treating this tumour to reduce toxicity and possible bronchial stenosis. (b) Axial CT image obtained 6 months after completion of therapy demonstrates left lung opacities included in the irradiated filed (*) consistent with radiation lung injury. There is additional development of focal right upper lobe opacity (arrow) outside of the treatment planning field. (c) Axial CT images obtained 8 months after completion of therapy demonstrates persistent post-radiation lung injury in the left upper lobe (arrowhead) with resolution of the right upper lobe consolidative opacity. (d) Axial CT image obtained 8 months after completion of therapy at a lower anatomic level than (c), detected migratory patchy lung opacities (thin arrow). Right upper lobe opacities detected on Fig. 10b have resolved in the interval. A clinical diagnosis of organizing pneumonia was made and treatment with steroid was indicated. Patient demonstrated clinical improvement and prednisone was gradually tapered and totally discontinued. After 4 months chest CT (not shown) demonstrated completed resolution of radiological findings.

Fig. 7. Sixty-six-year-old woman with left upper lobe lung cancer treated with definitive proton radiation therapy

Six months after treatment completion patient had a primary complaint of cough and shortness of breath. (a) Treatment planning field included three beams and a total dose of 87.5 Co-60 Gy. Proton therapy was chosen due to the fact that the tumour is located close to lobar bronchus and proton radiation therapy would be the optimal way of treating this tumour to reduce toxicity and possible bronchial stenosis. (b) Axial CT image obtained 6 months after completion of therapy demonstrates left lung opacities included in the irradiated filed (*) consistent with radiation lung injury. There is additional development of focal right upper lobe opacity (arrow) outside of the treatment planning field. (c) Axial CT images obtained 8 months after completion of therapy demonstrates persistent post-radiation lung injury in the left upper lobe (arrowhead) with resolution of the right upper lobe consolidative opacity. (d) Axial CT image obtained 8 months after completion of therapy at a lower anatomic level than (c), detected migratory patchy lung opacities (thin arrow). Right upper lobe opacities detected on Fig. 10b have resolved in the interval. A clinical diagnosis of organizing pneumonia was made and treatment with steroid was indicated. Patient demonstrated clinical improvement and prednisone was gradually tapered and totally discontinued. After 4 months chest CT (not shown) demonstrated completed resolution of radiological findings.

Fig. 8. An 87-year-old woman with a diagnosis of stage II NSCLC treated with definitive radiotherapy

(a) Axial CT image obtained 2 years after treatment ending demonstrate focal lung opacities with traction bronchiectasis and architectural distortion consistent with radiation fibrosis. Note sharp lateral border (arrowheads) consistent with post radiation changes. (b) Axial CT image obtained 4 years after treatment completion demonstrates lobulation of the lateral border suspicious for recurrent tumour (arrow). (c) PET-CT demonstrated FDG avidity in the suspected lesion. A lung biopsy confirmed the diagnosis of recurrent tumour.

Fig. 8. An 87-year-old woman with a diagnosis of stage II NSCLC treated with definitive radiotherapy

(a) Axial CT image obtained 2 years after treatment ending demonstrate focal lung opacities with traction bronchiectasis and architectural distortion consistent with radiation fibrosis. Note sharp lateral border (arrowheads) consistent with post radiation changes. (b) Axial CT image obtained 4 years after treatment completion demonstrates lobulation of the lateral border suspicious for recurrent tumour (arrow). (c) PET-CT demonstrated FDG avidity in the suspected lesion. A lung biopsy confirmed the diagnosis of recurrent tumour.

Fig. 8. An 87-year-old woman with a diagnosis of stage II NSCLC treated with definitive radiotherapy

(a) Axial CT image obtained 2 years after treatment ending demonstrate focal lung opacities with traction bronchiectasis and architectural distortion consistent with radiation fibrosis. Note sharp lateral border (arrowheads) consistent with post radiation changes. (b) Axial CT image obtained 4 years after treatment completion demonstrates lobulation of the lateral border suspicious for recurrent tumour (arrow). (c) PET-CT demonstrated FDG avidity in the suspected lesion. A lung biopsy confirmed the diagnosis of recurrent tumour.

Fig. 9. A 77-year-old woman with left upper lobe squamous cell carcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium shows a large left upper lobe mass (M) extending to the hilar region and obstructing the left upper lobe bronchus. (b) Treatment planning field include the left upper lobe and mediastinum treated with proton therapy with a total dose of 74 Co-60 Gy. (c) Axial CT image 12 months after completion of therapy demonstrated a new soft-tissue nodular opacity (*) anterior to the left upper lobe bronchus (arrowhead). Note is also made of a new left pleural effusion developed after 6 months after completion of radiation therapy. (d) PET-CT shows a nodular FDG uptake included in the irradiated area. A recurrent tumour was diagnosed at biopsy.

Fig. 9. A 77-year-old woman with left upper lobe squamous cell carcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium shows a large left upper lobe mass (M) extending to the hilar region and obstructing the left upper lobe bronchus. (b) Treatment planning field include the left upper lobe and mediastinum treated with proton therapy with a total dose of 74 Co-60 Gy. (c) Axial CT image 12 months after completion of therapy demonstrated a new soft-tissue nodular opacity (*) anterior to the left upper lobe bronchus (arrowhead). Note is also made of a new left pleural effusion developed after 6 months after completion of radiation therapy. (d) PET-CT shows a nodular FDG uptake included in the irradiated area. A recurrent tumour was diagnosed at biopsy.

Fig. 9. A 77-year-old woman with left upper lobe squamous cell carcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium shows a large left upper lobe mass (M) extending to the hilar region and obstructing the left upper lobe bronchus. (b) Treatment planning field include the left upper lobe and mediastinum treated with proton therapy with a total dose of 74 Co-60 Gy. (c) Axial CT image 12 months after completion of therapy demonstrated a new soft-tissue nodular opacity (*) anterior to the left upper lobe bronchus (arrowhead). Note is also made of a new left pleural effusion developed after 6 months after completion of radiation therapy. (d) PET-CT shows a nodular FDG uptake included in the irradiated area. A recurrent tumour was diagnosed at biopsy.

Fig. 9. A 77-year-old woman with left upper lobe squamous cell carcinoma of the lung

(a) Axial CT image after administration of intravenous contrast medium shows a large left upper lobe mass (M) extending to the hilar region and obstructing the left upper lobe bronchus. (b) Treatment planning field include the left upper lobe and mediastinum treated with proton therapy with a total dose of 74 Co-60 Gy. (c) Axial CT image 12 months after completion of therapy demonstrated a new soft-tissue nodular opacity (*) anterior to the left upper lobe bronchus (arrowhead). Note is also made of a new left pleural effusion developed after 6 months after completion of radiation therapy. (d) PET-CT shows a nodular FDG uptake included in the irradiated area. A recurrent tumour was diagnosed at biopsy.

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 10. Different radiological appearance after 3D CRT in patients with history of lung cancer and submitted to radiotherapy

(a–b) A 62-year-old man with a diagnosis of adenocarcinoma in the right upper lobe with bulky mediastinal adenopathy. Axial CT image with intravenous contrast medium (a) obtained prior to treatment showing a large right paratracheal mass (M) compressing the superior vena cava (SVC) (*) consistent with nodal metastatic disease. Axial CT image 2 years after completion of radiation therapy (b) shows well-defined area of consolidation (arrows), volume loss, and traction bronchiectasis typical of modified conventional pattern of radiation fibrosis. (c–d) A 60-year-old woman with metastatic NSCLC. Axial CT image obtained prior to treatment shows a right upper lobe nodule (arrow) abutting the pleural surface (c). Axial CT image 8 months post-radiotherapy (d) shows linear lung opacities in the right upper lobe (thin arrows) that resembles scarring tissue and are consistent with a scar-like pattern. (e–f) A 57-year-old man with NSCLC treated with 3D CRT. Axial CT image with intravenous contrast medium (e) obtained prior to treatment shows a large left upper lobe mass (white arrow) surrounding and narrowing the left main pulmonary artery (black arrow). Note tumour involvement in the left paratracheal region. Axial CT image obtained 18 months after completion of therapy (f) demonstrates lung opacities, patent bronchi, and bronchiectasis with mass-like appearance consistent with radiation fibrosis (arrow).

Fig. 11. A 61-year old woman with diagnosis of inflammatory carcinoma of the right breast

(a) Radiotherapy treatment planning field include the right chest wall with medial and lateral tangent fields to a total dose of 51Gy at 1.5Gy per fraction in 34 fractions. (b) Axial CT image obtained 4 months after treatment ending shows nodular opacities (arrows) included in the irradiated field consistent with nodular-like pattern of radiation pneumonitis.

Fig. 11. A 61-year old woman with diagnosis of inflammatory carcinoma of the right breast

(a) Radiotherapy treatment planning field include the right chest wall with medial and lateral tangent fields to a total dose of 51Gy at 1.5Gy per fraction in 34 fractions. (b) Axial CT image obtained 4 months after treatment ending shows nodular opacities (arrows) included in the irradiated field consistent with nodular-like pattern of radiation pneumonitis.

Fig. 12. A 64-year-old man with stage IIIA NSCLC, status post-right lower lobectomy with a positive subcarinal node undergoing post-surgical IMRT

(a) Treatment planning field is situated in the right hilar region and subcarinal nodal regions. Planned treatment dose is 50 Gy at 2 Gy per fraction in 25 fractions. (b) Axial CT image show nodular lung opacities included in the treatment planning field and consistent with nodular radiation pneumonitis away from the site of the primary tumour (arrow). (c) Axial CT image demonstrate nodular opacities in the contralateral lung (arrow). Note that although this opacity is included in the irradiated field, iso-dose distribution lines demonstrate that abnormality is included below the 20 Gy area.

Fig. 12. A 64-year-old man with stage IIIA NSCLC, status post-right lower lobectomy with a positive subcarinal node undergoing post-surgical IMRT

(a) Treatment planning field is situated in the right hilar region and subcarinal nodal regions. Planned treatment dose is 50 Gy at 2 Gy per fraction in 25 fractions. (b) Axial CT image show nodular lung opacities included in the treatment planning field and consistent with nodular radiation pneumonitis away from the site of the primary tumour (arrow). (c) Axial CT image demonstrate nodular opacities in the contralateral lung (arrow). Note that although this opacity is included in the irradiated field, iso-dose distribution lines demonstrate that abnormality is included below the 20 Gy area.

Fig. 12. A 64-year-old man with stage IIIA NSCLC, status post-right lower lobectomy with a positive subcarinal node undergoing post-surgical IMRT

(a) Treatment planning field is situated in the right hilar region and subcarinal nodal regions. Planned treatment dose is 50 Gy at 2 Gy per fraction in 25 fractions. (b) Axial CT image show nodular lung opacities included in the treatment planning field and consistent with nodular radiation pneumonitis away from the site of the primary tumour (arrow). (c) Axial CT image demonstrate nodular opacities in the contralateral lung (arrow). Note that although this opacity is included in the irradiated field, iso-dose distribution lines demonstrate that abnormality is included below the 20 Gy area.

Fig. 13. A 54-year-old woman with a diagnosed stage IIIA right upper lobe NSCLC metastatic to subcarinal and right paratracheal lymph node stations

(a) Axial CT image after administration of intravenous contrast medium and prior to treatment shows a right upper lobe nodule (right arrow) and right hilar adenopathy (white arrowhead) consistent with nodal metastatic disease. (b) Treatment planning field showing the right upper lobe and mediastinum involvement treated with IMRT in five beams to a total of 60 Gy. (c) Axial CT image obtained 6 months after treatment ending demonstrate right perihilar consolidative opacities consistent with radiation lung injury (black arrow).

Fig. 13. A 54-year-old woman with a diagnosed stage IIIA right upper lobe NSCLC metastatic to subcarinal and right paratracheal lymph node stations

(a) Axial CT image after administration of intravenous contrast medium and prior to treatment shows a right upper lobe nodule (right arrow) and right hilar adenopathy (white arrowhead) consistent with nodal metastatic disease. (b) Treatment planning field showing the right upper lobe and mediastinum involvement treated with IMRT in five beams to a total of 60 Gy. (c) Axial CT image obtained 6 months after treatment ending demonstrate right perihilar consolidative opacities consistent with radiation lung injury (black arrow).

Fig. 13. A 54-year-old woman with a diagnosed stage IIIA right upper lobe NSCLC metastatic to subcarinal and right paratracheal lymph node stations

(a) Axial CT image after administration of intravenous contrast medium and prior to treatment shows a right upper lobe nodule (right arrow) and right hilar adenopathy (white arrowhead) consistent with nodal metastatic disease. (b) Treatment planning field showing the right upper lobe and mediastinum involvement treated with IMRT in five beams to a total of 60 Gy. (c) Axial CT image obtained 6 months after treatment ending demonstrate right perihilar consolidative opacities consistent with radiation lung injury (black arrow).

Fig. 14. A 67-year-old man with history of a stage I NSCLC involving the right middle lobe, which was treated with definitive SBRT

(a) Axial CT image obtained prior to treatment demonstrate a 2 cm right middle lobe nodule (arrow). (b) Treatment planning field for a right middle lobe lung lesion treated definitively to a total dose of 50 Gy in four fractions with a nine-beam stereotactic body radiotherapy plan. (c) Axial CT image obtained 8 months after completion of therapy shows lung opacities included in the irradiated field (thin arrows). Note that contralateral lung and non-irradiated right lung are spared from lung damage.

Fig. 14. A 67-year-old man with history of a stage I NSCLC involving the right middle lobe, which was treated with definitive SBRT

(a) Axial CT image obtained prior to treatment demonstrate a 2 cm right middle lobe nodule (arrow). (b) Treatment planning field for a right middle lobe lung lesion treated definitively to a total dose of 50 Gy in four fractions with a nine-beam stereotactic body radiotherapy plan. (c) Axial CT image obtained 8 months after completion of therapy shows lung opacities included in the irradiated field (thin arrows). Note that contralateral lung and non-irradiated right lung are spared from lung damage.

Fig. 14. A 67-year-old man with history of a stage I NSCLC involving the right middle lobe, which was treated with definitive SBRT

(a) Axial CT image obtained prior to treatment demonstrate a 2 cm right middle lobe nodule (arrow). (b) Treatment planning field for a right middle lobe lung lesion treated definitively to a total dose of 50 Gy in four fractions with a nine-beam stereotactic body radiotherapy plan. (c) Axial CT image obtained 8 months after completion of therapy shows lung opacities included in the irradiated field (thin arrows). Note that contralateral lung and non-irradiated right lung are spared from lung damage.

Fig. 15. A 67-year-old woman with a left upper lobe NSCLC. The patient was a poor surgical candidate and was treated with definitive radiotherapy

Proton therapy has been chosen because of the ability to spare normal lung and non-involved mediastinal structures. (a) Treatment planning field demonstrate three fields using proton therapy. Right posterior oblique, left anterior oblique, and left posterior oblique fields were used with a total dose of 87.5 Co-60 Gy divided over 35 fractions. (b) Axial CT image 6 months after completion of therapy shows decrease in size of the tumour (arrow). (c) Axial CT image obtained 18 months after completion of therapy demonstrate left perihilar focal lung opacities with traction bronchiectasis consistent with post-radiation changes (*). Note that remaining lung was spared from radiation damage.

Fig. 15. A 67-year-old woman with a left upper lobe NSCLC. The patient was a poor surgical candidate and was treated with definitive radiotherapy

Proton therapy has been chosen because of the ability to spare normal lung and non-involved mediastinal structures. (a) Treatment planning field demonstrate three fields using proton therapy. Right posterior oblique, left anterior oblique, and left posterior oblique fields were used with a total dose of 87.5 Co-60 Gy divided over 35 fractions. (b) Axial CT image 6 months after completion of therapy shows decrease in size of the tumour (arrow). (c) Axial CT image obtained 18 months after completion of therapy demonstrate left perihilar focal lung opacities with traction bronchiectasis consistent with post-radiation changes (*). Note that remaining lung was spared from radiation damage.

Fig. 15. A 67-year-old woman with a left upper lobe NSCLC. The patient was a poor surgical candidate and was treated with definitive radiotherapy

Proton therapy has been chosen because of the ability to spare normal lung and non-involved mediastinal structures. (a) Treatment planning field demonstrate three fields using proton therapy. Right posterior oblique, left anterior oblique, and left posterior oblique fields were used with a total dose of 87.5 Co-60 Gy divided over 35 fractions. (b) Axial CT image 6 months after completion of therapy shows decrease in size of the tumour (arrow). (c) Axial CT image obtained 18 months after completion of therapy demonstrate left perihilar focal lung opacities with traction bronchiectasis consistent with post-radiation changes (*). Note that remaining lung was spared from radiation damage.