Radiation-induced bronchiolitis obliterans organizing pneumonia (BOOP) syndrome in breast cancer patients is associated with age

Abstract

Background: Radiation-induced bronchiolitis obliterans organizing pneumonia (BOOP) syndrome is a rarely observed phenomenon characterized by infiltration of the lungs outside of the radiation field, differentiating it from radiation pneumonitis (RP).The risk factors for radiation-induced BOOP (RT-BOOP) remain unclear and controversial. We retrospectively analyzed the incidence and risk factors for RT-BOOP associated with radiation therapy (RT) after breast conserving surgery (BCS) and post-mastectomy radiation therapy (PMRT).

Methods and materials: We analyzed 1,176 breast cancer patients treated with RT after BCS or PMRT between March 2005 and September2008 at the cancer institute hospital of the Japanese foundation for cancer research. Chest radiographs were routinely obtained every three to six months for at least 12 months after surgery, as well as when the patients experienced respiratory symptoms or fever.

Results: RT-BOOP syndrome was diagnosed in 16patients (1.4%), including12BCS patients (1.3%) and four PMRT patients (1.8%). An older age (≥52 years old) was significantly associated with the incidence of RT-BOOP syndrome in a univariate analysis (p =0.023). The type of treatment (BCS or PMRT) and irradiated lung volume at 20 Gy (V20) were not significantly associated with the incidence of RT-BOOP syndrome in the entire patient cohort. In the multivariate analysis, age and smoking were the significant factor associated with RT-induced BOOP syndrome (p =0.044 and 0.049, respectively).

Conclusions: RT-BOOP syndrome was a rarity, and the incidence for BCT cases was similar to that for PMRT cases. The irradiated lung volume was not significantly associated with RT-BOOP syndrome. An older age can predict the incidence of RT-BOOP syndrome.

Figure 1

The treatment protocols for patients with breast cancer for breast-conserving therapy (a) and post-mastectomy radiation therapy (b).

Figure 2

55-year-old patient received irradiation in the whole left breast (50 Gy/25 fractions) with an electron boost (10 Gy/5 fractions) to the partial breast. The lung V20 was 6.0%. Four months after RT following breast-conserving surgery, a severe cough, fever and decreased oxygen saturation measured by a pulseoximeter (SpO2; 88% at room air) were observed. Pulmonary lesions outside the irradiated field were observed on chest radiographs, which were located in the bilateral lungs on CT. Prednisolone was started at 30 mg/day based on a diagnosis of BOOP syndrome. The prednisolone was gradually tapered off, because the symptoms and pulmonary lesions were improved. However, the pulmonary lesions appeared again at 6.5 months after RT without any symptoms. Prednisolone was again administered until 7.5 months after RT. Although the pulmonary lesions appeared again at 9.5 months after RT, there were no symptoms.

Figure 3

The lung V20 of all patients according to the type of treatment. The cases that developed radiation-induced BOOP are shown by red circles.