FROM THE DEPARTMENT OF DIAGNOSTIC RADIOLOGY, THE NORWEGIAN RADIUM HOSPITAL,
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OSLO, NORWAY.
PULMONARY CONTRACTION FOLLOWING 6oC0 IRRADIATION OF MAMMARY CARCINOMA T. OPPEDAL and A. KOLBENSTVEDT Chest films following irradiation of mammary carcinoma often reveal a poorly defined, fan-shaped infiltration of the lung parenchyma radiating from the hilum and appearing from a few weeks to a few months after the end of treatment. The process is that of an irradiation pneumonitis, and is followed by gradual contraction of the involved parenchyma and displacement towards the mediastinum (HAGEN& KOLBENSTVEDT 1972). The end result is a fibrosis along the border of the mediastinum, easily overlooked and thus the chest films may give the false impression of resolution and disappearance of the radiation-induced abnormalities. Elevation of the hilum and diaphragm, and a shift of the mediastinum towards the affected side have been mentioned in the literature as signs of pulmonary retraction following radiation therapy (MCINTOSH& SPITZ1939, Ross 1956, LOUGHEED& MAGUIRE 1960). Less attention has been given to the concomitant elevation of the right superior interlobar fissure, which also constitutes a useful anatomic indicator of the degree of contraction (Fig. 3). The ventilatory function and the pulmonary gas exchange have been analyzed (HOST & VALE1973) and the pulmonary circulation (NOTTER et coll. 1970) has been investigated by use of isotopes from 6 to 14 months after radiation therapy. However, this may not reflect the final pulmonary impairment if the contraction proceeds during a longer period of time. Submitted for pubfication 19 November 1975. Acta Radiologica Therapy Physics Biology I5 (1976) Fasc. 4 August
329
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330
T.
OPPEDAL AND A. KOLBENSTVEDT
Fig. 1. Treatment fields in postoperative g°Co irradiation for mammary carcinoma, stages I and 11. Fig. 2. Diagram of interlobar fissure displacement. The distance between intersection point A (before treatment) and B (aFter treatment) was measured.
Therefore it seemed of interest to elucidate the extent and duration of pulmonary contraction as indicated by elevation of the right superior interlobar fissure during a period of at least 4 years following irradiation, and to obtain information about a possible reversibility of the abnormalities as suggested by BATE& GUTTMANN (1957). The degree of contraction was also correlated to age, weight and height of the patient, depth of the chest and the size of the irradiation fields. Material and Methods
During the years 1968 through 1972, a total of 72 patients with carcinoma of the right breast, stages I and 11, were treated by radical mastectomy followed by B°Co irradiation. Patients with carcinoma of the left breast were not included in the series, as no similar interlobar fissure exists on this side. Two adjacent fields were irradiated, the upper field was inclined 15" laterally to avoid the deeper midline structures, its medial border being 1 cm to the left side of the midline; that of the lower field was at the midline; the border between the two fields was located 1 cm below the jugular notch (Fig. 1). Each field received 57 Gy ( 5 700 rad) in 20 fractions over a period varying between 26 and 40 days. Because the right superior interlobar fissure was not visible in the pre-treatment films, 19 patients were excluded. An additional 15 patients were excluded due to absence of follow-up films for a minimum of 4 years after treatment, 8 of these because of too short a survival. There remained 38 patients fulfilling the criteria. One patient was aged between 30 and 39,7 between 40 and 49, 17 between 50 and 59, and 13 between 60 and 69 years. Chest radiography was performed in all patients before and immediately after the treatment. Over a 4-year period the total number of these follow-up films was 179 with a range of 1 to 11 films per patient.
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PULMONARY CONTRACTION FOLLOWING ‘OCO IRRADIATION
a
33 1
b
Fig. 3. Right lung. a) Before treatment. Arrows indicate interlobar fissure. b) 26 months after postoperative irradiation with T o . Contraction of the upper lobe with displacement upwards of the interlobar fissure and secondary distension of the lower lobe.
On re-examination of the films the right superior interlobar fissure was outlined with a marker. On top of the pre-treatment film, the later films were placed one by one, and the upward displacement of the interlobar fissure was measured as indicated in Fig. 2. The compatibility of the films with regard to the same phase of inspiration was checked by the position of the unaffected left hemidiaphragm. The height and weight of the patient and the height of the upper treatment field was noted, and the a.p. diameter of the thorax was measured on lateral films along the shortest line through the hilum, including the extrathoracic soft tissues.
Results Upward displacement of the interlobar fissure was the only sign of irradiationinduced pulmonary contraction in 7 of the 38 patients. The maximum elevation was 11.5 cm, the minimum was 0.5 cm. Nearly two thirds of the patients had a maximum
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332
T. OPPEDAL AND
A.
KOLBENSTVEDT
a
b
Fig. 4. a) Before treatment. Arrows indicate interlobar fissures. b) 14 months after postoperative irradiation with E°Co.Contraction of upper lobe with displacement upwards of both interlobar fissures. Secondary distension of the lower and middle lobes.
displacement of the interlobar fissure between 2 and 6 cm (Table). The contraction of the upper lobe led to a compensatory distension of the lower and middle lobes (Figs 3 and 4). The position of the interlobar fissure was more clearly visible in p.a. than lateral films, although occasionally well demonstrated in the latter (Fig. 4). The average elevation of the interlobar fissure in the 38 patients appears in Fig. 5, which reveals that 50 per cent of the displacement of the fissure occurred within 48 months and 75 per cent within 149 months after the end of treatment. Contraction of the lobe continued at a diminishing rate during the remaining observation period (Fig. 6). The maximum elevation observed during the last two years was 1.5 cm. No downward displacement of the interlobar fissure indicating reversal of contraction was noticed. No statistically significant correlation was found between contraction and age, weight or height of the patients. Neither was any significant correlation found between the extent of the elevation of the fissure and the height of the upper treatment field, Table Maximum displacement upwards of the interlobar fissure Displacement (cm) No. of patients
0-1.9 4
2.0-3.9 11
4.e5.9 13
6.0-7.9 4
8.0-9.9 3
10.0-11.9 3
PULMONARY CONTRACTION FOLLOWING 'OCO IRRADIATION
333
ELEVATION OF INTERLOBAR FISSURE CM
65-
4-
32-
Fig. 5. Average post-irradiation pulmonary contraction as measured by displacement upwards of the interlobar fissure (38 patients).
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112
24
36
48MOHTHS AFTER lRRADlATlON
which varied from 7.5 to 11 cm. The antero-posterior thoracic diameter varied from 22 to 32 cm. No difference in the degree of retraction of the lobe was found between patients with deep and narrow chests.
Discussion In a previous, similar series of 70 patients, post-irradiation abnormalities were observed in 61, i.e. 87 per cent (HAGEN & KOLBENSTVEDT). The elevation of the interlobar fissure was not registered in that series, which included patients irradiated on the left side. In the present group, all patients were irradiated on the right side and special attention was given to the interlobar fissure. Contraction of the right upper lobe was observed in all patients. Most of the contraction of the lobe occurred within one year after treatment, but the process continued through the entire observation period. This implies that analyses of the pulmonary function one year after treatment probably do not reveal the final pulmonary impairment. The upward displacement of the interlobar fissure cannot be related to the ipsilateral surgery. Similar changes have not been observed after radical mastectomy without postoperative irradiation, but they have been encountered in non-operated patients following mantle field irradiation. Small differences in the phase of inspiration when the films were exposed, as estimated by the position of the unaffected left hemidiaphragm, produced no noticeable effect on the site of the interlobar fissure. The reason why great individual differences in irradiation-induced abnormalities occur, remains obscure. Tall, thin patients with a narrow chest might have more lung tissue irradiated and therefore be liable to more severe contraction. However, this theory was not confirmed in the present material. MCINTOSH & SPITZstated that
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334
T. OPPEDAL AND A. KOLBENSTVEDT
a
b
Fig. 6. Right lung. a) Before treatment. Arrows indicate interlobar fissure. b) 2 years after treatment. Contraction of right upper lobe with interlobar fissure elevation has occurred. c ) 34 years after treatment. Further contraction has occurred as judged by the position of the interlobar fissure. C
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PULMONARY CONTRACTION FOLLOWING ‘OCO IRRADIATION
335
the lungs of elderly subjects with arterio-sclerosis were especially prone to radiation pneumonitis and permanent fibrosis. HAGEN& KOLBENSTVEDT reported a higher frequency of marked post-irradiation abnormalities in the older age groups as estimated by the extent of pulmonary infiltration. In the present series, the degree of pulmonary contraction was practically the same in all age groups. As the symptoms of radiation fibrosis are usually modest, and the final roentgenologic findings may be inconspicuous unless the films are scrutinized for signs of contraction of the upper lobe, the pulmonary injury seems to have received insufficient attention in the planning of radiation treatment. Three patients of the present series had contraction with elevation of the interlobar fissure of more than 10 cm and a corresponding compensatory distension of the lower and middle lobes. This fact deserves careful consideration when the treatment principles of mammary carcinoma are considered.
SUMMARY Pulmonary contraction, as measured by elevation of the right superior interlobar fissure, was investigated in 38 patients with carcinoma of the right breast, treated by radical mastectomy followed by irradiation with 6uCo.Contraction of the right upper lobe was observed to extend over a minimum of four years although at a diminishing rate.
ZUSAMMENFASSUNG Bei 38 Patienten, die wegen rechtseitigen Mammakarzinom mit radikaler Mammaamputation und BuCo-Bestrahlungbehandelt wurden waren, wurde die Lungenschrumpfung nach der Aufziehung der Fissura interlobaris superior beurteilt. Schrumpfung des rechten oberen Lungenlappens wurde mindestens vier Jahre beobachtet, obwohl im abnehmenden Masse.
RESUME Les auteurs ont examine sur 38 malades atteintes de cancer du sein droit, traitkes par mammectomies radicales suivies d’irradiation par le 6uCola retraction pulmonaire mesurke par I’elevation de la scissure interlobaire suptrieure droite. 11s ont constate que la retraction du lobe superieur droit s’ttend sur un minimum de 4 ans bien qu’elle aille en diminuant.
REFERENCES BATE D. and GUTTMANN R.: Changes in lung and pleura following two-million therapy for carcinoma of the breast. Radiology 69 (1957), 372. A.: Radiologic pulmonary changes following cobalt 60 HAGENS. and KOLBENSTVEDT treatment of mammary carcinoma. Acta radiol. Ther. Phys. Biol. 11 (1972), 386. HOST H. and VALEJ. R.: Lung function after mantle field irradiation in Hodgkin’s disease. Cancer 32 (1973), 328. G. H.: Irradiation pneumonitis in the treatment of carciLOUGHEED M. N. and MAGUIRE noma of the breast. J. Canad. Ass. Radiol. 11 (1960), 1 .
336
T. OPPEDAL A N D A. KOLBENSTVEDT
MCINTOSH H. C. and SPITZS.: A study of radiation pneumonitis. Amer. J. Roentgenol. 41 (1939), 605.
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G., LINDELL D. und VIKTERLOF K. J.: Strahlenreaktion in Lungen und Pleura bei NOTTER Mammakarzinompatienten. Fortschr. Rontgenstr. 112 (1970), 571. Ross W. M.: The radiotherapeutic and radiological aspects of radiation fibrosis of the lungs. Thorax 11 (1956), 241.
Acta Oncol Downloaded from informahealthcare.com by 157.211.3.38 on 11/13/14 For personal use only.
OSLO, NORWAY.
PULMONARY CONTRACTION FOLLOWING 6oC0 IRRADIATION OF MAMMARY CARCINOMA T. OPPEDAL and A. KOLBENSTVEDT Chest films following irradiation of mammary carcinoma often reveal a poorly defined, fan-shaped infiltration of the lung parenchyma radiating from the hilum and appearing from a few weeks to a few months after the end of treatment. The process is that of an irradiation pneumonitis, and is followed by gradual contraction of the involved parenchyma and displacement towards the mediastinum (HAGEN& KOLBENSTVEDT 1972). The end result is a fibrosis along the border of the mediastinum, easily overlooked and thus the chest films may give the false impression of resolution and disappearance of the radiation-induced abnormalities. Elevation of the hilum and diaphragm, and a shift of the mediastinum towards the affected side have been mentioned in the literature as signs of pulmonary retraction following radiation therapy (MCINTOSH& SPITZ1939, Ross 1956, LOUGHEED& MAGUIRE 1960). Less attention has been given to the concomitant elevation of the right superior interlobar fissure, which also constitutes a useful anatomic indicator of the degree of contraction (Fig. 3). The ventilatory function and the pulmonary gas exchange have been analyzed (HOST & VALE1973) and the pulmonary circulation (NOTTER et coll. 1970) has been investigated by use of isotopes from 6 to 14 months after radiation therapy. However, this may not reflect the final pulmonary impairment if the contraction proceeds during a longer period of time. Submitted for pubfication 19 November 1975. Acta Radiologica Therapy Physics Biology I5 (1976) Fasc. 4 August
329
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330
T.
OPPEDAL AND A. KOLBENSTVEDT
Fig. 1. Treatment fields in postoperative g°Co irradiation for mammary carcinoma, stages I and 11. Fig. 2. Diagram of interlobar fissure displacement. The distance between intersection point A (before treatment) and B (aFter treatment) was measured.
Therefore it seemed of interest to elucidate the extent and duration of pulmonary contraction as indicated by elevation of the right superior interlobar fissure during a period of at least 4 years following irradiation, and to obtain information about a possible reversibility of the abnormalities as suggested by BATE& GUTTMANN (1957). The degree of contraction was also correlated to age, weight and height of the patient, depth of the chest and the size of the irradiation fields. Material and Methods
During the years 1968 through 1972, a total of 72 patients with carcinoma of the right breast, stages I and 11, were treated by radical mastectomy followed by B°Co irradiation. Patients with carcinoma of the left breast were not included in the series, as no similar interlobar fissure exists on this side. Two adjacent fields were irradiated, the upper field was inclined 15" laterally to avoid the deeper midline structures, its medial border being 1 cm to the left side of the midline; that of the lower field was at the midline; the border between the two fields was located 1 cm below the jugular notch (Fig. 1). Each field received 57 Gy ( 5 700 rad) in 20 fractions over a period varying between 26 and 40 days. Because the right superior interlobar fissure was not visible in the pre-treatment films, 19 patients were excluded. An additional 15 patients were excluded due to absence of follow-up films for a minimum of 4 years after treatment, 8 of these because of too short a survival. There remained 38 patients fulfilling the criteria. One patient was aged between 30 and 39,7 between 40 and 49, 17 between 50 and 59, and 13 between 60 and 69 years. Chest radiography was performed in all patients before and immediately after the treatment. Over a 4-year period the total number of these follow-up films was 179 with a range of 1 to 11 films per patient.
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PULMONARY CONTRACTION FOLLOWING ‘OCO IRRADIATION
a
33 1
b
Fig. 3. Right lung. a) Before treatment. Arrows indicate interlobar fissure. b) 26 months after postoperative irradiation with T o . Contraction of the upper lobe with displacement upwards of the interlobar fissure and secondary distension of the lower lobe.
On re-examination of the films the right superior interlobar fissure was outlined with a marker. On top of the pre-treatment film, the later films were placed one by one, and the upward displacement of the interlobar fissure was measured as indicated in Fig. 2. The compatibility of the films with regard to the same phase of inspiration was checked by the position of the unaffected left hemidiaphragm. The height and weight of the patient and the height of the upper treatment field was noted, and the a.p. diameter of the thorax was measured on lateral films along the shortest line through the hilum, including the extrathoracic soft tissues.
Results Upward displacement of the interlobar fissure was the only sign of irradiationinduced pulmonary contraction in 7 of the 38 patients. The maximum elevation was 11.5 cm, the minimum was 0.5 cm. Nearly two thirds of the patients had a maximum
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332
T. OPPEDAL AND
A.
KOLBENSTVEDT
a
b
Fig. 4. a) Before treatment. Arrows indicate interlobar fissures. b) 14 months after postoperative irradiation with E°Co.Contraction of upper lobe with displacement upwards of both interlobar fissures. Secondary distension of the lower and middle lobes.
displacement of the interlobar fissure between 2 and 6 cm (Table). The contraction of the upper lobe led to a compensatory distension of the lower and middle lobes (Figs 3 and 4). The position of the interlobar fissure was more clearly visible in p.a. than lateral films, although occasionally well demonstrated in the latter (Fig. 4). The average elevation of the interlobar fissure in the 38 patients appears in Fig. 5, which reveals that 50 per cent of the displacement of the fissure occurred within 48 months and 75 per cent within 149 months after the end of treatment. Contraction of the lobe continued at a diminishing rate during the remaining observation period (Fig. 6). The maximum elevation observed during the last two years was 1.5 cm. No downward displacement of the interlobar fissure indicating reversal of contraction was noticed. No statistically significant correlation was found between contraction and age, weight or height of the patients. Neither was any significant correlation found between the extent of the elevation of the fissure and the height of the upper treatment field, Table Maximum displacement upwards of the interlobar fissure Displacement (cm) No. of patients
0-1.9 4
2.0-3.9 11
4.e5.9 13
6.0-7.9 4
8.0-9.9 3
10.0-11.9 3
PULMONARY CONTRACTION FOLLOWING 'OCO IRRADIATION
333
ELEVATION OF INTERLOBAR FISSURE CM
65-
4-
32-
Fig. 5. Average post-irradiation pulmonary contraction as measured by displacement upwards of the interlobar fissure (38 patients).
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112
24
36
48MOHTHS AFTER lRRADlATlON
which varied from 7.5 to 11 cm. The antero-posterior thoracic diameter varied from 22 to 32 cm. No difference in the degree of retraction of the lobe was found between patients with deep and narrow chests.
Discussion In a previous, similar series of 70 patients, post-irradiation abnormalities were observed in 61, i.e. 87 per cent (HAGEN & KOLBENSTVEDT). The elevation of the interlobar fissure was not registered in that series, which included patients irradiated on the left side. In the present group, all patients were irradiated on the right side and special attention was given to the interlobar fissure. Contraction of the right upper lobe was observed in all patients. Most of the contraction of the lobe occurred within one year after treatment, but the process continued through the entire observation period. This implies that analyses of the pulmonary function one year after treatment probably do not reveal the final pulmonary impairment. The upward displacement of the interlobar fissure cannot be related to the ipsilateral surgery. Similar changes have not been observed after radical mastectomy without postoperative irradiation, but they have been encountered in non-operated patients following mantle field irradiation. Small differences in the phase of inspiration when the films were exposed, as estimated by the position of the unaffected left hemidiaphragm, produced no noticeable effect on the site of the interlobar fissure. The reason why great individual differences in irradiation-induced abnormalities occur, remains obscure. Tall, thin patients with a narrow chest might have more lung tissue irradiated and therefore be liable to more severe contraction. However, this theory was not confirmed in the present material. MCINTOSH & SPITZstated that
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334
T. OPPEDAL AND A. KOLBENSTVEDT
a
b
Fig. 6. Right lung. a) Before treatment. Arrows indicate interlobar fissure. b) 2 years after treatment. Contraction of right upper lobe with interlobar fissure elevation has occurred. c ) 34 years after treatment. Further contraction has occurred as judged by the position of the interlobar fissure. C
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PULMONARY CONTRACTION FOLLOWING ‘OCO IRRADIATION
335
the lungs of elderly subjects with arterio-sclerosis were especially prone to radiation pneumonitis and permanent fibrosis. HAGEN& KOLBENSTVEDT reported a higher frequency of marked post-irradiation abnormalities in the older age groups as estimated by the extent of pulmonary infiltration. In the present series, the degree of pulmonary contraction was practically the same in all age groups. As the symptoms of radiation fibrosis are usually modest, and the final roentgenologic findings may be inconspicuous unless the films are scrutinized for signs of contraction of the upper lobe, the pulmonary injury seems to have received insufficient attention in the planning of radiation treatment. Three patients of the present series had contraction with elevation of the interlobar fissure of more than 10 cm and a corresponding compensatory distension of the lower and middle lobes. This fact deserves careful consideration when the treatment principles of mammary carcinoma are considered.
SUMMARY Pulmonary contraction, as measured by elevation of the right superior interlobar fissure, was investigated in 38 patients with carcinoma of the right breast, treated by radical mastectomy followed by irradiation with 6uCo.Contraction of the right upper lobe was observed to extend over a minimum of four years although at a diminishing rate.
ZUSAMMENFASSUNG Bei 38 Patienten, die wegen rechtseitigen Mammakarzinom mit radikaler Mammaamputation und BuCo-Bestrahlungbehandelt wurden waren, wurde die Lungenschrumpfung nach der Aufziehung der Fissura interlobaris superior beurteilt. Schrumpfung des rechten oberen Lungenlappens wurde mindestens vier Jahre beobachtet, obwohl im abnehmenden Masse.
RESUME Les auteurs ont examine sur 38 malades atteintes de cancer du sein droit, traitkes par mammectomies radicales suivies d’irradiation par le 6uCola retraction pulmonaire mesurke par I’elevation de la scissure interlobaire suptrieure droite. 11s ont constate que la retraction du lobe superieur droit s’ttend sur un minimum de 4 ans bien qu’elle aille en diminuant.
REFERENCES BATE D. and GUTTMANN R.: Changes in lung and pleura following two-million therapy for carcinoma of the breast. Radiology 69 (1957), 372. A.: Radiologic pulmonary changes following cobalt 60 HAGENS. and KOLBENSTVEDT treatment of mammary carcinoma. Acta radiol. Ther. Phys. Biol. 11 (1972), 386. HOST H. and VALEJ. R.: Lung function after mantle field irradiation in Hodgkin’s disease. Cancer 32 (1973), 328. G. H.: Irradiation pneumonitis in the treatment of carciLOUGHEED M. N. and MAGUIRE noma of the breast. J. Canad. Ass. Radiol. 11 (1960), 1 .
336
T. OPPEDAL A N D A. KOLBENSTVEDT
MCINTOSH H. C. and SPITZS.: A study of radiation pneumonitis. Amer. J. Roentgenol. 41 (1939), 605.
Acta Oncol Downloaded from informahealthcare.com by 157.211.3.38 on 11/13/14 For personal use only.
G., LINDELL D. und VIKTERLOF K. J.: Strahlenreaktion in Lungen und Pleura bei NOTTER Mammakarzinompatienten. Fortschr. Rontgenstr. 112 (1970), 571. Ross W. M.: The radiotherapeutic and radiological aspects of radiation fibrosis of the lungs. Thorax 11 (1956), 241.
