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Radiation Damage to Thoracic Tissues

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Radiation Damage to Thoracic Tissues Thorax: first published as 10.1136/thx.18.4.371 on 1 December 1963. Downloaded from Thorax (1963), 18, 371 Radiation damage to thoracic tissues A. G. W. WHITFIELD,' W. H. BOND, AND P. B. KUNKLER2 From the Departments of Medicine and Radiotherapy, United Birmingham Hospitals, University of Birmingham Radiotherapy to the thorax in conventional dosage roentgen therapy for cancer of the oesophagus, appears to be capable of causing damage to any of but we have not encountered these lesions. the tissues in the thoracic wall or within the After mastectomy and radiotherapy for breast thoracic cavity. Since the earliest days of x-ray cancer the shoulder not uncommonly becomes treatment radiation changes in the skin have been fixed or relatively so, and in such cases osteo- such an everyday problem that they scarcely porotic changes may be seen in the humerus and warrant discussion here except to note that with scapula (Fig. 3). To what extent such processes the advent of new radiotherapeutic techniques they stem directly from radiation and how much they are becoming less frequent and less severe. are attributable to disuse one cannot be certain but the latter is probably an important influence. THE THORACIC WALL, SHOULDER GIRDLE, AND Other types of bony lesion are occasionally seen. BREASTS Two examples are shown in Figures 4 and 5a. Figure 4 shows the shoulder of an old lady who, Radiation damage to the bony structure of the after radiotherapy for breast cancer, developed thoracic cage is relatively uncommon. Rib frac- shoulder pain attributable to necrosis of the head copyright. tures are its most frequent manifestation and their of the humerus. Figure 5a is from a woman who symptom is pain. Their presence in one or several at the age of 10 was given radiotherapy for what ribs is confirmed by careful scrutiny of the chest at thoracotomy was thought to be an inoperable radiograph (Fig. 1). They must, of course, be malignant lung tumour. No biopsy was taken. differentiated from pathological fractures resulting Thereafter the scapula failed to grow to its normal from metastases, but if they occur after radio- size and the breast was also affected (Fig. Sb). http://thorax.bmj.com/ therapy to the thorax the great probability is that When at the age of 30 she gave birth to a child they are attributable to it. Expansion of the bone there was no lactatory response on the damaged is never seen, the fractures usually occur in the side. Mammary hypoplasia following radiotherapy anterior axillary line, and surprising though it is in childhood has been reported previously (Rube, they unite well and pain soon abates (Fig. 2). They 1954; Kolaf, Vrabec, and Bek, 1957; Gros and usually follow radiotherapy for breast cancer but Keiling, 1958). may be a sequel to x-ray treatment for other thoracic disorders. Some concomitant radiation THE LUNGS damage to the lung is commonly evident. Age does on September 26, 2021 by guest. Protected not appear to be a factor in their causation as we The lungs are the most vulnerable of the tissues have seen them in early adult life. They have been within the thorax, and radiation damage is still previously described by Fike (1932), Freid and relatively common after x-ray treatment for breast Goldberg (1940), Eggs (1941), Leach, Farrow, cancer, though it occurs much less frequently than Foote, and Wawro (1942), Blumenfeld and Thomas in the early days of radiotherapy. This is particu- (1945), Braun and Frik (1954), Koldr and Vrabec larly so after wide-field irradiation for malignant (1957), and Baudisch (1960). Kolar and Vrabec lymphomas or lung secondaries. Six cases, two of (1957) and Baudisch (1960) have also reported 'them fatal, have recently been reported after radiation fractures of the clavicle after post- radioactive iodine therapy for carcinoma of the mastectomy radiotherapy for breast cancer, and thyroid with pulmonary metastases (Rall, Alpers, Borgstrom and Gynning (1957) described osteo- Lewallen, Sonenberg, Berman, and Rawson, 1957) porotic vertebral collapse after intense rotation but we have not encountered radiation lung damage arising in this way. In a series of 49 cases 1 Paper given at the Tenth International Congress of Radiology in Montreal, 1962 which we have studied, 25 followed routine post- 2 Presetit address: Radiotherapy Department, United Cardiff Hospitals mastectomy radiotherapy for breast cancer, 11 371 Thorax: first published as 10.1136/thx.18.4.371 on 1 December 1963. Downloaded from FIG. 1. Female, aged 40. Fractured sixth and seventh ribs after post-mastectomy radiotherapy for breast cancer. Some radiation damage to the right lung is evident. FIG. 2. Female, aged 27. Soundly united fracture of left copyright. second rib six months after radiotherapy through media- stinal fields for Hodgkin's disease involving mediastinal lymph nodes. Radiation fibrosis of the lung is also present. http://thorax.bmj.com/ on September 26, 2021 by guest. Protected FIG. 3. Female, aged 49. Fixation of left shoulder with osteop,orosis of humei-us and scapula after mastectomy and FIG. 4. Female, aged 84. Necrosis of head of humerus radiotherapy for breast cancer. Severe radiation damage to after radiotherapy for breast cancer. Radiation fibrosis of the lef lung is also showi,, the lung is also evident. Thorax: first published as 10.1136/thx.18.4.371 on 1 December 1963. Downloaded from Radiation damage to thoracic tissues 373 copyright. FIG. 5a 10- _at!5,_a _. .>F: to http://thorax.bmj.com/ w Cn 5- u '.i. am.. .:. 0..!F... I ..g t:. 2 4 6 8 b 12 14 16 WEEKS FIG. 6 .XWiSSTE: on September 26, 2021 by guest. Protected 0,l@X DYSPNOEA *:.s :>s .s .-s *:rs COUGH s : FIG. Sb DOOR STOP OBSTRUCTION - TO INSPIRATION FIG. 5a. Female. Failure of right scapula to grow to its normal size following radiotherapy in childhood for a RIB FRACTURES o malignant lung tumour. Radiation fibrosis of lung also present. OESOPHAGEAL - FIG. 5b. Same patient as in Fig. 5a, showing mammary hypoplasia on treated side. NONE FIG. 6. Interval between conclusion of radiotherapy and l~~~~~~ onset ofsymptoms of radiation pneumonia. 0 10 20 30 4o FIG.A t7. ... vSymptoms :. in patients with radiation lung damage. CASES FIG. 7 Thorax: first published as 10.1136/thx.18.4.371 on 1 December 1963. Downloaded from 374 A. G. W. Whitfield, W. H. Bond. and P. B. Kunlkler occurred after chest baths for lung secondaries or patients were left with a tendency to recurrent malignant lymphomas, two followed therapy bronchitis and pleurisy but only one was bronchi- directed to the whole of one side of the thorax, ectatic. During the pneumonia stage the sedi- six occurred after treatment limited to the media- mentation rate was usually considerably raised stinum, and the remaining five followed treatment but the only haematological abnormality we have through limited fields for carcinoma of the found was a slight polymorphonuclear leuco- bronchus or oesophagus. Where radiotherapy was cytosis in three of our most severe cases. unilateral, the lung damage was limited to the treated side in all but one case, whereas when both RESPIRATORY FUNCTION TESTS Respiratory function lungs had been treated all save one suffered tests were only occasionally performed but showed bilateral damage. It was usually strikingly limited a uniform pattern of abnormality. There wvas a to the area irradiated. diminution in all divisions of lung volume, but the ratio of the various divisions to total capacity was SYMPTOMS AND PHYSICAL SIGNS The interval not significantly altered from normal. The maxi- between the conclusion of x-ray treatment and the mum breathing capacity was likewise markedly development of symptoms attributable to radia- reduced. The arterial oxygen saturation was nor- tion pneumonia varied from 1 to 16 weeks with mal at rest but severe cases showed desaturation a peak incidence at one month (Fig. 6). Six on exercise, while the carbon dioxide content was patients had no symptoms (Fig. 7) and their lung normal or low at rest and on exercise. Similar damage was slight and was only revealed by findings have been reported by Leach (1943b), routine follow-up radiography of the chest. In Baldwin, Cournand, and Richards (1949), Stone, the remainder dyspnoea was the dominant symp- Schwartz, and Green (1956). Rodman, Karr, and tom. At first only evident on exercise, it increased Close (1960), and Cooper, Guerrant, Harden, and rapidly and in severe cases became obvious at Teates (1961). We have not examined the carbon rest. In those who survived it gradually diminished monoxide diffusing capacity in any of our patientscopyright. over a period of weeks but only exceptionally was but such abnormal physiology as we and others a normal exercise tolerance ever restored. A 'door have found indicates the presence of alveolo- stop' obstruction to full inspiration is evident in capillary block, and the histopathological features severe cases and was a striking feature of four of immediately confirm that such must be the the patients studied. Half the patients had a dry dominant functional defect. irritating cough aggravated by exercise or deep http://thorax.bmj.com/ breathing. In some this symptom was only PROGNOSIS Seven of our 49 patients, all with present in the pneumonia stage, but in many it severe bilateral damage, died as a result of alveolo- persisted in lesser degree indefinitely. Sputum was capillary block. The remaining 42 survived or died unusual both during the pneumonia stage and from other causes. In only two of these did the when fibrosis had supervened, no doubt because lungs revert to normal, the remainder showing the upper lobes are most commonly affected. varying degrees of residual fibrosis and disability. Fractured ribs were noted in four patients.
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