Belarus

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Belarus
_at_.By
Republic of Belarus
Area 207,600 sq. km. Population 10,366,719
(July 2000) Ethnic groups Byelorussian 77.9,
Russian 13.2, Polish 4.1, Ukrainian 2.9, other
1.9 Languages Byelorussian, Russian Capital
City Minsk (pop 1.7 million) Currency
Byelorussian ruble
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Belarus
_at_.By
Republic of Belarus
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Belarus
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Republic of Belarus
Red Catholic church in Minsk
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Belarus
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Republic of Belarus
Castle in the Mir Settlement, Minsk Region
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Belarus
_at_.By
Republic of Belarus
Farny Catholic church in Grodno
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Belarus
_at_.By
Republic of Belarus
Street in Grodno
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Belarus
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Republic of Belarus
Grodno Dramatic theater
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Belarus
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Republic of Belarus
Zubr (bison) In Belovezhskaja virgin forest
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We are radiologists
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Dr. Serguey A Khoruzhik MD, Computed Tomography
Unit, Grodno Regional Clinical Hospital, Grodno,
Belarus
CT Imaging of Radiotherapy Induced Pulmonary
Changes
Hammersmith Hospital, London, October 18th, 2001
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Lung Cancer Statistics in Belarus
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Lung Cancer Statistics in Belarus (continued)
Distribution of new cancer cases according to the
disease stage in 1999 I - 13,6, II - 23,7, III
- 33,5, IV - 20,2, ? - 9,0

• Lung cancer treatment in 1999
• Surgery alone - 39,4
• Chemotherapy alone or in combined regimens - 19,6

• Radiotherapy (RT) alone - 41,0

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Radiotherapy regimen
Split-course (Sp-RT)

• First RT stage 28 Gy in 2 Gy fractions twice
  daily 5 days a week

• 4 weeks of rest

• Second RT stage 30 in 1 Gy fractions twice daily
  5 days a week

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Computed tomography of the thorax

• Dynamic CT scans
• First CT - before RT
• Second CT scan - before second RT stage
• Follow-up CT scans - from 4 weeks to 1 year after
  RT

• To study
• Tumor response
• Radiation-induced lung injury

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Radiation-induced lung injury -
timing

• Before 3 months - acute (radiation pneumonitis)
• Before 9 month - late (organizing) pneumonitis or
  fibrosis
• 9-12 month - established fibrosis but...
• it still may
  evolve before 2 years
• After 2 years - no any change usually observed

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Radiation-induced lung injury -
CT patterns
(1) A homogeneous slight increase in attenuation,
uniformly involving irradiated portion of the
lung (2) Patchy consolidation within irradiated
lung, not necessarily conforming to the shape of
the portal (3) Discrete consolidation,
conforming to the shape of the portal, but not
uniformly outlining it (4) Solid consolidation,
conforming and totally involving the irradiated
region of the lung
Libshitz HI et al. JCAT 1984 8 15-19
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Radiation pneumonitis after
first RT stage (35 patients)

• Slight increase in attenuation - in 1 patient
• Minimal patchy consolidation - in 1

Earliest radiation-induced lung injury was seen 4
weeks after 28 Gy delivered
Khoruzhik SA et al. Proceedings of Republican
Conference "Modern Diagnostic Technologies in
Medicine", Minsk 2000. - p. 40
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Radiation pneumonitis after
first RT stage (continued)
4 weeks after 28 Gy
Earliest radiation-induced diffusely increased
attenuation in lung tissue
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Radiation pneumonitis after
first RT stage (continued)
4 weeks after 28 Gy
Minimal patchy consolidation
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Radiation pneumonitis after the
end of RT (16 patients)

• No radiation-induced lung injury were detected -
  in 5
• Slight increase in attenuation - 6 patients
• Patchy consolidation - 2 patient
• Discrete consolidation - 2 patients

Pneumonitis was seen in 10 of 16 patients (63) 4
to 11 weeks after Sp-RT
Khoruzhik SA et al. Lung Cancer 2000 29
(Supplement 1) 249
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Radiation pneumonitis after
the end of RT(continued)
8 weeks after RT
Patchy consolidation in the left lung
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Radiation pneumonitis after
the end of RT(continued)
5 weeks after RT
Discreet consolidation with clearly defined
lateral margin and mediastinum border traction
from the left
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Radiation pneumonitis after
the end of RT(continued)
Other radiotherapy induced pulmonary changes seen
before 3 months after RT

• Solid consolidation - 2 patients
• Fluid collection in pleural cavity 1
• Pleural thickening - 1

Khoruzhik SA et al. European Society of Thoracic
Imaging 8th Annual Meeting, Salzburg 2000. -
Final Program and Abstracts. - p. 69
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Radiation pneumonitis after
the end of RT (continued)
5 weeks after RT
Both discrete and solid consolidations seen in
the left lung
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Radiation pneumonitis after
the end of RT (continued)
4 weeks after RT
Streaky densities in left near-mediastinum region
along with minimal fluid accumulation in the main
pleural fissure from the left
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Evolution of radiation pneumonitis 3 to 8
months after RT (11 patients)

• In 8 patients who presented with pneumonitis
  initially
• Fibrosis starts to develop - in 5 patients
• Pneumonitis changed its radiological appearance
  - in 3

• In 3 patients who had no pneumonitis initially
• No radiation-induced lung injury was seen - in 1
• Pneumonitis developed - in 1
• Fibrosis starts to develop - in 1 patient

Khoruzhik SA et al. International Conference on
Non-Small Cell Lung Cancer, Bialystok 2001,
Proceedings, p. 56
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Evolution of radiation pneumonitis
(continued)
A
B
(A) Slight increase of lung attenuation from the
right 4 weeks after RT. (B) 4 months later
fibrosis starts to develop in the right lung.
Gross tumor recurrence is seen from the left.
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Late radiation changes in the lungs
Radiation fibrosis 7 months after RT
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Conclusions

• Radiation pneumonitis might be seen on CT in more
  then half of patients treated with radiotherapy
• Some changes in attenuation values of lung tissue
  may be seen as early as 4 weeks after 28 Gy
• Radiation pneumonitis may change its radiological
  appearance and in most of cases evolve to fibrosis

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Contact
Dr. Serguey A. Khoruzhik MD, Computed
Tomography, Grodno Regional Clinical Hospital,
BLK 52, 230025 Grodno, Belarus Phone (375
152) 772156, 331320 khoruzhik_at_grsmi.unibel.by http
//nld.unibel.by/e/personal/cv.htm