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Radiation Pneumonitis: A Possible Lymphocyte-mediated Hypersensitivity Reaction

C. Michael Roberts, MBBS; Elena Foulcher, BSc; John J. Zaunders, BSc; David H. Bryant, MD; Judy Freund, MBBS; David Cairns, PhD; Ronald Penny, DSc; Graeme W. Morgan, MBBS; and Samuel N. Breit, MD
[+] Article and Author Information

From St. Vincent's Hospital, University of New South Wales, and from Macquarie University, Sydney, Australia. Requests for Reprints: Samuel N. Breit, MD, Centre for Immunology, St. Vincent's Hospital and University of NSW, Sydney, 2010, Australia. Grant Support: In part by grants from The National Health & Medical Research Council of Australia and from St. Vincent's Hospital, Sydney, Australia.


Copyright 2004 by the American College of Physicians


Ann Intern Med. 1993;118(9):696-700. doi:10.7326/0003-4819-118-9-199305010-00006
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Objective: To determine if unilateral thoracic irradiation results in a lymphoid alveolitis in both irradiated and unirradiated lung fields.

Design: A prospective, nonrandomized study.

Patients: Women receiving postoperative radiotherapy for carcinoma of the breast were evaluated both before and 4 to 6 weeks after radiotherapy. Findings after radiotherapy in 15 asymptomatic patients were compared with findings in a group of patients with clinical radiation pneumonitis.

Measurements: History, physical examination, chest radiograph, quantitative gallium lung scanning, respiratory function tests, bronchoalveolar lavage, and lavage lymphocyte subset analysis.

Results: After irradiation, lavage lymphocytes increased significantly (34.5% versus 46.8%; P = 0.01) in the 17 patients studied prospectively. There was an associated reduction in vital capacity (102.5% versus 95.5%; P = 0.04). Comparison of results in patients before treatment, after treatment without clinical pneumonitis, and after treatment with clinical pneumonitis showed a dramatic increase in total lymphocytes after irradiation (6.3 versus 9.4 versus 35.2 million, respectively; P = 0.005), particularly in those with clinical pneumonitis. Only in those with clinical pneumonitis was this accompanied by an increase in the gallium index (3.7 versus 3.4 versus 9.0, respectively; P < 0.001). Vital capacity was also progressively reduced (102.5% versus 96.9% versus 76.7%, respectively; P = 0.04), as was diffusing capacity (98.6% versus 91.4% versus 72.6%, respectively; P = 0.003). No statistical differences existed between irradiated and unirradiated sides of the chest in either lavage or gallium lung scan studies.

Conclusion: In most patients, a lymphocytic alveolitis develops in both lung fields after strictly unilateral thoracic irradiation; this is more pronounced in patients developing clinical pneumonitis. These findings suggest that radiotherapy may cause a generalized lymphocyte-mediated hypersensitivity reaction.

Figures

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Figure 1.
Flow cytometric analysis.

Comparison of lavage lymphocytes from one patient with clinical radiation pneumonitis and two controls. These cells have been labeled with control monoclonal antibody, and antibodies to all T cells (CD3), helper T cells (CD4), suppressor/cytotoxic T cells (CD8), NK cells (CD56), two isoforms of tyrosine phosphatase (CD45RA and CD 45RO), and T-cell activation markers HLA DR, CD25 (interleukin-2 receptor), CD38, and CD69.

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