DVH data

Fourteen patients (70%) had V20 lung dose constraint <30%; however, in 6 (30%) V20 >30% of accepted due to the nature of the patient’s contours. The mean ipsilateral lung V5, V10, V20, V30, V40, and V50 were 39.5%, 27.8%, 22.5%, 18.7%, 15.0%, and 1.8%, respectively (Figure 7). Significant association between high V20 with decrease in FVC, FEV1, and DLCO was observed (= 0.01, = 0.002, and = 0.001, respectively). Further, neoadjuvant chemotherapy was associated with decrease in DLCO at day 90 (= 0.001).

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In our cohort, a significant reduction of FVC, FEV1, and DLCO and an association with ipsilateral lung V20 were observed at day 90 after the completion of PMRT; however, no deterioration of MMEF25–75and VO2max was observed. These results are in agreement with previously published data.12,13 An equal reduction of FVC and FEV1 with normal FEV1% pred suggests an acute exudative inflammatory process in the alveolar spaces, favoring a restrictive lung injury pattern (RIP or RIF).14 Further, unaltered MMEF25–75 supports the restrictive radiation-induced lung injury in our cohort, as deteriorated MMEF25–75 is related to damage to bronchioles leading to obstructive lung disease.15Similarly, VO2max, which is a measure of physical fitness of an individual, was found unchanged in our cohort. Possible explanation for this could be the compensation of RILT by contralateral healthy lung.16

Although we did not aim to investigate the ability of PFTs to predict the risk of RILT, but topic is still arguable, as some studies have reported that better baseline PFTs predicted lower risk of RILT, whereas some studies did not see any correlation between PFTs and RILT.17,18 Impact of PFTs to predict the risk of RILT can be explained by the few hypotheses: 1) theoretically, individuals with better baseline PFTs have relatively higher level of cellular oxygenation, thus more radiosensitivity of alveoli and more risk of RILT;19 2) on the other hand, patients with poor baseline PFTs are more likely to present with symptoms prior to radiotherapy, and in individuals with severe baseline pulmonary symptoms, the RILT score is less likely to decrease by one grade;19,20 3) as most of PFT data are available from lung cancer trials comprising patients who are mostly with emphysematous lungs. Since emphysema represents physiological missing lung parenchyma, theoretically one would expect less risk of RILT risk; and 4) physicians’ bias reduction of total dose or putting more stringent lung constraints in patients with poor baseline PFTs;21 however, further studies using the radiological data are warranted. As RILT with clinical symptoms is relatively rare (incidence <3%) and of mild nature especially with use of modern radiation therapy techniques, the treatment is oral steroids; therefore prevention (reducing lung volume and fraction size) is the key buttress.22 Further, treatment for patients with decrease in PFTs in the absence of clinical symptoms needs further investigation.

Limitations of the present study were 1) a relatively small sample size, 2) short follow-up duration, and 3) lack of correlation analysis between PFTs and RILT.


In conclusion, PFTs shall be performed in all breast cancer patients receiving PMRT for early detection of RILT as most of the patients in our cohort were asymptomatic. Studies incorporating longer duration of follow-up and large sample size are warranted to address clinical significance of PFTs in breast cancer patients receiving PMRT.


The authors report that no conflicts of interest in this work.

Eyad Fawzi AlSaeed,1 Faisal Khalid Balaraj,2 Mutahir A Tunio3
1Department of Radiation Oncology, Faculty of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia; 2Al Faisal University, Chair of Radiation Oncology, Tawam Hospital, Al Ain, United Arab Emirates; 3Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia


1. Krengli M, Sacco M, Loi G, et al. Pulmonary changes after radiotherapy for conservative treatment of breast cancer: a prospective study. Int J Radiat Oncol Biol Phys. 2008;70(5):1460–1467.

2. Fragkandrea I, Kouloulias V, Mavridis P, et al. Radiation induced pneumonitis following whole breast radiotherapy treatment in early breast cancer patients treated with breast conserving surgery: a single institution study. Hippokratia. 2013;17(3):233–228.

3. Lind PA, Marks LB, Jamieson TA, et al. Predictors for pneumonitis during locoregional radiotherapy in high-risk patients with breast carcinoma treated with high-dose chemotherapy and stem-cell rescue. Cancer. 2002;94(11):2821–2829.

4. Gong HY, Hu WG, Hu QY, Li XP, Song QB. Radiation-induced pulmonary injury accelerated pulmonary metastasis in a mouse model of breast cancer. Oncol Lett. 2015;10(6):3613–3618.

5. Toma CL, Serbescu A, Alexe M, Cervis L, Ionita D, Bogdan MA. The bronchoalveolar lavage pattern in radiation pneumonitis secondary to radiotherapy for breast cancer. Maedica (Buchar). 2010;5(4):250–257.

6. Kimsey FC, Mendenhall NP, Ewald LM, Coons TS, Layon AJ. Is radiation treatment volume a predictor for acute or late effect on pulmonary function? A prospective study of patients treated with breast-conserving surgery and postoperative irradiation. Cancer. 1994;73(10):2549–2555.

7. Ooi GC, Kwong DL, Ho JC, et al. Pulmonary sequelae of treatment for breast cancer: a prospective study. Int J Radiat Oncol Biol Phys. 2001; 50(2):411–419.

8. Budach W, Bolke E, Kammers K, Gerber PA, Nestle-Krämling C, Matuschek C. Adjuvant radiation therapy of regional lymph nodes in breast cancer – a meta-analysis of randomized trials-an update. Radiat Oncol. 2015;10:258.

9. Lind PA, Marks LB, Hardenbergh PH, et al. Technical factors associated with radiation pneumonitis after local +/- regional radiation therapy for breast cancer. Int J Radiat Oncol Biol Phys. 2002;52(1):137–143.

10. Bjermer L, Franzen L, Littbrand B, Nilsson K, Angstrom T, Henriksson R. Effects of smoking and irradiated volume on inflammatory response in the lung of irradiated breast cancer patients evaluated with bronchoalveolar lavage. Cancer Res. 1990;50:2027–2030.

11. Bentzen SM, Skoczylas JZ, Overgaard M, Overgaard J. Radiotherapy-related lung fibrosis enhanced by tamoxifen. J Natl Cancer Inst. 1996; 88(13):918–922.

12. Spyropoulou D, Leotsinidis M, Tsiamita M, Spiropoulos K, Kardamakis D. Pulmonary function testing in women with breast cancer treated with radiotherapy and chemotherapy. In Vivo. 2009;23(5):867–871.

13. Fleckenstein K, Gauter-Fleckenstein B, Jackson IL, Rabbani Z, Anscher M, Vujaskovic Z. Using biological markers to predict risk of radiation injury. Semin Radiat Oncol. 2007;17(2):89–98.

14. Schytte T, Bentzen SM, Brink C, Hansen O. Changes in pulmonary function after definitive radiotherapy for NSCLC. Radiother Oncol. 2015;117:23–28.

15. Quanjer PH, Weiner DJ, Pretto JJ, Brazzale DJ, Boros PW. Measurement of FEF25-75% and FEF75% does not contribute to clinical decision making. Eur Respir J. 2014;43(4):1051–1058.

16. Casla S, Lopez-Tarruella S, Jerez Y, et al. Supervised physical exercise improves VO2max, quality of life, and health in early stage breast cancer patients: a randomized controlled trial. Breast Cancer Res Treat. 2015;153(2):371–382.

17. Robnett TJ, Machtay M, Vines EF, McKenna MG, Algazy KM, McKenna WG. Factors predicting severe radiation pneumonitis in patients receiving definitive chemoradiation for lung cancer. Int J Radiat Oncol Biol Phys. 2000;48(1):89–94.

18. Dehing-Oberije C, De Ruysscher D, van Baardwijk A, Yu S, Rao B, Lambin P. The importance of patient characteristics for the prediction of radiation-induced lung toxicity. Radiother Oncol. 2009;91(3):421–426.

19. Wang J, Cao J, Yuan S, et al. Poor baseline pulmonary function may not increase the risk of radiation-induced lung toxicity. Int J Radiat Oncol Biol Phys. 2013;85(3):798–804.

20. Yuan ST, Frey KA, Gross MD, et al. Changes in global function and regional ventilation and perfusion on SPECT during the course of radiotherapy in patients with non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2012;82:e631–e638.

21. Hernando ML, Marks LB, Bentel GC, et al. Radiation-induced pulmonary toxicity: a dose-volume histogram analysis in 201 patients with lung cancer. Int J Radiat Oncol Biol Phys. 2001;51(3):650–659.

22. Zhang XJ, Sun JG, Sun J, et al. Prediction of radiation pneumonitis in lung cancer patients: a systematic review.J Cancer Res Clin Oncol. 2012; 138(12):2103–2116.

Source: Breast Cancer: Targets and Therapy.
Originally published May 29, 2017.