Original Article pissn J Korean Soc Radiol 2011;65(3): Radiation-Induced Pulmonary Injury after Cyberknife Radiosurgery for Lung Mali

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1 Original Article pissn J Korean Soc Radiol 2011;65(3): Radiation-Induced Pulmonary Injury after Cyberknife Radiosurgery for Lung Malignancy: CT Appearance 1 악성폐종양의사이버나이프방사선수술후방사선폐손상의 CT 소견 1 Jae Young Seo, MD 1, Young Jun Cho, MD 1, Sun Young Lee, MD 2, Keum Won Kim, MD 1, Cheol Mok Hwang, MD 1, Dae Ho Kim, MD 1, Ho Jun Kim, MD 1 Departments of 1 Radiology, 2 Radiation Oncology, Konyang University College of Medicine, Daejeon, Korea Purpose: To evaluate the CT appearance of radiation-induced pulmonary injury in patients who have undergone cyberknife radiosurgery for lung malignancy. Materials and Methods: Thirty-four patients with 39 malignant lung tumors who underwent cyberknife radiosurgery were enrolled for evaluation. A total of Gy was administered in 3 fractions. We evaluated the CT appearance of radiation pneumonitis and radiation fibrosis. We also evaluated the location of radiation pneumonitis and the minimal dose which causes radiation pneumonitis. Results: Radiation pneumonitis and radiation fibrosis occurred in 95% and 90% of cases, respectively. CT patterns of radiation pneumonitis demonstrated 20 cases (54%) as ground glass opacities (GGO). GGO included only 7 cases (19%), while 6 cases (16%) had patchy consolidations and 4 cases (11%) were diffuse consolidations, respectively. Radiation pneumonitis demonstrated 30 cases (81%) as concentric patterns surrounding the tumor, while 7 cases (19%) included the eccentric patterns. The radiation pneumonitis appeared within the Gy (mean 21 Gy). CT findings of radiation fibrosis demonstrated as the modified conventional patterns, which decreased to 17 cases (65%), while 7 cases (27%) had mass-like patterns and 2 cases (8%) had scar-like patterns, respectively. Conclusion: Radiation pneumonitis after cyberknife radiosurgery commonly develops as concentric patterns surrounding a tumor. The mass-like pattern of radiation fibrosis was sometimes difficult to distinguish from tumor recurrence. Thus, knowledge of the CT finding of radiation-induced lung injury might be helpful in distinguishing pulmonary changes from tumor recurrence. Index terms Neoplasm, Lung Radiation Injuries CT Stereotactic Radiosurgery Received April 21, 2011; Accepted July 12, 2011 Corresponding author: Young Jun Cho, MD Department of Radiology, Konyang University College of Medicine, 685 Gasuwon-dong, Seo-gu, Daejeon , Korea. Tel Fax cyj126@paran.com Copyrights 2011 The Korean Society of Radiology 서론 방사선치료의목표는정상조직의손상을최소화하고동시에표적부위 (target area) 에정확한선량을집중조사하는것이다. 최근 3차원입체조형치료 (three-dimensional conformal radiotherapy) 나세기조절방사선치료 (intensity-modulated radiation therapy) 등의방사선치료법의발전으로인해보다많은선량을정확하게집중조사할수있게되었고주위정상조직으로의방사선조사도줄일수있게되었다 (1-5). 폐암은호흡에따라서위치와모양이변화하기때문에표적부위에정확한선량을집중조사하기어렵고, 종양주위의정상조직으로 조사량이증가하여폐손상이증가할수있는데, 폐손상을줄이는것이매우중요하며이를위해다양한기법들이발전해왔다 (6-9) 년에 FDA 의승인을받은사이버나이프방사선수술 (cyberknife radiosurgery) 은호흡패턴에따른종양의움직임을실시간추적하여호흡에따라움직이는종양에매우정확하게방사선량을조사할수있다 (5-9). 사이버나이프방사선수술의이러한특징은종양체적 (tumor volume) 주위의안전역 (safety margin) 을줄일수있고국소종양제어를향상시킨다 (9). 사이버나이프방사선수술을이용한폐암의소분할고선량정위방사선치료 (hypofractionated high-dose stereotactic radi- submit.radiology.or.kr 대한영상의학회지 2011;65(3):

2 악성폐종양의사이버나이프방사선수술후방사선폐손상의 CT 소견 ation therapy) 의치료결과는여러논문에보고되어있다 (8-13). 그러나이로인한폐손상의방사선학적소견에대해서는 거의보고가되지않았다 (9, 10, 14, 15). 사이버나이프방사선수술후폐손상의 CT 소견은총방사선 량 (total radiation dose), 분할조사 (fraction irradiation), 선량 분포 (dose distribution), 치료기간 (overall treatment time), 그 외다양한요인들에의해고식적방사선치료 (conventional radiotherapy) 와는다르게나타난다. 본논문에서는폐종양의사 이버나이프방사선수술후방사선에의한폐손상의 CT 소견에 대해후향적으로분석하였다. 대상과방법 대상환자 2007 년 3 월부터 2009 년 9 월까지폐종양으로 42 명의환자 ( 남자 22 명, 여자 20 명 ; 평균나이 61.5 세 ; 범위 29~83 세 ) 가 본원에서사이버나이프방사선수술을시행받았다. 이중폐쇄 성무기폐를동반하여방사선에의한폐손상을판별하기어려 운 8 명은대상에서제외하였다. 34 명의환자에서 39 개의종양이발견되었는데종양의직경 은 8~66 mm( 평균, 28 mm) 였다. 21 개의종양은일차성폐 암이었고 18 개의종양은전이성폐암이었다 (Table 1). 34 명의 Table 1. Summary of Malignant Lung Tumors Primary Lung Cancer 21 Lesions Squamous cell carcinoma 9 Adenocarcinoma 7 Non-small cell carcinoma 5 Metastatic lung cancer 18 lesions Rectal cancer 7 Breast cancer 4 Hepatocellular carcinoma 2 Tongue cancer 2 Cholangiocarcinoma 1 Colon cancer 1 Sarcoma 1 Tumor size 8-66 mm (mean, 28 mm) Tumor location 39 lesions RUL 8 RML 2 RLL 8 LUL 12 LLL 9 Peripheral lung 23 Central lung 16 Note.-LLL = left lower lobe, LUL = left upper lobe, RLL = right lower lobe, RML = right middle lobe, RUL = right upper lobe 환자중, 29명의환자는한개의종양에대해, 그리고 5명의환자는 2개의종양에대해사이버나이프방사선수술을시행받았다. 종양의위치는우상엽이 8개, 우중엽 2개, 우하엽이 8개, 좌상엽 12개, 좌하엽이 9개있었다. 39개중 23개의종양은벽측늑막으로부터 3 cm 이내에위치하고있었고, 16개의종양은중심폐 (central lung) 에위치하고있었다. 저자들은환자들의사이버나이프방사선수술의날짜, 기간, 추적관찰기간, 총방사선조사량, CT 영상소견, 종양의병리학적소견, 그리고합병증에대해검토하였다. 그러나폐기능과만성폐쇄성폐질환, 흡연력등의임상적소견은평가하지못했다. 실시간종양추적장치사이버나이프방사선수술중에정확하게종양의움직임을추적하기위해실시간종양추적장치 (real time tracking system) 를이용하였다. 폐안의표적부위의움직임은표지자 (fiducial marker) 를이용하여추적하였다. 기준좌표로삼기위해길이 3 mm, 직경 1 mm의 3~5개의금침을투시나 CT를이용하여종양의안이나근처에위치시켰다 (9)(Fig. 1). 또한세개의발광다이오드 (light-emitting diodes; LEDs) 를환자의몸앞쪽에부착하였다. 발광다이오드에서나오는신호를연속적인호흡운동주기에따라외부호흡패턴으로인식하고, 내부장기의움직임은호흡의패턴에따른금침의위치를파악하는 X-선을이용하여종양의움직임을실시간으로추적하였다 (5, 16). 치료계획치료계획을위한흉부컴퓨터단층촬영은표지자삽입 2~3 일후시행하였고영상은 2-mm 절편두께, 1.5-mm 증가로재구성하였다. 육안적종양체적 (gross tumor volume; GTV) 은폐의축면영상에서측정하였고종양의현미경학적침범의가능성과호흡추적장치의불확실성을최소화하기위하여육안적종양체적에 3 mm를더하여임상표적체적 (clinical target volume; CTV) 을구하였다. 그러나사이버나이프방사선수술은환자가호흡을하는동안정확하게표적기관의움직임을추적할수있기때문에계획용표적체적 (planning target volume; PTV) 은따로구하지않았다. 모든환자들은 130 개의비동일면조사 (non-coplanar beam) 로치료를받았다. 총방사선량은 24~60 Gy( 평균 50 Gy) 로 3회분할하여치료하였는데, 이중총선량이 40 Gy 미만은 6예, 41~50 Gy는 7예, 51~60 Gy는 26예였다. 평균방사선치료기간은 3.8일 ( 범위 3~5일 ) 이었다. 258 대한영상의학회지 2011;65(3): submit.radiology.or.kr

3 서재영외 A B Fig. 1. Percutaneous marker placement under CT guidance. A. Prior to treatment, fiducial markers were placed in or near the tumor under CT guidance, utilizing the same technique of CT-guided biopsy. B. Chest plain radiography shows three fiducial markers (arrows) in the tumor area of right upper lobe. 컴퓨터단층촬영영상컴퓨터단층촬영은두대의나선형스캐너 (Aquilion 64, Toshiba Medical System, Tokyo, Japan; MX8000, Philips Medical Systems, Best, The Netherlands) 를사용하여관전압 120 kvp, 관전류 200 mas 의프로토콜로시행하였고, 영상은 5-mm 절편두께 5-mm 증가로재구성하였다. 120 ml의비이온성조영제 (Ultravist 300; Bayer Schering Pharma, Berlin, Germany) 를이중주입기 (dual injector, Medrad Inc., Indianola, PA, USA) 를이용하여 2.5 ml/sec 로경정맥을통해투여하였고 15 ml의식염수를 2 ml/sec 속도로투여하였다. 촬영시작지연시간 (scan delay time) 은 50초였다. 총 196 개의 CT 영상을얻었는데이중 39개는치료전영상이었고나머지 157 개는추적관찰영상이었다. 치료전영상의촬영과방사선치료시작의평균기간은 28일 ( 범위 2~60 일 ) 이었다. 추적관찰 CT 영상은사이버나이프방사선수술후 2~3 개월간격으로규칙적으로시행하였다. 사이버나이프방사선수술종료와마지막추적관찰 CT 영상간의평균기간은 13개월 ( 범위 5~25 개월 ) 이었고평균 4.3회 ( 범위 2~8회 ) 의추적관찰을시행하였다. 사이버나이프방사선수술후방사선에의한폐손상은 2명의영상의학과의사와한명의방사선종양학과의사가합의하에평가하였으며, 방사선치료후임상적또는방사선학적변화들을근거로감염과같은다른원인은배제하였다. 방사선폐렴의 CT 영상소견은방사선조사부위폐의간유리음영과경화의존재로평가하였고 Kimura 등 (14) 의분류를근거로네가지형태로분류하였다 : (A) 간유리음영 (ground glass opacity); (B) 간유리음영과경화의혼합음영 (ground glass opacity and consolidation); (C) 반점형경화 (patchy consolidation); (D) 미만성경화 (diffuse consolidation). 방사선섬유증의 CT 영상소견은경화, 견인성기관지확장증그리고폐용적감소의여부로평가하였고 Koenig 등 (3) 의분류에따라다음의세가지형태로분류하였다 : (A) 변형된고식적형태 (modified conventional pattern); (B) 종양유사형태 (mass-like pattern); (C) 반흔유사형태 (scar-like pattern). 변형된고식적형태의섬유화는고식적섬유화와비슷하지만비교적덜광범위한것이고, 종양유사형태는종양의위치에국한된경화, 반흔유사형태는종양의위치에용적감소를동반하는선상의음영을말한다. 또한방사선폐렴과방사선섬유증의빈도와발생시기를분석하였다. 방사선폐손상이생기는위치는종양에대해방사선폐손상이생기는위치에따라 (A) 동심성 (concentric pattern) 과 (B) 편심성 (eccentric pattern) 의두가지형태로분류하여분석하였다. 방사선폐손상의발생범위는치료계획 CT의등선량곡선 (isodose curve) 과추적관찰 CT에서관찰된방사선폐손상의최대범위를비교하여평가하였다. 방사선폐손상의범위가항상등선량곡선과일치하는것은아니므로폐변화를보이는영역 submit.radiology.or.kr 대한영상의학회지 2011;65(3):

4 악성폐종양의사이버나이프방사선수술후방사선폐손상의 CT 소견 의최대범위와일치하거나가장가깝게인접하는등선량곡선으 로하였으며, 이등선량곡선의방사선량도측정하였다. 치료계 획 CT 영상과추적관찰 CT 영상이일치하지않을때에는폐혈 관이나늑골등주변구조물이비슷한부위에서비교하였다. 결과 방사선폐렴은 95%(37/39) 에서관찰되었고치료종료후 1~6 개월에발생하였다 ( 평균 4 개월 ). 방사선폐렴의가장흔한 소견은간유리음영과경화의혼합음영이 20 예 (54%) 였고, 간 Table 2. CT Finding of Radiation Induced Pulmonary Injury CT Finding No of Lesion (%) Radiation pneumonitis 37 of 39 lesions (95) GGO 7 (19) GGO and consolidation 20 (54) Patchy consolidation 6 (16) Diffuse consolidation 4 (11) Radiation fibrosis 26 of 29 lesions (90) Modified conventional pattern 17 (65) Mass-like pattern 7 (27) Scar-like pattern 2 (8) Location of radiation pneumonitis 37 lesions Concentric pattern 30 (81) Eccentric pattern 7 (19) Note.-GGO = ground glass opacity 유리음영이 7 예 (19%), 반점상경화 6 예 (16%), 미만성경화 4 예 (11%) 였다. 방사선폐렴의위치는종양에대해동심성이 30 예 (81%) 로편심성 7 예 (19%) 에비해많이발생하였다 (Table 2). 방사선폐렴은종양주위에관찰되었고등선량곡선 (isodose curve) 과비교하였을때, 30% 등선량선내에서 24 병변으로 가장많이발생하였고, 40% 등선량선내에서 8 병변, 20% 등 선량선내에서 4 병변, 50% 등선량선내에서 1 병변이발생하 였으며방사선폐렴이발생한최소방사선량은 13~38 Gy( 평균 21 Gy) 였다 (Fig. 2)(Table 3). 20% 등선량선을벗어나서발생 한방사선폐렴은없었으며이부위의방사선량은평균 14.3 Gy( 범위 13~16 Gy) 였다. 방사선섬유증은방사선수술후 6 개월이상추적관찰을시 행한 29 예를대상으로평가하였는데 90%(26/29) 에서관찰되 었다. 방사선섬유증은치료종료후 6~13 개월 ( 평균 8 개월 ) 에 발생하였다. 변형된고식적형태의섬유화가 17 예 (65%) 로가 Table 3. Comparison of the Dose Distribution at the Treatment Planning CT Scan and the Maximal Extent of Radiation Pneumonitis at the Follow Up CT Scan No. (%) of Radiation Pneumonitis Maximal Extent of Radiation Pneumonitis Dose Distribution (Gy) 4 (11) Within 20% isodose line (mean,14.3) 24 (65) Within 30% isodose line (mean, 21) 8 (21) Within 40% isodose line (mean, 25) 1 (3) Within 50% isodose line 38 A B C D Fig. 2. A 46-year-old woman with rectal cancer metastasis, 43 Gy/3 fractions. A. Lung window CT scan before cyberknife radiosurgery shows a well-circumscribed tumor in the right lower lobe. B. CT scan obtained 3 months after completion of cyberknife radiosurgery shows a decrease in the size of the tumor. C. CT scan obtained 5 months after completion of cyberknife radiosurgery shows the appearance of ground glass opacities (arrows) which are typical finding of radiation pneumonitis around the lung tumor. D. When compared with isodose curve image, this radiation pneumonitis developed within the 30% dose line (19 Gy, arrow) of the isodose curve. 260 대한영상의학회지 2011;65(3): submit.radiology.or.kr

5 서재영외 장많이발생하였고다음으로종양유사섬유화와반흔유사섬유화가각각 7예 (27%), 그리고 2예 (8%) 에서관찰되었다. 급성방사선폐렴에서보였던간유리음영과경화의혼합음영 20예중 6개월이상추적한 15예중에서 11예는위축이되면서변형된고식적형태의섬유화로변하였고, 4예에서종양유사섬유화로변하였다 (Fig. 3). 간유리음영을보였던 7예는모두 6개월이상추적하였는데간유리음영이소실되거나경화로진행하였고, 이중 2예는변형된고식적형태의섬유화로, 1 예는종양유사섬유화로 1예는반흔유사형태로변하였다 (Fig. 4). 반점상경화를보였던 6예중 6개월이상추적한 5예중에서 2예는변형된고식적형태의섬유화, 2예는종양유사섬유화, 1예는반흔유사형태로변하였다 (Fig. 5). 미만성경화를보였던 4예중 6개월이상추적한 2예에서변형된고식적형태의섬유화로변하였다. 고찰 폐종양은호흡에따른움직임으로인하여정확하게종양을추적하는것이어렵다. 고식적방사선치료는이로인해넓은안전역을필요로하였으며 60 Gy 이상의방사선을조사할경우 중증의방사선독성의위험이있어어려움이있었다 (9, 17). 사이버나이프방사선수술은 99% 의금으로만들어진표지자를이용하여 X-선투시하에종양의움직임을추적할수있다 (7). 환자가호흡을하는동안에종양이움직이게되면, 사이버나이프장치 (Cyberknife system) 는그종양의움직임을실시간으로추적하면서선상가속기를움직여정확하게종양이있는부위에입체적이면서집중적으로방사선량을조사하게된다. 이로인해국소종양제어를향상시키고종양주위의안전역을줄여중증의방사선폐렴의위험을감소시키게된다 (8, 9). 또한폐종양에대해소분할고선량정위방사선치료가가능하여치료기간도단축할수있다. 방사선에의한폐손상은대개방사선구 (radiation port) 주위에국한되어나타난다 (4, 17-20). 조사된폐용적은중증의방사선폐손상의가장중요한요인이다. 조사된폐용적이 50% 이상이면, 중증의방사선폐렴이발생할확률이높아지며 25% 이하이면증상이있는방사선폐렴이발생할확률이낮다 (21). 총방사선량또한중요한요인이다. 방사선폐렴의방사선소견은총방사선량이 20 Gy 미만일때에는거의나타나지않으며, 40 Gy 이상일때에는거의항상발생한다 (17, 21). 1일조사분할 (daily dose fraction) 과분할횟수도방사선폐렴과직접적인 A B C D Fig. 3. A 29-year-old man with sarcoma metastasis, 52 Gy/ 3 fractions. A. Pre-treatment CT scan shows a well-circumscribed tumor in the left lower lobe. B. The treatment planning CT scan shows isodose curves. Note the fiducial marker (black arrow) with a streak artifact in the tumor. C. CT scan obtained 4 months after completion of cyberknife radiosurgery shows a decrease in the size of the tumor. Peritumoral consolidation and ground glass opacity (arrows) are seen around tumor with concentric pattern. When compared with isodose curve image (B), this radiation pneumonitis developed within the 30% dose line (22 Gy) of the isodose curve. D. CT scan obtained 25 months after completion of cyberknife radiosurgery shows a well-defined consolidation, traction bronchiectasis and volume loss at the tumor site that resembles a mass (small arrows). This lesion was conformed mass-like radiation fibrosis. Note the fiducial marker (arrow) with a streak artifact in radiation fibrosis. submit.radiology.or.kr 대한영상의학회지 2011;65(3):

6 악성 폐종양의 사이버나이프 방사선수술 후 방사선 폐손상의 CT 소견 연관이 있는데, 1일 조사분할이 2.67 Gy 이상일 경우는 방사선 균 4개월)에 95%(37/39)에서 발생하였고, 방사선섬유화는 폐렴의 위험도를 높이는 가장 중요한 요인이 된다(21). 저자들 6~13개월(평균 8개월)에 90%(26/29)에서 발생하였다. 이는 의 연구에서 사이버나이프 방사선수술의 평균 총 방사선량은 이전의 정위방사선치료(Stereotactic body radiotherapy; 이하 50 Gy(범위, 24~60 Gy)였고 이를 3분할로 나누어 조사하였 SBRT)에 의한 방사선 폐손상에 대한 결과와 유사하였다(1, 3, 는데, 1일 조사분할은 8~20 Gy(평균 13 Gy)로 많았다. 이로 14, 15). Aoki 등(1)은 48 Gy를 4분획으로 주사하였을 때, 급 인해 방사선폐렴은 사이버나이프 방사선수술 후 1~6개월(평 성 방사선폐렴과 만성 방사선섬유증 모두 100%에서 보였으 A B C Fig. 4. A 65-year-old woman with adenocarcinoma, 54 Gy/ 3 fractions. A. Pre-treatment CT scan shows a small, well-circumscribed tumor (arrow) in the left lower lobe. B. CT scan obtained 3 months after completion of cyberknife radiosurgery shows a slight decrease in the size of the tumor (small arrow) and peritumoral ground glass opacity. Note the fiducial marker (arrow) with a streak artifact near the tumor. C. CT scan obtained 6 months after completion of cyberknife radiosurgery shows a scar-like lesion (small arrows) in the tumor area. A B C Fig. 5. A 63-year-old woman with squamous cell carcinoma, 54 Gy/ 3 fractions. A. Pretreatment CT scan shows well circumscribed tumor in right upper lobe. B. CT scan obtained 3 months after completion of radiosurgery shows a decrease in the size of the tumor. Patchy consolidation is seen around tumor with eccentric pattern (arrows). C. CT scan obtained 10 months after completion of radiosurgery shows well defined area of consolidation, volume loss, and traction bronchiectasis which are similar to but less extensive than conventional fibrosis (arrows). 262 대한영상의학회지 2011;65(3): submit.radiology.or.kr

7 서재영외 며, 발생시기는급성방사선폐렴은 2~6개월 ( 평균 4개월 ), 방사선섬유증은 6~15개월 ( 평균 11개월 ) 이었다. Takeda 등 (15) 은 50 Gy를 5분획으로나누어조사하였을때, 간유리음영으로보였던급성방사선폐손상은방사선치료후 3~4개월에 18%, 진한폐경화 (dense consolidation) 로보였던만성방사선폐손상은 6~11개월에 73% 에서있었다고보고하였다. Kimura 등 (14) 은 48~60 Gy를 4~14 분획으로조사하였을때, 급성방사선폐렴은 67.3%, 만성방사선섬유증은 100% 에서있었다고보고하였다. 본연구에서방사선폐렴은주로간유리음영과경화의혼합음영이종양주위에서동심성으로많이발생하였다. 또한방사선폐손상의최대범위를등선량곡선과비교하였을때정확하게일치하지는않았지만 20% 등선량선내에서발생하였고이부위의방사선량은평균 14.3 Gy(13~16 Gy) 였다. 따라서방사선폐렴은최소 14.3 Gy 이상의고선량 (high-dose) 부위에서발생하였다. 전통적인방사선폐렴 (classic radiation pneumonitis) 은방사선구와일치하여폐손상이나타나며, 임상증상도기침과같이경증으로나타난다. 반대로산발성방사선폐렴 (sporadic radiation pneumonitis) 은면역매개과정 (immunemediated process) 에의해방사선조사부위에서멀리떨어진부위에서도발생할수있으며, 보통중증의임상증상과높은사망률을보인다 (15). 본연구에서산발성방사선폐렴은나타나지않았으며, 전통적인방사선폐렴의형태로나타났다. Aoki 등 (1) 도 SBRT 후 16 Gy 이상의방사선량내에서방사선에의한폐손상이나타났다고보고하여본연구의결과와유사하였다. 방사선섬유증의세가지형태중, 변형된고식적형태의섬유화가가장흔히관찰되었다. 종양유사형태의섬유화는때때로종양과감별이어려웠는데, 본연구에서는종양유사형태의섬유화 7예에서모두방사선섬유증의소견인견인성기관지확장증, 그리고용적감소를보였다. 그러므로, 이러한소견들이종양유사방사선섬유증과재발성종양을감별하는데도움이될것이며 PET CT 스캔또한재발성종양으로부터종양유사형태의섬유화를감별하는데도움이되었다 (17)(Fig. 6). 그러나종양유사방사선섬유증내에종양이소량남아있다가재발할수있으므로확진이될때까지추적관찰은필요하였다. 본연구는몇개의제한점이있다. 첫째는방사선으로인한폐손상에영향을주는인자인폐기능검사나항암치료여부등의임상적소견을반영하지않은점이다. 둘째는방사선폐손상에대해조직병리학적진단을하지않아감염에의한폐병변을완전하게배제하지못하였다. 셋째는방사선폐손상의범위를측정하기위해추적관찰 CT와치료계획 CT의등선량곡선과비교하여분석할때주관적인요소가작용할한계가있었다. 사이버나이프방사선수술후방사선폐손상의발생시기와빈도는이전의 SBRT 에의한폐손상과유사한결과를보였다. 사이버나이프방사선수술후방사선폐렴의 CT 소견은간유리 A B C D Fig. 6. A 42-year-old woman with breast cancer metastasis, 60 Gy/ 3 fractions. A. Pretreatment CT scan shows a well circumscribed tumor in left upper lobe. B. CT scan obtained 2 months after completion of radiosurgery shows a decrease in the size of the tumor. C. CT scan obtained 6 months after completion of radiosurgery shows consolidation at tumor site that resembles mass (arrows). D. PET CT scan shows normal activity in the mass, thus we confirmed that there is no recurrent tumor in the area of radiation fibrosis. Note.-PET CT = positron emission tomography computed tomography submit.radiology.or.kr 대한영상의학회지 2011;65(3):

8 악성폐종양의사이버나이프방사선수술후방사선폐손상의 CT 소견 음영과경화의혼합음영이종양주위에서동심성으로많이발생하였고, 최소평균 14.3 Gy 이상의고선량부위에서발생하였다. 방사선섬유증중종양유사형태의섬유화는때때로재발성종양으로오인할수있어사이버나이프방사선수술후방사선폐손상의 CT 소견을아는것이재발성종양과감별하는데도움이된다. 참고문헌 1. Aoki T, Nagata Y, Negoro Y, Takayama K, Mizowaki T, Kokubo M, et al. Evaluation of lung injury after three-dimensional conformal stereotactic radiation therapy for solitary lung tumors: CT appearance. Radiology 2004;230: Bucci MK, Bevan A, Roach M 3rd. Advances in radiation therapy: conventional to 3D, to IMRT, to 4D, and beyond. CA Cancer J Clin 2005;55: Koenig TR, Munden RF, Erasmus JJ, Sabloff BS, Gladish GW, Komaki R, et al. Radiation injury of the lung after three-dimensional conformal radiation therapy. AJR Am J Roentgenol 2002;178: Park HJ, Kim KJ, Park SH, Kay CS, Oh JS. Early CT findings of tomotherapy-induced radiation pneumonitis after treatment of lung malignancy. AJR Am J Roentgenol 2009;193: W209-W Kim GJ, Shim SJ, Kim JH, Min CK, Chung WK. Evaluation of Real-time Measurement Liver Tumor s Movement and SynchronyTM System s Accuracy of Radiosurgery using a Robot CyberKnife. J Korean Soc Ther Radiol Oncol 2008; 26: Chai GY, Lim YK, Kang KM, Jeong BG, Ha IB, Park KB, et al. Comparison of Three- and Four-dimensional Robotic Radiotherapy Treatment Plans for Lung Cancers. J Korean Soc Ther Radiol Oncol 2010;28: Sotiropoulou E, Stathochristopoulou I, Stathopoulos K, Verigos K, Salvaras N, Thanos L. CT-guided fiducial placement for cyberknife stereotactic radiosurgery: an initial experience. Cardiovasc Intervent Radiol 2010;33: Baba F, Shibamoto Y, Tomita N, Ikeya-Hashizume C, Oda K, Ayakawa S, et al. Stereotactic body radiotherapy for stage I lung cancer and small lung metastasis: evaluation of an immobilization system for suppression of respiratory tu- mor movement and preliminary results. Radiat Oncol 2009;4:15 9. van der Voort van Zyp NC, Prévost JB, Hoogeman MS, Praag J, van der Holt B, Levendag PC, et al. Stereotactic radiotherapy with real-time tumor tracking for non-small cell lung cancer: clinical outcome. Radiother Oncol 2009; 91: Haasbeek CJ, Lagerwaard FJ, de Jaeger K, Slotman BJ, Senan S. Outcomes of stereotactic radiotherapy for a new clinical stage I lung cancer arising postpneumonectomy. Cancer 2009;115: Inoue T, Shimizu S, Onimaru R, Takeda A, Onishi H, Nagata Y, et al. Clinical outcomes of stereotactic body radiotherapy for small lung lesions clinically diagnosed as primary lung cancer on radiologic examination. Int J Radiat Oncol Biol Phys 2009;75: Uematsu M, Shioda A, Suda A, Fukui T, Ozeki Y, Hama Y, et al. Computed tomography-guided frameless stereotactic radiotherapy for stage I non-small cell lung cancer: a 5-year experience. Int J Radiat Oncol Biol Phys 2001;51: Brown WT, Wu X, Amendola B, Perman M, Han H, Fayad F, et al. Treatment of early non-small cell lung cancer, stage IA, by image-guided robotic stereotactic radioablation-- CyberKnife. Cancer J 2007;13: Kimura T, Matsuura K, Murakami Y, Hashimoto Y, Kenjo M, Kaneyasu Y, et al. CT appearance of radiation injury of the lung and clinical symptoms after stereotactic body radiation therapy (SBRT) for lung cancers: are patients with pulmonary emphysema also candidates for SBRT for lung cancers? Int J Radiat Oncol Biol Phys 2006;66: Takeda T, Takeda A, Kunieda E, Ishizaka A, Takemasa K, Shimada K, et al. Radiation injury after hypofractionated stereotactic radiotherapy for peripheral small lung tumors: serial changes on CT. AJR Am J Roentgenol 2004;182: Collins BT, Vahdat S, Erickson K, Collins SP, Suy S, Yu X, et al. Radical cyberknife radiosurgery with tumor tracking: an effective treatment for inoperable small peripheral stage I non-small cell lung cancer. J Hematol Oncol 2009;2:1 17. Choi YW, Munden RF, Erasmus JJ, Park KJ, Chung WK, Jeon SC, et al. Effects of radiation therapy on the lung: radio- 264 대한영상의학회지 2011;65(3): submit.radiology.or.kr

9 서재영외 logic appearances and differential diagnosis. Radiographics 2004;24: ; discussion Movsas B, Raffin TA, Epstein AH, Link CJ Jr. Pulmonary radiation injury. Chest 1997;111: Abratt RP, Morgan GW. Lung toxicity following chest irradiation in patients with lung cancer. Lung Cancer 2002;35: Kim TH, Cho KH, Pyo HR, Lee JS, Zo JI, Lee DH, et al. Dosevolumetric parameters for predicting severe radiation pneumonitis after three-dimensional conformal radiation therapy for lung cancer. Radiology 2005;235: Park KJ, Chung JY, Chun MS, Suh JH. Radiation-induced lung disease and the impact of radiation methods on imaging features. Radiographics 2000;20:83-98 악성폐종양의사이버나이프방사선수술후방사선폐손상의 CT 소견 1 서재영 1 조영준 1 이선영 2 김금원 1 황철목 1 김대호 1 김호준 1 목적 : 악성폐종양으로사이버나이프방사선수술을받은환자들에서방사선폐손상의 CT 소견에대해분석하고자하였다. 대상과방법 : 본원에서사이버나이프방사선수술을시행받은 34명의환자의 39개악성폐종양을대상으로하였다. 모든환자는총방사선량 24~60 Gy( 평균 50 Gy) 를 3회분할하여치료하였다. 방사선폐렴의 CT 소견은방사선조사부위폐의간유리음영과경화의존재로평가하였고, 방사선섬유증은경화, 견인성기관지확장증그리고폐용적감소의여부로평가하였다. 또한추적 CT에서방사선폐렴의위치와발생하는부위의최소방사선량을각각평가하였다. 결과 : 방사선폐렴과방사선섬유증은각각 95%(37/39) 와 90%(26/29) 에서발생하였다. 방사선폐렴의 CT 소견은간유리음영과경화의혼합음영이 20예 (54%), 간유리음영이 7예 (19%), 반점상경화 6예 (16%), 미만성경화 4예 (11%) 였다. 방사선폐렴은종양에대해동심성이 30예 (81%) 로편심성 7예 (19%) 에비해많이발생하였다. 방사선폐렴이발생한최소방사선량은 13~38 Gy( 평균 21 Gy) 였다. 방사선섬유증은변형된고식적형태의섬유화가 17 예 (65%) 로가장많이발생하였고, 종양유사섬유화와반흔유사섬유화가각각 7예 (27%), 2예 (8%) 에서관찰되었다. 결론 : 사이버나이프방사선수술후방사선폐렴은종양주위에서동심성으로많이발생하였다. 방사선섬유증중종양유사형태의섬유화는때때로재발성종양과감별이어려우므로방사선폐손상의 CT 소견에대해아는것이재발성종양과방사선폐손상을감별하는데도움이될수있다. 건양대학교의과대학 1 영상의학과학교실, 2 방사선종양학과학교실 submit.radiology.or.kr 대한영상의학회지 2011;65(3):

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