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1. Bronchoscopy with transbronchial biopsies

The patient's course and repeat thoracic CT scan are unusual for radiation pneumonitis. Patients usually do not present with recurrent symptoms after full resolution. In addition, there is now significant consolidation outside of the radiation port to the thymus, including the opposite lung. VATS seems over aggressive at this point since the diagnosis might be established by bronchoscopy. The patient's physician was uncomfortable repeating the course of corticosteroids or empiric antibiotics without an established diagnosis. It is unclear how a PET scan could have helped.

Bronchoscopy was performed with bronchoalveolar lavage (BAL) and transbronchial lung biopsies obtained from left lower lobe. BAL cell count differential demonstrated 12% eosinophils. The transbronchial biopsies were read as "subacute injury with organization.  Extravascular eosinophils suggestive of eosinophilic pneumonia".

Eosinophilic pneumonia has been reported most often in association with radiation therapy for breast cancer (1,2). Patients demonstrate alveolar infiltrates that develop outside of the radiation port within 12 months of radiation therapy, without other identifiable cause of eosinophilic pneumonia. Patients typically respond well to corticosteroids.

Our patient was again treated with corticosteroids and responded well.

References

1. Solomon J, Schwarz M. Drug-, toxin-, and radiation therapy-induced eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):192-7. [CrossRef] [PubMed]
2. Cottin V, Frognier R, Monnot H, Levy A, DeVuyst P, Cordier JF; Groupe d'Etudes et de Recherche sur les Maladies "Orphelines" Pulmonaires. Chronic eosinophilic pneumonia after radiation therapy for breast cancer. Eur Respir J. 2004 Jan;23(1):9-13. [CrossRef] [PubMed]

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