Use of ACTH and cortisone in the treatment of post-irradiation pulmonary reaction.

Abstract

With the present trend toward higher radiation dosages in an attempt to control pulmonary, esophageal, and other thoracic lesions, the danger of producing post-irradiation pulmonary fibrosis has increased. Adrenocorticotropic hormone (ACTH) has been reported by Kennedy et al. (1) as producing beneficial effects in a patient with beryllium pulmonary granulomatosis. West and his associates (2) have observed clinical improvement in two patients with pulmonary fibrosis who were treated with ACTH and cortisone. Because of these results, ACTH and cortisone have been recently employed in a patient in whom an unusually severe post-irradiation reaction in the lung occurred after roentgen therapy for a pulmonary metastasis. Inasmuch as the hormone appeared not only to halt but partially to reverse the acute phase of the reaction, it has seemed worth while to record this case. G. K., a 68-year-old female, was referred in May 1950, for consideration of radiotherapy of a solitary metastatic nodule in the right middle lobe of the lung (Fig. 1). In November 1945 this patient had undergone intestinal resection for carcinoma of the sigmoid colon. A small rounded shadow of increased density in the left mid lung field had increased gradually from that time until January 1949, when resection of the left lower lobe was performed. The nodule proved to be metastatic from the carcinoma of the colon. Following this operation, the patient had no pulmonary complaints. A chest film in October 1949, ten months after the left lower lobectomy, revealed a single asymptomatic nodule in the right middle lobe, and by May 1950 this new nodule measured 4 cm. in diameter. After discussion of the possibility of resultant fibrosis and “radiation lobectomy,” radical x-ray therapy was instituted. Multiple small-port beam-directed x-ray therapy was used, following the plan of Winternitz and Smithers (3). The factors were 200 kv., 25 ma., 50 cm. target-skin distance, h.v.l. 0.9 mm. Cu. Eight anterior and eight posterior circular ports, each 8 cm. in diameter, were used, with cross-firing in such a manner as to “by-pass” the volume of tumor-bearing tissue. Each port received 2,250 r measured in air. A minimum tumor dose of 4,500 r was delivered in fifty-two days to a sphere-shaped volume of lung approximately 8 cm. in diameter. This included the nodule and the adjacent hilus. Treatment was concluded July 7, 1950. Three days later (July 10) the patient again entered the hospital because of exhaustion, weakness, tachycardia, poor appetite, nausea, and vomiting. On admission her temperature was 100.8°, pulse 90, and respirations 20. X-ray examination of the chest on July 12, 1950, showed faint streaky shadows in the periphery of the right upper lobe compatible with either virus pneumonia or radiation fibrosis. Because these abnormal densities were weIl out of the area over which the 16 small ports converged, radiation fibrosis was considered less likely at this early date.