Version May 2024
| Time since irradiation | Pathologic changes | Radiographic findings | Clinical manifestations |
| Hours to days | Immediate phase - Localized pulmonary edema, exudative alveolitis, loss of type I pneumocytes, increased surfactant | None | Asymptomatic |
| 2 to 4 weeks | Latent phase - Increased goblet cells and secretions in radiation port, mild CD4+ lymphocytic alveolitis throughout the lung | Bilateral perivascular haziness/ground-glass | Cough, occasionally, in those with large radiation ports |
| 3 to 12 weeks | Acute exudative phase - Sloughing of endothelial and epithelial cells, microvascular thrombosis, hyaline membrane formation | Early signs of ground-glass attenuation in irradiated areas | Subacute clinical presentation - Fevers (typically mild), dyspnea with exertion, cough (generally non productive), pleuritic chest pain, malaise, weight loss, crackles on exam, pleural effusion (10%) |
| 3 to 5 months | Intermediate phase - Resolution of alveolar exudate and dissolution of hyaline membranes Fibroblast migration proliferation, & collagen deposition in the most involved areas | Ground-glass attenuation in irradiated areas | Continued symptoms of subacute disease, frequently with diminishing severity |
| 5 to 9 months | Late intermediate transitioning to fibrotic phase | Organization of ground-glass attenuations into patchy, sometimes nodular consolidations, followed by confluent consolidation in the radiation port | Stabilization of residual symptoms from subacute disease, if present |
| After 9 to 12 months | Fibrotic phase - Areas of fibroblast-predominant healing in the intermediate phase result in myofibroblast proliferation and collagen deposition with local loss of lung volume. Progressive fibrosis may occur. | Organized opacities may resolve or become fibrotic. Linear opacities and dense consolidation are typical; fibrotic changes are accompanied by traction bronchiectasis, which can develop superinfection. | Patients may present clinically with cough and dyspnea in this phase as a result of scarring. Patients with previous subacute disease typically have stable or mildly improved symptoms. Fibrotic areas will produce fine crackles on exam. |
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