Advantages and disadvantages of corticosteroid use for acute exacerbation of interstitial pneumonia after pulmonary resection

Safe surgical lung biopsy in the diagnosis of interstitial lung disease under strict patient selection

BACKGROUND

Surgical lung biopsy (SLB) is recommended for diagnosing idiopathic pulmonary fibrosis in patients with interstitial lung disease (ILD). The safety of SLB is controversial, as the reported mortality and mobility vary according to the patient's background. This study aimed to assess SLB safety using eligibility criteria that excluded patients at the risk of postoperative complications, including acute exacerbations.

METHODS

We retrospectively reviewed 94 patients with ILD who underwent SLB at our institution between 2010 and 2021. Two peripheral lung locations were resected using 3-port video-assisted thoracoscopic surgery. Complications within 30 and 90 days after surgery were evaluated based on the Clavien-Dindo classification. Preoperative high-resolution computed tomography findings were evaluated according to the guidelines of the American Thoracic Society, 2018. Patients with a radiological usual interstitial pneumonia (UIP) pattern, preoperative oxygen dependence, or organ failure incompatible with general anesthesia were excluded from the study.

RESULTS

The median age of the patients was 66 years. The median vital capacity percentage was 81.0%. The following radiological patterns were observed: UIP, 0%; probable UIP, 30%; indeterminate UIP, 14%; and alternative diagnoses, 56%. The median operative time was 45 min. The 30- and 90-day mortality rates were both 0%. One patient (1%) developed an acute exacerbation of ILD on postoperative day 66. Other grade ≥ III complications were observed in 4 cases (4%), 3 of which were associated with air leakage. Home oxygen therapy was not initiated.

CONCLUSIONS

By excluding patients with poor SLB indications, our criteria are suggested to be valid for safe SLB.

Perioperative Anti-Fibrotic Treatment Prevents Acute Exacerbation of Idiopathic Pulmonary Fibrosis After Lung Cancer Surgery

BACKGROUND

The surgical treatment of concomitant lung cancer in patients with idiopathic pulmonary fibrosis is challenging due to the risk of life-threatening complications such as acute exacerbation development in the perioperative period. Few studies have investigated the role of anti-fibrotic drugs in this setting. The aim of this multicenter retrospective study was to evaluate the incidence of acute exacerbation, according to Collard, after lung resection in patients affected by concomitant idiopathic pulmonary fibrosis and lung cancer who were or were not on antifibrotic treatment. Secondary outcomes included: 30 and 90-day mortality and an estimation of overall and disease-free survival.

MATERIAL AND METHODS

The study population consisted of patients affected by idiopathic pulmonary fibrosis who received curative-intent lung surgery in three Italian academic centers between 2015 and 2022. Patients were divided into two groups based on whether they were on perioperative treatment with anti-fibrotic drugs (chronical or prophylactic use) or not. To define predictors of acute exacerbation, univariate and multivariable exact logistic regression analysis were performed. The Kaplan-Meier method with log-rank test was used to estimate survival.

RESULTS

During the study period, n = 55 patients underwent lung resection for lung cancer, including 29 patients who were treated with antifibrotic agents. Although the sample size was small and few events were studied, the incidence of acute exacerbation was significantly lower among patient on anti-fibrotic therapy (3.4% vs. 23.1%, p = 0.044); in addition, anti-fibrotic treatment was the strong factor preventing acute exacerbation at the multivariable analysis (OR 0.089, p = 0.038). Post-operative 30- and 90-day mortality rates were not significantly lower in the anti-fibrotic treatment group (0% and 0% vs. 7.7% and 11.5%, p = 0.21 and p = 0.099, respectively). Overall and disease-free survival rates were similar.

CONCLUSIONS

Considering the limitations of this retrospective study with a small sample size, anti-fibrotic perioperative treatment was associated with reduced incidence of acute exacerbation. Based on these real-world data, this pathway could be proposed as a prophylactic treatment in patients with concomitant idiopathic pulmonary fibrosis and cancer undergoing lung resection.

Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection

PURPOSE

Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function.

METHODS

This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery.

RESULTS

The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively).

CONCLUSION

Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Risk factors for acute exacerbation of interstitial lung disease following lung cancer resection: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to investigate the risk factors for acute exacerbation (AE) of interstitial lung disease (ILD) following lung cancer resection.

METHODS

We performed a literature screening on the databases including PubMed, Embase, Ovid MEDLINE® and the Web of Science for related studies published up to January 2021. Eligible studies were included and data on risk factors related to postoperative AE were extracted. All analyses were performed with random-effect model.

RESULTS

A total of 12 studies of 2655 lung cancer patients with ILD were included in this article. The meta-analysis indicated that male [odds ratios (ORs) = 1.78, 95% confidence interval (CI): 1.02-3.11, P = 0.041], usually interstitial pneumonia pattern on CT (OR = 1.52, 95% CI: 1.06-2.17, P = 0.021), Krebs von den Lungen-6 [standardized mean difference (SMD) = 0.50, 95% CI: 0.06-0.94, P = 0.027], white blood cell (SMD = 0.53, 95% CI: 0.12-0.93, P = 0.010), lactate dehydrogenase (SMD = 0.47, 95% CI: 0.04-0.90, P = 0.032), partial pressure of oxygen (weighted mean difference = -3.09, 95% CI: -5.99 to -0.19, P = 0.037), surgery procedure (OR = 2.31, 95% CI: 1.42-3.77, P < 0.001) and operation time (weighted mean difference = 28.26, 95% CI: 1.13-55.39, P = 0.041) were risk factors for AE of ILD following lung cancer resection.

CONCLUSIONS

We found that males, usually interstitial pneumonia pattern on CT, higher levels of Krebs von den Lungen-6, lactate dehydrogenase, white blood cell, lower partial pressure of oxygen, greater scope of operation and longer operation time were risk factors for AE of ILD following lung cancer resection. Patients with these risk factors should be more prudently selected for surgical treatment and be monitored more carefully after surgery.