Safety and effectiveness of pirfenidone combined with carboplatin-based chemotherapy in patients with idiopathic pulmonary fibrosis and non-small cell lung cancer: A retrospective cohort study

Drug-induced interstitial lung disease: a narrative review of a clinical conundrum

INTRODUCTION

Drug-induced interstitial lung disease (DI-ILD) is increasing in incidence, due to the use of many new drugs across a broad range of cancers and chronic inflammatory diseases. The presentation and onset of DI-ILD are variable even for the same drug across different individuals. Clinical suspicion is essential for identifying these conditions, with timely drug cessation an important determinant of outcomes.

AREAS COVERED

This review provides a comprehensive and up-to-date summary of epidemiology, risk factors, pathogenesis, diagnosis, treatment, and prognosis of DI-ILD. Relevant research articles from PubMed and Medline searches up to September 2023 were screened and summarized. Specific drugs including immune checkpoint inhibitors, CAR-T cell therapy, methotrexate, and amiodarone are discussed in detail. The potential role of pharmacogenomic profiling for lung toxicity risk is considered.

EXPERT OPINION

DI-ILD is likely to be an increasingly important contributor to respiratory disability in the community. These conditions can negatively impact quality of life and patient longevity, due to associated respiratory compromise as well as cessation of evidence-based therapy for the underlying disease. This clinical conundrum is relevant to all areas of medicine, necessitating increased understanding and greater vigilance for drug-related lung toxicity.

Acute exacerbation of postoperative idiopathic pulmonary fibrosis in a patient with lung cancer caused by invasive mechanical ventilation: A case report

Study design and objection

Idiopathic pulmonary fibrosis (IPF) is a progressive chronic disease characterized by damage to alveolar epithelial cells and abnormal deposition of the extracellular matrix. Although the disease course for most patients with IPF is progressive, in some cases the disease may appear as an acute exacerbation. Mechanical ventilation life support plays an important role in the treatment of patients with IPF but is associated with an increased risk of acute exacerbation of IPF (AE-IPF). Treatment is controversial and is not supported by sufficient clinical evidence. AE-IPF after lung cancer surgery is extremely rare, and the etiology and mechanism remain unclear, and its clinical manifestations are very similar to acute pulmonary edema and are easily misdiagnosed.

Summaryof background data

We describe a 66-year-old male patient with IPF complicated with lung cancer who underwent thoracoscopic resection of the right upper lobe of the lung. Seventy-two hours after surgery, chest computed tomography indicated that AE-IPF in the mechanically ventilated lung was significantly greater than that in the operated lung. The patient's own lung was used as a control and proved that mechanical ventilation can lead to AE-IPF.

Results and conclusions

By highlighting the clinical characteristics of patients with acute exacerbation of idiopathic pulmonary fibrosis, this article will enhance the vigilance of clinicians on AE-IPF caused by mechanical ventilation. Importantly, preoperative nintedanib therapy should be applied in advance to prevent AE-IPF on in patients with mild IPF. Precise pulmonary protective ventilation strategies need to be formulated for patients with IPF to reduce mortality.

Synchronous percutaneous core-needle biopsy and microwave ablation for stage I non-small cell lung cancer in patients with Idiopathic pulmonary fibrosis: initial experience

PURPOSE

This study aimed to retrospectively evaluate the safety and feasibility of computed tomography (CT)-guided synchronous percutaneous core-needle biopsy (CNB) and microwave ablation (MWA) for stage I non-small cell lung cancer (NSCLC) in patients with idiopathic pulmonary fibrosis (IPF).

METHODS

From January 2019 to January 2023, nineteen stage I NSCLC patients with IPF underwent CT-guided synchronous percutaneous CNB and MWA in this study. The technical success rate, complications, local tumor progression (LTP) and overall survival (OS) were observed, and the effect of synchronous percutaneous CNB and MWA were evaluated.

RESULTS

The technical success rate of synchronous percutaneous CNB and MWA was 100%. With a median follow-up time of 20.36 months, the median OS was 25 months (95% CI: 21.79, 28.20). The six-, twelve- and eighteen-month OS rates were 94.73%, 89.47% and 57.89%, respectively. The six-, twelve- and eighteen-month LTP rates were 0%, 10.52% and 31.57%, respectively. Major complications including pneumothorax, bronchopleural fistula and pneumonia occurred in 26.32% (5/19) patients. None of the patients died during the procedure.

CONCLUSIONS

According to the results of the current study, CT-guided synchronous percutaneous CNB and MWA appears to be a safe and effective for stage I NSCLC in patients with IPF and providing an alternative therapeutic option for local control of pulmonary malignancy in high-risk patients.

Epidemiology and comorbidities in idiopathic pulmonary fibrosis: a nationwide cohort study

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is frequently accompanied by comorbidities, with the management of these comorbidities crucial for clinical outcomes. This study investigated the prevalence, incidence, changes over time, and clinical impact of comorbidities in IPF patients, based on nationwide claims data in South Korea.

METHODS

This retrospective cohort study utilised nationwide health claim data in South Korea between 2011 and 2019. Patients with IPF were defined as those with ICD-10 code J84.1 and Rare Intractable Disease code V236 who made at least one claim per year. Patients were classified by sex, age, pirfenidone use and burden of comorbidities, and differences among groups were determined.

RESULTS

The yearly prevalence rate of IPF increased from 7.50 to 23.20 per 100,000 people, and the yearly incidence rate increased from 3.56 to 7.91 per 100,000 person-years over time. The most common respiratory comorbidity was chronic obstructive pulmonary disease (37.34%), followed by lung cancer (3.34%), whereas the most common non-respiratory comorbidities were gastro-oesophageal reflux disease (70.83%), dyslipidaemia (62.93%) and hypertension (59.04%). The proportion of some comorbidities differed by sex, age and use of pirfenidone. The proportion of lung cancer was higher in patients treated with pirfenidone, whereas the proportion of anxiety and depression were lower in patients not treated with pirfenidone. Charlson comorbidity index ≥ 4 was associated with increases in hospitalisations and total medical costs.

CONCLUSIONS

The yearly prevalence and incidence of IPF and comorbidities in Korea increased over time. These comorbidities affected the use of pirfenidone and medical resources.

Outcome following nivolumab treatment in patients with advanced non-small cell lung cancer and comorbid interstitial lung disease in a real-world setting

Background

Up to 10% of patients with advanced non-small cell lung cancer (aNSCLC) have pre-existing interstitial lung disease (ILD). These patients are usually excluded from immunotherapy clinical trials. Consequently, knowledge on outcomes following nivolumab treatment in these patients remains limited. The primary objective of this study was to evaluate survival outcome following nivolumab treatment in ILD patients with pre-treated aNSCLC in the real-world setting.

Patients and methods

The study included all patients with aNSCLC recorded in the French hospital database, starting nivolumab in 2015-2016. Patients were stratified by pre-existing ILD and three subgroups were studied [auto-immune or granulomatous (AI/G) ILD, other known causes ILD and idiopathic ILD]. Time to discontinuation of nivolumab treatment [time to treatment duration (TTD)] and overall survival (OS) were estimated using Kaplan-Meier survival analysis.

Results

Of 10,452 aNSCLC patients initiating nivolumab, 148 (1.4%) had pre-existing ILD. Mean age at nivolumab initiation was 64.6 ± 9.4 years in ILD and 63.8 ± 9.6 years in non-ILD. Compared to non-ILD, patients in the ILD group were more frequently men (p < 0.05) and had more comorbidities (p < 0.001). There was no significant difference between ILD and non-ILD groups for median TTD (2.5 versus 2.8 months; p = 0.6) or median OS (9.6 versus 11.9 months; p = 0.1). Median OS in AI/G ILD (n = 14), other known causes ILD (n = 75), and idiopathic ILD (n = 59) were 8.6, 10.7, and 9.6 months, respectively.

Conclusion

In this large cohort of aNSCLC patients with ILD, outcomes are similar to those obtained in the non-ILD population. Immunotherapy could be beneficial for these patients.

Idiopathic pulmonary fibrosis and lung cancer: future directions and challenges

Idiopathic pulmonary fibrosis (IPF) is a progressive disease of pulmonary scarring. New treatments slow disease progression and allow pulmonary fibrosis patients to live longer. Persistent pulmonary fibrosis increases a patient's risk of developing lung cancer. Lung cancer in patients with IPF differs from cancers that develop in the non-fibrotic lung. Peripherally located adenocarcinoma is the most frequent cell type in smokers who develop lung cancer, while squamous cell carcinoma is the most frequent in pulmonary fibrosis. Increased fibroblast foci in IPF are associated with more aggressive cancer behaviour and shorter doubling times. Treatment of lung cancer in fibrosis is challenging because of the risk of inducing an exacerbation of fibrosis. In order to improve patient outcomes, modifications of current lung cancer screening guidelines in patients with pulmonary fibrosis will be necessary to avoid delays in treatment. 2-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) computed tomography (CT) imaging can help identify cancer earlier and more reliably than CT alone. Increased use of wedge resections, proton therapy and immunotherapy may increase survival by decreasing the risk of exacerbation, but further research will be necessary.

Management of Lung Cancer in the Patient with Interstitial Lung Disease

Patients with interstitial lung disease (ILD), especially those with pulmonary fibrosis, are at increased risk of developing lung cancer. Management of lung cancer in patients with ILD is particularly challenging. Diagnosis can be complicated by difficulty differentiating lung nodules from areas of focal fibrosis, and percutaneous biopsy approaches confer an increased risk of complications in those with pulmonary fibrosis. Lung cancer treatment in these patients pose several specific considerations. The degree of lung function impairment may preclude lobectomy or surgical resection of any type. Surgical resection can trigger an acute exacerbation of the underlying ILD. The presence of ILD confers an increased risk of pneumonitis with radiotherapy, and many of the systemic therapies also carry an increased risk of pneumonitis in this population. The safety of immunotherapy in the setting of ILD remains to be fully elucidated and concerns remain as to triggering pneumonitis. The purpose of this review is to summarize the evidence regarding consideration for tissue diagnosis, chemotherapy and immunotherapy, radiotherapy, and surgery, in this patient population and discuss emerging areas of research. We also propose a multidisciplinary approach and practical considerations for monitoring for ILD progression during lung cancer treatment.

特发性肺纤维化相关的肺癌发病机制的研究进展

Idiopathic pulmonary fibrosis (IPF) is the most common interstitial lung disease (ILD) of unknown causes, which is characterized by pulmonary fibrosis. The median survival period after diagnosis is about 2-4 years. In recent years, the incidence rate of lung cancer associated with IPF (IPF-LC) is increasing, and the prognosis is worse than that of IPF alone. Pulmonary fibrosis may be closely associated with the occurrence and development of lung cancer. Although the pathogenesis of IPF-LC is still unclear, the current research shows that there are similarities between the pathogenesis of these two diseases at molecular and cellular levels. At present, the research on the cellular and molecular mechanism of lung cancer related to pulmonary fibrosis has become the focus of researchers' attention. This article reviews the related literature, focusing on the latest status of the cellular and molecular mechanisms and treatment of IPF-LC, hoping to help clinicians understand IPF-LC.
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[French practical guidelines for the diagnosis and management of IPF - 2021 update, full version]

BACKGROUND

Since the previous French guidelines were published in 2017, substantial additional knowledge about idiopathic pulmonary fibrosis has accumulated.

METHODS

Under the auspices of the French-speaking Learned Society of Pulmonology and at the initiative of the coordinating reference center, practical guidelines for treatment of rare pulmonary diseases have been established. They were elaborated by groups of writers, reviewers and coordinators with the help of the OrphaLung network, as well as pulmonologists with varying practice modalities, radiologists, pathologists, a general practitioner, a head nurse, and a patients' association. The method was developed according to rules entitled "Good clinical practice" in the overall framework of the "Guidelines for clinical practice" of the official French health authority (HAS), taking into account the results of an online vote using a Likert scale.

RESULTS

After analysis of the literature, 54 recommendations were formulated, improved, and validated by the working groups. The recommendations covered a wide-ranging aspects of the disease and its treatment: epidemiology, diagnostic modalities, quality criteria and interpretation of chest CT, indication and modalities of lung biopsy, etiologic workup, approach to familial disease entailing indications and modalities of genetic testing, evaluation of possible functional impairments and prognosis, indications for and use of antifibrotic therapy, lung transplantation, symptom management, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are aimed at guiding the diagnosis and the management in clinical practice of idiopathic pulmonary fibrosis.

Pirfenidone promotes the levels of exosomal miR-200 to down-regulate ZEB1 and represses the epithelial-mesenchymal transition of non-small cell lung cancer cells

Non-small cell lung cancer (NSCLC) is the malignancy with highest mortality and morbidity. Cancer-associated fibroblasts (CAFs) are the most abundant stromal cells in the tumor microenvironment of NSCLC. This research is performed to explore the biological functions of pirfenidone (PFD) to repress the malignant phenotypes of NSCLC cells, and its regulatory effects on exosomal microRNA-200 (exo-miR-200) derived from CAFs. In the present work, we report that, exo-miR-200 secreted by CAFs restrains the migration, invasion and epithelial-mesenchymal transition (EMT) of NSCLC cells; PFD treatment promotes the secretion of exo-miR-200 from CAFs and enhances the tumor-suppressive properties of exo-miR-200 on NSCLC cells; zinc finger E-box binding homeobox 1 (ZEB1) is identified as a target of miR-200, and PFD treatment repressed the expression of ZEB1 in NSCLC cells via inducing the expression and secretion of miR-200 in CAFs. In conclusion, PFD-induced miR-200 overexpression in CAFs inhibits ZEB1 expression in NSCLC cells, and thus decelerates the migration, invasion and EMT process. Our study may provide clues for the treatment of NSCLC.

French practical guidelines for the diagnosis and management of idiopathic pulmonary fibrosis - 2021 update. Full-length version

BACKGROUND

Since the latest 2017 French guidelines, knowledge about idiopathic pulmonary fibrosis has evolved considerably.

METHODS

Practical guidelines were drafted on the initiative of the Coordinating Reference Center for Rare Pulmonary Diseases, led by the French Language Pulmonology Society (SPLF), by a coordinating group, a writing group, and a review group, with the involvement of the entire OrphaLung network, pulmonologists practicing in various settings, radiologists, pathologists, a general practitioner, a health manager, and a patient association. The method followed the "Clinical Practice Guidelines" process of the French National Authority for Health (HAS), including an online vote using a Likert scale.

RESULTS

After a literature review, 54 guidelines were formulated, improved, and then validated by the working groups. These guidelines addressed multiple aspects of the disease: epidemiology, diagnostic procedures, quality criteria and interpretation of chest CT scans, lung biopsy indication and procedures, etiological workup, methods and indications for family screening and genetic testing, assessment of the functional impairment and prognosis, indication and use of antifibrotic agents, lung transplantation, management of symptoms, comorbidities and complications, treatment of chronic respiratory failure, diagnosis and management of acute exacerbations of fibrosis.

CONCLUSION

These evidence-based guidelines are intended to guide the diagnosis and practical management of idiopathic pulmonary fibrosis.

Small Cell Lung Cancer in the Course of Idiopathic Pulmonary Fibrosis—Case Report and Literature Review

Idiopathic pulmonary fibrosis is a poorly prognosed form of progressive interstitial pneumonia. Patients with IPF have a significantly increased risk of developing lung cancer, which further worsens the course of the disease. The most common histological types of LC among patients with IPF are squamous cell carcinoma and adenocarcinoma. Furthermore, all LC treatment modalities can lead to developing an acute IPF exacerbation. In this report, we present a rare case of coexistence of IPF and small cell lung cancer in a 76-year-old patient with chronic obstructive pulmonary disease, and a former smoker. For over 2 years, the patient was treated with an anti-fibrotic drug-pirfenidone, which slowed down the progression of IPF. Unfortunately, after being diagnosed with an active SCLC, the patient was excluded from further participation in the pirfenidone drug program. SCLC is characterized by high aggressiveness, rapid growth and high metastatic potential; therefore, it is necessary to apply antitumor treatment as soon as possible. The described patient was treated with carboplatin–etoposide chemotherapy. Early treatment tolerance was good and after two cycles of cytotoxic treatment, a partial response was present in CT. The presented case emphasizes the need for further research to determine the treatment regimens in patients with coexisting IPF and LC and the appropriateness of antifibrotic treatment in them. In addition, it can help to choose the treatment method for similar patients, indicating a combination of carboplatin and etoposide as an effective and, at the same time, relatively safes method in terms of the risk of IPF’s exacerbation.

Lung cancer in patients with fibrosing interstitial lung diseases – An overview of current knowledge and challenges

Patients with progressive fibrosing interstitial lung diseases (fILD) have increased morbidity and mortality. Lung fibrosis can be associated with lung cancer. The pathogenesis of both diseases shows similarities, although not all mechanisms are understood. The combination of the diseases is challenging, due to the amplified risk of mortality, and also because lung cancer treatment carries additional risks in patients with underlying lung fibrosis. Acute exacerbations in fILD patients are linked to increased mortality, and the risk of acute exacerbations is increased after lung cancer treatment with surgery, chemotherapy or radiotherapy. Careful selection of treatment modalities is crucial to improve survival while maintaining acceptable quality of life in patients with combined lung cancer and fILD. This overview of epidemiology, pathogenesis, treatment and a possible role for antifibrotic drugs in patients with lung cancer and fILD is the summary of a session presented during the virtual European Respiratory Society Congress in 2021. The review summarises current knowledge and identifies areas of uncertainty. Most current data relate to patients with combined idiopathic pulmonary fibrosis and lung cancer. There is a pressing need for additional prospective studies, required for the formulation of a consensus statement or guideline on the optimal care of patients with lung cancer and fILD.

Lung fibrosis can be associated with lung cancer. More and better-designed studies are needed to determine the true incidence/prevalence of lung cancer in fILD. Optimal treatment strategies urgently need to be defined and evaluated.https://bit.ly/37CzTMu

[A Case Report of Checkpoint Inhibitor Pneumonitis Caused by PD-1 Antibody-Safety and Effectiveness of Pirfenidone]

背景与目的

免疫检查点抑制剂相关肺炎（checkpoint inhibitor pneumonitis, CIP）是严重的免疫检查点抑制剂副反应，急性期治疗手段已有共识，但急性期之后的肺间质纤维化治疗手段仍是临床需要解决的问题。

方法

回顾性分析了青岛市中心医院立体定向放疗科收治的1例细胞程序性死亡受体1（programmed cell death1, PD-1）单抗导致免疫检查点抑制剂相关肺炎的非小细胞肺癌（non-small cell lung cancer, NSCLC）患者的诊断、治疗过程，并文献复习。

结果

患者男性，70岁，初始诊断：左肺低分化鳞癌T3N3M0 Ⅲc期纵隔淋巴结转移表皮生长因子受体（epidermal growth factor receptor, EGFR）/间变性淋巴瘤激酶（anaplastic lymphoma kinase, ALK）/原癌基因1酪氨酸激酶（C-ros oncogene 1 receptor tyrosine kinase, ROS1）/RAF阴性PD-L1（22C3）阴性。一线化疗进展后纳武利尤单抗单药二线治疗过程中确诊为免疫检查点抑制剂相关肺炎3级。初始大剂量糖皮质激素冲击治疗后患者肺部计算机断层扫描（computed tomography, CT）影像学和临床症状部分缓解，随后给予吡非尼酮口服（300 mg tid）11个月余，治疗过程中患者CT影像学和临床症状明显好转，除1级恶心外无其他不良反应。期间吡非尼酮与化疗、安罗替尼联合应用安全性好。

结论

本病例报道为目前吡非尼酮治疗CIP的第1例报道，为CIP治疗的临床实践和临床研究提出了新的思路。

Molecular and Clinical Features of EGFR-TKI-Associated Lung Injury

The tyrosine kinase activity of epidermal growth factor receptors (EGFRs) plays critical roles in cell proliferation, regeneration, tumorigenesis, and anticancer resistance. Non-small-cell lung cancer patients who responded to EGFR-tyrosine kinase inhibitors (EGFR-TKIs) and obtained survival benefits had somatic EGFR mutations. EGFR-TKI-related adverse events (AEs) are usually tolerable and manageable, although serious AEs, including lung injury (specifically, interstitial lung disease (ILD), causing 58% of EGFR-TKI treatment-related deaths), occur infrequently. The etiopathogenesis of EGFR-TKI-induced ILD remains unknown. Risk factors, such as tobacco exposure, pre-existing lung fibrosis, chronic obstructive pulmonary disease, and poor performance status, indicate that lung inflammatory circumstances may worsen with EGFR-TKI treatment because of impaired epithelial healing of lung injuries. There is limited evidence from preclinical and clinical studies of the mechanisms underlying EGFR-TKI-induced ILD in the available literature. Herein, we evaluated the relationship between EGFR-TKIs and AEs, especially ILD. Recent reports on mechanisms inducing lung injury or resistance in cytokine-rich circumstances were reviewed. We discussed the relevance of cytotoxic agents or immunotherapeutic agents in combination with EGFR-TKIs as a potential mechanism of EGFR-TKI-related lung injury and reviewed recent developments in diagnostics and therapeutics that facilitate recovery from lung injury or overcoming resistance to anti-EGFR treatment.