Long-term survival after complete resection of non-small-cell lung cancer in patients with interstitial lung disease

Impact of interstitial lung disease gender-age-physiology index in surgically treated lung cancer

BACKGROUND

The postoperative prognosis of patients with interstitial lung disease (ILD) and lung cancer is poor. Recently, the ILD-gender-age-physiology (GAP) index was identified as a clinical prognostic factor for patients with ILD. This study investigated the ILD-GAP index and oncological factors regarding postoperative outcomes.

METHODS

We retrospectively reviewed 87 lung cancer patients with comorbid ILD who underwent curative resection at our institution between April 2005 and December 2019. Short-term postoperative outcomes and overall survival (OS) based on the ILD-GAP index were examined. OS rates after surgery were calculated using the Kaplan-Meier method, and group differences were analyzed using the Log-Rank test. Univariate and multivariate analyses for OS were performed using the Cox regression model.

RESULTS

Multivariate analyses revealed ILD-GAP index ≥ 4 [Hazard ratio, 3.349; 95% confidence interval 1.375-8.155; P = 0.008] as a factor associated with OS. In the ILD-GAP index ≥ 4 group, no deaths occurred from primary lung cancer, with respiratory-related deaths being the most common, and exacerbation of ILD was more frequent (P = 0.007). Regarding perioperative results, a significant difference was observed in 90-day mortality (2.7% vs. 23.0% [P = 0.022]), and more patients required home oxygen therapy (14.9% vs. 69.2% [P < 0.001]) in the ILD-GAP index ≥ 4 group.

CONCLUSIONS

An ILD-GAP index ≥ 4 indicated a poor prognostic factor for patients with surgically treated lung cancer. Careful consideration of surgical indications is essential for patients with an ILD-GAP index ≥ 4.

Impact of smoking on resected lung cancer depends on epidermal growth factor receptor mutation

OBJECTIVES

Smokers comprise the majority of surgical patients with primary lung cancer. Epidermal growth factor receptor (EGFR) mutation-negative status impacts the treatment of recurrence. However, the prognostic impact of cigarette smoking stratified by EGFR mutation status has not been reported. Therefore, we assessed its impact on patients with resected lung cancer.

METHODS

We retrospectively analysed 362 consecutive patients who underwent complete resection for stage 1 primary lung cancer at our institution between 2012 and 2021. The EGFR mutation status was evaluated using the real-time polymerase chain reaction. We compared the overall survival (OS) and disease-free survival (DFS) between patients with and without a history of smoking.

RESULTS

The EGFR mutation-negative group included 194 patients, of whom 160 (83%) had a history of smoking. Male sex (P < 0.01), forced expiratory volume in 1 s (P < 0.01) and adenocarcinoma (P < 0.01) showed significant differences between the groups. In the EGFR mutation-positive group, the 5-year OS and DFS were similar regardless of smoking status (OS: 86% vs 75%; DFS: 73% vs 73%). In the EGFR mutation-negative group, the 5-year OS and DFS were significantly poorer in the smoking group (OS: 87% vs 65%, P = 0.05; DFS: 84% vs 54%, P = 0.01). Deaths from other diseases were relatively high (n = 19, 53%).

CONCLUSIONS

Cigarette smoking may be associated with a poor prognosis in EGFR mutation-negative lung cancer but had no impact on the prognosis of the EGFR mutation-positive group. This finding underscores the potential influence of smoking on the treatment of lung cancer recurrence but also highlights its significance in contributing to death from other diseases.

Surgical outcomes and perioperative risk factors of patients with interstitial lung disease after pulmonary resection

BACKGROUND

Patients of interstitial lung disease (ILD) combined with pulmonary lesions are increasingly common in clinical practice. Patients with ILD are at significantly higher risk for complications after pulmonary resection (including lobectomy and sublobar resection), especially acute exacerbations of ILD (AE-ILD). The purpose of this study is to summarize the short-term and long-term outcomes after pulmonary resection in ILD patients and to analyze the clinical factors affecting surgical safety.

METHODS

From January 2004 to January 2022, a total of 78 patients who were diagnosed with ILD and underwent pulmonary resection at our center were enrolled in this study. Clinical data, pathological findings, surgical procedures, and intraoperative safety of these patients were collected retrospectively. Postoperative 90-day complications and mortality, long-term surgical outcomes from postoperative 90 days to 24 months, and changes in ILD condition were investigated. Logistic regression analysis was used to identify the risk factors associated with postoperative complications.

RESULTS

The median age of patients was 66.5 (range 33-86) years, 82.1% (64/78) of patients were male, and 78.2% (61/78) of patients had comorbidities. Idiopathic ILD and secondary ILD accounted for 86% and 14%, thoracotomy and video-assisted thoracoscopic surgery accounted for 12.8% and 87.2%, and lobectomy and sublobar resection accounted for 37.2% and 62.8%, respectively. Postoperative 90-day complications occurred in 25.6% (20/78) of patients, with pulmonary complications and AE-ILD occurring in 15.4% and 9.0% of patients, respectively. The postoperative 90-day mortality rate was 5.1% (4/78), and the cause of death was AE-ILD. Exacerbation of ILD or other complications occurred in 12.8% (10/78) of patients from postoperative 90 days to 24 months. Univariate logistic regression analysis showed that comorbidity, extent of resection, systemic lymph node dissection, operation time, intraoperative blood loss, and pathology of pulmonary lesion were associated with postoperative 90-day complications. In multivariate logistic regression analysis, age-adjusted Charlson Comorbidity Index and intraoperative blood loss were identified as independent risk factors of postoperative 90-day complications.

CONCLUSIONS

Patients with ILD have a significantly higher risk of postoperative 90-day complications and mortality after pulmonary resection, especially pulmonary complications and AE-ILD. After postoperative 90 days, the risk of deterioration of pulmonary status remains high, including exacerbation of ILD and complications associated with long-term use of glucocorticoids and immunosuppressant. Age, comorbidity and intraoperative blood loss are high risk factors for postoperative 90-day complications.

Treatment of idiopathic pulmonary fibrosis and progressive pulmonary fibrosis: A position statement from the Thoracic Society of Australia and New Zealand 2023 revision

Idiopathic pulmonary fibrosis (IPF) is a progressive disease leading to significant morbidity and mortality. In 2017 the Thoracic Society of Australia and New Zealand (TSANZ) and Lung Foundation Australia (LFA) published a position statement on the treatment of IPF. Since that time, subsidized anti-fibrotic therapy in the form of pirfenidone and nintedanib is now available in both Australia and New Zealand. More recently, evidence has been published in support of nintedanib for non-IPF progressive pulmonary fibrosis (PPF). Additionally, there have been numerous publications relating to the non-pharmacologic management of IPF and PPF. This 2023 update to the position statement for treatment of IPF summarizes developments since 2017 and reaffirms the importance of a multi-faceted approach to the management of IPF and progressive pulmonary fibrosis.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Association Between Interstitial Lung Disease and Outcomes After Lung Cancer Resection

BACKGROUND

Prior studies have noted that patients with interstitial lung disease (ILD) possess an increased incidence of lung cancer and risk of postoperative respiratory failure and death. We sought to understand the impact of ILD on national-scale outcomes of lung resection.

METHODS

A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted of patients who underwent a pulmonary resection for non-small cell lung cancer between 2009 and 2019. Baseline characteristics and postoperative outcomes were compared between patients with and without ILD (defined as interstitial fibrosis based on clinical, radiographic, or pathologic evidence). Multivariable logistic regression models identified risk factors associated with postoperative mortality, acute respiratory distress syndrome, and composite morbidity and mortality.

RESULTS

ILD was documented in 1.5% (1873 of 128,723) of patients who underwent a pulmonary resection for non-small cell lung cancer. Patients with ILD were more likely to smoke (90% vs 85%, P < .001), have pulmonary hypertension (6% vs 1.7%, P < .001), impaired diffusing capacity of lung for carbon monoxide (diffusing capacity of lung for carbon monoxide 40%-75%: 64% vs 51%; diffusing capacity of lung for carbon monoxide <40%: 11% vs 4%, P < .001), and undergo more sublobar resections (34% vs 23%, P < .001) compared with patients without ILD. Patients with ILD had increased postoperative mortality (5.1% vs 1.2%, P < .001), acute respiratory distress syndrome (1.9% vs 0.5%, P < .001), and composite morbidity and mortality (13.2% vs 7.4%, P < .001). ILD remained a strong predictor of mortality (odds ratio, 3.94; 95% CI, 3.09-5.01; P < .001), even when adjusted for patient comorbidities, pulmonary function, extent of resection, and center volume effects.

CONCLUSIONS

ILD is a risk factor for operative mortality and morbidity after lung cancer resection, even in patients with normal pulmonary function.

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.

Survival analysis in lung cancer patients with interstitial lung disease

OBJECTIVE

Lung cancer patients with interstitial lung disease (ILD) are prone for higher morbidity and mortality and their treatment is challenging. The purpose of this study is to investigate whether the survival of lung cancer patients is affected by the presence of ILD documented on CT.

MATERIALS AND METHODS

146 patients with ILD at initial chest CT were retrospectively included in the study. 146 lung cancer controls without ILD were selected. Chest CTs were evaluated for the presence of pulmonary fibrosis which was classified in 4 categories. Presence and type of emphysema, extent of ILD and emphysema, location and histologic type of cancer, clinical staging and treatment were evaluated. Kaplan-Meier estimates and Cox regression models were used to assess survival probability and hazard of death of different groups. P value < 0.05 was considered significant.

RESULTS

5-year survival for the study group was 41% versus 48% for the control group (log-rank test p = 0.0092). No significant difference in survival rate was found between the four different categories of ILD (log-rank test, p = 0.195) and the different histologic types (log-rank test, p = 0.4005). A cox proportional hazard model was used including presence of ILD, clinical stage and age. The hazard of death among patients with ILD was 1.522 times that among patients without ILD (95%CI, p = 0.029).

CONCLUSION

Patients with lung cancer and CT evidence of ILD have a significantly shorter survival compared to patients with lung cancer only. Documenting the type and grading the severity of ILD in lung cancer patients will significantly contribute to their challenging management.

Efficacy and Safety of Carbon-Ion Radiotherapy for Stage I Non-Small Cell Lung Cancer with Coexisting Interstitial Lung Disease

Simple Summary

Interstitial lung disease (ILD) is a risk factor for lung cancer, but the treatment options are often limited because of concerns that ILD may worsen with treatment. In this study, we analyzed whether the presence or absence of ILD affects the outcome of carbon-ion radiotherapy (CIRT) for clinical stage I non-small cell lung cancer (NSCLC). For all cases, CT and clinical data were reviewed by a respiratory physician to determine the presence of ILD. Overall survival and disease-specific survival were lower in patients with ILD than in patients without ILD. There was no significant difference between the ILD group and the non-ILD group with respect to safety. CIRT was not associated with significantly more side-effects in patients with ILD than in patients without ILD. Coexisting ILD was a poor prognostic factor with respect to CIRT for clinical stage I lung cancer, as reported for other treatment methods.

Abstract

Interstitial lung disease (ILD) is a risk factor both for the development and treatment failure of lung cancer. In this retrospective study, we analyzed the outcome of carbon-ion radiotherapy (CIRT) in 124 patients with clinical stage I non-small cell lung cancer (NSCLC), of whom 26 (21%) had radiological signs of pre-existing ILD. ILD was diagnosed retrospectively by a pulmonologist based on critical review of CT-scans. Ninety-eight patients were assigned to the non-ILD group and 26 patients (21.0%) to the ILD group. There were significant differences in pre-treatment KL-6 values between the two groups. The three year overall survival and cause-specific survival rates were 83.2% and 90.7%, respectively, in the non-ILD group, and 59.7% and 59.7%, respectively, in the ILD group (between-group differences, p = 0.002 and p < 0.001). Radiation pneumonitis worse than Grade 2 was observed in three patients (3.0%) in the non-ILD group and two patients (7.6%) in the ILD group (p = 0.29). There were no cases of acute exacerbation in the ILD group. CIRT for stage I NSCLC was as safe in the ILD group as in the non-ILD group. Coexisting ILD was a poor prognostic factor in CIRT for clinical stage I lung cancer.

[Surgical Treatment of Lung Cancer Combined with Interstitial Lung Disease]

BACKGROUND

Interstitial lung disease (ILD) is a group of diffuse lung diseases that mainly involve the interstitial and alveolar cavities and result in loss of alveolar-capillary functional units, leading to restrictive ventilatory dysfunction and diffusion impairment. There was an increased incidence of lung cancer on the basis of ILD, and perioperative risk of patients with lung cancer combined with ILD (LC-ILD) was significantly increased. The aim of this study is to summarize the safety and experience of surgical treatment of LC-ILD.

METHODS

A retrospective analysis was performed on 23 patients with LC-ILD who underwent pneumonectomy in Beijing Hospital from January 2012 to December 2019, and their clinical manifestations, image feature, pathology, surgical safety, perioperative complications and treatment experience were summarized.

RESULTS

A total of 23 patients were included in this study, including 20 males (87.0%) with an average age of (69.1±7.8) years, and 19 cases (82.6%) were smokers. Of the ILD types, 14 cases (60.9%) were idiopathic pulmonary fibrosis, 7 cases (30.4%) were idiopathic nonspecific interstitial pneumonia, and 2 (8.7%) were interstitial lung disease associated with connective tissue diseases. The pathology of lung cancer included adenocarcinoma (30.4%, 7/23), small cell carcinoma (30.4%, 7/23), squamous cell carcinoma (26.1%, 6/23), small cell carcinoma mixed with squamous cell carcinoma (4.3%, 1/23) and large cell neuroendocrine carcinoma (8.7%, 2/23). Surgical approaches included video assisted thoracoscopy (69.6%, 16/23) and anterolateral thoracotomy (30.4%, 7/23), with lobectomy (52.2%, 12/23), double lobectomy (4.3%, 1/23), and sublobectomy (39.1%, 9/23). There were 11 cases (47.8%) of postoperative complications, including 8 cases (34.8%) of pulmonary complications, 4 cases (17.4%) of acute exacerbation of ILD (AE-ILD), 6 cases (26.1%) of atrial fibrillation, and 1 case (4.3%) of acute left ventricular dysfunction. The 90-day mortality is 8.7% (2/23) and the cause of death was acute exacerbation of ILD.

CONCLUSIONS

Most of LC-ILD were elderly patients with multiple comorbidities and decreased pulmonary function, leading to significantly increased surgical risk. The ILD should be fully evaluated and controlled before surgery, intraoperative trauma should be minimized, and special attention should be paid to pulmonary complications and AE-ILD after surgery. Postoperative AE-ILD has a poor prognosis and glucocorticoids may be effective. Early diagnosis and treatment is the key to treatment of AE-ILD.

Prognostic impact of home oxygen therapy on patients with resected non-small-cell lung cancer with interstitial lung disease

PURPOSE

Non-small-cell lung cancer (NSCLC) patients with interstitial lung disease (ILD) have a poor prognosis. The present study evaluated the prognostic impact of home oxygen therapy (HOT) in NSCLC patients with ILD.

METHODS

Overall, 3099 consecutive patients underwent complete resection of stage IA to IIIA NSCLC at our institution between 2002 and 2016. ILD was diagnosed and categorized based on high-resolution computed tomography. The criteria for HOT included less than 90% resting oxygen saturation in the peripheral arteries and severe exertional dyspnea. We retrospectively compared the overall survival between ILD patients with and without HOT.

RESULTS

ILD was observed in 150 (5%) patients. Seventeen (11%) patients needed HOT at discharge. The incidences of usual interstitial pneumonia (UIP) pattern (p = 0.03) and blood loss (p < 0.01) were significantly higher in the patients requiring HOT than in those without HOT. Significantly more patients developed complications (p = 0.04) in the HOT group than in the non-HOT group, with three (18%) having acute exacerbations. The 3-year overall survival rate was significantly lower in the HOT patients than in those without HOT (28% vs. 63%, p = 0.03).

CONCLUSIONS

Patients requiring postoperative HOT showed a significantly poorer prognosis after complete resection than those without HOT. Therefore, the indication for surgery should be investigated cautiously in order to prevent the need for postoperative HOT.

Is operation safe for lung cancer patients with interstitial lung disease on computed tomography?

Aims:

Interstitial lung disease (ILD) is associated with the incidence of non-small cell lung cancer (NSCLC). Patients with ILD are at risk of acute exacerbation (AE) after pulmonary resection. However, there have been no recognized treatment guidelines for NSCLC patients with ILD on computed tomography (CT).

Methods:

We reviewed the medical records of 156 consecutive patients with ILD on high-resolution CT who have undergone pulmonary resection and between 2014 and 2018. Data regarding general information, imaging features, perioperative indicators, and long-term prognosis of patients were compared.

Results:

The mean patient age was 67.24 ± 6.80 years. Postoperative AE occurred in seven (4.5%) patients; five (71.4%) of the seven patients who had an AE died within 30 days. The incidence of postoperative AE was 5.3% among patients who underwent lobectomy (n = 6). Overall survivals (OS) was significantly poorer in patients with possible usual interstitial pneumonia (UIP)/UIP [hazard ratio (HR) 2.34, 95% confidence interval (CI) 1.11–4.95, p = 0.026] and severe postoperative complications (Grade ⩾3) (versus no complication: HR 2.58, 95% CI 1.11–6.02, p = 0.028; versus mild complications: HR 6.05, 95% CI 2.69–13.6, p < 0.001). Age (HR 1.071, 95% CI 1.006–1.137, p = 0.030) and ILD patterns (HR 2.420, 95% CI 1.024–5.716, p = 0.044) were independent prognostic factors for OS. Forced vital capacity (FVC) (odds ratio 0.351, 95% CI 0.145–0.850, p = 0.020) was an independent prognostic factor for patients who needed postoperative intensive care unit intervention.

Conclusion:

Pulmonary resection for NSCLC Patients with ILD on CT is a safe procedure. However, surgical indications for lobectomy need to be more carefully for these patients, especially for possible UIP/UIP patients and patients with lower FVC.

The reviews of this paper are available via the supplemental material section.

Perioperative pirfenidone treatment as prophylaxis against acute exacerbation of idiopathic pulmonary fibrosis: a single-center analysis

PURPOSE

Lung cancer in patients with idiopathic pulmonary fibrosis (IPF) is associated with a poor prognosis and postoperative acute exacerbation (AE) of IPF is a fatal complication. Studies have shown that perioperative pirfenidone treatment (PPT) may reduce the incidence of AE-IPF. We evaluated the efficacy of PPT in preventing AE-IPF and improving overall survival.

METHODS

The subjects of this study were 56 patients with IPF who underwent resection of lung cancer in our hospital between January, 2011 and September, 2016. Pirfenidone was administered to patients from 4 weeks before the operation and continued for longer periods. Thirty-six patients received PPT and their outcome was compared with that of the other 20 patients who did not.

RESULTS

There were no differences in age, gender, smoking history, respiratory function, or surgical procedures between the groups. AE-IPF developed in three patients (8%) in the PPT group and four (20%) patients in the non-PPT group, without a significant difference between the groups. The interval was significantly longer in the PPT group (p = 0.03). PPT reduced postoperative mortality significantly (p = 0.04).

CONCLUSIONS

Although perioperative pirfenidone treatment did not obviously prevent postoperative AE-IPF, it may reduce the mortality of lung cancer patients with IPF.

Interstitial Lung Disease Associated with Lung Cancer: A Case-Control Study

Interstitial lung disease (ILD) seems to be associated with an increased risk of lung cancer (LC) and to have a poorer prognosis than LC without ILD. The frequency of ILD in an LC cohort and its prognosis implication need to be better elucidated. This retrospective, observational, cohort study evaluated the frequency of ILD among LC patients (LC–ILD) diagnosed over a 2-year period. LC–ILD patients’ characteristics were compared to those with LC without ILD (LC–noILD). Lastly, we conducted a case–control study within this cohort, matching three LC–noILDs to each LC–ILD patient, to evaluate the ILD impact on LC patients’ prognoses. Among 906 LC patients, 49 (5.4%) also had ILD. Comparing LC–ILD to LC–noILD patients, respectively, more were men (85.7% vs. 66.2%; p = 0.02); adenocarcinomas were less frequent (47.1% vs. 58.7%, p = 0.08); median [range] and overall survival was shorter: (9 [range: 0.1–39.4] vs. 17.5 [range: 0.8–50.4] months; p = 0.01). Multivariate analysis (hazard ratio [95% confidence interval]) retained two factors independently associated with LC risk of death: ILD (1.79 [1.22–2.62]; p = 0.003) and standard-of-care management (0.49 [0.33–0.72]; p < 0.001). Approximately 5% of patients with a new LC diagnosis had associated ILD. ILD was a major prognosis factor for LC and should be taken into consideration for LC management. Further studies are needed to determine the best therapeutic strategy for the LC–ILD population.

Serum Carcinoembryonic Antigen Level Predicts Cancer-Specific Outcomes of Resected Non-Small Cell Lung Cancer With Interstitial Pneumonia

Background

It has been well accepted that the prognosis of non-small cell lung cancer (NSCLC) patients with interstitial pneumonia (IP) is significantly poor. However, there are only a few studies that indicated the prognostic factors, especially tumor markers, among NSCLC patients with IP.

Methods

Forty-one NSCLC patients with IP who underwent surgery at our institution were included. Patients died of other diseases including postoperative acute exacerbation (AE) of IP were excluded. Univariate and multivariate analyses were calculated by the Cox proportional hazards regression model.

Results

The 5-year cancer-specific survival of overall and stage I patients were 37.4% and 39.2%, respectively. The 5-year cancer-specific survival of patients with high serum carcinoembryonic antigen (CEA) level was 9.4%, while that with normal serum CEA level was 55.6%. However, serum cytokeratin-19 fragment (CYFRA 21-1) and squamous cell carcinoma-related antigen (SCC) levels were not associated with patients’ survival. Furthermore, serum CEA level was significantly associated with poorer cancer-specific survival in univariate and multivariate analyses.

Conclusions

This study demonstrated that serum CEA level might serve as an efficient prognostic indicator after surgery in NSCLC with IP.