Measuring Surgery Outcomes of Lung Cancer Patients with Concomitant Pulmonary Fibrosis: A Review of the Literature

New progress of tuberculosis scar carcinoma

It has been demonstrated that scar tissue and fibrosis may increase the likelihood of developing malignancies. Specifically, scar tissue has been linked to the occurrence and progression of lung cancer (LC), though the precise mechanisms necessitate further research for explanation. Lung scarring can stem from various causes, with carcinogenesis on scarring lesions in pulmonary tuberculosis (PTB) being the most frequent (accounting for approximately 75% of cases). Notably, having previously cured, PTB is the second most common risk factor for LC after smoking, with approximately 3% of PTB patients experiencing LC as a secondary condition. This essay will delve into the mechanisms, treatment, and prognosis of tuberculosis scar carcinoma (TSC).

The balance between lung regulatory T cells and Th17 cells is a risk indicator for the acute exacerbation of interstitial lung disease after surgery: a case-control study

BACKGROUND

Acute exacerbation (AE) of interstitial lung disease (ILD) (AE-ILD) is a life-threatening condition and the leading cause of 30-day mortality among patients who underwent pulmonary resection for lung cancer in Japan. This study was conducted to clarify the characteristics of the immune environment of lung tissues before the onset of AE-ILD.

METHODS

This retrospective matched case-control study compared the immune phenotypes of helper T cells in lung tissues from patients with and without AE-ILD after surgery. In total, 135 patients who underwent surgical resection for lung cancer and were pathologically diagnosed with idiopathic interstitial pneumonia (IIP) at our institute between 2009 and 2018 were enrolled. Thirteen patients with AE-IIP and 122 patients without AE (non-AE) were matched using a propensity score analysis, and 12 cases in each group were compared. We evaluated the percentages of T helper (Th)1, Th2, Th17, regulatory T (Treg), and CD8 cells in CD3⁺ T cells and the Th1:Th2, Th17:Treg, and CD8:Treg ratios in patients with AE by immunostaining of lung tissues in the non-tumor area.

RESULTS

We found a significant difference in the lung Th17:Treg ratio between the AE and non-AE groups (1.47 and 0.79, p = 0.041). However, we detected no significant differences in the percentages of lung Th1 (21.3% and 29.0%), Th2 (34.2% and 42.7%), Th17 (22.3% and 21.6%), Treg (19.6% and 29.1%), and CD8⁺ T cells (47.2% and 42.2%) of CD3⁺ T cells between the AE and non-AE groups.

CONCLUSION

The ratio of Th17:Treg cells in lung tissues was higher in participants in the AE group than in those in the non-AE group.

CLINICAL TRIAL REGISTRATION

This study was approved by the ethics committee of our institute (2,016,095).

Pre-existing pulmonary fibrosis is associated with adverse outcomes after lung resection

INTRODUCTION

Pulmonary fibrosis is a risk factor for the development of lung cancer. However, the low incidence of the pathology means that it is not well represented in thoracic surgery risk scoring systems. We aimed to assess whether short and long-term outcomes after lung resection for primary lung cancer were worse in patients with pre-existing pulmonary fibrosis.

METHODS

A total of 5029 consecutive patients undergoing lung resection for primary lung cancer between 2012 and 2018 in two UK centres were included. Primary outcomes were 90-day & 1-year mortality, post-operative complications and overall survival. Univariable analyses were used to compare outcomes between patients with and without pre-existing pulmonary fibrosis.

RESULTS

In total, 0.7% (n = 33) of patients had a pre-existing diagnosis of pulmonary fibrosis (idiopathic pulmonary fibrosis 48.5%, non-specific interstitial pneumonia 6.1%, unknown 45.5%). Overall, 90-day and 1-year mortality were all significantly higher amongst patients with fibrosis (90-day: 18.2% vs 3.6%, p < 0.001; 1-year: 36.4% vs 10.7%, p < 0.001). The rate of reintubation was significantly higher for patients with fibrosis (9.1% vs 2.9%, p = 0.038) yet there was no difference in post-operative length of stay between groups (fibrosis: 6 days [IQR 4-9 days] vs non-fibrosis: 5 days [IQR 4-8 days], p = 0.675). Overall survival was also significantly reduced for patients with pulmonary fibrosis (log-rank analysis, p < 0.001).

CONCLUSIONS

Despite its small size, this study suggests that short and long-term outcomes after lung resection are worse for patients with pre-existing pulmonary fibrosis. Segmental resections could be considered in these patients where oncologically appropriate to minimise peri-operative risk.

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.

Lung Cancer Surgery with Persistent COVID-19 Infection

A 71-year-old man with a history of drug-induced interstitial pneumonia was diagnosed with COVID-19 infection and simultaneously found to have a pulmonary mass, suggesting a coexisting lung cancer. Approximately 1 month after COVID-19 pneumonia resolved, the patient electively underwent right upper lobectomy. Postoperatively, acute exacerbation of interstitial pneumonia occurred and the patient died on the fifteenth postoperative day. By quantitative reverse transcription polymerase chain reaction, high levels of COVID-19-derived RNA were detected in the specimen of lung parenchyma. Despite resolved COVID-19 infection, it may persist locally in the lungs, with the risk of acute exacerbation of interstitial pneumonia due to secondary stressors including surgery.

A case of pulmonary pleomorphic carcinoma with preexisting interstitial pneumonia successfully treated with pembrolizumab

Pulmonary pleomorphic carcinoma is often refractory to chemotherapy and follows an aggressive clinical course. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced lung cancer, and a few cases with pleomorphic carcinoma have been reported to show tumor shrinkage after therapy with ICIs. When treating patients with ICIs, patient selection is essential, and monitoring and management of immune‐related adverse events, including pneumonitis, are needed. We herein report a case of pulmonary pleomorphic carcinoma with preexisting interstitial pneumonia treated with pembrolizumab, antiprogrammed cell death 1 antibody. Our report highlights important considerations necessary when treating advanced pleomorphic carcinoma patients complicated with interstitial pneumonia. We also review the literature regarding the use of ICIs in such patients.

Endobronchial Ultrasonography with a Guide Sheath Transbronchial Biopsy for Diagnosing Peripheral Pulmonary Lesions within or near Fibrotic Lesions in Patients with Interstitial Lung Disease

Simple Summary

Lung cancer often occurs around fibrotic lesions in patients with interstitial lung disease (ILD). In patients with ILD, several methods are available for diagnosing peripheral pulmonary lesions (PPLs), such as bronchoscopy with radial endobronchial ultrasound (R-EBUS), transthoracic needle biopsy, and surgical lung biopsy. As well as previous reports, in patients with ILD, bronchoscopy with R-EBUS might be an option as the primary procedure for diagnosing PPLs with fewer complications. However, the utility and safety of bronchoscopy with R-EBUS for PPLs in patients with ILD remain unknown. In this study, we assessed the efficacy and complications as the initial diagnostic procedure of bronchoscopy with R-EBUS according to the proximity of PPLs to fibrotic lesions. Our study might make a contribution to physicians who treat PPLs in patients with underlying ILD.

Abstract

In patients with interstitial lung disease (ILD), the most frequent locations of lung cancer are within or near fibrotic lesions. However, the diagnostic yield for peripheral pulmonary lesions (PPLs) within or near fibrotic lesions using endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) may be unsatisfactory compared to that for PPLs distant from fibrotic lesions because of the difficulty in reaching the lesions. Our objectives were to evaluate the yield for PPLs using EBUS-GS TBB according to the proximity of PPLs to fibrotic lesions and to determine factors affecting the yield for PPLs. We retrospectively investigated 323 consecutive lesions using EBUS-GS TBB between 1 November 2014 and 31 December 2016. We identified PPLs with ILD in such lesions. PPLs with ILD were divided into PPLs within or near fibrotic lesions which met the criterion of PPLs, and of fibrotic lesions overlapping each other (PPLs-FL) and those distant from fibrotic lesions, which met the criterion of PPLs and the area of fibrotic lesion not overlapping each other (PPLs-NFL). Of the 323 lesions, 55 were included (31 PPLs-FL and 24 PPLs-NFL). The diagnostic yield for PPLs-FL was significantly lower than for PPLs-NFL (45.2% vs. 83.3%, p = 0.004). Multivariate analysis revealed that PPLs-NFL (odds ratio (OR) = 7.509) and a probe position within the lesion (OR = 4.172) were significant factors affecting diagnostic yield. Lesion’s positional relation to fibrotic lesions and the probe position were important factors affecting the successful diagnosis via EBUS-GS TBB in these patients.

Molecular Mechanisms and Cellular Contribution from Lung Fibrosis to Lung Cancer Development

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, fibrosing interstitial lung disease (ILD) of unknown aetiology, with a median survival of 2–4 years from the time of diagnosis. Although IPF has unknown aetiology by definition, there have been identified several risks factors increasing the probability of the onset and progression of the disease in IPF patients such as cigarette smoking and environmental risk factors associated with domestic and occupational exposure. Among them, cigarette smoking together with concomitant emphysema might predispose IPF patients to lung cancer (LC), mostly to non-small cell lung cancer (NSCLC), increasing the risk of lung cancer development. To this purpose, IPF and LC share several cellular and molecular processes driving the progression of both pathologies such as fibroblast transition proliferation and activation, endoplasmic reticulum stress, oxidative stress, and many genetic and epigenetic markers that predispose IPF patients to LC development. Nintedanib, a tyrosine–kinase inhibitor, was firstly developed as an anticancer drug and then recognized as an anti-fibrotic agent based on the common target molecular pathway. In this review our aim is to describe the updated studies on common cellular and molecular mechanisms between IPF and lung cancer, knowledge of which might help to find novel therapeutic targets for this disease combination.

Links between Inflammation and Postoperative Cancer Recurrence

Despite complete resection, cancer recurrence frequently occurs in clinical practice. This indicates that cancer cells had already metastasized from their organ of origin at the time of resection or had circulated throughout the body via the lymphatic and vascular systems. To obtain this potential for metastasis, cancer cells must undergo essential and intrinsic processes that are supported by the tumor microenvironment. Cancer-associated inflammation may be engaged in cancer development, progression, and metastasis. Despite numerous reports detailing the interplays between cancer and its microenvironment via the inflammatory network, the status of cancer-associated inflammation remains difficult to recognize in clinical settings. In the current paper, we reviewed clinical reports on the relevance between inflammation and cancer recurrence after surgical resection, focusing on inflammatory indicators and cancer recurrence predictors according to cancer type and clinical indicators.

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

OBJECTIVES

Acute exacerbation of interstitial pneumonia (AE-IP) is the top cause of 30-day mortality in surgery for lung cancer patients. The general treatment for AE-IP is corticosteroid; however, there are some disadvantages of corticosteroid use after surgery. This study was conducted to report the clinical course of AE-IP after surgery and evaluate the effect of corticosteroid use.

METHODS

This retrospective study was performed on 337 patients with interstitial pneumonia who underwent surgical resection for lung cancer at our institute between 2009 and 2018. AE-IP were observed in 14 patients (4.2%) and their management and clinical outcome were investigated.

RESULTS

All patients received methylprednisolone pulse therapy. Six patients (42.9%) became convalescent after pulse therapy and eight (57.1%) died within 90 days after surgery due to lack of therapeutic efficacy. Oxygenation and ground-glass opacities of the survivors improved within 3 days after starting pulse therapy. Patients who responded to the first pulse also responded to the second pulse. Four patients developed complications including two with bronchopulmonary fistulas that may be related to steroid treatment. Even if the corticosteroid was effective, all AE-IP patients died within 1 year after surgery.

CONCLUSIONS

Corticosteroid therapy is effective for AE-IP after surgery; however, it may lead to severe complications after surgery.

Impact of idiopathic pulmonary fibrosis on recurrence after surgical treatment for stage I-III non-small cell lung cancer

Background

Idiopathic pulmonary fibrosis (IPF) is an independent risk factor for lung cancer (LC) development; however, its effect on recurrence after curative surgery remains unclear.

Objectives

This study aimed to determine the impact of IPF on recurrence-free survival following curative surgical resection of stage I–III non-small cell lung cancer (NSCLC) and investigate the effects of patient and surgical factors on the risk of recurrence.

Methods

We reviewed retrospectively collected data of patients with surgically resected stage I–III NSCLC from two tertiary care hospitals in South Korea. By propensity score matching, patients with IPF (LC with IPF) were matched to those without IPF (LC without IPF).

Results

In total, 3416 patients underwent surgical resection, and 96 were diagnosed with underlying IPF. In the LC with IPF group, 89.6% patients were men, and the average age was 69.7 years. Sublobar resection was performed more frequently in the LC with IPF group than in the LC without IPF group, while the rate of mediastinal lymph node dissection and dissected node number were lower in the former group. The 5-year recurrence-free survival rate was significantly lower in the LC with IPF group (49.2%) than in the LC without IPF group (69.1%; P<0.001). Multivariable Cox regression analysis revealed that IPF and postoperative stage III were independent risk factors for recurrence.

Conclusions

IPF may increase the risk of recurrence after curative surgical treatment for NSCLC. Close surveillance for recurrence is mandatory for patients with underlying IPF.

Airway Microbiota as a Modulator of Lung Cancer

Recent research on cancer-associated microbial communities has elucidated the interplay between bacteria, immune cells, and tumor cells; the bacterial pathways involved in the induction of carcinogenesis; and their clinical significance. Although accumulating evidence shows that a dysbiotic condition is associated with lung carcinogenesis, the underlying mechanisms remain unclear. Microorganisms possibly trigger tumor initiation and progression, presumably via the production of bacterial toxins and other pro-inflammatory factors. The purpose of this review is to discuss the basic role of the airway microbiome in carcinogenesis and the underlying molecular mechanisms, with the aim of developing anticancer strategies involving the airway microbiota. In addition, the mechanisms via which the microbiome acts as a modulator of immunotherapies in lung cancer are summarized.

Postoperative acute exacerbation of interstitial pneumonia in pulmonary and non-pulmonary surgery: a retrospective study

BACKGROUND

Acute exacerbation of interstitial pneumonia (AE-IP) is a serious complication of pulmonary surgery in patients with IP. However, little is known about AE-IP after non-pulmonary surgery. The aim of this study was to determine the frequency of AE-IP after non-pulmonary surgery and identify its risk factors.

METHODS

One hundred and fifty-one patients with IP who underwent pulmonary surgery and 291 who underwent non-pulmonary surgery were retrospectively investigated.

RESULTS

AE-IP developed in 5 (3.3%) of the 151 patients in the pulmonary surgery group and 4 (1.4%) of the 291 in the non-pulmonary surgery group; the difference was not statistically significant. A logistic regression model showed that serum C-reactive protein (CRP) was a predictor of AE-IP in the non-pulmonary surgery group (odds ratio 1.187, 95% confidence interval 1.073-1.344, P = 0.002).

CONCLUSIONS

This is the first study to compare the frequency of AE-IP after pulmonary surgery with that after non-pulmonary surgery performed under the same conditions. The results suggest that the frequency of AE-IP after non-pulmonary surgery is similar to that after pulmonary surgery. A high preoperative C-reactive protein level is a potential risk factor for AE-IP after non-pulmonary surgery.

Molecular Mechanisms of Pulmonary Fibrogenesis and Its Progression to Lung Cancer: A Review

Idiopathic pulmonary fibrosis (IPF) is defined as a specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurring primarily in older adults, and limited to the lungs. Despite the increasing research interest in the pathogenesis of IPF, unfavorable survival rates remain associated with this condition. Recently, novel therapeutic agents have been shown to control the progression of IPF. However, these drugs do not improve lung function and have not been tested prospectively in patients with IPF and coexisting lung cancer, which is a common comorbidity of IPF. Optimal management of patients with IPF and lung cancer requires understanding of pathogenic mechanisms and molecular pathways that are common to both diseases. This review article reflects the current state of knowledge regarding the pathogenesis of pulmonary fibrosis and summarizes the pathways that are common to IPF and lung cancer by focusing on the molecular mechanisms.

Scar tissue to lung cancer; pathways and treatment

Lung cancer still remains diagnosed at a late stage although we have novel diagnostic techniques at our disposal. However; for metastatic disease we have novel therapies based on pharmacogenomics. Tumor heterogenity provides us different treatments. There are several reasons for carcinogenesis; fibrosis and scar tissue provides an environment that induces malignancy. In the current review we will try and elucidate the pathways involved from scar tissue to carcinogenesis.