Diffuse Lung Disease: Student/Resident Case Report Poster - Diffuse Lung Disease |

Surgical Resection in Lung Cancer With Undiagnosed Idiopathic Pulmonary Fibrosis: A Potentially Fatal Outcome FREE TO VIEW

Weyman Lam, MD; Mukul Singal, MD; Harender Kalonia, MD; Jayashri Bhaskar, MD
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Rochester General Hospital, Rochester, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):518A. doi:10.1016/j.chest.2016.08.532
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SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF), a serious disease with poor prognosis, is exacerbated by surgical intervention. We report a case where surgery resulted in rapid progression of subclinical and previously undiagnosed disease.

CASE PRESENTATION: A 79 year old former smoker, with history of emphysema, had an incidentally discovered solid lobulated right lower lobe nodule on an abdominal CAT scan that was obtained for GI symptoms, which subsequently resolved. Mild subpleural interstitial lung disease was also noted. He had mild dyspnea on exertion but denied cough, fevers, chills, night sweats or weight loss. Right lower lobectomy revealed a 5 centimeter, well differentiated adenocarcinoma, with negative nodes and clean margins (T2aN0M0), as well fibrosis with usual interstitial pneumonia (UIP) pattern consistent with IPF. One month after surgery, he developed progressive dyspnea and hypoxia. CT of the chest showed an acute pulmonary embolus in the right lower lobe arterial stump, new scattered bilateral ground glass opacities and right greater than left effusions. Pleural fluid cytology and cultures were negative, as were tests for HIV or rheumatologic disease. His hypoxic respiratory failure did not respond to steroids or diuretics and he died one month later.

DISCUSSION: The role of surgery for lung cancer in interstitial lung disease (ILD) is controversial. Multiple studies have reported acute exacerbations of respiratory insufficiency, with increased post-operative mortality, especially in patients with UIP/IPF type disease. The cause is unknown. Our patient underwent surgery for his lung malignancy before a diagnosis of IPF. Early stage lung cancer patients with IPF can be carefully chosen for surgery, but reliable pre-operative predictors of improved survival are lacking. Studies have shown that lower pre-operative carbon monoxide diffusing capacity (DLCO), higher composite physiological index (which is derived from the forced expiratory volume in the first second (FEV1), the forced vital capacity (FVC) and the DLCO, and possibly the type of resection might predict post-operative acute respiratory failure. Wedge resection may be associated with a lower incidence of IPF exacerbation. In our patient, preoperative DLCO was 44% of predicted, but FEV1 and FVC values were 108% and 120% of predicted.

CONCLUSIONS: This case illustrates the importance of exercising caution before recommending resection of stage I lung cancer to patients with underlying interstitial lung disease, especially IPF. Limited surgery or non-surgical options should be considered. Long-term survival data and randomized trials are needed to compare surgical and non-surgical options.

Reference #1: Is lung cancer resection indicated in patients with idiopathic pulmonary fibrosis? J Thorac Cardiovasc Surg. 2008 Nov;136(5):1357-63.

Reference #2: Pulmonary fibrosis and lung cancer: risk and benefit analysis of pulmonary resection J Thorac Cardiovasc Surg. 2003 Jun;125(6):1321-7.

DISCLOSURE: The following authors have nothing to disclose: Weyman Lam, Mukul Singal, Harender Kalonia, Jayashri Bhaskar

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