Ann Thorac Surg 2006;82:336-338
© 2006 The Society of Thoracic Surgeons
Case report
Acute Exacerbation of Interstitial Fibrosis After Pulmonary Resection
Mustafa Yüksel, MD
a
,
*
,
Mehmet O
uzhan Özyurtkan, MD
a
,
Korkut Bostanc
, MD
a
,
Rengin Ahskal, MD
b
,
Nihat Kodall, MD
c
a Department of Thoracic Surgery, Acbadem, Istanbul, Turkey
b Department of Pathology, Acbadem, Istanbul, Turkey
c Department of Radiology, Marmara University Medical Faculty, Acbadem, Istanbul, Turkey
Accepted for publication September 15, 2005.
* Address correspondence to Dr Yüksel, Department of Thoracic Surgery, Marmara University Hospital, PK 97, Acbadem, 34718 Istanbul, Turkey (Email: myuksel{at}marmara.edu.tr).
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Abstract
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Idiopathic pulmonary fibrosis is a chronic diffuse lung disease of unknown cause, and a risk factor for increasing morbidity and mortality after lung resection. Acute exacerbation of idiopathic pulmonary fibrosis after lung surgery for lung cancer is rare. The outcome is unsatisfactory despite therapy. We report two cases of acute exacerbation of idiopathic pulmonary fibrosis after resection for lung cancer.
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Introduction
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Idiopathic pulmonary fibrosis (IPF) is a chronic and diffuse lung disease of unknown cause [1, 2]. High resolution computed tomographic (HRCT) findings, combined with the clinical profile are sufficient for a confident diagnosis of IPF, even in the absence of lung biopsy [1–3]. Idiopathic pulmonary fibrosis is associated with an increased risk of lung cancer [2]. Mortality and morbidity are high in patients with IPF who underwent lung resection [2]. Cases of accelerated worsening of IPF after lung resection have been reported [2, 4, 5].
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Case Reports
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Patient 1
An 80-year-old man presented with a left lower lobe mass. A high-resolution computed tomographic scan revealed a mass in the left lower lobe superior segment, bilateral subpleural interstitial reticular opacities with traction bronchiectasis, and honeycombing (Fig 1). The patient had diabetes mellitus and pulmonary fibrosis. He had been on a bronchodilator and antidiabetics. He had a 54-pack year history of cigarette smoking. Preoperative respiratory function tests were normal, but his blood gas analysis showed low arterial blood oxygen saturation (90%) and a partial pressure of arterial oxygen of 66 mm Hg. He underwent an uncomplicated left lower lobectomy with radical lymph node dissection. On postoperative day 3 he started complaining of dyspnea. A moderate hypoxemia (PaO2 56 mm Hg) had developed. Chest roentgenogram revealed diffuse ground glass opacities in the left lung and lower segments of the right lung, and diffuse reticular interstitial pattern in the right lung as signs of acute exacerbation of IPF (Fig 2). Despite steroid therapy he required mechanical ventilation on postoperative day 9, and he died of respiratory failure on postoperative day 20. Histolopathologic study of the resected lobe revealed a T2N0 squamous cell carcinoma, and patchy areas of interstitial fibrosis.
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Fig 1. Preoperative high-resolution computed tomographic scan of patient 1. A mass in the left lower lobe superior segment (thin arrow), diffuse fine reticular opacities in both peripheral lung, predominantly in the right side (white arrows), bilateral hazy fissures (stars), and traction bronchiectasis (thick arrows).
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Fig 2. Control chest roentgenogram of patient 1 on postoperative day 3. Diffuse ground glass opacities in the left lung and lower segments of the right lung, and diffuse reticular interstitial pattern in the right lung.
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Patient 2
A 57-year-old man presented with a left upper lobe lesion. A high-resolution computed tomographic scan showed a mass in the left upper lobe, bilaterally located patchy areas of intralobular and interlobular septal thickening, ground glass opacities, and honeycombing (Fig 3). He had a diagnosis of IPF, but he had not been on any medication. He had a 15-pack year history of cigarette smoking. His preoperative pulmonary function tests and blood gas analysis were within normal limits. He underwent an uncomplicated left upper lobectomy with radical lymph node dissection. On postoperative day 5, he developed moderate hypoxemia (PaO
2 53 mm Hg) and dyspnea. A controlled, high-resolution computed tomographic scan revealed bilateral progression of basal and peripheral interstitial opacities and honeycombing, which showed an acute exacerbation of IPF (Fig 4). He received therapy of an oral steroid, antibiotic, and oxygen. He responded well and was discharged on oxygen and steroid therapy on postoperative day 48. Histolopathologic examination revealed a T2N2 adenocarcinoma and patchy areas of interstitial fibrosis. The patient died on postoperative day 88 due to respiratory failure.
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Fig 3. Preoperative high-resolution computed tomographic scan of patient 2. A mass in the apical segment of the left upper lobe (thin arrow), interlobar thickenings (stars), slight honeycombing at the peripheral lung (white arrow), and traction bronchiectasis (thick arrow).
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Fig 4. Control high-resolution computed tomographic scan of patient 2 on postoperative day 5. Diffuse reticular opacities (thin arrow), irregular septal opacities (white arrow) in the left lung, diffuse ground glass opacities (stars), and traction bronchiectasis (thick arrow) in the right lung.
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Comment
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More than 100 disorders have been classified as diffuse lung diseases [6]. These entities are grouped together because of certain common clinical, histologic, and radiographic features [6]. Idiopathic pulmonary fibrosis is a diffuse lung disease that more commonly affects male patients older than 50 years of age [1, 6]. It is controversial whether or not all patients with presumed IPF require biopsy [3, 6]. Idiopathic pulmonary fibrosis is also associated with an increased risk of lung cancer [2]. Approximately 2% to 4% of lung cancer patients have IPF [4]. Mortality and morbidity were higher in patients with IPF who underwent lung resection [2]. The incidence of postoperative acute exacerbation of IPF is about 20% [4]. It is suggested that the acute exacerbation could have been triggered by a high concentration of oxygen or mechanical lung injury during surgery [5]. Most patients who develop postoperative acute exacerbation are treated with steroids, but the mortality rate is 50% or greater [4]. Adult respiratory distress syndrome (ARDS) may also cause such a clinical condition and should be stated in the differential diagnosis. However, ARDS more commonly develops in the first 2 days after the precipitating event. The deterioration in ARDS is more rapid, and the pulmonary edema and hypercarbia are more prominent findings [7]. Radiologic findings may help to differentiate between adult respiratory distress syndrome and IPF [3, 7].
We reported two cases of acute exacerbation of IPF after surgery for lung cancer. Both patients died despite therapy. We emphasize that more efforts should be made to develop strategies to prevent postoperative acute exacerbation of IPF.
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References
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- Ambrosini V, Cancellieri A, Chilosi M, et al. Acute exacerbation of idiopathic pulmonary fibrosisreport of a series. Eur Respir J 2003;22:821-826.[Abstract/Free Full Text]
- Kumar P, Goldstraw P, Yamada K, et al. Pulmonary fibrosis and lung cancerrisk and benefit analysis of pulmonary resection. J Thorac Cardiovasc Surg 2003;125:1321-1327.[Abstract/Free Full Text]
- American Thoracic Society/European Respiratory Society international multidisciplinary consensus classification of the idiopathic interstitial pneumonias Am J Respir Crit Care Med 2002;165:277-304.[Free Full Text]
- Hoshikawa Y, Kondo T. Perioperative lung injuryacute exacerbation of idiopathic pulmonary fibrosis and acute interstitial pneumonia after pulmonary resection. Nippon Geka Gakkai Zasshi 2004;105:757-762.[Medline]
- Sakamoto S, Homma S, Kawataba M, et al. Fatal acute exacerbation of idiopathic pulmonary fibrosis/usual interstitial pneumonia initially in the right lung after surgery lobectomy for the left lung cancer Nihon Kokyuki Gakkai Zasshi 2004;42:760-766.[Medline]
- Knight H, Ponn RB. Diffuse lung diseaseIn: Shields TW, LoCicero III J, Ponn RB, editors. General thoracic surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 1342-1373.
- Hudson LD, Steinberg KP. Acute respiratory distress syndromeclinical features, management, and outcome. In: Fishman AP, Elias JA, Fishman JA, editors. Fishman's pulmonary diseases and disorders. 3rd ed. New York: McGraw-Hill; 1998. pp. 1069-1083.
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Abstract
Introduction
