Lung cancer? Pulmonary fibrosis? Diagnosis and treatment are silly and indistinguishable

*For medical professionals only

Come and learn about this case!

The patient, a 76-year-old male, was admitted to hospital

ask

Based on the above information, what is your diagnostic treatment?

answer

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Answer: Based on imaging diagnosis, the diagnosis of idiopathic pulmonary fibrosis is ruled out of known causes of pulmonary fibrosis

Histopathology is not confirmed

What disease is most likely to be diagnosed in the patient?

answer

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Answer: Based on imaging diagnosis, the diagnosis of idiopathic pulmonary fibrosis is ruled out of known causes of pulmonary fibrosis

Answer: IPF is easily combined with lung cancer, chronic obstructive pulmonary disease, pulmonary hypertension, congestive heart failure and other diseases

How to consider the treatment of IPF with SLCL?

answer

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Answer: Due to the presence of active tumor diseases is the criterion for excluding participation in the drug program of pirfenidone; The patient stops antifibrotic therapy

Patients are eligible for carboplatin-etoposide regimen and are well

Expert reviews

1.
IPF clinical featureSIP
is a chronic fibrotic interstitial lung disease (ILD) of unknown etiology, and radiology and histopathology are characterized
by ordinary interstitial pneumonia (UIP).

Occurs predominantly in older people, characterized by dyspnea and progressive deterioration of lung function, prone to pneumothorax and mediastinal emphysema, IPF is one of the worst prognostic types of all interstitial lung diseases, and survival after diagnosis is 3 to 5 years
.
At present, the biggest problems with IPF are missed diagnoses and misdiagnoses
.

The vast majority of patients do not have any symptoms in the early stages, and as the disease progresses, lung function gradually deteriorates, showing a "feeling of suffocation"
like dyspnea and shortness of breath.

Some elderly patients often ignore the symptoms of dyspnea, believing that it is physical discomfort
caused by increasing age.

When the patient has symptoms such as shortness of breath and dyspnea, it is already in the middle and advanced stages of the disease, and the ventilation function of the lungs has been damaged by at least 50%.


Therefore, for middle-aged and elderly people, especially smokers, repeated coughs, shortness of breath, long-term exposure to dust, people with family history should be more vigilant, should regularly go to the hospital for lung function examination
.
2.
Among the IPF patients who chose
the treatment plan for IPF with lung cancer, the prevalence of lung cancer was 2.
7% to 48%, which increased the risk by 5 times compared with the general population, surpassing COPD patients
.

The pathological type of IPF-complicated lung cancer is Squamous cell carcinoma, followed by adenocarcinoma, with lesions mostly located in the lower lobe or peripheral
.

It should be noted that when the fibrosis lesion is more severe, even the typical signs of lung cancer are easily masked and missed
.

Therefore, dynamic follow-up should be performed when the patient has a definitive diagnosis of IPF, close attention should be paid to when new nodules or nodule changes occur, and pathological examinations can be taken if necessary to confirm the diagnosis
.
The biggest contradiction in IPF-complicated lung cancer treatment options is that whether surgery, chemotherapy, or radiation therapy can lead to an acute exacerbation of IPF, and patients may die
from acute respiratory failure.

However, patients with IPF and lung cancer were excluded from most clinical trials of advanced NSCLC
.

A 2021 study by Masatoshi Kanayama's team in Japan found that taking pirfenidone during the perioperative period significantly reduced the risk
of acute exacerbations in patients with IPF and lung cancer after undergoing radical lung cancer resection.
Another study in Japan, Dr.
Kohei Ohira's J-SONIC trial, is the world's first phase III randomized controlled trial on IPF complicated with lung cancer, which aimed to evaluate the efficacy
of Nidanib combined chemotherapy with chemotherapy alone in the treatment of IPF with advanced NSCLC.

Primary endpoint median EPF: 14.
6 months in nidanibu group, 11.
8 months in chemotherapy alone, HR =0.
89 (90% CI: 0.
67 to 1.
17), secondary endpoint median OS: nidanib group 16.
1 months, chemotherapy group alone 13.
1 months, HR =0.
61 (95% CI: 0.
40 to 0.
93), side effects: febrile neutropenia due to combined nidanib treatment, There were more cases of diarrhea and proteinuria, but there was no difference
in quality of life between the two groups.

Therefore, a combination of nidanib combined with chemotherapy may be a treatment option
for IPF with advanced NSCLC (particularly non-squamous cell carcinoma).
France and Japan therefore put forward the treatment of IPF with lung cancer in the IPF guidelines:
1) In the population of patients diagnosed with IPF, pay attention to monitoring the occurrence of lung cancer;
2) It is recommended that smokers quit smoking and inform them of relevant auxiliary measures for smoking cessation;
3) It is recommended to have an annual CT scan, which can detect lung cancer at the same time, which is of great significance for patients with tumor limitations and lung function allowing surgery;
4) In patients with both confirmed and confirmed lung cancer, it is recommended to include IPF in treatment decisions;
5) Regarding surgical treatment, because the operation has basic lung function requirements and may also induce AE-IPF, it is necessary to carry out individualized and fine assessment, weigh the pros and cons after decision-making, and it is not clear whether preoperative trial of antifibrosis prevention is useful;
6) Regarding chemotherapy, chemotherapy may induce AE-IPF, respiratory failure, and requires adequate evaluation, follow lung cancer treatment guidelines, and take individualized treatment;
7) Regarding radiotherapy, since it can cause radiation pneumonitis, fibrosis and AE-IPF, in principle, radiotherapy should be avoided as much as possible;
8) Targeted therapy and immunotherapy, complexine enzyme inhibitors and immunotherapy can induce ILD, and the advantages and disadvantages should be weighed, and personalized treatment should be guided by precision medicine to avoid inappropriate drug exposure
.
When diagnosing and treating lung cancer, because there is a risk of acute exacerbation of IPF, the principle
of individualized and comprehensive management should be mastered.

As far as the current research is concerned, the treatment method is more effective with early surgical resection, and there are still many problems related to IPF complicated lung cancer, which require further clinical and basic research
.


Expert Profile
Professor Wang Kun

Master tutor

• Director of Thoracic Surgery, Anning People's Hospital Affiliated to Kunming University of Science and Technology
• Director of the Pulmonary Center of the Hospice Medical Community
• Head of Kunming Nodule Lung Cancer Diagnosis and Treatment Center
• Kunming Municipal Health Commission thousands of engineering talents
• Leader of the integrated innovation team of lung nodule screening and early diagnosis and treatment of lung cancer in the Hospice Medical Community
• He is a director of the Yunnan Branch of the European and American Returned Scholars Association, a member of the Yunnan Charity Federation, a member of the Thoracic Surgery Expert Committee of the Wu Jieping Medical Foundation, a member of the Thoracic Surgeons Branch of the Yunnan Medical Doctor Association, a member of the Vascular Surgery Branch of the Yunnan Medical Doctor Association, a member of the Elderly Tumor Branch of the Yunnan Geriatric Association, and a member of the Oncology Branch of
  the Kunming Medical Association.
  
  
• Selected as the 2017 China Good Doctor;
• In 2005, he went to West China Hospital for 1 year of further study;
• From 2014 to 2015, he was a visiting scholar in the Department of Thoracic Surgery at Stanford University Hospital for 1 year, under the supervision of Joseph Shrager;
• 1999-2019 Department of Thoracic Surgery of Tumors in Yunnan Province;
• 2020-present Chest Center of the First People's Hospital of Anning City, Affiliated to Kunming University of Science and Technology
• He presided over and participated in 12 scientific research projects of The National Natural Science and Technology, the National Health and Family Planning Commission and Yunnan Province, the secretary of the preparation of "Clinical Lung Cancer", and took the lead in carrying out naked-eye 3D single-hole thoracoscopic surgery
  in Yunnan Province.
  
   
  

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