Invited commentary

Abstract

Doctor Fujimoto and colleagues have added a compelling addition to the literature documenting unique circumstances surrounding pulmonary resection in patients with idiopathic pulmonary fibrosis (IPF). This report is unusual in that it limits analysis to patients with pulmonary fibrosis that was documented at the time of consideration for lung resection. Missing are the patients identified postoperatively by pathologic evidence of fibrosis within resected tissue or a complicated course later attributed to a preexisting but unappreciated case of fibrosis [1Kawasaki H. et al.Postoperative morbidity, mortality, and survival in lung cancer associated with idiopathic pulmonary fibrosis.J Surgical Oncology. 2002; 81: 33-37Crossref PubMed Scopus (74) Google Scholar, 2Kumar P. et al.Pulmonary fibrosis and lung cancer Risk and benefit analysis of pulmonary resection.J Thorac Cardiovasc Surg. 2003; 125: 1321-1327Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar]. Missing also are patients with similar, but less virulent forms of interstitial lung disease. The homogeneity of the current report is its strongest attribute. The report displays how IPF might challenge our selection criteria for potential surgical candidates with lung cancer. The fact that all 21 patients received a complete resection and survived the operation reflects well upon the authors' selection process that excluded more than two-thirds of the potential patients referred for surgery. However, despite seemingly excellent spirometry results with a mean forced vital capacity that was 99% of predicted values, 7 out of 21 resected patients died from respiratory failure due to IPF during a mean 2-year follow-up. The “competing risk” of progressive lung failure from IPF clearly must be kept in mind during the evaluation of such patients and spirometry alone is inadequate assessment for the extent of disease. The long-term survival results are disappointing, but important to convey. Other reports have not described the same high rate of late mortality in patients who survived a complete resection. The authors' characterization of 5 out of 7 cancer recurrences as second primaries is unusual, but their criteria for this characterization are sound. The triple threat of increased perioperative risk, late respiratory failure, and late risk of second primaries make IPF patients challenging subjects for surgical decision-making.