Breathe Easier: A New Approach to Lung Cancer Surgery in ILD Patients
"Modified Risk Scoring System Helps Doctors Make Better Decisions, Improving Outcomes for Patients with Interstitial Lung Disease"
Lung cancer poses a significant threat, and for individuals also battling interstitial lung disease (ILD), the challenges are compounded. These patients often face acute exacerbation (AE) of their ILD following lung resection, a surgical procedure to remove cancerous tissue. Postoperative AE of ILD is a serious complication and the leading cause of death after lung cancer surgery. Therefore, selecting the right surgical approach is paramount to ensure both cancer treatment and patient survival. It is important to achieve the optimal balance between effectively removing the cancer and minimizing the risk of triggering AE, which can be fatal.
Recognizing this critical need, The Japanese Association for Chest Surgery (JACS) has been at the forefront, working to understand and mitigate the risks associated with lung cancer surgery in ILD patients. JACS has identified key risk factors and developed a risk scoring system to predict the likelihood of postoperative AE. These advancements provide doctors with valuable tools to assess individual patient risk and tailor surgical strategies accordingly.
This article delves into a modified version of the JACS risk scoring system, exploring its potential to further refine surgical decision-making. By carefully evaluating patient-specific factors, this modified system aims to help surgeons select the most appropriate procedure – one that maximizes the chances of successful cancer treatment while minimizing the danger of acute exacerbation. Ultimately, the goal is to improve outcomes and offer hope for lung cancer patients facing the added complexity of ILD.
The Clinical Burden of ILD
Interstitial lung disease is clinically important in patients undergoing pulmonary resection for primary lung cancer because postoperative acute exacerbation of idiopathic pulmonary fibrosis is a recognized concern. A 2023 retrospective cohort analysis used The Society of Thoracic Surgeons General Thoracic Surgery Database to compare postoperative outcomes after non-small cell lung cancer resection between patients with and without ILD, covering procedures performed from 2009 through 2019. The CDC's Lung Cancer Stat Bite summarizes new cases, deaths, survival, and the stages at which lung cancer is diagnosed, providing broader context for the disease burden.
Surgery and Its Risks
Lung resection is described as the standard treatment for early-stage lung cancer involving interstitial pneumonia. However, survival outcomes after resection can be poor because of acute exacerbations, respiratory failure, and lung cancer. A separate study assessed the surgical risk of lung cancer in patients with ILD through a single-center retrospective comparison of patients who underwent surgery with or without ILD, while another large cohort examined percutaneous lung cryoablation in 37 patients with ILD, including 15 with IPF.
A Complicated Surgical History
Modern lung cancer surgery developed through continual innovation and milestones associated with early pioneers in thoracic surgery. As understanding of ILD and lung cancer evolved, researchers described lung cancer arising in fibrotic lung parenchyma, where the fibrotic abnormalities can worsen prognosis. Contemporary reviews emphasize that ILD complicates both diagnosis and treatment, including difficulty interpreting radiological findings and increased risks of acute exacerbation after surgery and pneumonitis after radiation therapy or immunotherapy.
Understanding the Modified Risk Scoring System
The original risk scoring system developed by JACS included seven key risk factors: sex, history of AE, preoperative steroid use, serum Krebs von den Lungen-6 level, percent predicted vital capacity, CT findings, and surgical procedure. However, to isolate the impact of the surgical procedure itself, researchers developed a modified system that excludes surgical procedures as a risk factor. This allows for a more objective assessment of a patient's underlying risk profile before considering surgical options.
- Group A: Risk score 0-6
- Group B: Risk score 7-10
- Group C: Risk score 11-14
- Group D: Risk score 15-18
Postoperative Exacerbation Risk
A retrospective study examined 60 lung cancer patients with ILD to determine whether a modified risk-scoring system could help select an optimal surgical procedure while balancing curability and the risk of postoperative acute exacerbation. In that study, 8 patients, or 13.3%, experienced postoperative acute exacerbation. The findings support risk assessment as a potential aid to surgical selection, but they also show that acute exacerbation remained a significant postoperative failure risk.
Exacerbation Patterns Across Diseases
The comparative sources address exacerbation patterns in COPD and multiple sclerosis rather than lung cancer surgery in ILD patients. In COPD, frequent colds were associated with greater cigarette-smoke exposure, reported as 46 versus 33 pack-years, and prior exacerbations increased the risk of future exacerbations. In the multiple-sclerosis case series, seven patients developed rapid exacerbation after interferon-beta 1a and two after interferon-beta 1b, showing that treatment-associated worsening can also occur in another disease context.
The Promise of Personalized Surgical Planning
The modified risk scoring system offers a valuable tool for personalizing surgical approaches in lung cancer patients with ILD. By carefully considering individual risk factors and the potential impact of different surgical procedures, doctors can make more informed decisions that optimize patient outcomes. While further research is needed to validate these findings and refine the risk scoring system, this approach represents a significant step forward in improving the safety and efficacy of lung cancer surgery for this vulnerable population. It emphasizes the importance of a multidisciplinary approach, where pulmonologists and thoracic surgeons work together to tailor treatment plans to the unique needs of each patient.
What Remains Uncertain
Research on interstitial lung abnormalities continues to examine how subtle preoperative findings relate to outcomes after lung cancer treatment. One 2025 study excluded patients with previous lung cancer, prior lung resection, or clinically evident ILD before cancer detection and reviewed preoperative scans using established criteria for interstitial lung abnormalities. Another report states that the effect of histopathologically confirmed interstitial abnormalities in surgical specimens on treatment-related complications and survival after curative surgery remains unknown.