Management of Lung Cancer in the Patient with Interstitial Lung Disease

Abstract

Patients with interstitial lung disease (ILD), especially those with pulmonary fibrosis, are at increased risk of developing lung cancer. Management of lung cancer in patients with ILD is particularly challenging. Diagnosis can be complicated by difficulty differentiating lung nodules from areas of focal fibrosis, and percutaneous biopsy approaches confer an increased risk of complications in those with pulmonary fibrosis. Lung cancer treatment in these patients pose several specific considerations. The degree of lung function impairment may preclude lobectomy or surgical resection of any type. Surgical resection can trigger an acute exacerbation of the underlying ILD. The presence of ILD confers an increased risk of pneumonitis with radiotherapy, and many of the systemic therapies also carry an increased risk of pneumonitis in this population. The safety of immunotherapy in the setting of ILD remains to be fully elucidated and concerns remain as to triggering pneumonitis. The purpose of this review is to summarize the evidence regarding consideration for tissue diagnosis, chemotherapy and immunotherapy, radiotherapy, and surgery, in this patient population and discuss emerging areas of research. We also propose a multidisciplinary approach and practical considerations for monitoring for ILD progression during lung cancer treatment.

Clinical characteristics and prognostic impact of acute exacerbations in patients with interstitial lung disease and lung cancer: A single‐center, retrospective cohort study

“…Patients with ILD‐LC are at increased risk of radiation pneumonitis, with reported rates ranging from 19% to 32% 11,24,25 . In the present study, the median incidence of AE (16.8%) was similar to that of previous studies 12 . However, patients who underwent surgery in our study (4.3%) had a lower incidence of AE compared to other studies 21 .…”

“…11,24,25 In the present study, the median incidence of AE (16.8%) was similar to that of previous studies. 12 However, patients who underwent surgery in our study (4.3%) had a lower incidence of AE compared to other studies. 21 The postoperative risk of AE is evaluated in all patients prior to surgery at our institution.…”

“…11 As the development of AE after treatment can be fatal, the selection of optimal treatment strategies for patients with ILD-LC must ensure a balance between efficacy and safety considerations. 12 However, previous studies have often evaluated the incidence of AE after a specific therapy, such as surgery or chemotherapy. 11,13 In addition, the majority of these studies included a small proportion of patients with ILD.…”

“…In patients treated with radiotherapy, ILD is reportedly associated with an increased risk of pulmonary toxicity 11 . As the development of AE after treatment can be fatal, the selection of optimal treatment strategies for patients with ILD‐LC must ensure a balance between efficacy and safety considerations 12 . However, previous studies have often evaluated the incidence of AE after a specific therapy, such as surgery or chemotherapy 11,13 .…”

Treating lung cancer in patients with interstitial lung disease: what do we know?

“…Surgical resection may be contraindicated due to reduced lung function or comorbidities including pulmonary hypertension. Surgery, radiation, chemotherapy, and immunotherapy are associated with an increased risk of AE-ILD in patients with IPF and other types of ILD (10)(11)(12)(13). In a cohort of 1,763 patients with ILD who underwent resection of lung cancer at 61 centers in Japan, AE-ILD occurred in 9.3% of patients with a mortality of 43.9% (13).…”