Acute Exacerbation of Usual Interstitial Pneumonia After Resection of Lung Cancer Hiroaki Sugiura, MD, Atsuya Takeda, MD, PhD, Toshiko Hoshi, MD, PhD,

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Acute Exacerbation of Usual Interstitial Pneumonia After Resection of Lung Cancer Hiroaki Sugiura, MD, Atsuya Takeda, MD, PhD, Toshiko Hoshi, MD, PhD, Yoshinori Kawabata, MD, Koichi Sayama, MD, PhD, Masahiro Jinzaki, MD, PhD, Sachio Kuribayashi, MD, PhD The Annals of Thoracic Surgery Volume 93, Issue 3, Pages 937-943 (March 2012) DOI: 10.1016/j.athoracsur.2011.12.010 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 High-resolution computed tomography of the lung at the mid-level portion of the right lower lobe shows typical honeycombing pattern. Black arrows indicate an accumulation of cystic air spaces with thickened walls in the periphery of the lobe. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Lung cancer in the right upper lobe with possible honeycombing finding in the background lung. Preoperative thin-section computed tomographic image shows (A) primary lung cancer in the periphery of the right upper lobe, and (B) thin-walled cystic change (black arrow) superimposed on ground-glass opacities and reticular opacities in the periphery of the right lower lobe. (C) Photomicrograph with hematoxylin and eosin staining shows patchy bands of fibrosis in the background tissue of the right upper lobe. Structural remodeling and fibroblastic foci are present both along the subpleural surface and within the parenchyma, findings that fulfill the pathologic criteria of usual interstitial pneumonia pattern. Magnification ×2. Size bar: 5 mm. (D) High-resolution computed tomographic image of the right lower lung 7 days after right upper lobectomy shows acute exacerbation of usual interstitial pneumonia, with a pattern of diffuse heterogeneous ground-glass opacities. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Lung cancer in the left upper lobe with possible honeycombing finding in the background lung. (A, B) Preoperative thin-section computed tomographic image of the left upper lobe shows well-demarcated primary lung cancer and cysts with slightly thicker walls than in the surrounding emphysematous regions, a finding that suggests some fibrotic change superimposed on emphysematous change (black arrows). Intermingled cysts and ground-glass opacities are present in the periphery of the right lower lobe (arrowheads). These cystic changes were classified as possible honeycombing. (C) Photomicrograph with hematoxylin and eosin staining shows subpleural, chronic, interstitial pneumonia with emphysematous change. Although no bands of dense fibrosis were observed and the cyst walls were rather thin, this lesion was considered as fulfilling the histologic criteria of usual interstitial pneumonia pattern and was interpreted as usual interstitial pneumonia with thin-wall honeycombing. Magnification ×2. Size bar: 5 mm. (D) High-resolution computed tomographic image of the right lung shows acute exacerbation of usual interstitial pneumonia 8 days after left upper lobectomy, with a pattern of ground-glass opacities. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Preoperative thin-section computed tomographic image of the lower lung lobes at the apex of the diaphragm in a patient with usual interstitial pneumonia shows diffuse ground-glass opacities and reticulation bilaterally, primarily in a peripheral dominant distribution. Neither typical nor possible honeycombing is present. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Flow chart of patients in the study shows the number of lung cancer patients, those who had usual interstitial pneumonia (UIP) pattern in the background lung, patients for whom preoperative computed tomographic (CT) images were available, and their computed tomographic results classification group. The number in the brackets in each box represents the number of patients who experienced postoperative acute exacerbation. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Comparison of the incidence of postoperative acute exacerbation in each computed tomographic classification group. The Annals of Thoracic Surgery 2012 93, 937-943DOI: (10.1016/j.athoracsur.2011.12.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions