key: cord-0882245-30khq9az
authors: Nakagomi, Takahiro; Goto, Taichiro; Hirotsu, Yosuke; Higuchi, Rumi; Tsutsui, Toshiharu; Amemiya, Kenji; Oyama, Toshio; Mochizuki, Hitoshi; Omata, Masao
title: Lung Cancer Surgery with Persistent COVID-19 Infection
date: 2021-12-10
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.11.015
sha: 9966c07e49a655a97c85476b2937c037f93019d2
doc_id: 882245
cord_uid: 30khq9az

A 71-year-old man with a history of drug-induced interstitial pneumonia was diagnosed with COVID-19 infection and simultaneously found to have a pulmonary mass, suggesting a coexisting lung cancer. Approximately one month after COVID-19 pneumonia resolved, the patient electively underwent right upper lobectomy. Postoperatively, acute exacerbation of interstitial pneumonia occurred and the patient died on the 15th postoperative day.

The pandemic of COVID-19 involves an increasing number of surgical cases of lung cancer detected in association with COVID-19 infection. Especially in case of lung cancer associated with interstitial pneumonia, meticulous attention needs to be paid to the acute exacerbation of interstitial pneumonia in the perioperative period. However, it is not clear whether previous infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may persist in the local area for a long period and lead to increased morbidity and mortality for subsequent procedures even after radiologic resolution.

A 71-year-old male heavy-smoker with a history of drug-induced interstitial pneumonia and its acute exacerbation (AE) was diagnosed with COVID-19 (E484K mutation, variant of SARS-CoV-2). Computed tomography (CT) showed a ground-glass appearance characteristic of COVID-19 and a 5-centimeter mass in the upper lobe of the right lung, suggesting the coexistence of COVID-19 and lung cancer in the same lobe (Fig 1) . After treatment with Remdesivir, the viral antigen test of pharyngeal swab was negative, and resolution of pneumonia was also confirmed radiologically. At 30 days after the discharge, the patient was rehospitalized and underwent surgery for lung cancer. Right upper lobectomy and lymph node dissection were performed, and the postoperative course was uneventful until, on the fifth postoperative day, the patient developed an acute exacerbation of interstitial pneumonia, which necessitated ventilator management. Steroid pulse therapy was initiated, however J o u r n a l P r e -p r o o f interstitial pneumonia was gradually aggravated and the patient died on the 15th postoperative day (Fig 2) . Pathological examination of resected specimens showed that the tumor was squamous cell carcinoma, staged as T2bN1M0, stage IIB (Fig 3A) , and RT-PCR revealed SARS-CoV-2 still persisted in the local lung (S2, Segment 2). sample. Histologically, active pneumonitis with abundant neutrophilic infiltrate was microscopically observed in S2 lung (Fig 3C) .

The mortality risk of surgery after COVID-19 infection has been reported to be increased up to 5-6 weeks (3) 

Acute exacerbation (AE) of interstitial pneumonia after surgery may be caused by various enigmatic reasons, reflecting its difficult-to-treat pathology (5) . A multicenter retrospective cohort study conducted by the Japanese Association for Chest Surgery with 1763 cases reported an incidence of AE in the first 30 postoperative days of 9.3% and mortality rate of 43.9% (6) . A subsequent multivariate analysis identified the following as significant respective risk factors for AE: male gender, preoperative steroid use, KL-6 > 1000 U/mL, %VC < 80%, UIP pattern, history of AE, segmentectomy or a more extensive surgical procedure (reference, wedge resection). In our case, the patient, with a history of AE and on a dose of steroids, is considered to be high-risk originally, while it is possible that the residual COVID-19 infection further increased the risk of AE. 

Discovery of a sars-cov-2 variant from the p.1 lineage harboring k417t/e484k/n501y mutations in kofu, japan

Development of genetic diagnostic methods for detection for novel coronavirus 2019(ncov-2019) in japan

Timing of surgery following sars-cov-2 infection: An international prospective cohort study

Comparison of rna in situ hybridization and immunohistochemistry techniques for the detection and localization of sars-cov-2 in human tissues

Measuring surgery outcomes of lung cancer patients with concomitant pulmonary fibrosis: A review of the literature

Impact and predictors of acute exacerbation of interstitial lung diseases after pulmonary resection for lung cancer

Acute exacerbation of interstitial lung disease as a sequela of covid-19 pneumonia

Covid-19 and acute exacerbation of

Not applicable.J o u r n a l P r e -p r o o f