The importance of determining surgical indications in cases of lung cancer and interstitial pneumonia with multiple intrapulmonary lymph nodes

• It is difficult to determine whether surgery is indicated in patients with lung cancer with multiple nodular shadows in multiple lung lobes.
• Physicians are reluctant to perform surgery for patients with lung cancer and interstitial pneumonia.
• However, surgery is the only treatment method that is expected to achieve cure of lung cancer with interstitial pneumonia.
• ∼10-mm nodular shadows located near the pleura may represent an intrapulmonary lymph node.
• Even for patients with lung cancer with interstitial pneumonia, a biopsy should be actively performed to determine the indication for surgery.

IntroductionWhen considering treatment for pulmonary cancer complicated by interstitial pneumonia, the greatest problem is acute exacerbation. We report two cases of pulmonary cancer complicated by interstitial pneumonia in which multiple intrapulmonary lymph nodes were noted.Case presentationsCases 1 and 2 were 76- and 62-year-old males, respectively. Both cases were diagnosed as pulmonary cancer complicated by interstitial pneumonia, and upon chest CT, it was noted that, in addition to the primary lesions, there were multiple nodule shadows under the pleura in the lung lobe, which required identification in order to rule out lung metastasis. In Case 1, the pulmonary nodules were first resected during surgery and a swift diagnosis was made, determining them to be intrapulmonary lymph nodes, which were then operated on curatively. In Case 2, the patient underwent thoracoscopic observation during surgery, the shadows were diagnosed visually as intrapulmonary lymph nodes, and curative surgery was implemented.Discussion and conclusionsThe greatest problem in treating pulmonary cancer complicated with interstitial pneumonia is acute exacerbation, wherein, in the absence of any surgical indications, alternative treatment is limited. Thus, contra-indicating surgery for a patient due to a diagnosis of metastasis within the lungs, based only on nodule images, should be avoided. If nodules are noted in the area of the pleura, the possibility exists that these could be intrapulmonary lymph nodes, along with metastasis within the lung, and thoracoscopic surgery should be implemented proactively while keeping these in mind.