International practice guidelines recommend a pre-operative physiologic evaluation for patients planned for lung cancer surgery 1, 2. Steps may include baseline lung function testing, prediction of post-operative (PPO) values for forced expiratory volume in one second (FEV1) and diffusing capacity for carbon monoxide (DLCO), and a range of exercise testing modalities, including low-technology options and cardiopulmonary exercise testing (CPET) 1. Multidisciplinary team discussions can inform the decision to proceed to surgery or to consider alternatives such as stereotactic ablative radiotherapy (SABR) 2. In the first educational selection for 2026, Jeon et al. report a study of 419 patients who underwent lobectomy for non-small cell lung cancer (NSCLC) in Korea between 2016 and 2018 3. Patients were expected to undergo curative surgery, had an Eastern Cooperative Oncology Group (ECOG) status of 0 or 1, and were able to walk. Lung function tests were performed pre-operatively and repeated at 2 weeks, 3 months, 6 months, and 12 months post-operatively. Predicted post-operative FEV1, forced vital capacity (FVC), and DLCO were calculated using the approach recommended in the CHEST guidelines 1. A range of clinical information was collected, including moderate or vigorous physical activity (MVPA) levels, surgical outcomes and complications. Results were stratified by resected lobe to allow comparison of lobe-specific changes. Post-operative lung function monitoring showed an initial decline of around 25% in the first 2 weeks, followed by gradual recovery over the 12 months of follow-up, and this pattern was observed across all lobar subgroups. Right upper lobectomy was associated with a lack of recovery in observed FEV1 compared with PPO FEV1. Other factors, including open surgery, were also associated with lower recovery of FEV1. Age, sex, smoking history, and known chronic obstructive pulmonary disease did not significantly affect recovery. Non-recovery in DLCO was also significantly higher in patients who underwent right upper lobectomy, and a reduction in MVPA at 2 weeks post-operatively also predicted this outcome. Postoperative complications were significantly increased in those with lower PPO-FEV1 and DLCO. These findings suggest that the lobe resected during lung cancer surgery may affect the likelihood of post-operative recovery of lung function, and that all lobes should not be considered equal. Maintenance of physical activity should be encouraged in the post-operative period. Medical students learn that rheumatoid arthritis is associated with interstitial lung disease, a key extra-articular manifestation that is associated with an increased risk of hospital admission, outpatient attendance, in-hospital death and overall mortality 4. Risk factors include male sex, older age, smoking history, and being ‘seropositive’ for specific autoantibodies 4, 5. The educational selection for February further explores this relationship, using Mendelian Randomization (MR) to examine the causal effect of RA on ILD 6. Genetic variants are used to analyse instrumental variation, allowing inference of causality between an exposure and the outcome 7. There are several conditions for instrumental variables (IV) to hold true, including that the IV is associated with the exposure, there are no causes of the IV that also influence the outcome through other means (confounding), and the IV only affects the outcome through the exposure and not through any other trait that affects the outcome 6. Zhang et al. analysed two large genome-wide association studies for RA and ILD, each with thousands of participants of predominantly European descent and millions of single-nucleotide polymorphisms (SNPs). SNPs associated with RA were identified and further evaluated, leaving 52 independent SNPs for examination of their causal effect on ILD development. Statistical analysis demonstrated a causal effect, with no evidence of directional pleiotropy or heterogeneity, and no outlier SNPs were identified. Leave-one-out analysis didn't affect the causal estimate. The final estimate of risk revealed an odds ratio of 1.155 for ILD in patients with a genetic predisposition for RA (confidence interval 1.083–1.232). The findings presented by Zhang et al. provide genetic evidence for a causal link between RA and ILD, and suggest that clinicians caring for patients with RA must remain vigilant for potential lung involvement. However, the datasets included participants of predominantly European descent, which limits generalisability to other populations. Limitations in the ILD dataset prevented reverse MR analysis, rendering bidirectional evaluation impossible. Thus, further study in other well-defined populations is required. Amiodarone-induced lung disease (AILD) is a feared complication of this anti-arrhythmic agent, with estimates suggesting a prevalence of around 5% 8. Cumulative dose exposure, older age, male sex, and pre-existing lung disease are among the identified risk factors 9. The most common pulmonary presentation is interstitial pneumonitis, and radiologically, the changes may appear as interstitial abnormalities or ground-glass opacities. Amiodarone is an iodine-containing compound that can accumulate in adipose tissue and organs such as the liver and lungs. Areas of high attenuation in the lungs or liver on computed tomography are supportive of the diagnosis of AILD. In the final study for this editorial, Bogot et al. evaluate the use of Dual-energy CT (DECT) to identify iodine deposition 10. The authors identified 83 consecutive patients being worked up for possible AILD between 2014 and 2016, with two having breathing artefact on their imaging that limited evaluation. Two experienced pulmonologists rated each patient as either low- or high-likelihood for AILD on clinical grounds. Patients were followed up for up to 2 years, and the physicians were blinded to each other's evaluations. Two senior thoracic radiologists assessed standard 1 mm slice HRCT imaging and then DECT imaging for iodine deposition, and a final rating of low- or high-likelihood was applied. Radiologists were blinded to the clinical data, and a consensus radiologic opinion was reached (Figure 1). Of the 81 patients, 24 (29.6%) were assessed as having a high likelihood of AILD clinically. Alternative diagnoses in those assessed as low likelihood included cardiac failure and other lung diseases, including airways diseases, pulmonary infections and fibrotic interstitial lung diseases. Iodine deposition was demonstrated on DECT imaging in areas of consolidation, ground-glass opacity, atelectasis and interlobular septa. HRCT and DECT combined allowed classification of 60 patients as low likelihood of AILD and 21 as high. There was substantial correlation between clinical and radiologic probability assessments, with Cohen's k = 0.61 (CI: 0.41–0.80), p < 0.001. The specificity and negative predictive value of radiologic assessment were 0.912 (0.840–0.962) and 0.867 (0.798–913), respectively. Five cases received a high likelihood rating based on DECT but were not clinically felt to have AILD (false positives). The author has nothing to report. The author declares no conflicts of interest.
Mark Lavercombe (Mon,) studied this question.