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which generally starts at the posterior bases of the lower lobes and then progressively extends in a caudal-cranial mode&#44; remains unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0001"><span class="elsevierStyleSup">1-3</span></a> One hypothesis suggests that the concurrent action of cell senescence&#44; genetic predisposition&#44; exposure to cigarette smoke and mechanical stress caused by respiratory lung movements leads to the localised exhaustion of the tissue renewal capacity and&#44; eventually&#44; alveolar loss and abnormal lung remodelling&#46;<a class="elsevierStyleCrossRefs" href="#bib0003"><span class="elsevierStyleSup">3-5</span></a></p><p id="para0003" class="elsevierStylePara elsevierViewall">We present the case of a patient who developed a probable UIP pattern after undergoing a left lower lobe &#40;LLL&#41; lobectomy due to a tumour&#46; Interestingly&#44; the patient&#39;s remaining left upper lobe &#40;LUL&#41; exhibited reticulation and traction bronchiectasis that resembled the features usually observed in the lower lobes&#44; which indicated the possible relevance of mechanical tension theory&#46; The patient consented to the publication of this clinical case&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">A 70-year-old male former smoker underwent a computed tomography &#40;CT&#41; scan that revealed a 13-mm LLL cavitated nodule &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>A&#41;&#44; which the CT transthoracic biopsy indicated to have features of squamous cell lung carcinoma&#46; After staging&#44; the patient underwent an LLL lobectomy with lymph node removal&#46; The pathologic assessment revealed a stage I tumour &#40;pT1b N0 R0&#41; according to the American Joint Committee on Cancer criteria &#40;7th edition&#41;&#46; No other histologic features related to interstitial lung disease were identified&#46; The patient was admitted for follow-up and no adjuvant therapy was administered&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0005" class="elsevierStylePara elsevierViewall">During follow-up&#44; the patient remained stable&#44; with his only respiratory symptom being exertional dyspnoea &#40;Modified Medical Research Council Dyspnoea Scale score&#8239;&#61;&#8239;1&#41;&#46; However&#44; the protocolled 18-month CT scan revealed a peripheral and basal reticulation with traction bronchiectasis&#44; which persisted at the 21-month assessment and exhibited slight progression at the 24-month evaluation&#46; Although bilateral&#44; these imaging features were more evident in the inferior portion of the LUL &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>B&#41;&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">After a multidisciplinary team &#40;MDT&#41; discussion&#44; a cryobiopsy of the patient&#39;s LUL was performed&#44; which revealed the replacement of portions of alveoli by irregular fibrous scars in a patchwork pattern and fibroblast foci&#46; The scars were&#160;composed of collagen with scant chronic inflammation&#46; Moreover&#44; their distribution was predominantly paraseptal&#46; The adjacent pulmonary parenchyma presented minimal interstitial inflammation&#46; These aspects were compatible with a UIP pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0002">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><p id="para0007" class="elsevierStylePara elsevierViewall">Apart from being a former smoker&#44; the patient did not report any relevant exposures and his autoimmune panel was within the normal range&#46; The final diagnosis of IPF was established during an MDT meeting and the patient was prescribed 801 mg of pirfenidone three times a day&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Following an LLL lobectomy&#44; the development of an UIP pattern mainly affecting the LUL strengthens the potential relevance of mechanical tension in relation to the manifestation of fibrosis&#46; Pre-existing factors such as ageing&#44; exposure to environmental pollutants &#40;e&#46;g&#46; smoking habits&#41; and unknown genetic abnormalities may promote the occurrence of IPF after an insult that increases the magnitude of the respiratory mechanical stress&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Mechanical forces can be particularly concentrated in the peripheral and basal anatomical parts of the lung&#44; thereby triggering the formation of microscopic damage to the alveolar structure&#44; which may cause repetitive small scarring events &#40;fibroblast foci&#41; and&#44; eventually&#44; honeycomb changes&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Additionally&#44; a subsequent increase in the extracellular matrix stiffness and the progressive scarring of the lung tissue significantly change the respiratory mechanics&#44; rendering the lung more fragile and more exposed to non-physiological stress during both spontaneous breathing and mechanical ventilation&#44; which can promote progressive lung damage and the dysregulation of mechano-transduction and tissue repair&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Carloni et al&#46; demonstrated that mechanical stress during lung inflation is heterogeneously distributed in different anatomical parts of the lung parenchyma and&#44; further&#44; that these overloaded regions correspond to those involved in early IPF lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> More recently&#44; Wu et al&#46; showed that the loss of Cdc42 function in alveolar stem 2 cells &#40;AT2&#41; causes periphery-to-centre progressive fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> It has been established that the application of mechanical stretch to AT2 cells activates the transforming growth factor beta &#40;TGF-&#946;&#41; pathway&#44; which induces a disturbance in the homeostatic microenvironment&#44; leading to aberrant wound healing and promoting the fibrotic process&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> The authors also showed that Cdc42-null AT2 cells in post-pneumonectomy and untreated aged mice could not regenerate new alveoli&#44; resulting in sustained exposure to elevated mechanical tension&#44; which activated TGF-&#946; signalling&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> This study provides new insights that emphasise the association between mechanical tension and progressive lung fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">The precise recognition of this physiologic process is vital&#44; as it can inform the identification of preventive measures to avoid fibrosis and suggest new therapeutic paths&#46;</p></span>"
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Letter to the Editor
A curious manifestation of mechanical tension theory in idiopathic pulmonary fibrosis
A. Trindadea,
Corresponding author
anatildetrindade@gmail.com

Corresponding author.
, S. Diasb, A. Moraisc,d,e
a Pulmonology Department, Hospital Professor Doutor Fernando Fonseca, Lisboa, Portugal
b Pulmonology Department, Hospital Pedro Hispano, Porto, Portugal
c Pulmonology Department - Centro Hospitalar Universitário de São João, Porto, Portugal
d Faculdade de Medicina da Universidade do Porto, Portugal
e i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal
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which generally starts at the posterior bases of the lower lobes and then progressively extends in a caudal-cranial mode&#44; remains unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0001"><span class="elsevierStyleSup">1-3</span></a> One hypothesis suggests that the concurrent action of cell senescence&#44; genetic predisposition&#44; exposure to cigarette smoke and mechanical stress caused by respiratory lung movements leads to the localised exhaustion of the tissue renewal capacity and&#44; eventually&#44; alveolar loss and abnormal lung remodelling&#46;<a class="elsevierStyleCrossRefs" href="#bib0003"><span class="elsevierStyleSup">3-5</span></a></p><p id="para0003" class="elsevierStylePara elsevierViewall">We present the case of a patient who developed a probable UIP pattern after undergoing a left lower lobe &#40;LLL&#41; lobectomy due to a tumour&#46; Interestingly&#44; the patient&#39;s remaining left upper lobe &#40;LUL&#41; exhibited reticulation and traction bronchiectasis that resembled the features usually observed in the lower lobes&#44; which indicated the possible relevance of mechanical tension theory&#46; The patient consented to the publication of this clinical case&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">A 70-year-old male former smoker underwent a computed tomography &#40;CT&#41; scan that revealed a 13-mm LLL cavitated nodule &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>A&#41;&#44; which the CT transthoracic biopsy indicated to have features of squamous cell lung carcinoma&#46; After staging&#44; the patient underwent an LLL lobectomy with lymph node removal&#46; The pathologic assessment revealed a stage I tumour &#40;pT1b N0 R0&#41; according to the American Joint Committee on Cancer criteria &#40;7th edition&#41;&#46; No other histologic features related to interstitial lung disease were identified&#46; The patient was admitted for follow-up and no adjuvant therapy was administered&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0005" class="elsevierStylePara elsevierViewall">During follow-up&#44; the patient remained stable&#44; with his only respiratory symptom being exertional dyspnoea &#40;Modified Medical Research Council Dyspnoea Scale score&#8239;&#61;&#8239;1&#41;&#46; However&#44; the protocolled 18-month CT scan revealed a peripheral and basal reticulation with traction bronchiectasis&#44; which persisted at the 21-month assessment and exhibited slight progression at the 24-month evaluation&#46; Although bilateral&#44; these imaging features were more evident in the inferior portion of the LUL &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>B&#41;&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">After a multidisciplinary team &#40;MDT&#41; discussion&#44; a cryobiopsy of the patient&#39;s LUL was performed&#44; which revealed the replacement of portions of alveoli by irregular fibrous scars in a patchwork pattern and fibroblast foci&#46; The scars were&#160;composed of collagen with scant chronic inflammation&#46; Moreover&#44; their distribution was predominantly paraseptal&#46; The adjacent pulmonary parenchyma presented minimal interstitial inflammation&#46; These aspects were compatible with a UIP pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0002">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><p id="para0007" class="elsevierStylePara elsevierViewall">Apart from being a former smoker&#44; the patient did not report any relevant exposures and his autoimmune panel was within the normal range&#46; The final diagnosis of IPF was established during an MDT meeting and the patient was prescribed 801 mg of pirfenidone three times a day&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Following an LLL lobectomy&#44; the development of an UIP pattern mainly affecting the LUL strengthens the potential relevance of mechanical tension in relation to the manifestation of fibrosis&#46; Pre-existing factors such as ageing&#44; exposure to environmental pollutants &#40;e&#46;g&#46; smoking habits&#41; and unknown genetic abnormalities may promote the occurrence of IPF after an insult that increases the magnitude of the respiratory mechanical stress&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> Mechanical forces can be particularly concentrated in the peripheral and basal anatomical parts of the lung&#44; thereby triggering the formation of microscopic damage to the alveolar structure&#44; which may cause repetitive small scarring events &#40;fibroblast foci&#41; and&#44; eventually&#44; honeycomb changes&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> Additionally&#44; a subsequent increase in the extracellular matrix stiffness and the progressive scarring of the lung tissue significantly change the respiratory mechanics&#44; rendering the lung more fragile and more exposed to non-physiological stress during both spontaneous breathing and mechanical ventilation&#44; which can promote progressive lung damage and the dysregulation of mechano-transduction and tissue repair&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Carloni et al&#46; demonstrated that mechanical stress during lung inflation is heterogeneously distributed in different anatomical parts of the lung parenchyma and&#44; further&#44; that these overloaded regions correspond to those involved in early IPF lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> More recently&#44; Wu et al&#46; showed that the loss of Cdc42 function in alveolar stem 2 cells &#40;AT2&#41; causes periphery-to-centre progressive fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> It has been established that the application of mechanical stretch to AT2 cells activates the transforming growth factor beta &#40;TGF-&#946;&#41; pathway&#44; which induces a disturbance in the homeostatic microenvironment&#44; leading to aberrant wound healing and promoting the fibrotic process&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> The authors also showed that Cdc42-null AT2 cells in post-pneumonectomy and untreated aged mice could not regenerate new alveoli&#44; resulting in sustained exposure to elevated mechanical tension&#44; which activated TGF-&#946; signalling&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> This study provides new insights that emphasise the association between mechanical tension and progressive lung fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">The precise recognition of this physiologic process is vital&#44; as it can inform the identification of preventive measures to avoid fibrosis and suggest new therapeutic paths&#46;</p></span>"
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