Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage a patient with multiple similar appearing ground glass opacities (~8-9) on Chest CT where one has been surgically removed and confirmed to be adenocarcinoma in situ?
This is a common scenario. Determining the stage of lung cancer can be challenging. Many patients, especially those with chronic lung disease, will have multiple non-specific abnormalities seen on CT scans. The patient with multiple GGO's on CT can be especially challenging. GGO's can represent canc...
Are there any treatment related considerations in a patient with HIV who is on antiretroviral therapy and receiving adjuvant radiation for breast cancer treatment?
Though I have not recently treated many breast or cervical cancer patients with HIV disease compared to the mid-80s and 90s, yet I still continue to treat prostate and head and neck cancer patients with the disease. In these cases, it has been my experience that if patients are taking their HAART as...
What is your routine workup and treatment approach to patients with NSCLC NOS discovered in mediastinal nodes but without obvious primary lung lesions or metastatic disease?
Aside from PET/CT and MRI? Depends on smoking history but would strongly consider NGS for mNSCLC
Would you continue treatment of a rectal metastasis in a patient who is found to have radiographic evidence of contained rectal perforation during the treatment?
Good clinical question. In my experience, I have treated quite a few of both rectal and anal cancer cases, but not one from a metastatic nature that I can recall. But, in any event, my clinical instincts/experienced would push me to ask the following questions: Is this a change in his my daily/weekl...
How do you approach incidentally diagnosed mantle cell lymphoma found on a routine screening colonoscopy?
Stage IE MCL would be very rare; this is probably disseminated disease with extra nodal GI involvement which is seen in the majority of such patients. I would treat as disseminated disease, PS and comorbidity permitting per NCCN guidelines.
Do you do recommend further mediastinal staging for patients with SCLC or inoperable NSCLC with N1 disease on PET?
I would usually request an EBUS. PET is really outstanding for staging of all lung cancer, but sensitivities in the 90+%, but it will occasionally miss the small nodes of the mediastinum. In SCLC, with a N1 node "with high SUV" the pretest probability of having an N2 node is quite high, so it would ...
How do you manage acute esophagitis that persists > 1-2 months after completing chemoradiation for lung cancer?
Harsh protracted esophagitis was reported in 4% of Int. O139(1999)i.e., grade 4 regardless of once or twice daily cycle 1 concurrent. CONVERT reports 18% grade 3!or higher, either QD 66 or BID 45. No reports of > 1 mo duration. Consider endoscopy and culture. Empiric carafate and anti-fungal/candida...
Should patients with idiopathic pulmonary fibrosis be placed on nintedanib or pirfenidone before starting radiotherapy for lung cancer?
This is an interesting question but this is a small patient population in our practice and we have not initiated either drug in the setting of IPF to prevent possible radiation related side effects to the lung because we are unaware of any information to suggest that there would be a benefit.
How do you approach rectal spacer for the patient with renal failure?
Have not come across this but I would presume it would be filtered with dialysis in pts with renal failure.
Do you refer patients to cardiology if they have no history of cardiac disease but will be receiving XRT with high mean doses to the heart?
Great question! Yes, we are starting to refer patients to cardiology who have Stage III NSCLC or LS-SCLC and are receiving high-dose radiation therapy. Trying to tease out whether its heart dose or central tumor location, or some combination of the two, that confers a poorer prognosis is challenging...