Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
For NSCLC patients with limited diagnostic tissue that is insufficient for genetic testing, do you offer repeat biopsy (of accessible site), blood based testing, or both to evaluate for actionable driver mutations?
If a patient has insufficient tissue for molecular testing, I will immediately send a liquid biopsy while simultaneously setting up a repeat biopsy. Our blood-based testing returns within 5-7 days. If a driver mutation is found on liquid biopsy, I will cancel the repeat tissue biopsy. If no driver m...
How would you manage palliation in a patient with postobstructive pneumonia caused by a mediastinal mass?
I'm guessing you're thinking of a lung cancer patient with hilar obstruction, lobar atelectasis, and 2nd pneumoia. These patients often get great palliation from RT. The primary challenge is finding the obstructing mass (which benefits from RT) and separating it from the infection (doesn't benefit)....
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 important is a severely diminished diffusion capacity in determining whether to offer a lung cancer patient radiotherapy?
Conventionally, Pulmonary function tests (PFTs) are considered essential before considering thoracic surgery and by extension this rule has applied to definitive radiation. This is because baseline pulmonary function (PF) can predict the risk of pulmonary complications after thoracotomy, and patient...
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.
What is the role for "liquid biopsy" for patients with newly diagnosed metastatic NSCLC?
I send ctDNA on essentially every new diagnosis of metastatic lung cancer in my clinic. This is for a few reasons. The major reason is that I find these tests come back in about 7-10d on average, and while we have relatively rapid tissue-based NGS-based testing for actionable biomarkers with our pat...
How do you identify immunotherapy-related pneumonitis vs. radiation pneumonitis in a patient status post chemoradiation receiving consolidation immunotherapy?
Unfortunately, it can be quite difficult to discern the two. Radiation pneumonitis is classically more focal within the treatment field, however, it is absolutely possible to get a more diffuse pneumonitis even with focal RT (albeit uncommon).https://www.ncbi.nlm.nih.gov/pubmed/15256622Immunotherapy...
How do you approach elderly patients with stage III NSCLC who have a reasonable performance status?
Prior to answering this question, I should be clear that I have no additional geriatric oncology training or expertise other than someone who has treated lung cancer patients for more than 25 years. Generally I approach elderly patients in the same way I approach the younger with the caveat that I f...
In a patient with ILD and metastatic NSCLC with positive PD-L1, would you give chemo/pembrolizumab, chemotherapy alone, or pembrolizumab alone?
We always discuss the risks and benefits of treatment to every patient; however, patients still rely upon our best judgment to guide decisions. I would not recommend a PD-1 or PD-L1 inhibitor to a patient with known interstitial lung disease. These patients were excluded from the Keynote, Checkmate,...
How would you treat a patient with extensive-stage small cell carcinoma and severe end-stage COPD on home oxygen?
I would base this decision on the patient's performance status, not solely on a diagnosis of COPD or the use of supplemental oxygen. While the IMpower 133 trial included patients with ECOG PS of 0-1, in the outpatient setting I would generally offer chemoimmunotherapy to a patient with PS 0-2. Pneum...