Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What is the optimal management of patients with stage II lung cancer without nodal metastasis, but unresectable due to poor pulmonary reserve?
This population of stage II patients without nodal involvement would include T2bN0 (stage IIA) or T3N0 (stage IIB) disease. NCCN 2020 lists either CRT or hypofractionated RT/SBRT as acceptable options. In my experience, if these patients are nonsurgical, then they typically also have multiple co-mor...
When a patient presents with 2 lung lesions, do you routinely recommend a biopsy of both lung lesions?
2nd lesion may be a satellite met.
Is there an increased risk of pneumonitis in COVID-19+ patients receiving lung irradiation?
This is still very much an open question, since COVID-19 has not existed long enough for us to assess the full impact of the virus on radiation pneumonitis/fibrosis risk. It may be challenging to accurately determine the primary etiology of lung-related changes for COVID-positive patients who receiv...
Do you use an age limit cutoff for SBRT in lung cancer?
We do not use an age-based cut-off when considering safety/eligibility for SBRT, instead treating patients with appropriate overall health and condition, and lesions which are sufficient to warrant treatment. Our own institutional experience (Videtic et al., Pract Radia Oncol 2017) describes the ou...
When do you stop immunosuppressants in patients with GPA?
It depends on the severity of the initial presenting symptoms and which organs were involved. However, generally, I don't stop all treatments and maintain the patient on at least MTX or azathioprine, potentially for life, even if these were not part of the initial remission-inducing regimen, such as...
How do you treat extensive stage small cell lung cancer in the very elderly (more than 80 yrs)?
I typically do not go by the chronological age of the patient, but rather their performance status and co-morbid conditions. For patients >80 year old with PS 0-1, I would have no hesitation in using standard carboplatin-etoposide-immunotherapy. For patients with marginal PS, I would use the same dr...
What is your next step in patients with polymyositis without interstitial lung disease who are refractory to methotrexate?
In general, first-line treatment for myositis patients includes methotrexate, azathioprine or CellCept. The exact choice of agent depends on concomitant manifestations of the disease, like lung disease or arthritis, and can move on to the next one if they fail one of them. At the same time though, w...
What agent do you try next in patients with myositis-related interstitial lung disease who are refractory to mycophenolate mofetil and azathioprine?
In those refractory to MMF or AZA, tacrolimus would be the next good option. There is data to support the use of tacrolimus in those who are more refractory, especially those who are MDA5 or have an antisynthetase syndrome.
When do you use tacrolimus in patients with myositis-related interstitial lung disease?
Tacrolimus can be used as a first-line treatment for any myositis-related ILD; however, it does require more frequent monitoring than other agents. I usually use tacrolimus as a first-line treatment for MDA5-associated ILD given the published literature from Japan and China. In the majority of cases...
What is the role of nintedanib in the treatment of SSc-ILD?
Nintedanib has shown to be effective for treating patients with ILD associated with systemic sclerosis, as the annual rate of decline in FVC was lower with nintedanib than with placebo (SENSCIS trial). However, the majority of patients treated with nintedanib in this trial were also on MMF therapy. ...