Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Can liquid biopsy be substituted for tissue biopsy in a lung mass that is radiologically suspicious for primary lung cancer when CT-guided biopsy cannot be done?
Generally, the utility of liquid biopsy remains in the ability to provide genomic information from cfDNA. A liquid biopsy will not provide a definitive tissue diagnosis and does not provide information about histology. When a histologic diagnosis is made with biopsy or FNA but the sample is insuffic...
How do you manage end-organ toxicity such as hepatotoxicity or pulmonary toxicity in a patient receiving RET-inhibitors for NSCLC?
For liver toxicity, I would hold the TKI for grade 3 of higher elevations in the transaminases, and monitor 3-5 days thereafter and then weekly. If the LFTs resolve, I would resume the TKI at a dose reduction. If the LFTS remain normal a couple weeks after resolution, I might even consider dose re-e...
Is there a role for anti-IL6 therapy in SSc-associated ILD?
There may be a role for IL-6 inhibition for the treatment of ILD in scleroderma, but this has not been fully explored yet in clinical trials. However, the Phase II and Phase III studies of tocilizumab both suggested stabilization of FVC compared to the placebo arm. The Phase III faSScinate study inc...
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...
How do you treat an AAV patient with recurrent bronchial stenosis that has not responded to rituximab induction therapy and dilatations?
Difficult situation and one we have recently seen at our center in a few patients. This case brings up a few key issues in the management of ANCA-associated vasculitis: We always need to confirm the diagnosis to the best of one’s ability. Look everywhere that is logical. This is especially tough wi...
What is the risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplantation?
The risk of ILD recurrence in MDA5/Ro52 positive dermatomyositis following a lung transplant is probably very low, although specific data is unavailable. Polymyositis was documented as the recipient diagnosis for 87 lung transplants during the time period from 1988-2022 in the United States. Dermato...
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
These are tough cases. While we ideally aspire to have full (and congruent) staging information, this is not always possible.There are therefore competing pressures. Factors that favor AP/PA, 3 Gy fractions include 1) the need to initiate treatment rapidly given symptomatic burden and 2) the desire ...
Would you use inhaled steroids with or without oral steroids for the treatment of radiation pneumonitis?
I have not tried inhaled steroids instead of oral steroids for symptomatic radiation pneumonitis much in my practice. Many patients are already on inhaled steroids at baseline, and many who develop pneumonitis have severe symptoms. That being said, avoiding oral steroids could be particularly import...
What immunosuppressive agents aside from steroids would you use to treat bronchiolitis obliterans in a patient with long-standing seropositive RA?
There is little doubt that bronchiolitis obliterans can be a devastating lung disease. Corticosteroids remain the primary anchor therapy, however, virtually all patients will require an additional agent. Rituximab has become the primary choice and there is evidence, though mostly anecdotal, that it ...
How do you approach the management of SSc-ILD in a patient on immune checkpoint therapy?
If the oncologist thinks immune checkpoint inhibitor therapy is the best treatment for the patient's cancer, we try to facilitate this. We obtain baseline pulmonary function tests and CT scans. Repeat every three months while on therapy. Usually, these patients have pulmonary involved also, in parti...