Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
What are your criteria for treating a patient with lung SBRT in the absence of a biopsy?
First I would say that there is no standard answer to this, and the crtieria are going to depend on your population and the experience of you and your colleagues.. The group at VU has published their experience treating "clincially diagnosed" early lung cancer with SBRT, and found that the outcomes ...
How do you approach lung tumors with vessel encasement, especially in someone with active hemoptysis?
It's a good question and not one that has a ton of published data to support. If you look at the GYN literature for palliation of vaginal bleeding, hypofractioned RT can be a very useful treatment, suggesting a role in other sites. My impression is always that those are very vascular malignanies and...
When should SBRT be preferred in operative patients who cannot undergo a lobectomy?
Numerous retrospective studies have examined clinical outcomes between SBRT and surgery using a variety of different statistical tests- propensity analyses, matched-pair comparisons, multivariable analyses, and so forth. Collectively, these studies report conflicting results. No randomized data with...
Do you use anti-PD-1/anti-PD-L1 therapies in lung cancer patients with a prior history of radiation pneumonitis?
I have used anti-PD-1 directed therapies in patients with a prior history of radiation pneumonitis. The history had excluded her from one clinical trial of these agents but not another that is also combining the anti-PD-1 directed therapy with a CTLA-4 agent. If someone is on steroids for a current...
Do you consider idiopathic pulmonary fibrosis a contraindication to lung SBRT?
The number of IPF patients treated at our institution has been relatively small, at less than 5%. When they have presented with medically inoperable early lung cancer, we have discussed the risk and benefits of lung SBRT with a focus on lung toxicity that may be more prevalent in this clinical scena...
What is your next step in management for a patient with immunotherapy induced pneumonitis that does not improve on high dose steroids for 48 hours?
There is an excellent answer to this question from my colleague Dr. @Dr. First Last that can be found here. She provides an overview of the data as well as multiple references.
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 ...
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.