Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
When should SBRT be preferred in operative patients who cannot undergo a lobectomy?
Two large randomized trials (JCOG0802/WJOG4607L; CALGB 140503) have recently been published demonstrating that small (≤ 2 cm), peripheral, node-negative NSCLCs can be effectively managed with a sublobar resection. The JCOG trial demonstrated that segmentectomy was associated with improved survival c...
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 ...
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...