Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
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...
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...