Interventional Pulmonary Approach to Lung Nodules

Additional Info

• Segment Number:1
• Audio File:uab/1705ua5a.mp3
• Doctors:Thachuthara-George, Joseph
• Featured Speaker:Joseph Thachuthara-George, MD
• CME Series:Medical Innovations
• Post Test URL:https://cmecourses.som.uab.edu/login/index.php
• Guest Bio:Joseph Thachuthara-George, MD is an Assistant Professor specializing in Pulmonary, Allergy & Critical Care Medicine at UAB Medicine. 
  
  Learn more about Joseph Thachuthara-George, MD 
  
  5/11/2020
  5/11/2023
  
  Dr. Thathuthara-George has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host):  Lung nodule management is complex and requires a multidisciplinary approach to provide comprehensive care.  Interventional pulmonology is an evolving field that utilizes minimally invasive modalities for the initial diagnosis and staging of suspected lung cancers.  My guest today is Dr. Joseph Thanchuthara-George, he’s an interventional pulmonologist at UAB Medicine.  Welcome to the show Dr. George.  So, what are some of the causes of lung nodules and may they be from the metastases or originally diagnosed there?
  
  Dr. Joseph Thanchuthara-George (Guest):  First of all, thank you for having me in the show and this interview.  So, coming to the lung nodules, lung nodules can be due to multiple reasons, it can sometimes be non-cancerous also, it can be infection, inflammation or cancer.  And when it comes cancer, the later lung nodules, if it is from metastases, usually you can have multiple nodules in the lung.  If it’s a single nodule it’s probably a primary originates from the lung.  And that’s, there a multiple reasons for the lung nodules and metastases or a primary lung depends on the number as well as the characteristics of the nodule.
  
  Melanie:  What about the clinical presentation, how would you detect malignancy?
  
  Dr. George:  In general, lung cancers are really challenging because, the highest mortality rate is mainly because lung cancers are detected really late in the process.  So, because of that, most of the time the lung nodules or early stages of lung cancer, patients are usually asymptomatic.  Now we have this lung cancer screening program.  Where we tend to do a screening CT on patients who are had a high risk for developing lung cancer.  The other ways of detecting lung nodules are you do a CT for some other reason, a CT of the chest if you are suspecting a blood clot or for some other reason you do a CT and incidentally you find a spot in the lung or a lung nodule.  And that’s how most of our patients get referred to us, when they incidentally find the nodule.  And most of them are asymptomatic in terms of their lung symptoms.
  
  Melanie:  So how do you determine nodule growth?
  
  Dr. George:  So, nodule growth, depending on the size of the nodule.  A nodule is any basically in the lung less than 30 millimeters or less than 3 centimeters.  If it’s more than 3 centimeters, it’s a mass.  And if it’s less than 3 centimeters and greater than 8 millimeters you consider it as a nodule, and if it’s less than 8 millimeters, you can do a CAT scans, there are several CAT scans, and based on that CAT scan you can determine if that nodule has grown in size or not.  And depending on the origin of size of the nodules, you follow it up at 3 months or at 6 months.  And then you see if it has grown in size.  If it has grown more than 26% of the diameter, then means the volume of the nodule has doubled and that is concerning; usually for less than 400 days.
  
  Melanie:  Can you calculate in a pretest probability of malignancy?
  
  Dr. George:  Yes, we can.  There are usually two ways, there is an objective way, or there’s a way researchers at the Mayo clinic had doubled up the model to calculate the pretest probability.  And there are online modules available where you can plug in the numbers and that will give you a pretest probability.  In general, the independent predictors of this malignancy of a lung nodule, are age, older the age have the chance of it being malignant.  A history of smoking, current or past smoking.  A history of any cancer other than in the chest or extra thoracic cancer malignancy; that increases the chance of being malignancy.  And damage of the nodule, the larger the diameter the larger the chance.  Than characteristics, or we call it peculations of the nodule, or irregular surface of the nodule and if it is in the upper lobe.  These are the characteristics that determine the probability of malignancy in this lung nodules.  And there is software that can predict, give you the actual number or person that prediction for this being cancer.
  
  Melanie: And tell us about bronchoscopy detection for malignancy and then speak about some treatments.
  
  Dr. George:  Okay.  So, coming to bronchoscope approach has been used as the usually we use it as a primary modality of diagnosis, mainly because there are new, new bronchoscopy methods that are available.  So, whenever we see one nodule, our approach in general is to see if there are any lymph nodes around the trachea or bronchia.  So, what we usually do is, we go in with an endobronchial ultrasound; this is the bronchoscope with a probe at the end.  And we scan the area from within the airway, around the area to see if there are any lymph nodes.  And if there is a right-side lung nodule, we start looking from the left side.  And if we find any of the lymph node, then we do a needle aspiration of that lymph node.  By this way, one we can diagnose if there is cancer in that area, and also stage at the same time.  If there is lymph node positive on the other side, it is a higher stage of cancer.  So, then we don’t necessarily have to go for the lung nodule.  If  all those lymph nodes are negative, then the approach is depending on the size and the location of the lung nodule, we can either use regular biopsies from the lung from the bronchoscope or sometimes we use navigation from the laparoscopy.  Those are the main modalities that we use.
  
  Melanie:   And how are pulmonary nodules treated?  And speak about tumor debulking.
  
  Dr. George:  So, pulmonary nodules, first once we diagnose the nodule, it depends on whether the patient is a candidate for resection or not.  That depends on the stage of the tumor, again we do the endobronchial ultrasound and needle aspiration of the lymph nodes to determine the state.  If it’s an early state, and the tumor can be resected than if their lung function are favorable then we send them to surgery.  If it cannot be resected and the patient is not a candidate for surgical resection, then what we do is we place some markers, they are called fiducial markers with our navigation bronchoscopy.  And this can help with radiation treatment.  And to tell you about the navigation bronchoscopy, which is actually a newer technique it gives you a roadmap to reach all the lung nodules which are far out in the lung.  And it is similar to a GPS and that is what we use in navigation.  Coming to the tumor debulking, it’s usually not for nodules.  Once the nodules get bigger and pick up some mass, then it can block the windpipe or the airway.  So, what we usually do is depending on the characteristic of the tumor that is blocking the airway, we go into with the rigid bronchoscope that is rigid hollow tube, and then sometimes we use laser or we just use cautery or forceps to remove the tumor.  And if the airway is still narrow, then we place a stent in there to keep the airway open.  And this will buy us time for the patient to get treatment and or shrink the tumor.
  
  Melanie:  Can navigational bronchoscopy be utilized to assist radiation oncologist for SBRT for example?
  
  Dr. George:  That’s true.  So, we work with the radiation oncology team here.  And whenever there is a lung nodule they need to use SBRT, with the navigational bronchoscopy we place markers around the lung nodule.  So, that they can direct their SBRT in reference to these markers.  And they can do the treatment for the lung nodules.
  
  Melanie:  And speak about palliative management and non-surgical candidates, what else can be done?
  
  Dr. George:  So, in palliative from a bronchoscopy standpoint, we make breathing better.  If there is a blockage in the airway, we look at the area and see if what is blocking it, or if it something compressing it from outside.  If it is something compressing from outside, then we put a stent in to keep it open and make them breathe better.  If it’s from a tumor from inside, then we go and remove the tumor with the bronchoscope by using laser or cautery or argon plasma coagulation.  And sometimes we just use our forceps to debulk the tumor.  And that kind of opens up the airway and helps them breathe better.  The other thing we do is, if there is fluid around the lung, that is causing collapse of the lung, then we sometimes put a catheter in there on a long term for which patient can drain at home and that will also help with their breathing.
  
  Melanie:  And wrap it up for us with your best advice for other physicians about an interventional pulmonary approach to lung nodules.
  
  Dr. George:  In general, even when you come across a lung nodule the main question is what are the pretest probability for this being cancer and whether it needs to be followed up or a repeat CAT scan in 3 or 6 months.  Or whether it needs to be biopsied or not.  And usually we have our lung nodule clinic and a lot of the community pulmonologist sends patients to us.  And we sometimes follow them on a regular basis, and depending on their risk for lung cancer we tend to do biopsies.  Two things, if it’s less than 8 millimeters of lung nodule you can always follow the threshold of criteria and follow the lung nodules on a regular interval.  If it’s more than 8 millimeters and there is concern for cancer.  You can be referred to our interventional pulmonary clinic, and we will see them within 1 week time.  That’s our one time and within 2 weeks we will usually do our procedure.  And if we will feel that this needs to be addressed by a surgeon or a radiologist then can call to make with them because we have a monthly disciplinary team here where we work closely with our surgeons, radiation oncologist, radiologist, pathologist and oncologist.  And we have our team aboard also, so difficult cases we discuss there as well.
  
  Melanie:  And within the last few minutes, Dr. George, how can a community physician refer a patient to UAB Medicine?
  
  Dr. George:  So, there are two ways, there is a UAB MIST Operator, they can call.  Or they can always call out pulmonary call center, that our number is 205-996-5862 or other number is 205-934-7679.  This and they if they want to refer a patient to Interventional Pulmonary well they just need to tell them and the message will come to us and our office will call them if they need things from there.
  
  Melanie:  And tell us about your team.  Why is UAB so great to work with?
  
  Dr. George:  UAB is a very big place and that means that they have almost everything that is needed to function as a well-oiled machine for this kind of multidisciplinary approach.  We have a full set of OR for our interventional pulmonary procedures.  We have good relations with our surgeons as well as our oncologists, radiologists, and pathologists.  And also, we have an excellent team of support.  Our Bronx staff who was doing this for many years, these things are not new to them.  Even though we recently added some new modalities.  But they picked up very fast and we have a very good coordinating team here already in place and that makes it really easy for us to take care of this patient and in the more efficient way.
  
  Melanie:  Thank you so much for being with us today, doctor.  It’s great information.  You’re listening to UAB Medcast and for more information on resources available at UAB Medicine.  You can go to uabmedicine.org/physician.  That’s uabmedicine.org/physician.  This is Melanie Cole, thanks so much for listening.
  
  
  
• Hosts:Melanie Cole, MS