Lung Cancer: Radiological Diagnosis (Part
James Ravenel - Radiology
Linda Austin – Psychiatry
Dr. Linda Austin:
I’m Dr. Linda Austin and I’m talking with Dr. James Ravenel, Associate Professor
of Radiology at the Medical University of South Carolina. This is Part 2 of a podcast series in which
we’re talking about the radiographic evaluation of patients with lung
cancer. Dr. Ravenel, you were explaining
that after chest x-ray, one might opt to do a CT scan. And after that, one might opt to do
punctional PET scan image of the lungs.
What comes next?
Dr. James Ravenel: In many cases, we like to do the PET scan
first because not only will it give us information about the nodule, it will
give us information about whether there’s disease elsewhere in the body. In many cases, this can give us the optimal
place to do a biopsy. Obviously, before
you get treated for lung cancer, it has to be diagnosed, and that’s typically
done by putting a needle, under CT guidance, into the lesion. It has some risks to it. Occasionally, we may even recommend that you
go directly to surgery. But in that
case, we want to make sure that you don’t have disease elsewhere in the
body. PET scan allows us to do
that. And, for instance, if we saw
something in the lung and something in the liver, we might recommend that you
have the liver biopsied because that will determine your treatment. Even if we biopsied the lung lesion, we might
still have to biopsy the liver lesion in order to determine your treatment.
I like to do a PET scan first in
most cases because it will help us choose the appropriate site for biopsy. If the lesion is very hot, we might say that
you should go directly to surgery. If
it’s warm or we’re not quite sure, or we think that you’re going to need tissue
before we determine a course of treatment, then we might recommend a CT guided
Dr. Linda Austin: Now, explain what you mean by hot, if the lesion is very hot.
Dr. James Ravenel: Hot is
a term that we use for metabolic activity.
We can make the PET scan turn any color we want and then use gradations
of color. Since we use orange, people
talk about these lesions being hot but, really, what we’re referring to is
Dr. Linda Austin: So, in other words, the more metabolic
activity, the more concerned you would be?
Dr. James Ravenel: Right.
Tumors tend to utilize glucose, utilize sugars, at a higher rate that
Dr. Linda Austin: Now, at the point, then, of diagnosis, I
assume you would turn the patient over to the surgeon or the oncologist for
Dr. James Ravenel: Correct.
Dr. Linda Austin: And would you, typically, not be involved,
then, for awhile again?
Dr. James Ravenel: Well, it depends on the stage of disease and
what needs to be done next. Oftentimes,
we will, here at the medical university, discuss the patient on a
multidisciplinary tumor board so that the surgeons, oncologists, radiation
oncologists, pathologists, and radiots will all get together and decide what
they think is the best plan of action.
Oftentimes, I may have input into saying where the best site for biopsy
is, what stage of disease I think it is and, occasionally, have impact on,
maybe, what to do next.
Once we’ve set out a plan of
action, typically, the next thing we’ll follow is a biopsy of the lesion or
surgery, and then a recuperation period after surgery or, potentially,
chemotherapy and radiation therapy.
Dr. Linda Austin: Then, typically, how often do you follow the
patient after the course of therapy is done?
Dr. James Ravenel: Typically, we’re following most patients who
are on chemotherapy every two cycles of chemotherapy. A cycle of chemotherapy is, essentially, one
course of treatment. So, they’ll
typically do two courses of treatment and then follow up and see whether
they’re making an impact on the cancer.
That’s usually about six weeks apart.
So, at that point, I’ll look at it and, in general, if everything even
looks stable, we’re pretty happy with lung cancer. I’ll report back to the oncologist, in that
case, and say what I see, whether things are getting better, getting worse, or
staying the same. If they’re not getting
better, we have to make a decision whether we should try another course of
chemotherapy or to keep trying the same chemotherapy and see if it will get
Dr. Linda Austin: Now, when you said that if it looks as if the
lesions are at least stable, that’s a good thing, why is that?
Dr. James Ravenel: Unfortunately, once we get to a point of lung
cancer being metastatic, we’re really looking in terms of palliation, that is,
making you more comfortable, extending the quality as well as the quantity of
your life. So, a tumor that’s not
growing is, in this setting, as good as a tumor that’s just shrunk a little
Dr. Linda Austin:
What happens once they’ve, let’s say, chemotherapy, is discontinued,
reached the end of therapy and all that’s happened is that the tumor has been
Dr. James Ravenel: Typically, that’s a decision that’s made
between the patient and their oncologist, or anybody else who might have impact
on their treatment. They will oftentimes
follow them off of treatment every three to six months, depending on the impact
they think they’ve made on the cancer, to make sure that it doesn’t start
growing again. If it starts growing
again, they might decide to treat with a different type of chemotherapy, or use
the same chemotherapy. For the most
part, they will follow them periodically and, in essence, screen them for
Dr. Linda Austin: What is it like for you, as a radiologist, to
follow these patients? You must get to
know them at least through their images, if not as human beings.
Dr. James Ravenel: I do.
Most of these patients come back on the same day I read, so I tend to
see their cases over and over again.
And, obviously, for me, that’s rewarding that they’re coming back and
they’re still alive. It’s also very
helpful to me in that I know, many times, a lot about them from discussing them
with their physicians, and I can tailor my reporting in order to help the physicians
plan the best course of action. In other
words, if you just come into a case, sort of in the middle of it, you may see
something that you’re worried about, but because I know the patient from three
and four and five CTs ago, when I see something, I can oftentimes put it into
better context in terms of how it’s going to impact their cancer management.
Dr. Linda Austin: I think that’s such important information
because patients and family members are often unaware that, behind the
oncologist or the surgeon, there is a team of people, and the radiologist is
certainly a very important part of that team, making decisions and discussing
Dr. James Ravenel: Right.
And I think that might be, for us, the hardest part, in that we don’t
have that personal or emotional relationship with the patient. Yet, what we say can have as much or more
impact than some of the things that they may talk about with their oncologist,
in terms of making determinations as to whether the cancer is getting better or
Dr. Linda Austin: Is it possible for patients or family members
to talk with you directly?
Dr. James Ravenel: It is.
We typically have not done that, but I have had several patients that
have discussed their care with me. I
think, for the most part, they’re getting enough information from their other
doctors, but if the patient wanted to discuss their case with me, or their
images, I would be happy to do that.
Dr. Linda Austin: Dr. Ravenel, thank you so much for talking with
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