Lung Cancer: Radiological Diagnosis (Part 2)
Guest: Dr. James Ravenel - Radiology
Host: Dr. 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 functional 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 lung biopsy.
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 metabolic activity.
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 non-malignant tissues.
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 treatment, correct?
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 better.
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 bit.
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 stabilized?
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 recurrent disease.
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 and following.
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 getting worse.
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 us.
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