Joyce A. O’Shaughnessy, MD: One other question I have on management, and Mark, you may have others, is on bronchoscopy. What’s the role of bronchoscopy, BAL [bronchoalveolar lavage], biopsy, etc? Obviously, that’s in the purview of the pulmonologist, but it’s nice to have some rules of thumb because then you really want to get that referral going if you have a sense that one is needed, for example.

Mark D. Pegram, MD: I was going to ask Charles that same question.

Charles A. Powell, MD, MBA: We don’t do it routinely. Many times, we can feel comfortable in the diagnosis by reviewing the temporal association of the onset of symptoms and imaging findings with the treatment timing. In the obvious cases, we don’t find evidence suggestive of an infection. We don’t see a fever, or the blood evaluation doesn’t show an elevated white cell count, for example. All patients will have some evaluation to examine for infection. We’ll try and assess sputum, we’ll do PCR [polymerase chain reaction] on respiratory secretions for viruses, and we’ll do some blood amino assays to examine for signs or symptoms of infections, fungal infections or pneumocystis, for example. Those are all noninvasive approaches, and if they’re all negative and the temporal course is confirmatory, then there’s no need for bronchoscopy. But in some cases, it may not be so clear-cut, and those are the cases where we move on and move toward bronchoscopy.

Just getting fluid BAL is sufficient if the main diagnostic possibility is infection versus pneumonitis. We can’t diagnose pneumonitis from bronchoscopy, but we can exclude infections with a high degree of certainty with a lavage. If we’re thinking about lymphangitic carcinomatosis, and that is certainly a possibility in patients who have advanced cancer, then a bronchoscopy with a biopsy will be helpful. That’s an indication for when we would approach doing a bronchoscopy with a biopsy to determine if the interstitial findings that we see on imaging are attributable to progression of the cancer versus a pneumonitis. We don’t do it routinely. We do it after we perform our noninvasive evaluation, and we’ll move toward a bronchoscopy with or without a biopsy based upon the findings and our suspicion that the opacities and the disease is related to drug or not.

Mark D. Pegram, MD: What about surgical biopsy? What type of cases have you seen where video-assisted thoracoscopic biopsy may be indicated for this condition?

Charles A. Powell, MD, MBA: Yes, it won’t be helpful because there are no specific findings in a lung biopsy finding, whether it be from a bronchoscopy approach or whether it be from a VATS, a video-assisted thoracoscopic surgical approach. There’s no specific finding that would be diagnostic of a pneumonitis. If we had a high suspicion for, let’s say, lymphangitic carcinomatosis, and we did not achieve that diagnosis with a bronchoscopic biopsy, then perhaps in rare cases in which it would make a difference in the management, one might move toward a surgical biopsy. But I can’t even remember the last time we moved to do a surgical biopsy in a case of potential drug-related pneumonitis.

Mark D. Pegram, MD: Thank you.

Joyce A. O’Shaughnessy, MD: Thank you. Great discussion. We really covered a lot of the key management points.

Transcript edited for clarity.