Treatment for Idiopathic Pulmonary Fibrosis

As everyone working in this field knows, the prognosis of idiopathic pulmonary fibrosis (IPF) is quite dismal (3 years survival of 50%). There have been many treatment regimens that have been suggested, but it is not clear whether any of them are of any use.

The latest issue of the New England Journal of Medicine (NEJM) has 3 articles and one editorial on this subject. The last one on acetyl-cysteine confirms that it does not really work.

However one more phase III trial by Talmadge King’s group on the use of pirfenidone, conducted because the US FDA was not convinced about its efficacy given the conflicting results from previous trials, shows that it does improve decline in lung function and overall survival.

The paper that however does bring a smile and some more hope is the first one by Richeldi Luca et al that shows the usefulness of nintedanib (where do come up with these names) in improving the reduction in FVC in patients with IPF.

There is a lovely short commentary / editorial that puts all these papers in perspective and even addresses the question of whether both nintedanib and pirfenidone should be used together and whether that would help even more or not. This is an interesting thought.

All of these are must reads for all those who have patients with IPF whose care they are responsible for.

 

Sub-centimeter Lung Nodule Biopsies

This article from the November issue of the American Journal of Roentgenology discusses the results of 305 CT guided core biopsies / aspirations of small lung nodules, less than 1.0 cm in diameter, over 13 years.

The only major variable that decided success was aspiration instead of core biopsy.

I have been very clear about doing core biopsies for lesions in the body as against FNAC / aspiration for many years now. Tissue today is needed for so much more than just establishing a diagnosis that if we are going to put a needle in the lungs, or other parts of the body, it would be a travesty to come away with only cells, without tissue.

Here is an example of a 7.5 mm lung nodule biopsied earlier this year that turned out to be tuberculosis on histopathology.

Biopsy of 7.5 mm lung nodule

Biopsy of 7.5 mm lung nodule

Overdiagnosis – Pulmonary Thrombo-Embolism

This one is an eye-opener.

This editorial from British Medical Journal talks about the the issue of incidentalomas, which we as radiologists are aware of – lung nodules, adrenal nodules, breast lesions, etc.

What is less known is the issue of overdiagnosis. And as far the problem with pulmonary thrombo-embolism is concerned, I was quite unaware that a good number of subsegmental lesions do not need treatment, as described in this article in the same issue of the journal.

What does this mean for us? We cannot step down our ability to read thrombo-emboli. However, the treating physicians do need to make a judgement call on whether all of these patients need treatment or not.

The title of this series is “Too Much Medicine” and the article starts with the phrase “When a Test is Too Good..” All very interesting.

 

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