Pneumonitis is a serious treatment-related side-effect of both radiation, immunotherapy and some chemotherapies. This episode of MesoTV includes discussion on diagnosis, treatment and the dilemma facing both patients and doctors while making decisions on how to approach mesothelioma specific therapy during and post treatment for this condition.
Dr. Daniel Sterman is a member of the Board of Directors at the Mesothelioma Applied Research Foundation. He is also Director of Pulmonary, Critical Care and Sleep Medicine at NYU Langone Medical Center.
Pneumonitis vs pneumonia
Pneumonitis and pneumonia are two very serious conditions, both affecting the lungs, but they are very different from each other. Pneumonitis is a medical term referring to inflammation of the lung caused by noninfectious. Pneumonia, on the other hand, is another form of inflammation defined as inflammation of the lung, but associated with a type of infection. Pneumonitis is inflammation without infection. Pneumonia is inflammation with infection. Pneumonitis and pneumonia can be hard to distinguish and diagnose from an x-ray or CAT scan. When The lung of a patient with has pneumonitis will oftenthe lung looks cloudy on an x-ray.
Pneumonitis vs progression of disease
Mesothelioma often presents a pleural malignancy with nodules along the pleural surface with fluid in the pleural space and occasionally in lymph nodes in the center portion of the chest. Rare types of meso can possibly enter the lung through the visceral pleura and can make the lung look cloudy on an x-ray, but it is not common. Dr. Sterman said it is fairly easy for doctors to distinguish between pneumonitis and progression of pleural mesothelioma.
How does radiation therapy relate to pneumonitis
There are many reasons why someone could get pneumonitis and one of those reasons is radiation therapy, a treatment for mesothelioma. Radiation pneumonitis is not necessarily limited to the area to which radiation is administered, but it can affect other areas of the body as well. Pneumonitis symptoms can be very subtle including a dry cough, clear mucus production and shortness of breath. Typically, symptoms don’t occur while radiation is ongoing and generally arise a few weeks after radiation therapy treatment has ended. Dr. Sterman said the best team to assess the situation and prescribe treatment would be a radiation oncologist, pulmonologist, medical oncologist, and a thoracic surgeon. There are many implications to treatment of pneumonitis, most notably consideration of immunosuppressants because high dose steroids for long periods of time are needed for treatment.
High dose steroid treatment
Dr. Sterman believes a common mistake doctors make when treating pneumonitis is to prescribe a dose of steroids that is too low, and then tapering patients off the steroid treatment too quickly. He said when a doctor takes either of those actions, the patient either won’t get better or will have a recurrence of pneumonitis. Dr. Sterman often starts patients with doses of milligrams per kilogram of their ideal body weight, which is usually around 60 milligrams of prednisone, or 30 milligrams twice a day if there are steroid- related side effects. Steroids can cause insomnia, in which case they should be taken in the morning.
Is pneumonitis curable?
Inflammation of the lung, which causes pneumonitis, is reversible and curable with corticosteroids, however it often leaves the patient with permanent scarring of the lung. Scarring can happen even with early recognition and treatment of pneumonitis. There may be residual effects and clinical decline in pulmonary status as well, but that doesn’t mean steroids were ineffective. When clinicians determine whether the patient is dealing with pneumonitis or fibrosis the treatment plan changes as well, because fibrosis cannot be treated with steroids and could cause harm to patients.
Medical therapy induced pneumonitis
Immunotherapy can unleash immune responses against tissues in the body, not just the cancer tissue. Cross reactivity can be a complication of treating cancer of the chest, where there may be proteins on the surface of the tumor cells doctors hope white cells attack, but the proteins could be shared with normal cells in the lung, thus also damaging non-cancerous cells. This is the reason why one might also see pneumonitis in areas that aren’t receiving radiation therapy directly. Pneumonitis is seen more often after treatment with combination immunotherapy than single immunotherapy.
Recall pneumonitis
Recall pneumonitis can occur in areas that haven’t been radiated and where pneumonitis was not previously present. Dr. Sterman describes immunotherapy as not a stimulation of the immune system, rather a taking off of brakes from the immune system. It is those brakes that allow the immune system to ignore the proliferation of the cancer. However, while removing the breaks activates the immune system against the cancer, it can also activate it against healthy tissue. That’s why immunotherapy can pose additional challenges for patients with cancer in the chest because who already experience shortness of breath and limited lung capacity heading into therapy treatment. These patients are most impacted by pneumonitis related to immunotherapy.
Look ahead
Researchers are now looking at discovering which patients may have a predisposition to pneumonitis. Dr. Sterman said patients with prior pneumonia, history of auto-immune disease and radiation therapy could be on that list.
Learn more about pneumonitis by watching the video interview above with Dr. Daniel Sterman.
Our sponsors
MesoTV is a program by the Mesothelioma Applied Research Foundation. This program is made possible by our generous sponsors: Maune Raichle Hartley French & Mudd, LLC (MRHFM); Belluck & Fox; Bristol Myers Squibb; Novocure; Merck; The Gori Law Firm; Early Lucarelli Sweeney & Meisenkothen.
