Dr. Pawar Satyajit Jalinder
Medical oncology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
My father has started Keytruda end of October and has received two treatments. His third is coming up early next week. For the past three weeks, he has developed this tickle cough that comes in jags, and he coughs very hard to try and pull up what he says feels like a thin stick substance in his throat. He has had something similar in the past as he always had terrible allergies. But I am worried about Keytruda's risk of lung inflammation. It seems his cough happens mostly when lying down, and for the past two weeks, he has had some shortness of breath with the cough. When you take his oxygen levels when he sits up, it is usually 97 range but always in the 90s; after some coughing jags, it goes into the 80s but quickly returns to the 90s. What should we do? Because this is his last hope, and we do not want to stop treatment. He has no fever, no chest pain when breathing, no retention of fluids, and when the PA listened to his lungs said they sounded good. Shortness of breath upon exertion, too, which they have said is from the radiation he also got in October. Please help.
Thank you.
Hello,
Welcome to icliniq.com.
I have gone through your query, and I understand your concern about Keytruda being the last hope. As I can gather from your question, your father has received two dosages of Keytruda, and third is due soon. But I could not figure out the exact indication or nature of the condition for which he is receiving it as his state or prior treatments can also contribute to his lung condition. Leaving that aside, Keytruda has a small but significant chance of affecting the lungs. Usually, it is mild, and only 1 to 3% can have severe inflammation, even managed with medications. The median time of onset of pneumonitis is after ten weeks. In your father's case, if symptoms have recently started and have kept on worsening. I would keep pneumonitis as a close differential. As his third dose is soon, I would like to know if this symptom is due to lung damage due to radiation or any new infection or part of his disease. As he has received radiation, this also becomes a usual timing for radiation-related pneumonitis.
I would give him symptomatic treatment based on examination and X-ray findings (attachment removed to protect patient's identity). If his symptoms do not improve, I would consider doing an HRCT (high resolution computed tomography) chest, which would explain the nature of lung involvement and possible cause.
If you can provide me with details regarding his condition like
1. Nature of illness.
2. Stage of the illness.
3. Finding on imaging.
4. Blood reports and ECHO (echocardiogram).
This can rule out other causes, and then we can attribute lung damage to Keytruda. If you have any questions regarding this, you can always revert here.
Thank you.
Patient's Query
Hello doctor,
1. He has stage 4 bladder cancer. A few small spots spread to his lungs but tiny sacrum bone, which he received a week of targeted radiation in October, and a couple of nodes in his stomach and chest that lit up.
2. Stage 4.
3. Last Pet Scan early October day before his surgery below.
IMPRESSION:
1. Redemonstrated asymmetric thickening of the bladder dome and left lateral wall, keeping with the primary site of disease. 2. New multiple FDG-avid lung nodules, most likely representing metastases. 3. Increased retroperitoneal and bilateral pelvic metastatic lymphadenopathy. 4. Increased extent of the sacral osseous lesion with pathologic fracture, representing metastatic disease. 5. Additional focus of FDG uptake in the L1 spinous process may represent additional osseous metastasis; however, posttraumatic change can demonstrate a similar finding. 6. Small but FDG-avid left mediastinal lymph nodes are indeterminate, may represent metastasis. 7. Focal increased FDG uptake in the right side of the root of the penis without definite CT correlate may represent metastatic disease. 8. Normal echo, and 10. blood level he has low inred blood cells, , the hemoglobin levels in HCT remains low from past summer. He seems to have the coughing issue mostly when laying down. His last chest x ray was done in October, and below is the summary. He was in ER due to an infection post bladder removal. I must note he has terrible allergies and has had similar coughing issues in his life. It's the new shortness of breath feeling that has us worried. We do not want to have to stop this treatment. Recent chest X Ray in mid-October.
FINDINGS:
A single view of the chest shows an average-sized heart. The lungs are clear. The visualized bones and soft tissues are unremarkable.
IMPRESSION: No evidence of acute pulmonary disease.
Thank you.
Hello,
Welcome back to icliniq.com.
Thank you for clarifying my questions, as it has given me a better picture of your father’s condition. He has stage 4 bladder cancer which has progressed on the initial line of tt and for which he has been started on Keytruda (which is the standard line of tt). As he has received radiation to the sacral area - I would not expect it to affect his lungs. Coughing while lying down could be due to - acid reflux, early symptoms of heart failure, or interstitial edema in the lung due to inflammation or allergies. At the current stage, ECHO can give some idea about his heart function. But otherwise, everything is normal - and his symptoms could be due to aggravation of his allergies. Keep monitoring his signs. If not worsening or stable, I would suggest you to go ahead with Keytruda.
If you have any other questions, kindly revert back.
Thank you.
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