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Post Lobectomy Persistent Pneumonia

Hey! Hope all's well. Hoping to get your advice for a particular case I'm facing.

Patient dx. Stage 4 NSCLC EGFR mutated. Placed on TKI, and achieved complete metabolic response after 6 months. Treated with curative intent to remove all potential persistent sites of disease, even if microscopic. Lobectomy done. Pathology produced less than 5% disease viability, with all local and regional resected lymph nodes clean/cancer free.

Patient experienced pneumonia in the first few days post op, and placed on a 7 day course (5 day IV, 2 day oral). Then released home. This is two months ago.

Over the last month or so, patient experiencing increasing persistent coughing. Cough is productive, with yellow mucus released at times. Several x-rays done by surgeons team that did not indicate any abnormalities. Bloodwork was clean.

On PET/CT done this week, the following was the impression:

New intense hypermetabolic findings mostly at the right hemithorax. Predicting that it is likely bacterial/post op, but leaving the door open for potential disease recurrence. -- on CT portion, consolidation over those very same areas. Local lymph nodes are inflamed.

Patient was then placed on 7 day 750mg levofloxacin

My questions are mainly: 1. How likely is it that the FDG avid areas are indeed pneumonia derived? If so what sort of response should the patient experience over the next week or two? Oncologist seems very confident that it is indeed a pneumonia as the way it looks on both scans resembles other pneumonia patients she's had.

  1. Oncologist claimed that some of the consolidation/FDG areas are actually nodules filled with phlegm that the patient has failed to expell. What methods have you recommended to patients, at home, to cough out phlegm? Spirometer? Can that be expected to be cleared by the end of antibiotics course?
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source https://www.reddit.com/r/Radiology/comments/sc6d7o/post_lobectomy_persistent_pneumonia/

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