Dr Ramsey on Signs and Symptoms of Pneumonitis in Locally Advanced NSCLC

Meghan Ramsey, MD, interventional pulmonologist, thoracic specialist, clinical associate professor, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford Medicine, discusses common signs and symptoms, as well as atypical presentations, of pneumonitis in locally advanced non–small cell lung cancer (NSCLC).

One of the most common signs of pneumonitis is incidental radiographic challenges observed with surveillance CT scans, Ramsey begins. When patients come in for their regular 3-month surveillance imaging, subtle or not-so-subtle changes may appear, such as ground-glass opacities or new consolidative, patchy opacities suggestive of pneumonitis, Ramsey details. Grade 1 pneumonitis often presents asymptomatically; patients are not hypoxemic and do not notice any symptoms, leading to incidental radiographic discoveries, she says. As the severity of pneumonitis increases to grade 2 and beyond, symptoms develop and become noticeable, Ramsey explains.

The symptoms of pneumonitis are very nonspecific, Ramsey states. Various pulmonary pathologies can present as shortness of breath, dyspnea on exertion, and hypoxemia, which are also associated with pneumonitis but not exclusive to it, she reports. Other common symptoms include cough and fever, with a dry cough being particularly noted in pneumonitis cases, Ramsey adds.

Atypical presentations of pneumonitis can include more systemic immune-related adverse effects, presenting with multi-system organ involvement, she continues. Examples include vasculitis-type symptoms, sarcoidosis-like features, or inflammatory myositis presentations, Ramsey details. These systemic reactions often have lung pathology associated with them, leading to conditions such as interstitial lung disease. Therefore, it is crucial to maintain a high index of suspicion when patients present with systemic symptoms, considering that these could be related to their immunotherapy, Ramsey emphasizes.

Recognizing pneumonitis early, even when it presents with non-specific symptoms or as an incidental finding, is essential in the management of the condition effectively. Regular surveillance imaging plays a critical role in early detection, allowing for timely intervention and management to prevent progression to more severe grades. This proactive approach is particularly important in patients undergoing immunotherapy, who may be at higher risk for developing pneumonitis and other immune-related toxicities.