Fayez Kheir1, Jin Ye Yeo2
1Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 2JTD Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. JTD Editorial Office, AME Publishing Company. Email: jtd@amepc.org
Expert Introduction
Dr. Fayez Kheir (Figure 1) is currently an assistant professor of medicine with expertise in interventional pulmonary at Massachusetts General Hospital, Harvard Medical School, Boston, USA. He completed his pulmonary and critical care training as well as master’s in the clinical research and medical education scholar program at Tulane University, New Orleans, LA. He then completed his interventional pulmonary fellowship at the Harvard program. Dr Kheir’s research focuses on developing and testing minimally invasive procedures in interventional pulmonary focusing on patient-relevant outcomes. He has been involved in multiple clinical guidelines, designed multiple medical trials, invited as a reviewer for multiple medical journals, and led as well as co-authored over 130 manuscripts.
Figure 1 Dr. Fayez Kheir
Interview
JTD: What drove you to specialize in interventional pulmonary medicine?
Dr. Kheir: The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine. The use of minimally invasive procedures and advanced technology to treat and diagnose various respiratory diseases inspired me to pursue this subspeciality as a career.
JTD: In your career, who is someone you look up to most? How has this person impacted you and/or your career trajectory?
Dr. Kheir: This is an easily asked question but very difficult to answer. Throughout my journey, there were many people who inspired me and influenced or impacted my career. It will be very difficult to name each individual so I do not forget anyone. What I have learned that it is the collective exceptional qualities in each person I interacted with who impacted my journey in medicine.
JTD: Could you provide an overview of the current landscape of publications in the treatment and management of pleural disease?
Dr. Kheir: The management of some pleural diseases such as malignant pleural effusions and primary spontaneous pneumothorax has seen considerable progress within the past decade, with a number of randomized controlled trials now informing practice. This resulted in evidence-based guidelines, pointing towards a more individualized and specialized management. Pleural infection management has been evolving with many trials addressing optimal management either with intrapleural fibrinolytic therapy, medical thoracoscopy or early VATS (1-2). In contrast, this has not been mirrored in other pleural diseases such as non-malignant pleural disease or secondary spontaneous pneumothorax, where the evidence base still forms largely from observational studies.
JTD: Are there any recent advancements in minimally invasive procedures to treat and manage pleural disease that impressed you?
Dr. Kheir: Major progress has been made in pleural diseases which have reduced morbidity and unnecessary/invasive interventions. The vast majority of pleural research till now has been limited to addressing the best minimally invasive technique to evacuate pleural space or address pneumothorax. However, addressing the underlying causes of the pleural conditions is challenging. There is a lack of translational science in pleural diseases to escalate the research beyond plumbing. Perhaps, the future will address the role of intrapleural chemotherapy, immunotherapy, immunogenic therapy, oncolytic viral, and intrapleural drug-device combination in various pleural malignancies.
JTD: Diagnostic tests play a role in the planning of treatment strategy of patients. Earlier this year, your team found that diagnostic test results from the combined Envisia Genomic Classifier (EGC) and lung cryobiopsy are associated with changes in clinical management decisions in patients with fibrotic interstitial lung diseases (ILDs).(3) What is the significance of identifying this association for patients with fibrotic ILDs?
Dr. Kheir: Interstitial lung diseases (ILDs) include an array of complex and heterogeneous diseases that can be challenging to diagnose. A specific ILD diagnosis provides important prognostic and treatment implications. We have previously demonstrated how the genomic classifier may be incorporated into the diagnostic evaluation of patients with fibrotic ILD to increase diagnostic confidence in the absence of surgical lung biopsy (4). However, a critical remaining question was whether this test will impact management decisions potentially leading to quicker actionable diagnoses. In this study, we showed that a positive genomic classifier test for usual interstitial pneumonia (UIP) pattern identified up to 22% of patients that had indeterminate cryobiopsy interpretations by pathology, leading to an additional change in treatment strategy of 17%. This might impact treatment decision making in patients without a confident diagnosis leading to the appropriate use of antifibrotics in patients with UIP patterns found on either cryobiopsy or genomic classifier.
JTD: What are your thoughts on expanding the application of the EGC from diagnosis to prognosis of patients with ILDs? How does the EGC compare with current prognostic factors of ILD?
Dr. Kheir: There is still a paucity of data to suggest that the current genomic classifier might serve as a prognostic biomarker. Our study suggested that patients with positive genomic classifier for UIP without treatment progressed as compared to patient with negative genomic classifier for UIP. However, the sample size was small and did not reach statistical significance. Regarding how the EGC compares with current prognostic factors of ILD, this question remains inadequately answered and requires further research.
JTD: In your opinion, what are some significant research gaps in the field of interventional pulmonary medicine?
Dr. Kheir: The practice of interventional pulmonology has been rapidly evolving due to unmatched technological and technical advances. This has led to new approaches to diagnosing and treating lung, airway, and pleural diseases. Despite growth, challenges remain whether which technology is more effective. For example, we have multiple available navigational platforms for the diagnosis of lung nodules but there is a lack of well-designed comparative studies among them.
JTD: How has your experience collaborating with JTD been over the past few years?
Dr. Kheir: So far it has been a very positive experience. Through JTD, I had the opportunity to collaborate with many colleagues in the US as well as internationally on different topics in interventional pulmonary disease. I would like to acknowledge the visionary leadership of JTD and extend gratitude to the editorial leaders who have steered the course of the journal and propelled it to its current standing.
JTD: As the newly appointed Associate Editor-in-Chief of JTD, what are your expectations for JTD?
Dr. Kheir: As we embark on this journey together, my expectations for JTD is to work closely with the editor-in-Chief and the editorial board to maintain and enhance the journal's reputation for excellence. Also, set clear timelines for manuscript review, revision, and publication, and ensure that these deadlines are met as much as possible; ensure that all submissions are evaluated objectively based on their merit; foster a diverse and inclusive environment by inviting authors from various background; solicit feedback from authors, reviewers, and readers, and use this feedback to implement changes that enhance the quality and impact of the journal; and maintain the highest ethical standards in all aspects of the journal's operation. My goal is to enhance the journal with well-developed international clinical guidelines that will globally help physicians treat patients with various respiratory diseases.
Reference
- Kheir F, Thakore S, Mehta H, et al. Intrapleural Fibrinolytic Therapy versus Early Medical Thoracoscopy for Treatment of Pleural Infection. Randomized Controlled Clinical Trial. Ann Am Thorac Soc. 2020;17(8):958-964
- Bedawi EO, Stavroulias D, Hedley E, et al. Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial-MIST-3. Am J Respir Crit Care Med. 2023;208(12):1305-1315
- Kheir F, Abdelghani R, Espinoza D, et al. Employment of the envisia genomic classifier in conjunction with cryobiopsy in patients with undiagnosed interstitial lung disease. CHEST Pulmonary. 2024;2(2):100034. doi:10.1016/j.chpulm.2023.100034
- Kheir F, Alkhatib A, Berry GJ, et al. Using Bronchoscopic Lung Cryobiopsy and a Genomic Classifier in the Multidisciplinary Diagnosis of Diffuse Interstitial Lung Diseases. Chest. 2020;158(5):2015-2025