Small nodules in right and left lungs

Portal Forums Lung/Thoracic Cancer Work-Up/Staging of Lung Cancer Small nodules in right and left lungs

This topic contains 19 replies, has 3 voices, and was last updated by  catdander forum moderator 2 years, 2 months ago.

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August 4, 2012 at 10:44 pm  #1246353    

webber

On 4/28/2010 I had a ct of my ab and pelvis. In lung bases were 2 pleural based densities, 1 in the right middle lobe and other in left lower lobe. Both measured 2-3 mm in diameter and were thought benign findings in a 27 yr old female. Fast forward to 4/19/2012.The scan was done at a different location with a different machine and this time the lung base findings were the left lower demonstrates a 4mm non calcified pulmonary nodu,e and a sub pleural density in the left lower chest 3.5 mm. When my prior ct from the other location was obtained radiologist stated that the nodular opacity in the right lower lobe was about 1mmlarger but difference not distinctly significant and the small pleural based nodule is more conspicuous but again questionable. I spoke with this radiologist personally and he stated that no further follow up was needed and that even if I smoked my whole life and all of my family had lung cancer he would still feel confident that these are granulomas that are caused by a fungus very common in Wi and Mn. I asked him if I should get a scan of my whole chest and he said “not unless you want to find more benign nodules and have to rescan all over again for the next 2years. I went to my other doctor who I had recently left due to insurance and she looked over everything and called regions hospital in mn to have another radiologist look. He said there was no change at all, benign and there was also a second nodule in my right lung in 2010 that was not seen in 2012because I was not scanned as high.He said any more scans would be exposing me to too much. I fought and got anfull chest. This showed 4mm pleural based in middle lobe and 4mm lower lobe. Left lung a 4mm pleural based and also3mm pleural based in thelingula. I have seen 2 pulmonoligsts both say no follow up and that lung cancer does not present itself this way and this isnclearly from infection,histoplasmosis or blastocycosis. Wouldnt they calcify? Should I get another ct or does everyone agree

August 5, 2012 at 7:59 am  #1246356    

catdander forum moderator

Hello webber, I know this has been a frightening process but it sounds like you don’t have cancer. Everything the doctors have said sounds reasonable. Cancer would grow, sometimes within 8 weeks sometimes as slow as several months. Something that small not doing anything probably won’t, it’s very common. In fact your story is a good example of why routine lung cancer screening isn’t believed to be best for people without cause to expect lung cancer. Small nodules are found then watched for a year or so and causes extreme worry.

It sounds probable that the 2 nodules found a couple a years ago are the same size today as then. CT scans are sequence of x rays taken one after the other as the camera moves over the body. A difference in a mm or 3 doesn’t necessarily mean something is growing. It’s as possible that the x ray was taken and showing a slightly different position than previously. Cancer is rarely detected in the mm size range.

It is completely standard of practice (meaning best outcomes show) that a watch and wait approach is usually taken on anything smaller than a cm in the lung. If it doesn’t grow it’s not worrisome for cancer.

Dr. West checks the site each evening and will add anything more.

Sounds like you’re in the clear. Congratulations! Let us know if you have further questions.
Janine
forum moderator


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 5, 2012 at 9:39 am  #1246362    

webber

Thank you so much for taking the time to reply! I have talked to many radiologists, two gp docs and two pulmanrywho all believe no further follow up is needed. All of the radiologists were confident that there was no change in two years and that there was artifact from two different machines. Five radiologists from 3 different locations reviewed these and all agreed. One family doc even wrote in my chart no lung cancer! No concern for lung cancer! The other family doc said we could repeat the scan in a year but the radiologists said it would be overkill and the u of m lung nodule clinic said the risks from all the radiation are worse and that for two years with no change it is fine. My concern is that only 3 out of 4 had been seen 2 years ago. Yet, everyone states they are all benign although the 4th hasn’t been followed for two years. Why the confidence in that? I have seen them and the are on the outer limits of the lung, very round and the rest of my lungs look great according to the pulmonolgists. They also say they are most likely granulomas but I wonder, why aren’t they calcified then and how they can be so confident that is what they are when they aren’t calcified. They also say that lung cancer never presents itself as multiple nodules that are pleural based but is that true? I am so concerned and before this had debilitating anxiety and this has been awful. The only type of doctor that I have not spoken with is an oncologist and would like to. I turned 29 in April and smoked for almost 10 years with an average of about 10-15 cigarettes a day. I know that for people that have multiple nodules 4mm and less and are low risk do not even require follow up. The doctors and radiologists say that even with my smoking history I am still very low risk for lung cancer and didn’t necessarily need follow up but I was followed because I pushed and pushed. I have been my own advocate and would like to feel comfortable with no follow up or pushing for one last ct.

August 5, 2012 at 10:23 am  #1246364    

catdander forum moderator

I can only imagine the hell of worrying for so long. Usually the only way to get an appointment with an oncologist is to be diagnosed with cancer. A Pulmonologist is the person most likely do the work up on diagnosis for lung cancer.
A doctor will comment on your concerns within the day.

I hope you get the answers you want, which is no cancer, just like your chart says. I hope you can return to a normal life without the worry of cancer. You’re too young to change your life because of lung cancer or the threat of it.

All the best,
Janine


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 5, 2012 at 10:46 am  #1246366    

catdander forum moderator

This quote is from Dr. J. Weiss, one of our most prolific contributors who also has a full practice and ongoing research trials,
“Some workups have relatively standard workups, but even here, the choice of which protocol to follow depends on the judgement of the clinician. For lung diseases, the best first step for a patient is getting a good pulmonologist.” http://cancergrace.org/lung/topic/differential-diagnosis-for-lung-diseases/


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 5, 2012 at 11:10 am  #1246367    

webber

Janine, thank you! It is hard to come by reassurance for something so scary at such a young age. I have almost made myself a nuisance to the doctors, pulmonologists and the radiologists having them check and recheck the scans to make sure there is no change. It is comforting to know that everyone is one the same page but I would like the few questions that I feel unanswered to be and by people that see this everyday and this is what they do. It is hard being from such a small area to truly feel comfortable even with everything. I have been through this site so many times and have used the nodule calculator that dr. West had suggested in one of his articles, I have watched the interview between him and another doctor about these nodules and just how common they really are. I just felt it was time to reach out and ask about my situation as everyone here seems so knowledgable and very straight forward and confident with their answers. I waited until my two year mark was up and to gather all of my information before doing so because I certainly do not want to bother anyone or consume time that should be spent elsewhere. I am hoping the information that i gather here can allow me to let go and use this horrible experience to remember to take care of me! I am young and with that comes the thought that you are indestructible. I have quit smoking, luckily I have never used drugs or drank and I am very active. My Kung function tests were normal, my bloodwork is normal, my vitals are always great. This is the only unhealthy issue I have left. I want to feel proud I quit smoking, not beat myself up thinking I may have caused myself cancer. I have three babies and it’s devastating to think. Again, thank you so much for being here for me as I am awaiting the response from the doctor. And thank you for being such a help to others!

August 5, 2012 at 11:51 am  #1246370    

Dr West

Unfortunately, assessing what nodules represent is an estimate of probabilities, and I don’t think it’s possible to say with 100% certainty that anyone’s nodules aren’t cancer, but the odds can be exceptionally low, as it sounds like they are for you. I’d like to recommend that you view this podcast by Dr. David Yankelevitz, who is a real expert in CT screening and notes that one challenge of this is that the more scans we do, the more tiny nodules we detect, especially as our CT technology gets better and better and is able to identify incredibly tiny details. He even makes the point in his talks that the technology is becoming so good that he can likely identify 1-2 mm nodules in just about everyone in the audience if he were to scan them — but if everyone has tiny nodules, it defies the concept that lung nodules must be abnormal. Moreover, it’s absolutely true that in certain parts of the country, pulmonary nodules from airborne pathogens are so common that they dramatically escalate the “nodule problem” of screening people.

Here’s the portion of his podcast in which he discusses nodule detection and follow up:

http://cancergrace.org/lung/2011/12/07/yankelevitz-lung-nodules-podcast/

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

August 5, 2012 at 12:14 pm  #1246371    

webber

Thank you Dr. West. I had watched the podcast previously and certainly understand that in certain areas nodules are higher. Being that I had these for two years and they are not growing would you release someone of follow up in your expertise opinion? I have been told that lung cancer does not present itself as all pleural based nodules in both lungs without a primary site and that cancer certainly does not look round and smooth and the rest of the lung so healthy. I have been told and have read that what I have would be more likely mets from another site more than it would be primary lung cancer. I have had a ct of everything and there is nothing suspicious. Is this true of cancer of the lung not presenting this way? If they are indeed granulomas from fungus that we have here than they must take quite sometime to calcify. This is all very complex and I would like nothing than your opinion as a last bit of reassurance that I can let this go and be healthy 29 year old. Thank you so much!

August 5, 2012 at 12:25 pm  #1246372    

catdander forum moderator

And there’s the rub. No one can guarantee that for you. It’s not that you’re not asking the right questions or asking the right people. It’s that there are no guarantees, but you come about as close as anyone can with known tiny stable nodules for 2 years can. That’s saying a lot.

Thank you for the kudos,
Janine


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 5, 2012 at 12:41 pm  #1246373    

webber

I understand. If you have heard no more follow up needed from as many people as I have, would you let this go? Maybe that’s the question I needed to ask?

August 5, 2012 at 1:15 pm  #1246374    

catdander forum moderator

If I was happy that my information was from a reputable source, Intellectually, absolutely I would.

Interestingly, I just received insurance yesterday for the first time in 7 months. 7 months ago I was in a pulmonologist’s care for a post pertussis cough. It is all very probable an escalation of allergies (cat dander, dog dander…). But without insurance I’ve not followed up on it. At first my husband and I were worried about lung disease and even cancer but since it’s not gotten any worse I all but stopped worrying about that. I’m just happy I can now get back to solving the problem without getting rid of my 2 very hairy dogs.

I hope you are able to (like my husband’s onc put’s it) get back to living your life.


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 5, 2012 at 3:49 pm  #1246376    

Dr West

I can’t really give a medical opinion to you. I would say that your findings are really very reassuring and that the recommendations you’ve received from the doctors you have already consulted sound very sensible. I wouldn’t say that it would be outlandish to scan again, but there’s good reason to not lose sleep worrying about this and to have a low level of suspicion based on both the characteristics you describe and the thoughtful opinions from the consultants you’ve already met with.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

August 5, 2012 at 5:15 pm  #1246379    

webber

Janine, I am so happy for you that you will now be able to follow up! I hope that you will find the answers you need! I wish I could help you like you have helped me but I will have you in my thoughts as you reaching out to me was so kind!

Dr. West, I understand you can not give me a medical opinion but thank you so much for helping me! Honestly, it makes me feel so much better to know that you do NOT think that it is bizarre that the doctors are deciding to not do any follow up. Even after all of the doctors and all of the research for some reason I just needed an experience voice to tell me this is normal to stop follow up. So thank you for saying it’s not “outlandish” to not do anymore testing and that everything seems very reassuring. It is a great thing what you do to help people ease their fears with your expertise and voice. Thank you!

August 5, 2012 at 7:41 pm  #1246383    

Dr West

I’d point to the discussion by Dr. Yankelevitz on the Fleishner Society guidelines that are really considered the expert-developed state of the art. They say that no follow-up is needed (it can be considered optional) for a low risk person with incidentally discovered lung nodules that measure 4 mm or smaller. I’m not sure I wouldn’t do another scan in the next year, perhaps in 6 or more likely 12 months, to ensure no change, but according to the best guidelines we have, it is reasonable to consider nodules 4 mm or smaller that are incidentally detected in a lower risk person as not requiring further evaluation.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

August 5, 2012 at 7:47 pm  #1246384    

Dr West

Just to clarify, I meant to say that it wouldn’t be wrong (“outlandish”) to do additional scans, but it fits either way. I tried to clarify in my most recent comment above that I might tend to be a little more conservative and do another scan or two after a healthy interval (after all, the patients I see ended up with lung cancer, so I have a very negatively biased perspective), but I know that the data say that the odds of very small nodules in a lower risk person are really extremely favorable.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

August 5, 2012 at 8:04 pm  #1246385    

webber

Thank you Dr. West for the clarification. Would you consider someone of my age and smoking history to still be of low risk? I honestly feel like theonly young person with multiple nodules right now and for my kids I want to make sure I am doing everything I can to take precaution. My initial thought before coming here was to get one more ct at the six month mark and if there is no change seen then that is two and a half years of no growth what so ever. If that is the case I would like to go on and hope that if it is cancer it is the rare slow growing. I would like to then take everyone’s word that these are indeed granulomas.

August 6, 2012 at 8:07 am  #1246397    

catdander forum moderator

webber, you’re low risk.
Thank for the kind words about my low risk probs.
Janine


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

August 6, 2012 at 2:11 pm  #1246407    

webber

I had to share this information I received today with Janine and dr. West. Back in 2006 I had a ct scan in another state that I was living. I knew that back in 2006 the software was not near what it is now. I called there today and was able to have a radiologist relook at my images from 2006 with new software and it turns out that in 2006 I actually had these nodules!!!! This means that my nodules have been followed and have remained the same for 6 years now! This radiologist has said “these findings are all most consistent with benign process most likely of old granulomatous disease. Identification of nodules in retrospect on the previous study from 2006 and 2012 would give a 6 year follow up.identification of similary nodules on recent outside study would be consistent with stable benign nodules over 6 years. No followup is felt to be further warranted.”
Thoughts?

August 6, 2012 at 4:21 pm  #1246414    

Dr West

We usually consider an absence of change over a two year interval to be reason to discontinue imaging follow-up. Obviously, no change over 6 years is even more reassuriing. Congratulations.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

August 7, 2012 at 10:01 am  #1246444    

catdander forum moderator

Yeah Webber! and family


My husband, 53 @ dx of stage 3 squam nsclc R. pancoast tumor 8/09 caused destruction of 3 ribs, touching brachial plexus. 2 core and 1 VATS undx biopsies. Open thoracotomy for 1 positive biopsy (unresectable). Chemorads, 9/09. MRI by pancoast specialty surgeon 11/09 spine met found, stage IV, Rad to spine, Chemo changed from cis/etop to navelbine/carbo. 6 cycles total. Tarceva 2/10-11/10. 3cm tumor L lung, biopsy undx w/collapsed lung. Gemzar, 12/10 through 7/12. NED 3/12, stop tx 7/12. Remains NED as of 8/14.

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