6 mm nodule recurrence probably BAC/or BAC acinar - 1262129

teachern
Posts:7

In 2009 I had VATS LLLobectomy for stage 1a BAC/acinar. Five years later 6mm nodule in RML is becoming dense and I am wondering if surgery affords better survival than Cyberknife. I had breast radiation on the right in 2009 as well. Does the previous radiation prevent my having cyberknife? Is surgery REALLY the best option? (age 63 female, BRCA2, never smoker)
Thank you.

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Reply # - February 7, 2014, 08:40 PM

catdander
Posts:

Hello teachern, I'm very sorry you're dealing with cancer again. There isn't one answer to fit everyone with recurrent or indolent BAC but there is good reason to caution against doing anything too early. Any treatment holds dangers plus starting treatment earlier than needed will limit options when needed further down the line. Below are 2 links. The first is an algorithm on options for dealing with BAC but also for indolent cancers no matter the histology. The second is a thread written by a long time Grace member started just this Tuesday on this very subject. I hope they can help with your planning.

http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

http://cancergrace.org/topic/a-cautionary-tale

All best,
Janine

Reply # - February 7, 2014, 10:40 PM

Dr West
Posts: 4735

I think there is a very significant risk of overtreatment of a 6 mm nodule that is demonstrating subtle changes over a 5 year interval of follow up. The short answer is that there is no evidence comparing cyberknife to surgery in this situation, and in someone with multifocal and very indolent lung cancer, I really try to focus on whether the progression is clinically significant enough to require treatment. If so, I ask what is the treatment that is likely to do well with the least risk. In a 6mm nodule that has taken 5 years to demonstrate changes, the risk of surgery may well exceed the risk of a cancer moving at that pace over the next few years. I think there is significant appeal to doing stereotactic radiosurgery as the least dangerous approach if there is truly enough progression to justify treating the cancer.

-Dr. West

Reply # - February 9, 2014, 05:37 AM

teachern
Posts: 7

Thank you, Dr. West (and Janine too!),
Just a couple of notes of explanation: 2009 LLLobectomy was for a single pulmonary nodule. The first one was BAC/Acinar/Adenocarcinoma.

New nodule showed up in 2011. It became 6 mm, very pale and shadowy on CT in 2013, but now it is dense and bright on CT. Is this a second primary cancer and not multifocal BAC?

That being said, is it still considered slow growing, since it's been around only 3 years?
Is it best to have it surgically removed to test the tumor for mutations and to make sure it is not breast cancer in the lung? Is it worth the pain and surgery? (I am sure you can "hear" my fear.) (as opposed to cyberknife)

I do have an appt with a radiation/cyber knife dr. at ucsd in 10 days. (and tentative surgery in March----or maybe JUNE because my husband is going through his own health concerns right now)
Thank you.

Reply # - February 9, 2014, 09:34 AM

catdander
Posts:

There's no way to know if it's the same BAC process, a new cancer altogether, or not cancer. However if you've had indolent BAC in the past it's mostly possible to be BAC.
I must say as a wife of a man who's had so much of his cancer to be of outlier status, good and bad, there can't be any assumptions. Without cancer cells in hand you just can't know for sure. It's why we often call oncology an art form.

For a tumor to grow just 6mm in 3 years is extremely slow. In fact a tumor that's just 6mm is considered small enough to just watch in any situation. The following section of Dr. West's last comment says, " in someone with multifocal and very indolent lung cancer, I really try to focus on whether the progression is clinically significant enough to require treatment. If so, I ask what is the treatment that is likely to do well with the least risk. In a 6mm nodule that has taken 5 years to demonstrate changes, the risk of surgery may well exceed the risk of a cancer moving at that pace over the next few years." From the info you've given your tumor is both indolent and clinically insignificant suggesting the very best thing to do is leave it be. Again I point you to the "cautionary tale" I posted above.

The algorithm is for stage IV and recurrent cancers. A new primary would be treated as an early stage cancer.

Note the algorithm suggestion for what you've noted would fall to "continue clinical and radiographic follow up" in other words continue to see your doctor and have scans every 3 + months.

Janine

Reply # - February 9, 2014, 09:39 AM

Dr West
Posts: 4735

I consider slow progression to be something along the lines of "you need to squint or can't perceive any progression between scans done over an interval of six months or longer". If there is a single area of clear progression out-pacing everything else in the background, then I think that merits local treatment.

As for the question of a new primary cancer, I believe that the new area is the same cancer process as the established cancer, not a new primary, unless proven otherwise. I think the concept of a new primary cancer in the setting of an established multifocal cancer is usually invoked as a fanciful concept to justify what people biased are to do when the best actual evidence suggests against it. I'm not saying it's a bad idea to treat a solitary area of progression in a background of very indolent multifocal disease, but it's not necessary to just fancifully call it a new primary cancer to justify the idea.

-Dr. West

Reply # - February 19, 2014, 02:19 PM

teachern
Posts: 7

Thank you! I went for a consult with UCSD SBRT doctors, and I have chosen the radiation route rather than the lobectomy!!!! I know the down side is no tumor testing, no biopsy, no lymph node removal. BUT the up side is no surgery and no down time and getting rid of a tiny, 6mm, indolent nodule with lung saving! YIPPEE!
Nancy

Reply # - December 31, 2014, 01:35 PM

teachern
Posts: 7

I had the true beam in March, and all was well on the May CT. The November CT showed growth from 7 mm to 13mm and the radiologist said it looks like mycobacterium. So I am having another CT in a week or two (January, 2015). If the new CT shows changes, then the ucsd tumor board will examine the case.
I am just wondering what questions to ask and the relationship between mycobacterium and the BAC in the left lung (lobectomy in 2009 for BAC/acinar adeno) or is it considered all new info, new lesion, no relationship??? Does mycobacterium mimic cancer or vice versa?
Thank you in advance for any insight.

Reply # - December 31, 2014, 01:55 PM

Dr West
Posts: 4735

I wouldn't presume any clear relationship. Mycobacterium can definitely appear similar to cancer, which is why a biopsy is our go-to approach to really clarify what is happening if the imaging doesn't show the ambiguous lesion clearly getting better over time.

I would also add that it is VERY typical to see a lesion treated with focal radiation become larger and have vague borders, just as a consequence of the radiation given. This "post-treatment effect" doesn't necessarily represent anything but some inflammatory changes that can evolve to long-term scarring in the treated area.

Good luck.

-Dr. West

Reply # - January 1, 2015, 10:31 AM

teachern
Posts: 7

Thank you, Dr. West, for your rapid response AND for the encouraging opinion that it is typical to see fuzzy edges and enlarged field following radiation. I am feeling relieved, hopeful, and BETTER!

Now, how do I diplomatically repeat this info to my doctors.... ??? (I had asked previously if the changes were due to radiation.)

Very sincere thanks and gratitude for all you do here at Grace! Amazing work!

Reply # - January 1, 2015, 10:50 AM

JimC
Posts: 2753

Hi teachern,

What others have done in the past in print Dr. West's comments and bring them to your doctor with the question "is it possible that this is what is appearing on my scan?" Some doctors are receptive and others are not, but it's worth a try.

Good luck with the next scan.

JimC
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