Dear Dr West,
My mom was diagnosed with Stage 1A NSCLC back in January 2010. Her primary cancer was 2.5cm in size and had SUV 2.8 at the time of diagnosis. Upon surgery in March 2010 (right upper lobectomy), they found cancer in her mediastinal lymph nodes, and restaged her as Stage 3A. She was also found to be EGFR positive. She was treated with adjuvant Tarceva first (per her doctor in Asia) for 4 weeks, before she was admitted to UC Irvine Cancer Center. She then had 4 cycles chemo (Cisplatin and Alimta) followed by 4 weeks of radiation. All her follow-up PET/CT scans from January 2011 to February 2015 then have indicated stable scarring and no evidence of recurrent disease.
Her most recent PET/CT done on 02/10/16 described a “4 mm nodule in what is most likely the middle lobe in the right perihilar region has increased in size and is now 10mm and at SUV 1.3”. This nodule first was mentioned in her PET/CT in 2013 as “stable 4mm nodule in right lung and metabolically negative,” and again in 2015 as “the 4mm right middling nodule anteriorly is felt to represent scarring and is unchanged since prior study.”
I have read your “When Do Recurrences of Lung Cancer Happen After Surgery,” and I was curious to see what you would think of our situation. Is it more likely that it is a new cancer since recurrence is too far out for Stage IIIA to be the same cancer? Or is it possible that it is an indolent cancer since it was previously mentioned 3 years ago?
We’re feeling so anxious as her doctor’s appointment is not until Feb 24, and we have had a such a great run with clean scans. Reading through the posts on here definitely helps. Thank you, Dr West and everyone , for your work on this site.
Mimi
Reply # - February 14, 2016, 04:10 AM
My thought would be, what if
My thought would be, what if it's not cancer at all and that's a possibility. Just because we've had cancer before doesn't mean every nodule seen will be cancer. With no growth on that 4mm for over a year, the possibility of cancer is less. The SUV is not high enough to even be considered for cancer. Has she been sick at all with any respiratory illnesses? Until that nodule grows, there's no way to know if it's cancer or not.
Take care, Judy
Reply # - February 14, 2016, 02:36 PM
Hi Mimi,
Hi Mimi,
I'm so sorry your mom is going through this fearful event. The answer to all your questions is yes, yes and yes. It might be cancer and it might not be cancer. If it does represent cancer it might be a very indolent cancer. If it is such an indolent cancer it might be from the original cancer. I'm afraid it would be difficult to impossible to tell if it's the same process if it turns out to be an indolent cancer and would most likely be treated as a primary...if it's cancer.
If it does turn out to be an indolent primary, treatment most likely would be with curitive intent (depending on your mom's health), such as radiation and chemo either together (concurrent) or sequential. I don't know if surgery would be an option since she's already lost a lobe of lung tissue.
If it's cancer it's still on the same side of the chest and still considered curable. Indolent is good. So for all the bad that comes with possible cancer recurrence of lung cancer your mom ironically is still in a good place.
If it's cancer it most likely is worth getting an opinion from a large teaching/research cancer center.
Please keep us posted.
Breathe,
Janine
Reply # - February 14, 2016, 05:36 PM
Yes, it can reoccur. I've had
Yes, it can reoccur. I've had 3 nsclc's separated by 6 yrs. 2,1A's & an 3A. I believe there called new onsets because of the time lapse between them. Keep plugging away, new treatments are being discovered every day.
Good Luck !! Andy
Reply # - February 14, 2016, 06:27 PM
Thank you everyone for your
Thank you everyone for your encouraging responses. I really appreciate it.
Judy,
My mom recently got slight cold, but nothing major in terms of respiratory illnesses. I agree that the SUV is not high enough to be extremely concerned. Our radiologist said that too, but he also said it's suggestive of a recurrent cancer and suggested a biopsy or resection. I guess we won't know for sure until we have a biopsy or just watch to see if it continues to grow. But I really hope that it'll turn out to be nothing!
Janine,
My mom is in very good health. She handled her initial surgery and chemo/radiation without any issues. We're definitely hoping to treat with curative intent if it's on the table for us. I wonder if SBRT would be an option for her as well.
Andy,
Wow, you've had such a journey. Hope you're doing well and keep on fighting those beasts!
Mimi
Reply # - February 15, 2016, 04:12 AM
Was there more of a
Was there more of a description of the nodule such as smooth edges, non-calcified, etc.? . Scans do not confirm cancer not even a PET scan. They can show suspicion for cancer, but only a biopsy can confirm.
Has she seen a medical onc yet? Or is she being followed by the rad onc?
Take care, Judy
Reply # - February 15, 2016, 06:16 AM
Hi Mimi,
Hi Mimi,
As Judy suggested, there are certain features of nodules as they appear on scans which can provide some insight into the risk that they may represent cancer, and Dr. West has discussed these features here. And as Andy's experienced shows, even after a long period with clear scans, cancer can recur, although the farther out from the original cancer diagnosis, the more likely it would be a new primary, if it's cancer at all.
We will hope that it isn't, and that your fears can be put to rest.
JimC
Forum moderator
Reply # - February 15, 2016, 07:22 PM
Judy,
Judy,
She's been followed by her medical oncologist for the last 5 years. She had scans every 6 months for first 3 years after treatment, and then annually after that. There's no further detailed description of the nodule. Her scans from 2013 and 2015 described it as stable nodule and unchanged since prior studies. The 2014 scan did not mention it, but this scan was also done at a different facility so maybe they had a different view of it. Then the recent 2016 scan mentioned it as possibly recurrent cancer due to the growth from 4mm to 10mm and now metabolically active. We're seeing her medical oncologist on Feb 24. I'll post updates soon.
Jim,
Thank you for your comforting words. I'll look into those posts.
Mimi
Reply # - February 18, 2016, 01:02 PM
Just wanted you to know I'm
Just wanted you to know I'm keeping your mom in my thoughts with best hopes for whatever the news may be.
Janine
Reply # - February 18, 2016, 08:12 PM
Hi Janine,
Hi Janine,
Thank you for your constant support. It means a lot to us.
So we met with her oncologist yesterday. Because of her good performance status and the size of the nodule being relatively small at 10mm, he recommended surgery. He said it will probably be a wedge resection, but he'll defer to the surgeon for the actual course of action. I did ask if he suspected whether this was recurrent cancer or new cancer, and he said that we won't know until we have the pathology report after the surgery. Now we're waiting to see the surgeon for a consult. I am curious to know if there are any data on what type of surgery is best in case of a "local recurrence" (her original cancer was in the upper right lobe and this growing nodule is in her right middle lobe) as in my mom's case? I have read that the recurrence rate is higher with a smaller resection (wedge or segmentectomy) vs a lobectomy. Is this still valid? Her lung function is very good despite the loss of the right upper lobe, and since the right middle lobe is the smallest one, I wonder if a lobectomy would also be recommended for her to lower risk of recurrence.
Thank you again for all of your thoughts.
Mimi
Reply # - March 18, 2016, 10:41 AM
Hi everyone,
Hi everyone,
I'd like to share an update on my mom’s situation. After reviewing the nodule on her PET/CT scan, oncologist said that the nodule at 10mm is too small for a biopsy and recommended surgery to take the nodule out. The surgeon told us that the nodule is too deep and central in the right lower lobe that he would probably have to do a thoracotomy to take out her entire right lung (which now just has the middle and lower lobe left since she already had her right upper lobe taken out in 2010). He told us that since she will potentially lose her right lung from this surgery, he would want to confirm that the disease has not spread to her mediastinal lymph nodes yet before performing the surgery. He referred us to see a pulmonologist to get an EBUS done. The pulmonologist performed the EBUS (with electromagnetic navigational bronchoscopy) yesterday and said that the sample he took from the tumor looks like adenocarcinoma, so he believes that it’s most likely recurrent cancer. He took additional tumor samples to send out for tumor profiling, but he did not sample any of her lymph nodes. The pulmonologist told us that it was not necessary to sample the lymph nodes since recurrent cancer means she is now a Stage IV and systemic treatment is standard of care at this point.
I have some questions, and I hope GRACE can offer some insight in our situation.
1) Her original cancer in 2010 was NSCLC adenocarcinoma. Can we say her the nodule in her right lower lobe is recurrent cancer because it is proven adenocarcinoma? Is it possible to have a new primary cancer that has the same subtype adenocarcinoma?
2) If the this nodule is considered recurrent cancer after 5 years, is her cancer considered indolent? And since her performance status is excellent, would surgery or chemo/radiation be a potential option for her? Or is her case now treated as a Stage IV patient?
Sorry for the long post, and please feel free to share any thoughts you might have. Thank you.
Mimi
Reply # - March 18, 2016, 02:14 PM
I would want to know if there
I would want to know if there is cancer in the nodes and have a mediastinsocopy done to check for this.
Ask the doctor that recommended this to set it up. As for surgery to remove the 10mm nodule and having to remove the entire remaining lung, I wouldn't go that route. This is just my opinion as a LC patient. Systemic treatment would be a targeted drug or chemo not surgery. Wait on the mutation testing and see if she's eligible for one of the newer TKI's. Since I'm not a doctor, I can offer you my opinion and hope it helps in your decision. Take care, Judy