We need a surgeon willing to do a lobectomy. - 1274046

Hi cessnaflyer,

Welcome to GRACE. I share your concern about the difficulty of a biopsy of such a small nodule, and I'm not sure that a negative result from one GGO will tell you much.

I think this is a good time to obtain a second opinion at another institution, since this is not a common set of circumstances.

JimC
Forum moderator

Jim, they're not so much looking for another biopsy but a surgeon that will do surgery with so many GGO's. I sent them here thinking maybe Dr. West could comment on the type and extent of the cancer and if it's futile of doing surgery in this situation or not.
Take care, Judy

I agree that a second opinion would be a good idea. My wife had one of the top oncologists on this earth. If after you hear additional advice from Dr. West or Jim and want a referral contact me and I will provide you with additional information. I am also sure there are other excellent oncologists closer to home but a second opinion is certainly in order. Bob

Bob, he's looking for a thoracic surgeon that might do the surgery under the circumstances listed. With that many GGO's, my thought is that it's really not feasible. This is why I would like a response from Dr. West.
Explaining the situation that his wife is in and the probability of surgery or not.
Take care, Judy

Jim, can we get Dr. West to comment on this post. Concerned about the type and GGO's involved. Could this be BAC? Even if not BAC, would surgery even be feasible? This is what they're looking for.
Take care, Judy

Judy,

I have already sought his input here.

JimC
Forum moderator

Thanks Jim! Is Janine doing ok, haven't seen her responding. Take care Judy

I'm sorry to say that this is NOT stage I lung cancer: it is multifocal BAC, a subject that has been a major focus of my interest for over a decade.

The many GGOs are part of the same process as the largest nodule, and it is very likely that the other lesions aren't showing up on the PET scan only because they are smaller, not because they are a different process.

This is not to say that surgery or radiation would be absolutely ridiculous under any circumstance, but I would say that this would ONLY make sense if there is a period of follow-up in which that single nodule is growing but NONE of the other nodules are changing over at least 6 months, and I think it would make more sense to consider focusing on one nodule only if nothing else is growing over more like 9-12 months.

But in the more likely event that several of the other nodules are just a few steps behind and there are several nodules showing progression over 6-12 months, surgery to remove one lesion will provide absolutely NO benefit and will provide harm in two ways:

1) there is always some risk with a surgery -- infection, bleeding, and other risks when someone undergoes general anesthesia

2) this line of thinking all too often leads to the compounded error of removing the lesion and surrounding lung tissue and then removing more as other lesions grow -- then other lesions grow, and far too much desperately needed lung tissue has been taken out over multiple poorly advised surgeries over several years.

So while I think it is possible that surgery could make sense, I think it would be a horribly bad idea to do without knowing that only one lesion is growing over a convincingly long time.

You can always find a surgeon willing to do surgery, no matter how bad an idea it is, but it should be a red flag when surgeons are going against their financial incentives and saying it's a bad idea. That shows restraint and fair judgment, not necessarily closed-mindedness.

Good luck.

-Dr. West

Here, by the way, is a summary of the exact situation you are looking at:

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

This was not written for one case, but it is what I consider to be the best approach, and it is from a textbook on lung cancer in which I was asked to write the chapter on how to manage multifocal BAC. It is a general approach that other experts refer to as the clearest articulation of how this challenging situation should be managed.

-Dr. West

OK. I suppose if she understands that she may well be shortening her survival in the process and a surgeon is inclined to do this despite it being widely considered medically inappropriate, there isn't much point in discussing the reasons why so many people are arguing that it isn't the best strategy.

-Dr. West

As I mentioned in my first, longer response, the concern is that at some point in the future, her lungs will be compromised by the growth of the nodules in the background, and she will need all of the good lung tissue she can possibly have. If a fair bit of that lung tissue has been removed from a prior surgery or two or three over time, she could have more shortness of breath and diminished lung capacity than she would have had if that good lung tissue had been left in by not pursuing a surgery that wasn't going to cure the underlying process anyway.

The value of longer follow up is that you can confirm that one spot is growing much faster than anything in the background. This way, you can have more confidence of two things:

1) That one largest spot is emerging as a clinically significant problem and isn't just going to grow at a glacial pace over many years, and

2) The other nodules won't start growing significantly before you've recovered from the surgery, making the surgery clearly futile.

I can reassure you that there is plenty to be confused about. "Bronchioloalveolar carcinoma" is a term that many clinicians use and still favor, even though pathologists who review the biopsies under the microscope have been told to use different terms. However, it's still overwhelmingly likely based on your description that what is called "well differentiated adenocarcinoma, predominantly acinar and focally lepidic" is what I'd call BAC. However, sometimes the vast majority of the cancer is non-invasive and very slow-growing, but one area is behaving differently, invasive, and more aggressive. That's a situation in which I'd ignore what's in the background and treat it as if you are only dealing with lesion growing faster than everything else.

I refer to that concept as "getting out the lead runner", to use a baseball analogy, but again, you really only know that from taking time to see what the cancer is doing before charging in.

-Dr. West

Dr. West, what type of treatment would be recommended, if any? Thanks for your response as I had a feeling this was BAC and didn't want them to make uninformed decisions and referred them to you since you're the BAC specialist we all know. Take care, Judy

Judy,

I would follow the algorithm I wrote in the link above. That describes the entire thought process in this kind of situation. So if there is multifocal progression at a clinically significant rate, check for mutations, and if not present, I'd favor chemotherapy +/- Avastin. My personal approach in someone with advanced lung adenocarcinoma (of which BAC is a subtype) is carbo/Alimta (pemetrexed) +/- Avastin. And of course, if there's a driver mutation, use the targeted therapy of choice for that marker.

I hope that helps.

-Dr. West