9 mm nodule

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cms3011
9 mm nodule

Hey, everyone. So I actually sent Dr. West an email about this, but I'm posting to the forums just to be safe.

My mom is 81, but in good shape and healthy outside of some stomach stuff. Former smoker, but quit 2+ decades ago, even though she would occasionally cheat up until maybe 15 years ago. In fall of 2017 she went in for a resection to remove a 15 mm glass nodule from her right lung (middle lobe) that doctors suspected might be cancer. Unfortunately, the surgeon -- who apparently is one of the most skilled thoracic surgeons in NYC and has done hundreds of these kinds of surgeries -- wasn't able to see the entire nodule and as a result had to remove the entire middle lobe. Biopsy showed that it was indeed cancer, which in a weird way was a relief given that there were doubts about the decision to go under the knife, especially considering the loss of the entire lobe. 

Fast forward to February 2019 and a CT scan shows that a tiny solid nodule (3 or 4 mm) on the right upper lobe had jumped to 9 mm. Radiologist recommended 3 month follow up; surgeon advised 6-8 weeks. On the most recent scan, taken last week (so 7 weeks after the Feb one) the nodule was unchanged/still 9 mm. Radiologist suggested 3 month follow up CT scan, but surgeon says the nodule is suspicious and indicated that surgery is definitely on the table, although it's hard to tell what he thinks because he is evasive and almost religious in his refusal to take a stance. Pulmonologist said waiting vs. surgery is a coin flip, but that there's no guarantee the nodule won't get bigger or spread if cancerous and also, even if it stays the same size it won't change the fact that the nodule doubled since July and isn't getting smaller. My mom's primary doc doesn't think it will get smaller and recommended surgery. On top of that, I just spoke to the NP who assisted the surgeon and she inidcated that the surgeon recommended following up with a CT scan in 3 months, even though I kind of got the impression he was pro-surgery. She also suggested that it was unlikely to get worse in only 3 months. 

So that's where we are at this point. Also worth noting is the fact that my mom had a terrible cold and cough about two and a half months ago/only a few weeks before that February scan. She's been fine for two months now (her cough got better with antibiotics), but there was some clustering/additional tiny nodules likely related to illness that didn't show up in the most recent (3/26) scan. Unfortunately, the 9 mm nodule was unchanged. 

The fact that this solid nodule doubled in size from July 2018 to February 2019 (and has been described as suspicious by the surgeon) makes me feel like it probably needs to come out, but I hate the idea of my healthy/active mom losing MORE lung function and wonder if it makes sense to wait another 3 months before making a decision (my preference). Could a benign nodule jump in size like this over a ~7 month period? Could an infection or inflammation cause the increase, or could it have been a long lasting infection in the first place (but then wouldn't it have decreased from February to now?)? Obviously there are no guarantees with this stuff, but are we taking an unacceptable risk by waiting for 3 more months? 

Any advice here would be much appreciated. 

Best,
CS

JanineT Forum M...
Hi CS,  Welcome to Grace.  I

Hi CS, 

 

Welcome to Grace.  I'm so sorry your mom and family are going through this.  FYI, it's always best to post here on the forums, for a couple of reasons.  Dr. West responds to posts here when Jim or I need input so responding to emails isn't on his packed calendar.  And, when you use the forums everyone with the same questions can utilize your thread.  Sharing info about cancer treatment with as many people as possible is one of Dr. West's continuing goals.  (unless of course he's your mom's oncologist). 

 

The easy and often baffling answer to your questions about all the input you've gotten is they are all right.  The more precise answers are a little more complicated. 

First of all, it's important to keep in mind that there are rarely set answers to these questions and depend on the individual person's health, prognosis, and personal wants and expectations.  And, cancer can do anything. 

It's usually a good idea to wait 3 months between scans to look for changes because it usually takes that long to see changes if they're going to happen.  And yes 3 months probably won't change outcomes. 

The nodule's change could still be inflammation from her recent infection though like you said with antibiotics it would normally have changed that, but inflammation could linger.  

The surgeon sounds like he may not want to give a definitive answer because there isn't one, there's no biopsy to say definitively the nodule is cancer which is usually needed before treatment is started or surgery is done. Core needle biopsies are much much less invasive than surgery.  Thoracic surgery is one of the most invasive, dangerous and painful surgeries done.  There are many instances in every oncologist's practice where a nodule that looks and acts like cancer, isn't.  My husband had what everyone thought was a new metastatic nodule but probably wasn't.  

 

If I read correctly the surgeon said surgery was on the table.  That just means it's a possibility.  But, according to the np, the surgeon said he recommended follow up.  A noted thoracic surgeon's recommendation is pretty significant.  If you're not sure about the surgeon's recommendation then I'd find out.  If you're having trouble reading what the surgeon is recommending perhaps ask what would he do if it were his mom.  That often gets to the bottom of it.  

 

Let me know if I've answered any of your questions and please feel free to ask for clarification.  We'll get Jim's thoughts as well.  He's more precise than me. ;)

 

All the best,
Janine

 

 

Jim C Forum Mod...
Jim C Forum Moderator's picture
9 mm nodule

Hi CS,

Let me add my welcome to GRACE, and I too am sorry that you and your family have to deal with this issue and the uncertainty that accompanies it.

 

Despite what Janine said about me, I think she's covered everything pretty thoroughly. One question I would ask the surgeon: what is there about the nodule that makes it suspicious for cancer? Though only a biopsy can definitively determine whether it's cancer, there can be indications from its appearance that make it more likely,  such as edges which are "spiculated" (uneven) as opposed to smooth and rounded. 

 

As Janine stated, there's no right answer. A 3 month interval between scans is more likely to reveal any growth, although it does seem that if the nodule is cancer it's not currently growing rapidly.

 

Jim C Forum Moderator 

cms3011
Thanks very much for your

Thanks very much for your replies, Janine and Jim. I think we're gonna wait three months and then see where we are at that point. 

Best,

Chris

cms3011
update on nodule

Hey, everyone. So just a quick update here - my mom's solid 9 mm nodule grew to 11 mm per the latest ct scan on 6/25. Likely malignant. We just got back the results of the petscan, however (taken 7/11), and while it showed no signs of spread, the nodule was described as being 15 mm (with an uptake of 3.2). Does it seem likely that the nodule would have grown that much (4 mm) in basically two weeks after having grown only 2 mm from February 2019 to June, or could this be an issue of different radiologists measuring the nodules differently? Obviously cancer can go from being not especially aggressive to quite aggressive in a short period of time. ALSO, does this kind of growth, if legit, make something like SBRT (which we're discussing with a radiation oncologist about tomorrow) less preferable to surgery? Any advice here would be appreciated. 

Chris

JanineT Forum M...
Hi Chris, Not only could

Hi Chris,

 

Not only could different radiologists read the same scan differently but in tests, the same radiologist read the same scans differently.   On top of that the scans were different.  A stand-alone CT usually has a higher resolution than a CT/PET so it's common to have a few mm different in readings.  Another reason for the 2mm difference is that the picture could have been taken at a slightly different place on the nodule.  Think of the picture that's being measured as a slice of bread, one piece is slightly bigger than the one next to it.  So yes the 2 mm difference doesn't mean the nodule grew in just a few days.  

 

Here is an article that describes the phenomenon.   Did my cancer grow in 10 minutes?!: The limitations of CT scanning 

 

I'm glad your mom has the opportunity to see a radiation onc.  NSCLC can certainly be completedly eradicated with SBRT.  As a personal example, my husband was cured of nsclc with the help of regular radiation. 

 

Let us know what your mom decides.  

All the best,

Janine

 

 

cms3011
Thank you, Janine. Just a

Thank you, Janine. Just a quick note - the difference was actually 4 mm from 6/25 to 7/11 (11 mm vs 15 mm). So perhaps it's a combination of growth + measurement? I found it curious that the radiologist noted the module's original size of 5 mm in July 2018, but didn't mention anything about it growing significantly in the past two weeks. 

cms3011
Sorry, no need to reply here.

Sorry, no need to reply here. Radiation oncologist didn't seem all that concerned about the pet scan measurement. Thinks radiation is a good option should we decide to go that route. 

JanineT Forum M...
No problem:)  It's not really

No problem:)  It's not really the radiologist who decides on the significance of scan changes though sometimes they do make suggestions.  Mainly the radiologist reports facts about a scan.  The doc who orders the scan is in the best place to interpret the significance of the findings (they are the ones with direct knowledge of all the info on the patient).  

You would need to ask but the difference in type of scan and different equipment plays a big role in different measures.  I just meant to give you as many reasons as possible as to why there was a difference in just a week.   The difference seen in stand-alone CT in a year is probably more accurate measure of change.  The PET was possibly given to check SUV and other possible places of uptake.