GGO and FDG uptake

Tue, 09/14/2021 - 17:58

Hi everyone, I'm new here and I'm grateful to have found this site.I created a post a few minutes ago but I can't find it! I hope I'm not duplicating this. I was diagnosed stage 1A add no carcinoma in August 2020. I had my upper left lobe removed via VATs surgery. My tumor was 2.5 x 2.5 x 2.1 cm, adenocarcinoma, lepidic predominant with focal papillary feature.  Grade 1-2, well to moderately differentiated. At the time of diagnosis, a PET scan showed a maximum SUV of 24.2 (which I believe is extremely high). Additionally a 2.1 cm ground glass opacity was found on my right lung with SUV 1.3.  Since surgery, I've had no further treatment, I have CT scans every 3-4 months.  I've had a new GGO identified in my lower left lobe (1.4 cm) along with small nodes (4 mm and 3 mm) all stable. 
I have a few questions:

Does high SUV Max indicate aggression? Is it predictive of likely reoccurrence?  

Is it unusual I'm not receiving treatment for large GGOs? My research indicates the likelihood of them being cancer is high given their size.

Thank you very much for any input. 


JanineT Forum …

Hi Daria,


Welcome to Grace.  I'm sorry to meet you in this way and glad you found us too.  You did get your first and this post through though we have to publish all the new threads individually to keep out the spammers.  Maybe we need to make that more clear upfront.  We're in the midst of updating the site so this is the perfect time to recognize fixable issues.  Thanks


It's not unusual to not treat GGOs that aren't changing or maybe just not causing problems.  Watching a nodule do nothing isn't at all easy but it is better than moving too quickly and using up all your options too quickly.  There are several stages of GGOs' density; pure (all cloudy), part solid, mostly solid.  Density and/or its growth would factor into decision making.  Typically the more pure a ggo the less suv uptake because there's so little tissue (often a nodule wont show any uptake before it's a cm in size.  and yes 24 suv is high for any 2 cm nsclc tumor and means the tumor was very active.  It suggests that other nodules will begin to increase in size and density.  Radiologists compare scans to watch for these changes not just in size but also density.  Too, it can be close to impossible to precisely measure all these components in of a GGO and would be a fine discussion to have with your onc about your progression of scans.


There is a worry that local treatments, surgically or radiologically removing too much healthy tissue will do more harm than good.  Systemic treatment (chemo, tki, immunotherapy is used to keep it all at bay possibly forever).  It's more of a balancing act than ever with better radiation treatments that save more healthy tissue and more systemic treatment options. 


It's never a bad idea to have a 2nd opinion from a specialist at a large academic research institute where the onc has the opportunity to focus all their work on this type of issue.  It's pretty typical for someone to see a 2nd opinion doc during transition times and then having day to day treatments and follow-ups with an onc in your vicinity.  This is an excellent article for many reasons but specifically on 2nd opinions. 


Let me edit this post and say that the new ggo could be inflammation or infection and may be gone in the next scan. 


I hope this helps and that you get what you need.

All the best,


JanineT Forum …

I contacted Dr. West to see if anything had changed since the writing of his article I link.  He replied, "Really nothing.  It's still the same principles of balancing between under treatment and real risk of over treatment (don't just accept everything because a surgeon says it's possible -- the treatment could be far worse than the disease), focusing on disease that is CHANGING and rate of change while trying to ignore stable findings in the background, favoring local therapy (generally focal radiation) for an isolated spot or two of progression even if against a background of stability, and give the best systemic therapy IF there's clinically significant multifocal progression (not just asymptomatic barely perceptible progression on scans several months or years apart). Since 2014, we've found a few more targets and have a few more targeted therapies, but the principles for BAC or the disease formerly known as BAC still apply just the same."


I'm don't think it's mentioned in that article but oligometastatic nsclc and very indolent nsclc is now treated pretty much the same in respect to targeting one or two rogue/changing/progressing spots with focal radiation.  

I did notice the timing between CTs is quite short in the algorithm (6 to 8 weeks) when your watching something suspicious like a new ggo.