Help Needed Interpreting Some Words on Latest 3-month CT Scan Lungs - 1295111

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cbwriter
Help Needed Interpreting Some Words on Latest 3-month CT Scan Lungs - 1295111

Hi friends –

Hoping you all can provide some insight if you can. I really would love those in the know to interpret what some terms mean with reference to my wife’s 3-month CT scan with and without contrast.

Back story: She has multiple nodules in both lungs, found as incidentals back in the summer of 2016. Since then, VATS surgery, CT scans every 3 months, PET scan that did have hypermetabolic activity on one nodule, and 6 treatments of SBRT in the fall of 2017 as a result of a biopsy that revealed adenocarcinoma non small cell lung cancer stage 1. VATS in 09/15 with genetic testing showed everything negative except BRIP1 positive.

They did not do any genetic testing from the FNA from this latest biopsy in October of 2017.

Latest CT scan from today reveals everything is stable, no new growths or changes except this:

“A bilobed density in the left lower lobe noted previously has become more solid in appearance although the size and configuration remain stable. This is of uncertain significance. Other scattered small nodule densities bilaterally are unchanged in size and number.”

It also says the focal density noted peripherally in the left lower lobe has become more nodule-like, although unchanged in size, measuring about 1 cm.

We see the oncologist on the 30th.

My questions:
1. What is bilobed density? I know bilobed means in general, but what does it mean as it pertains to the shape of this nodule? Is this a good thing?
2. It is now more solid in appearance. Everything I am reading from the American Cancer Society and other places is that solid nodules are less likely to be malignant. Thoughts? Is this a good thing? Do nodules that change to solid without any other changes raise a red flag?
3. What does it mean that the focal density has become more nodule like? Is this a good thing?

Thanks so much!
Carol

JimC
Hi Carol,

Hi Carol,

Congratulations on what appears to be a stable scan. I've looked into the issue of bilobed densities, and nothing I've found indicates that shape is more or less likely to be cancer. Dr. West discusses other imaging features of nodelues here: http://cancergrace.org/lung/2007/11/10/risk-of-ca-among-spns/

As you can see there are various factors in play, so it's difficult to say whether there is enough information from the scan report to make a judgment. But no growth is alwats a good finding.

I hope you get good news from your oncologist.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

cbwriter
Ty so much for the fast reply

Ty so much for the fast reply. That's what we were thankful for: no growth at this time. It did grow slowly over a year from 8 mm to 9 then to a cm but the oncologist said they are just watching it.

Here's what I could use some major help understanding: It is now more solid in appearance. Everything I am reading from the American Cancer Society and other places is that solid nodules are less likely to be malignant. Thoughts? Is this a good thing? Do nodules that change to solid without any other changes raise a red flag?

I appreciate you very much, Jim!

onthemark
Hi cbwriter,

Hi cbwriter,

I also have a mix of ground glass and solid nodules but have graduated to yearly scans for now as nothing is changing. Pathology on my surgical specimen showed one AAH, one AIS and one invasive adenocarcinoma. Having remaining lesions on the scans,this is a situation where the absence of change, or very slow change, is what is important.

It is one thing if the nodule starts as solid and grows. It is a different situation if the nodule starts out as a hazy patch or ground glass and develops a solid component.

The latter can be an indication of transformation to a more malignant form of disease (i.e. from precancerous AAH to frank invasive adenocarcinoma for instance). However, if the solid component of the lesion is less than 5 mm it is 'minimally invasive' and not as dangerous.

These can also be very slow growing and there is no need to be in a rush to treat any individual one in the context of lungs with bilateral ggos. If one lesionstarts to take off and it's growth dominates the overall picture where everything else is stable, there is a practise to 'take out the lead runner' with local treatment as Dr. West has mentioned in his posts.

However 'more solid in appearance', which is what is written in your report, sounds less definitive than 'developing a solid component'. I am not sure what to make of that except it indicates gradual change rather than sudden change.

cbwriter
WOW, very interesting, and

WOW, very interesting, and thanks for your prompt reply, onthemark.

I really hope the oncologist does not want to do anything at this point. She's been doing so well and scheduled for knee replacement surgery (unrelated). She's seen a gynocologist, urologist, proctologist, and all the necessary tests have been fine. She saw a cardiologist and got a clean bill of health.

I just am uneasy on the report that says "A bilobed density in the left lower lobe noted previously has become more solid in appearance although the size and configuration remain stable. This is of uncertain significance."

catdander
Hi cbwriter,

Hi cbwriter,

It's so good to hear your wife has been doing well. I can't explain BAC as well as onthemark just did. On the subject of radiologists' reporting there is no standardized terminology so it would be dangerous to make assumptions about differences in wording. But asking her oncologist about the meaning would be a good idea.
I'm assuming you've read all that Dr. West has written on the subject of BAC, So you probably know there will be the risk the BAC will transform into a solid and or more aggressive cancer. Hence watching closely. I'd imagine specifying bilobed was just to to specify which nodule that was becoming more solid. The solid part being of uncertain significance not the bilobed shape. Again a question best answered by oncologist.

Hoping for the best,
Janine

cbwriter
Understood. Thanks so much

Understood. Thanks so much for replying to me. <3

cbwriter
I wanted to thank everyone

I wanted to thank everyone who replied and provide an update. The doctor explained that the bilobed shape was how the radiologist described the nodule. It is a small nodule and at this point, we just watch it. As for the solid nature that it partially has, he said he would be more concerned if it changed in size. So a very good visit and thank you all for your kindness and knowledge.

Carol

catdander
That's good news! I hope y

That's good news! I hope y'all just watch that nodule do nothing for all time.

Best of luck
Janine

cbwriter
Wags of gratitude, me too -

Wags of gratitude, me too - <3

messagejim
BAC with Adeno features Small Soft tissue density Component App

Long history of  BAC with adeno.   Been following slowly growing nodules since 2008.  Surgery in 2011.  Multi-focal lesions.  Following two for awhile.  One has been 2 mm with no change for few years.  The other has been increasing about 2-3 mm per year for several years and has always appeared as ground glass .   Note was added:   The 18 mm average diameter mixed ground glass and soft density nodule measured 16 mm average diameter on the prior study (annual scans).   The imaging appearace is that of a relatively small (but growing), relatively indolent primary lung cancer.  Given the presense of a small soft tissue component on the current study, further diagnostic evaluation should be considered.    

Growth appears to be consistent with what we have been watching for past 11 years.     Actually, less growth over past year as compared with prior year.    What would potential benefit be of further diagnostic evaluation?    Am I correct to think this is still considered a stable scan?

JanineT Forum M...
Hi messagejim, I'm sorry to

Hi messagejim,

 

I'm sorry to hear about your cancer no matter how indolent it's always concerning to say the least.  You're right to think 2 mm in a year is very indolent and could be continued to be watched withuot further followup.  It's possible for a ggo to become more solid with time which can cause the cancer to become more aggressive.  Given that radiologists sometimes make recommendations it makes sense that that note would be added to the report.  But your doctor who sees you and has all your information is in the best position to make treatment decisions.  If you're being seen by your primary doc it would be a good idea to get the opinion of a pulmonologist or oncologist.  In short it's usually fine to do as little as possible. 

 

This thread and it's links may be of further help. 

 

I hope this helps.

All the best,

Janine

messagejim
Thanks Janine.   

Thanks Janine.    Pulmonologist is discussing with surgeon and oncologist and says we will do one of three options:

1.  Do 6 month scan (been doing 1 year scan) to make sure solid nature is not increasing at fast rate.

2.  Radiation

3.  Consider surgery.    We talked about he lead runner theory and he has same view.  I will post again once i hear his recommendation. 

 

 

messagejim
Follow Up

Petscan was good.  No uptake as expected.  Had meeting with surgeon.   Basically, he told me that I need to either have surgery or radiation.  He said that once it starts growing it will eventually spread and be a problem.  I told him that based on my research and discussions with many doctors at different hospitals (and GRACE), it is not at all certain that with BAC it will eventually spread but of course no one can tell for sure.     Back in 2011 when i had the inital VATS, the doctor was also doom and gloom and beleives the surgery saved my life but it is not at all clear that I should have had that surgery given the multifocal and indolent nature of it.  He also disagreed with my statement that BAC tends to be multifocal.    Also said that if thee is growth need surgery.  When i told him that the growth this year was actually less than last year, he mentioned the new solid component.  Seems to me this surgeon and the one in 2011 are not even considering the fact this is BAC. 

Couple of questions:

This is in middle lobe and I already had my lower lobe removed in 2011.  He said the middle lobe is not as vital to lung function with only a 5 % loss of lung function if I had surgery.  Is that generally correct?

Radiation an option?  He thought that would be a reasonable approach but strongly suggested surgery.  Any downside to radiation?

What would you suggest for a second opinion?  Do you know if it is possible for me to send Doctor West my images, etc... and we have appointment over phone?    I will likely also see another doctor in Chicago but would like Doctor West input before I make any decision.      Most surgeons and oncologists in my expereince just stick to standard protocols and I really want to make sure I consult with someone knowledgeable with BAC.

 

Thank you,

   Jim

  

 

 

 

JanineT Forum M...
A second opinion from a BAC

Hi Jim,

 

It's good to hear you're moving forward to address the recent scans.  I wonder if there are more options to look at since lung surgery is quite invasive.  A second opinion from a BAC lung cancer oncology specialist would provide some excellent perspective and the opportunity to get the best understanding of your unique situation.  Dr. West who is one such oncologist has often discussed the idea of less is more in indolent situations.  You can compare your indolent BAC to runners who run a marathon.  Slow, steady takes the race, meaning doing as little treatment as possible to remain stable.  People very often live otherwise normal long lives this way.  Unfortunately, many oncologists who don't specialize in lung cancer treat all lung cancers aggressively leaving patients with unnecessay morbidity and fewer options later when they need them the most.

 

I'm not saying this is your situation but it's important to know you're getting it right the first time.  Here's a good way to look at your type of situation. And here is one of my favorite posts, it's about 2nd opinions. 

 

Keep us posted and best of luck,

Janine

messagejim
A Second Opinion from a BAC

Thanks Janine.  Advice was to get a petscan.  If it lights up we obviously approach more aggressively.  My understanding is that BAC does not tend to light up at all and while doing a petscan makes sense in a normal cancer situation does not likely make much sense in a BAC situation.      If they suggest anything beyond watching I will be sure to take up your advice and get that second opinion.   Thank you.  I will advise once I have petscan results.  

JanineT Forum M...
Good Luck and Good Hopes!

Good Luck and Good Hopes!

messagejim
Follow Up

Petscan was good.  No uptake as expected.  Had meeting with surgeon.   Basically, he told me that I need to either have surgery or radiation.  He said that once it starts growing it will eventually spread and be a problem.  I told him that based on my research and discussions with many doctors at different hospitals (and GRACE), it is not at all certain that with BAC it will eventually spread but of course no one can tell for sure.     Back in 2011 when i had the inital VATS, the doctor was also doom and gloom and beleives the surgery saved my life but it is not at all clear that I should have had that surgery given the multifocal and indolent nature of it.  He also disagreed with my statement that BAC tends to be multifocal.    Also said that if thee is growth need surgery.  When i told him that the growth this year was actually less than last year, he mentioned the new solid component.  Seems to me this surgeon and the one in 2011 are not even considering the fact this is BAC. 

Couple of questions:

This is in middle lobe and I already had my lower lobe removed in 2011.  He said the middle lobe is not as vital to lung function with only a 5 % loss of lung function if I had surgery.  Is that generally correct?

Radiation an option?  He thought that would be a reasonable approach but strongly suggested surgery.  Any downside to radiation?

What would you suggest for a second opinion?  Do you know if it is possible for me to send Doctor West my images, etc... and we have appointment over phone?    I will likely also see another doctor in Chicago but would like Doctor West input before I make any decision.      Most surgeons and oncologists in my expereince just stick to standard protocols and I really want to make sure I consult with someone knowledgeable with BAC.

 

Thank you,

   Jim

JanineT Forum M...
Hi Jim, Glad to know the PET

Hi Jim,

 

Glad to know the PET was clear.  You know how I feel about a 2nd opinion and glad to know you're looking into it.  I imagine there are good options in or around the Chicago area.  I'll make sure JimC comments as well he lived there and knows the system there.  I think Dr. West does have the option to do telemedicine consultations and case reviews though I'm not sure if that's with patients or other oncologists.  That has to do with the institution's practices, Dr. West has been an advocate since its inception.  Call his office here to find out exactly what his practice can offer today.  

 

No matter how 'vital' a bit of lung tissue is a resection very invasive and carries a lot of implications for problems.  And it's only as vital as how much other tissue you have to work with.  When you have lung cancer you need to save every bit you can and that includes saving it for the long haul.  The solid component is something to consider but I'd rather have a lung cancer specialist help me consider the possibilities.  Less invasive options might include watch the solid component to see what it's going to do.   Maybe surgery by a dedicated thoracic surgeon is right.  (note the difference between a 'dedicated thoracic surgeon' and 'cardiothoracic surgeon") Another consideration is stereotactic body radiation therapy, or SBRT, it's a treatment that delivers extremely precise, very intense doses of radiation to cancer cells while minimizing damage to healthy tissue. 

 

All the best,

Janine

Jim C Forum Mod...
Jim C Forum Moderator's picture
Follow up

Hi Jim,

 

I would heartily agree with Janine's suggestion that if surgery is the path you choose, the surgeon should be a dedicated thoracic surgeon. Such a surgeon will have the most thorough, relevant experience for your needs.

 

On the other hand, surgery may not be the best option. If you're looking for a second opinion in the Chicago area, I would not hesitate to recommend Dr. Thomas Hensing at the Kellog Cancer Center, with locations in Evanston and Glenview. He was my wife's oncologist, and not only is he fully versed in the latest lung cancer research, but he is an excellent communicator and extremely compassionate. He has contrbuted to the GRACE site in the past.

 

Also a contributor to GRACE, Dr. Jyoti Patel at Northwestern is a leading lung cancer researcher and would also be a good choice. 

 

You may find that any doctor you choose for a second opinion will suggest surgery, but if so that will help you feel more confident that it's the correct choice.

 

Jim C Forum Moderator 

 

messagejim
Update Second Opinion

Met with Doctor West at City of Hope in California and Doctor Bonomi at Rush in Chicago.  Both suggested radiation or 6 month scan.  Interesting how most lung cancer specialists do not treat BAC any different than typical lung cancer.    Appreciate your advice and glad I talked to lung cancer specialists who actually deal with my stituation and scans rather than a general one size fits all approach.  I think I am going to opt for radiation. 

 

 

JanineT Forum M...
Jim, I'm so glad you were

Jim,

 

I'm so glad you were able to see Dr. West and Bonomi.  You are the definition of being your own advocate.  I look forward to hearing how things go and "don't" progress. :)

 

All the best,

Janine

cards7up
Dr. West

Is this our Dr. West? did he move to California?  Take care, Judy

Jim C Forum Mod...
Jim C Forum Moderator's picture
Dr. West

Hi Judy,

Yes, he did. He practices at the City of Hope. Seattle's loss is Southern California's gain!

Hope you're doing well.

Jim C Forum Moderator