Hi,
I have a history of 1.2cm indolent, LPA, with 8mm of invasive adeno resected in 2011 with a lower left lobectomy. Since my tumor was first identified by CT in 2010, I have never had any growth on any of my pre- and post-op surveillance CTs. The resected tumor was stable for 13 months prior to surgery, and the assorted "freckles" in my lungs (including a couple of 2mm things, a 4mm GGO, and a 6mm nodule near the minor fissure, presumed to be a reactive lymph node) have been stable in 3-1/2 years of CT scans. I also have a Hx of small airways disease.
I just got my latest scan results, and I have a new 5mm GGO at the left posterior apex. I know the drill on nodules. I am assuming we will bump up my inhaled meds for a few months to eliminate the possibility of inflammation and rescan. (But I have been dealing with inflammation for years and have never had a nodule come or go.)
I have read tons of research on the likely malignancy of small GGOs. However, those studies always exclude patients with a cancer Hx.
So, I know I am entering a watch and wait game. Plus, I understand that even if the nodule persists after 3-4 months and its likelihood of malignancy increases, that still doesn't mean treatment is warranted, given the indolent nature of my previous tumor, and the waiting game might continue. However, while I am waiting I would love information that I can't find research on: in a patient with history of LPA, how likely is a new 5mm GGO to be malignant?
Thank you.
Reply # - December 15, 2013, 09:02 PM
Reply To: New GGO with a Hx of LPA
It seems like you have good perspective on this. Re-scanning seems a reasonable plan for similiar settings to the one you describe. It is not unusual for a GGO to regress on a surveillance CT scan. I know a lung surgeon who says tongue-in-cheek that Cipro has 'cured' more GGOs than any chemotherapy or surgery. It is true that GGOs sometimes can be due to adenocarcinoma in situ. This 'in situ' term is important, and has recently been reclassified, to emphasize that it is not identical to invasive cancer. Hope this helps.
Reply # - December 15, 2013, 09:14 PM
Reply To: New GGO with a Hx of LPA
I don't think there's any data to answer to the question you ask about the probability that a new lung nodule in someone with a history of lepidic predominant adenocarcinoma (LPA) is somewhere in the AIS or, less likely, invasive adenocarcinoma, but I suspect it's very high. In my mind, the central question is "so what? is this threatening or really an incidental finding?". I agree with Dr. Creelan that it sounds like you have a good understanding of the complexity of this situation, so the real issue is trying to navigate between potential undertreatment and overtreatment. You may have read my last post about this issue, which is really quite relevant to your situation:
http://cancergrace.org/lung/2013/12/14/lc-overdiagnosi/
Good luck.
-Dr.West
Reply # - December 16, 2013, 08:15 AM
Reply To: New GGO with a Hx of LPA
Thank you for replying. I recently commented that having a cancer that perpetually falls in the gray area can cause lots of anxiety because nothing is ever clear, but I would rather deal with that anxiety than the clarity that comes from a more aggressive cancer. However, while I play the waiting game, I try to minimize the anxiety by constructing a decision tree in my mind, so I feel I have a path to follow when or if new info comes in. This website plays an invaluable role in that process.
Your responses above were pretty much what I expected, but I do have a follow on question. What's the best way to make the decision to treat, should my nodule persist and grow slowly? My last tumor looked like a pure GGO on scans, and its indolent behavior suggested pure BAC (using the terminology at the time). When resected it included 8mm of invasive adeno. Invasive yet indolent. I presume over time those invasive cells could have picked up steam and considered invading. How do we identify the tipping point with the invasive adeno component where it because a threat for invasion? Do we base this solely on growth rate?
I know this is more art than science, and I am lucky I have a wonderful oncologist (who is one of your team members from Stanford), so I trust she will guide me through these tricky waters. But I do my follow up with my pulmonologist, and I won't see her unless this persists, which at a minimum would be 3 months from now.
Reply # - December 16, 2013, 03:26 PM
Reply To: New GGO with a Hx of LPA
It helps to have someone you trust overseeing your case, since I do agree that that it more art than science. Yes, theoretically, a cancer can always chance its pace and become more threatening, and that's theoretically more likely with an invasive cancer. You can also never be sure you don't have an invasive cancer, at least microscopically invasive, without removing it and looking at it under a microscope.
My perspective is that the behavior of the cancer is most important. A cancer that shows no change or a barely appreciable change over 6 months or more is one that I think has such a vanishingly low chance of leading to danger over the next few years that I would say that risk is highly likely to exceed benefit for surgical intervention. That's probably the rough guideline I'd use, perhaps modified by the characteristics of the patient: if I saw even 1-2 mm of growth in 6 months in a fit patient with what I expected might be >20 more years of survival otherwise, I'd be pretty conservative. In someone in their 70s or older, or with a history of other significant medical problems that might well overshadow the threat of the cancer, I'd be more reluctant to intervene on any lesion that showed only subtle chances over an interval 4-6 months or longer.
-Dr. West