new nodule while on chemo with good response - 1272613


Dear Dr. West and team
Background: Husband diagnosed stage 3A adenocarcinoma 09/14/2015. Tumor in left lung 5x3 cm and possible one lymph node involvement close to tumor site. In addition, COPD, mild emphysema plus bronchiectasis that was indicated on his scans. We were offered pneumonectomy in major cancer center if 1) Lung function improves (it did and he passed stress test) and 2) mediastinoscopy will not reveal cancer in the rest of lymph nodes (it did not). To buy him time to improve lung function 4 chemotherapy sessions were given of Cisplatin and Alimta in high dosage. After 2nd infusion had CT scan (11/18/2015) and tumor responded by shrinking about 50%. He is also taking prednisone pill (10 mm reduced to 5mm) His shoulder pain is gone, he gained 40 lb since diagnosis.
Present situation: Pre surgical scans 12/30/2015 MRI and PET. MRI is fine but PET revealed area of inflammation 0.7 x 0.9 SUV 3.6 in his ‘good’ right lung. In his CT scan 11/18 nothing was noted of this nature. There was some area of inflammation/infection noted in right lung but our doctor did not address it at all. This SUV pop up came as a big surprise to all his team and us because he had such a good response to chemo. He got a cold without fever jus sneezing and mild runny nose 2 weeks ago. On January 4th, surgeon gave him Zpack to take for 5 days, after he got re-scaned 01/13/2016– CT scan this time. We were told yesterday that the area remains the same in size so fine needle biopsy is needed. We will have it next week.
Questions: 1. Is it unusual to have a potentially cancerous nodule to pop up while being on chemo and responding well? 2. If the nodule will turn out be malignant is the chemo considered unsuccessful even if it shrunk main tumor? 3. With the area this small they may not be able to get enough material for analysis. If this happens It could be Surgeon’s call to operate regardless of inconclusive biopsy? Would you suggest second opinion on surgery ? Thank you.



Hi ng, I'm very sorry your husband is going through this. I know how difficult it is for you but I'm sure he's very lucky to have you there to help. One of the first things to know is cancer can and will do anything. So yes cancer can grow in one spot while shrinking from chemo in another. Most would consider a change if cancer is growing though it's hard to say unsucessful if shrinkage is achieved at all. Though much of that is semantics the important thing is to understand what's happening and options for decision making.

It may be difficult to get enough tissue for a definitive biopsy. Usually a cm or more is considered needed.

Maybe most important is second opinions are quite important at crossroads such as this. The following link is to a blog post that explains the many benefits of 2nd opinions,…

I hope this helps.
Best of luck,

Posts: 194

This is a complicated situation, and there is no one-size-fits-all answer to your questions. It is true that biopsy of tiny 7 mm lesions is technically difficult and frequently inconclusive or non-diagnostic.

Yes, I recommend getting a second opinion. Surgical management of Stage 3 lung cancer is probably one of the most complicated topics in our field.

Here are some salient questions that I would recommend asking your treatment team:

1. If the biopsy is inconclusive or just shows 'in situ' changes, how will that change anything?
2. Would it be possible to proceed with surgery and just watch the right-sided lung findings? And then consider SBXRT in the future if right-sided lesion enlarges.

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Dr. Creelan, thank you so much for sharing your opinion. Could you also tell us what are your thoughts on the following: if he last chemo of cisplatin and alimta was on December 16, how long it is prudent to investigate surgery in our case-- We don't want to lose the benefits of the treatment he received . Of cause, we will also talk to our team.
Again, I appreciate your reply, our situation is complecated so I am trying to get a range of opinions .