Slowly Changing Nodule - 1269029

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galben
Slowly Changing Nodule - 1269029

I receive yearly CT scans as a follow-up to rectal Cancer. On my latest scan, the radiologist was more detail oriented and went back three years comparing scans. I have had a stable nodule in the lower right lung since diagnosis. Also present has been an area described as focal density in the upper right lung with a nodule. The latest report states that this nodule is spiculated and has grown from 3x4mm to 6x5mm (in 3 years) and is adjacent to a 1cm GGO which has also increased slightly since diagnosis. Also reported was another 4mm nodule in the same area that appeared a year ago but has remained stable. There is also scarring or atelectasis in the middle lobe. Given the characteristics and seeming changes of the upper nodule, the radiologist report states that it is suspicious for malignancy. That was in December and my oncologist was comfortable with waiting for follow up scans as was I, since if it has grown, it has been a slow process and the nodule does not look like a met. If anything, he says it looks like a primary lung but could still just be scarring. I am being rescanned in April without contrast this time to check for changes. If no change, my guess is we will follow up with scans. My oncologist mentioned a biopsy might be the next step. My questions are, is the nodule large enough to biopsy? Can GGO be biopsied? Is GGO ever just scarring? Is there a risk of seeding with biopsy? By the way, I am a 57 year old female non-smoker. Thanks in advance for your input.

JimC
Hi galben,

Hi galben,

Welcome to GRACE. I'm sorry you need to deal with these questions, but I'm glad you found GRACE to help you.

As you state, your nodules have been extremely slow-growing, so much so that even they do represent cancer they may not require treatment at this time. Most of your nodules are too small to easily biopsy; usually 1 cm is the lower limit. Although your GGO meets the size requirement, its less than solid nature could make getting sufficient tissue for a definitive diagnosis difficult, and as you point out it could represent a different process. Seeding is not unheard of, but does not occur frequently.

Dr. West has written about the risk of over-treating a slow-growing cancer here. It's in the context of multifocal BAC but the principles apply whether it's BAC or not.

Good luck with your upcoming scan.

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>

galben
Thanks so much for your

Thanks so much for your response. The info is pretty much what I had surmised. It sounds like I would want to consider biopsy if the nodules grew larger than 1 cm, particularly in a shorter period of time. If they are stable on this scan, I would assume my oncologist will wait until my rectal Cancer follow-up scans to check again, which is fine with me. I read the linked article and agree with the idea of not over treating. After going through treatment for rectal Cancer, I am not excited to start that process again. Best case scenario is that these nodules aren't Cancer. But if they are, I would be comfortable with just doing surveillance as long as things are slow going. (And aren't mets) I wonder how many doctors out there support this type of thinking. I have one more question about nodule characteristics. Is scarring ever spiculated? My oncologist showed me this nodule and it did look star shaped so naturally, I am curious about what I am dealing with. Again thanks for the info. This is a very informative site.

Dr West
The size of a biopsy that can

The size of a biopsy that can be readily biopsied depends on skill and bravado of the radiologist attempting the biopsy, as well as the location of the cancer -- lesions near the bottom of the lung, closer to the diaphragm, move up and down with respiration and are harder to get to, size for size. Generally, 1 cm is a reasonable cut off, but there are some radiologists who can often biopsy and get a diagnosis from a lesion as small as a few mm, and there are larger nodules in an inaccessible place, for which it might not be possible to get a good biopsy because of the location.

It is possible to biopsy a ground glass opacity (GGO) that typically corresponds to a non-solid lesion, though the yield is higher when biopsying a solid lesion or the solid portion of a lesion with some solid and some non-solid component.

Seeding is extremely rare, on the order of a 1 in 10,000 risk. In the vast majority of patients, the risk of not obtaining a diagnosis far exceeds the very, very slight risk of seeding by the tumor during a biopsy procedure.

I describe a single case of needle track seeding here, the only case I've ever encountered in 15 years specializing in lung cancer:

http://cancergrace.org/lung/2009/09/07/needle-track-seeding/

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

galben
Here's the update to my

Here's the update to my original post. I had my follow-up scan last week. The report says there is little growth and the radiologist gave the measurements of 6 x 6 mm to the spiculated/poorly defined nodule with the adjacent sub solid nodule as 13 mm. Like the last radiologist, he compared back to old scans and because of prior growth as well as the nodule characteristics said it was "concerning for slow-growing malignancy and recommends a thoracic surgery consult. I will be seeing my oncologist next week and I'm not sure what he will recommend. I don't really want to jump into invasive procedures if it makes sense to continue watching. Of course, I have already been radiated to the nines with rectal cancer so don't relish too frequent scanning either, although I still have 2 more years of annual scans left. From what I've read, it sounds like a pet scan might not be the most efficient follow up so I'm not sure what to think about how to proceed. Of course, I do want to monitor this somehow? Anyway, I know you can't tell me what to do but I am interested in any insight someone on here has to offer. Thanks.

catdander
galben,

galben,

I understand the hesitancy of unnecessary radiation though when following what may be cancer even indolent cancer it's much more appropriate to follow with CT (with or without contrast) scans than to abstain because of possible radiation from the scans.

If my husband still has cancer it too is very indolent though quite unusual for his type of cancer. You are right to question how important it is to treat something slow moving with much urgency. I've learned to look at my husband's case much like Dr. West looks at other indolent nsclc (often but not all BAC). He's treated and written a bit on the subject. If you and you oncologist don't see the same when looking at options a second opinion is always appropriate.

Here are a couple of posts that may be helpful,

While entitled BAC subtype it also speaks to any indolent nsclc and how I will look at my husband's squamous nsclc is it were to show up again, http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

On second opinions, http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide-...

I hope this is helpful.

Janine

galben
Thanks Janine! I have read

Thanks Janine! I have read that article and the algorithm. Looking at that, I would think my follow-up would be watch and wait. I am already on an annual scan schedule for rectal cancer follow-up for probably two more years since I was stage 3. Chest CTs are included in that work-up. That's how this current situation started, an incidental finding.

I really appreciated the article on second opinion, very informative. I have a feeling my oncologist will want to watch and wait but we'll see.

It is hard for me to imagine that I could have a second primary cancer. I was and am healthy except for treatment related issues/long term side effects.

Glad to read that your husband is NED!

galben
I just wanted to give a

I just wanted to give a status update on my situation. As part of my follow-up, I had posted elsewhere about having had a PET-CT, which showed a low, possibly insignificant amount of uptake in 7mm of the 1.3cm sub solid nodule. My oncologist had another radiologist go through my past scans and his feeling was that there had been just small amounts of change over time so continuing to watch and wait is appropriate. This was what I wanted to hear after everything I read on this site. So in October, I will be getting scanned again. I was nearing the end of my rectal cancer follow-up but it looks like the lung surveillance will bring more CTs to my future. My oncologist said that if the next scan shows no growth, I will still need follow-up for 4-5 years for this nodule. Does this sound typical? Regardless, I am hopeful this is scarring or just so indolent that we don't need to do anything invasive.

Laura

JimC
Hi Laura,

Hi Laura,

That's great to hear that everyone agrees there is only a small amount of change over time, not at all consistent with cancer. There's no set standard on how long to watch a small nodule, and you might want to ask if the final scan would be one year after the previous CT, or perhaps after a longer interval.

If you haven't already seen these links, they may help you put everything in perspective. The first is a podcast from Dr. David Yankelevitz on Management and Evaluation of Pulmonary Nodules. The second is a post from Dr. West on the length of follow-up on GGOs.

Good luck with your next scan, and please let us know how it goes.

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>