Vascular dementia and lung cancer treatment - 1293977

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Vascular dementia and lung cancer treatment - 1293977

I wish to seek advice please re the following.
My elderly relative, 89 yrs old femaie ex smoker, has a pulmonary nodule of 6 mm which is deemed malignant on repeat Ct scans over 4 months. Grown from 4 to 6 mm in that time. Has no symptoms and was picked up routinely. Mediastinal lymphadenopathy, on same side, also on CT scan.

A PET scan was considered but there is a refusal for insurer to pay.
Also has vascular dementia for 2 years, with poor orientation,minimental score of 10, has full time carers 24 /7 over the last 6 months.. Recognises all of family and has reasonable quality of life.
Frail physically and mobile but needing assistance at times or can walk with aid.

Blood work up shows longstanding poor kidney function at about 30% functioning of normal - investigated previously and deemed to be a decline of old age.
No other significant medical history.
Oncologist recommends no further investigation or treatment feeling she will poorly tolerate any such interventions and also feels previous suggestions of a PET scan will add nothing further.

Can I please ask your views on this and in particular whether there is any advantage in pursuing a tissue diagnosis and whether there any other views on treatment here.
Also can anyone give some guidance on prognosis here..
Thank you..

Hi Frank,

Hi Frank,

Welcome to Grace. Often people are too frail to withstand the effects of anti cancer treatment. However it shouldn't be assumed this person has cancer. A 4 or 6 mm nodule is usually too small to be picked up on a PET so it's easy to see why the insurance company wouldn't want to pay for a very expensive procedure. For anyone it's an ordeal for a frail 89 yr old...? A PET scan just isn't the next step in this type of situation. Normally a "wait and see" approach is the next step and rescan in 3 or 6 months. Normally a nodule needs to be at least 1 cm before a PET can pick up molecular activity found in cancer, inflammation or infection. 1 cm is also the size a nodule needs to be before a biopsy can be taken.

The change is pretty insignificant as is the size. It could be the difference between the "slices" of the 2 pictures. Imagine a 6 mm oval or an american football. If you slice it up like a loaf of bread on slice will be smaller. The assumption that it's cancer is even more a stretch. Whether or not your relative is strong enough to take anti cancer treatment is a good question to be asking but we aren't able to answer that. But know this really isn't something a you healthy person would have biopsied at this time. A wait and see approach would be the next step. Rescan in 3 or 6 months to see if the nodule still appears to be growing.

As for being too frail, SBRT is a type of radiation treatment that may be an curitive option for very small (1 or 2 cm) lung cancer site.

All best,

Hi Janine,

Hi Janine,

Thank you very much for your reply.
Is the presence of mediastinal lymphadenopathy significant and also I should have mentioned the nodule is spiculated and I am not sure if this is significant.

Interestingly the respiratory physician was more in keeping with your view that the significance was unclear re the imaging results but the radiologist seemed to be of a stronger view that this was malignant.

Any comments are welcomed.

Kind regards,

The radiologist specializes

The radiologist specializes in reading scans and reporting on the finds, she has no further info on the person being scanned. They often make suggestions to the doctor but should not be taken as a recommendation over the treating oncologist who has all the information. At any rate a PET scan for a sub cm lung nodule is not standard because there is no data suggesting any kind of benefit in clinical care (and there's lots of data on the subject). The swollen mediastinal lymph node and the shape of the nodule are both signs that the nodule could represent cancer. However a swollen lymph node could represent other benign activities in the lymph system. Usually lung cancer tumors are spiculated in shape but not all spiculated nodules are cancerous. These are things suggestive of cancer but in no way an absolute. As I said above a wait and see approach is the standard of care.

Most oncologists with any time in clinical care can tell you that they see scans that look like cancer that ends up not cancer every week. If anticancer treatment is something your relative would like to look into it's worth speaking to the oncologist again to make sure all the bases are being covered.

From Cleveland Clinic on, "The radiographic edge characteristics of a pulmonary nodule influence the probability of malignancy. Nodule edges can be smooth, lobulated, irregular, and spiculated based on CT appearance. Typically, benign nodules have well-defined borders while malignant nodules are irregular or elongated. However, one cannot use edge characteristics alone as an endpoint as there is much overlap. The LR for a smooth edge is 0.3, for a lobulated edge 0.74, and for an irregular or spiculated edge 5.54.12 A spiculated edge is an independent predictor of malignancy in a lung nodule."

All best

Thank you Janine for your

Thank you Janine for your very helpful replies.