When to see oncologist - 1294493

Tue, 05/29/2018 - 09:15

I have been followed since 2011 for multiple lung nodules. In 2014, a cluster of multiple 4mm nodules developed in the RUL originally thought to represent a mucoid impaction. It continued to progress with new nodules forming in a linear fashion. By Oct 2017 they appeared to have consolidated . A EBUS was performed in Dec 2017 and I was diagnosed at as an adenocarcinoma Stage 1A (2.8 cm). It was predominant solid at 40% with 30% micropapillary and 30% acinar. Positive KRAS. PDL1> 95 %.
A total RUL was performed on 1/31/18 and no further treatment was recommended. I had my scans reviewed by an outside facility and a RLL nodule, present since 2016 had progressed from 4x5 mm to 7x9 mm. It has a small solid component and the outside facility highly recommended resection. My local provider took it to tumor board and because of it's location, they do not feel resection is feasible, nor do they want to radiate it w/o confirmation of malignancy. I am now scheduled for an attempted percutaneous bx and radiowave ablation. I have asked repeatedly when I should see an oncologist and am told it isn't necessary at this time. Would appreciate your thoughts.

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Hi gigzabuk,

I'm sorry to hear about the possible cancer growth. I would think it is time to see a lung cancer specialist. Someone who treats BAC regularly. These people tend to be medical oncologists so even if you and your treatment team decide you don't need systemic treatment (what a medical oncologist does) you are getting the opinion of someone most able to speak about your options. Also if the new growth is cancer your treatment options have gotten more complicated. A large teaching hospital with a large cancer center can take your case to a "tumor board" to discuss all aspects of your case with all the different specialists contributing and prepare plan options that maybe more sophisticated than just one person can prepare.

Often people come back from a 2nd opinion with the same plan. Don't confuse that with having wasted time, it's important to get whatever feedback you can even if it just confirms you're on the right path. Here's a good blog on the subject, http://bit.ly/2JhK3Uz

I hope this is a CT reading fluke and not cancer growth. Especially with GGOs it's difficult to put a clear boarder around a mass so 4 mm might be small enough for the CT to have hit a different place and radiologist to see a bit differently.

All best,


I am at a major cancer center, Cleveland Clinic and see a lung cancer pulmonologist. I have asked about seeing an oncologist but they didn't think it was necessary. They just presented my case at tumor board which is why they decided no further surgery but ablation. However, if the nodule in my lower lobe also proves to be malignant, then I assume my original staging of a 1A would be changed to possibly a 3A? I would guess for sure I would need oncology a that point. Thank you for your response.


Hi gigizabuk,

Your staging will depend on whether there is a lepidic component in the biopsy of these nodules. In can be stage 1 with multiple nodules if each one has a lepidic component that usually appears as 'ground glass' on ct scans. Do you have ct scan reports for the appearance of these nodules?


Hi gigizabuk,

One point that I'd add is that at a major center such as the Cleveland Clinic, the tumor board would include a medical oncologist who would have provided his/her input on your situation.

Also, if this is viewed as BAC, the treatment options would not be the same as those for a typical stage IIIA lung cancer, as there would be a concern that you could over-treat a relatively indolent cancer.

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Thank you for your response. The initial RUL 2.8 cm nodule was an adenocarcinoma. The growing one in the RLL states it is an opacity and I was told has a very small (2mm) solid component.


Hi Gigizabuk,

From what I understand the RLL nodule in question grew from 4x5 mm sometime in 2016 to 7×9 mm sometime in 2018. It has a very small solid component now which is 2 mm. So I am assuming the rest is a 'ground glass opacity' or 'non-solid opacity'.

This is relatively indolent or slow overall growth and as long as the solid component is less than 5mm gives a favourable long term prognosis.

Lepidic growth is often associated with the non-solid part of the opacity. Even if it is cancer it is a relatively indolent kind and not an imminent threat. It has been mentioned often that these "BAC type" lesions are often over treated, if that is what it is.

An advantage of ablation is that it preserves lung function in the surrounding tissue.

I am a little bit unsure about your situation. Is the plan to wait to get biopsy results before doing an ablation, or is the biopsy and ablation a single surgical operation?

If you get a positive biopsy why not wait for that and get radiation treatment?

You have time to get a second opinion with an oncologist if you have questions about your treatment options.


The above info is correct. The reason they are favoring ablation vs radiation is that they are somewhat doubtful that they will be able to get a good pathological specimen due to its small solid component. They are planning to do the ablation as a single procedure with the bx . The only thing that would change the plan is that when they do the bx, they will look at the specimen immediately and if there is any indication it is benign, they wouldn't do anything further. Thanks so much for your ongoing responses.


Hi gigazabuk,

That sounds like a sensible plan. Another option is to wait and scan in 3 months and see if the solid component on ct grows larger and then biopsy at that point.

If this were your first nodule of concern that might very well be the recommendation since it is less than 1 cm and has a solid component less than 5 mm,

but since the tumour that was surgically removed was larger and had a 'solid component' on pathology... not to be confused with 'solid' on a ct scan, they are going to want to be more aggressive than wait and see.

It seems to me you are in good hands with their treatment recommendation.