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diagnosis time line

mylungs
Posts: 5
Joined: Oct 2009

I am 59 yr old male. Smoked for 20 years and quit 16 years ago.

During a routine exam, I had a chest x-ray, my first in 25 years. I also had complete blood work and everything was routine.

A less than .3 cm growth was discovered in my upper left lung.

My internist wants me to return in 3 months for another chest xray.

Should I be waiting 3 months, or should I see an oncologists ASAP?

Thanks.

PBJ Austin
Posts: 347
Joined: Mar 2009

Personally there's no way in heck I would wait. It might be nothing but if it is cancer then early detection is important so I would move the process along. Sorry if I sound like an alarmist but it would drive me nuts to wait 3 months.

mylungs
Posts: 5
Joined: Oct 2009

I was feeling the same way since I do not know the growth cycle of lung tumors. From experience, I know the growth rate for breast cancer (mother) and multiple myeloma (older brother) and therefore I know 3 months is a long time to wait. Lung cancer has never struck our family which is large.

Thanks for your comment and I will try to keep cool.

soccerfreaks's picture
soccerfreaks
Posts: 2801
Joined: Sep 2006

A .3cm 'growth' is a 3mm growth if I am not mistaken (as I often am). I had a 4mm spot on my right lung and was advised it was too small for them to make any determinations from. Without going into the entire history, I had valid scans performed in August of '07 that showed growth from a June scan, and even so waited until Jan 31, 2008 to have the biopsy (and subsequent lobectomy). Even so, the growth was so small that while they could establish the KIND of cancer, they could not determine whether it was metastasis from an earlier case of squamous cell cancer to the head/neck are.

Nearly two years later, I am NED (no evidence of disease) so that wait didn't hurt in my case.

While I understand the impatience and anxiety that PBJ references, the simple fact is that cancer often requires that we wait.

In your case, be advised that you might not even have cancer. Your doctors, in three months time, will examine that spot, compare it to the most recent results and determine whether it has grown. If it has, then they will probably opt to do a biopsy to establish whether it is a malignancy or not. There is always the hope that this is scarring from your smoking days, or from episodes with either bronchitis or pneumonia, for example.

Best wishes with this. It is often true, as Tom Petty sings, that 'the waiting is the hardest part'.

Take care,

Joe

PBJ Austin
Posts: 347
Joined: Mar 2009

Joe, that song played in my head 1000 times while I was awaiting my results. My mother calls me the impatient patient and it's SO true. :-)

I defer to Joe's expertise on cancer.

Mylungs, I hope you will keep in touch, we do care about your results.

OncoSurge
Posts: 21
Joined: Oct 2009

"...A less than .3 cm growth was discovered in my upper left lung.
My internist wants me to return in 3 months for another chest xray..."

At that size, your options are quite limited. It may be appropriate to obtain a CT-scan.
A medical oncologist will probably provide very little. He/she will not treat without a tissue diagnosis.

The question is how aggressive and invasive you want to be with a potentially benign lesion??? It is just these sized lesions that make CT-scan screening a difficult issue. CT-scans of "high risk" patients will identify numerous small lesions in smokers. Sometimes it is cancer but often it is scar and/or inflamation. You won't know unless
a) it grows alot
b) grows a little but is amenable to biopsy
or
c) you just cut it out

There is no "right" answer yet. We have no data on if there is a difference if you resect a small cancer of 0.3cm or wait until it is 1.1cm. I know folks will jump out of their seat and presume to know the "obvious benefit"... but there is absolutely no data. The other thing to consider is the patient population. Lung cancer is often in smokers. This means often in patients with overall "sick" lungs. If you wack out every spot on their lungs, you may be exposing unwell folks to "unnecessary" surgery. This will further diminish their total lung function. The question for Thoracic Surgical Oncologists is always when and where do you draw the line? How many folks do you expose to negative/non-therapeutic lung resection in order to catch the single lung cancer. The question is the same for breast cancer as well.... How many times do you cut on a woman's breast just to be sure??? Your doctor can only make so many of those decisions.... then it is up to the patient.
Keep in mind, these small lesions can easily be missed on VATS biopsy....

There are some new technologies to potentially bridge the gap faced with new but small indeterminate lesions... Electromagnetic Navigation Bronchoscopy (SuperDimensions/ InReach) is starting to help with small lesions. It enables potential sampling of smaller lesions that are more difficult to reach with conventional bronchoscopy. If it doesn't get a conclusive biopsy, it can potentially enable you to leave a marker that will direct VATS biopsy....

Or, you can do close surveillance observation.

you can take a look at the following website.... it is "commercial" but there are some good facts.

http://www.spotonyourlung.com/

soccerfreaks's picture
soccerfreaks
Posts: 2801
Joined: Sep 2006

I appreciate that someone in the 'healthcare profession' is offering expert advice on these boards, particularly in the Lung Cancer board, but I have some issues and some questions with some of your statements, OncoSurge, and am hopeful that you can clear them up for me.

First and foremost, are you in fact on 'oncological surgeon' as your screen name suggests? If so, you are providing a wonderful service to those of us who have or have had lung cancer and the fact you take time to come in here even on weekends is to be lauded. If not, however, it is rather disingenous, wouldn't you think, to give yourself a name that would suggest experience of that sort? Just wondering.

I note, as a follow-up, that in your posts you seem to really stress the need for a "thoracic surgical oncologist". In my own experience, which started with head/neck cancer and later worked into lung cancer, I retained the same Oncologist throughout, but had different surgeons for the cancers, one a nationally recognized ENT, the other a nationally recognized cardiopulmonologist. My OncoMan was involved in both, but did not participate in the actual surgeries. Just wondering.

You suggest in this post herein that smokers ('high risk patients') will show numerious small lesions in their lungs as a result of CT scans. I smoked for nearly 40 years and my smoking was never an issue with my scans. Issues I had included an infected tooth and a lung infection. Nothing to do with 'sick lungs' or smoking. In my case, at least, they did a scan, then did another three months later, and could tell from the relative size of the 'spots' on the latter scan, in relation to the former scan, what was growing and what was not. Smoking had nothing to do with it, except that they were probably not going to operate to begin with unless I quit. I find your evaluation regarding smoking both interesting and contrary to my own experience.

You further suggest in this regard that doctors may 'wack out' every spot they see in 'sick lungs', yet in my experience, my doctors advised that if my spots were pervasive nothing would be done. They were certainly not going to do multiple invasive biopsies, multiple invasive cuts across lobes and lungs. It is counter-productive, as you do suggest, but also, in my experience, not even up for discussion. I am again in wonderment.

Your statement about VATS is also curious to me, as I am of the impression that doctors who perform these procedures (I had one) can see what they are going after before they even pick up a scapel. What exactly are they missing? And if there are other markers/spots, why then do the VATS? Just curious.

Finally, the tone of your message seems to be that it is really in the hands of the patient as to whether a surgery will be performed when the dx describes a very small spot. In my experience, doctors will not perform procedures that they consider unnecessary or premature. That is what makes them qualified and trustworthy surgeons. I was never asked if, while my lung spot was too small, I wanted to go ahead and, what the heck, take a slab of lung just for grins and giggles.

I am not a professional, and I am not an expert, but I found much of your response curiouser and curiouser.

I look forward to your educated and professional response.

Take care,

Joe

OncoSurge
Posts: 21
Joined: Oct 2009

I will try to answer your questions. I hope you find the answers satisfactory.
I will start with the caveat... as a surgeon, responding on these boards, I can only provide generalizations based on some of what folks mention. I am a strong believer that formal recommendations and advise should be made in person with your physician and all the records in front of your physician and he/she being able to look at your results and images and not just the reports.

So, to your first question, YES. But, I do not really view my presence or comments very much a service, though I hope they may help some and encourage folks to seek out more education and care.

To your follow-up, Yes, I stress a GENERAL THORACIC SURGEON for thoracic tumors. In lung cancer in particular, general surgeons and heart surgeons do sometimes perform lung cancer removal. However, according to the analysis "SEER" and medicare data 1992-2002 there is an 11% increased five year survival if your lung cancer is treated by a general thoracic surgeon (non-cardiac thoracic)... Now here is the terminology issue. A board certified/fellowship trained surgeon for this gets confusing. Your heart surgeon falls under the category of "thoracic surgeon" or "cardiovascular surgeon" or "cardiothoracic surgeon". The board certification is issued by the American Board of Thoracic Surgery. In practice, folks are viewed as either "general thoracic (i.e. non-cardiac)" surgeons or cardiac surgeons. So, back to the survival, the analysis found better survival in patients treated by "non-cardiac" thoracic surgeons(i.e. General Thoracic Surgeons). Currently, out of recognition of the importance of focus, the training for these fields has been changed to two seperate pathways. As for "cardiopulmonologist".... I have never heard any surgeon use that term.

As for smokers.... Not all smokers will show multiple lesions. Smoking does not necessarily make it a "problem" in CT scans. However, with exceedingly rare exceptions, all longterm smokers will have abnormalities on a chest CT-scan. Sometimes this will be obvious scarring, blebs, etc... But, you may see numerous "benign" appearing nodules. An imaging film is not diagnostic. One of the fundamental tenants in using radiology imaging is as you note... comparison to previous films. It may have characteristics suggestive of x, y, z. Growth and/or change is critical finding when comparason films are available. You also note having some issues with infection. Again, smokers are at increased risk of infection/s. This can complicate the CTscan interpretation. Thus, radiologist may report something like, "nodule may represent scar or resolving infection can not rule out tumor or malignancy" and/or "recommend repeat imaging...". Pulm Function Tests (PFTs) will often demonstrate some degree of decreased function, aka sick lungs. A longtime smoker will often have abnormalities on CT-scan, when tissue removed will often have gross abnormalities, and will often have functional abnormalities (i.e. decreased PFTs). Thus, these are not healthy lungs.

As for multiple biopsies... Every patient is different. Every doctor is different. Waiting and watching may be absolutely unacceptable to some patients. There are unfortunately patients that have multiple suspicious nodules for any number of reasons. I have unfortunately seen patients that absolutely could not wait and/or tolerate surveillance. They wanted a definate answer to what was the "spot" on their lung. They shopped around and found a surgeon. They had the resection... sometimes coming back to us with a complication. Again, each patient is different and each clinical situation needs to be assessed. I will tell you that a large trial was conducted on screening CT-scans. They did find some early cancers. However, they also found that the screening CT led to a not insignificant number of surgical biopsies of the lung that turned out to be benign. Thus, we do not have any firm set recommendations or protocols for chest CT screening. I am NOT suggesting that surgeons take out every lesion. On the contrary, I am saying that with small lesions (like in large lesions), diagnosis is only possible with tissue. If one has a small lesion and must have a diagnosis... your options are limited.

VATS..... VATS uses a videoscope. It can NOT see into the lung tissue. Or as an example, think of it this way. If you have a milk jug full of milk, you then spray paint the jug with green paint. Look at the jug through a video camera. You have no idea there is white milk inside cause you can only see the green surface of the jug. The lung is for all intense purposes a ~solid organ. The video-scope will only see the surface of the lung. We now have new technologies that can potentially assist. You can use ct to assist to place a wire guide (like we do in breast cancer), bronchoscopy to inject a dye that will bleed to the surface of the lung, or place a solid marker so the surgeon can feel the bump of the marker... There are numerous techniques to assist in guiding VATS. You do the VATS to get the tissue; but you have to find the target tissue.

In the hands of the patient..... Yes, absolutely is in the hands of the patient. Again, every patient's experience is unique. But, patients do drive what will be done. To your point of not being offered the option of surgical biopsy... Patients may choose to request and/or demand what was not offered or felt to be the best approach. Some will not accept waiting (others insist on waiting against advice). Some surgeons are very much pushed by malpractice threats. Unfortunately, it is not all black and white. For example, suppose a patient has a lesion. The recommendation is to wait and repeat images. Suppose you wait three months and lesion doesn't change. Suppose the patient really insists they "know something is wrong". They push for surgery. Ultimately, surgery gets performed. Lesion is found to be a small cancer. Suppose, the lymph nodes are positive. Some patients will insist it was the fault of the surgeon not operating sooner and instead waiting. I would disagree with that, but cases occur. And, lawyers are called. I don't want to turn this into a referendum on malpractice, or to tell you what you should have done or not.

Again, each patient is different as is each tumor. I do practice under certain specific beliefs. One of those is that I will do my best to inform my patients what is available and what past experience has found. In the end, it doesn't matter if I quote a 20, 30, 80% survival/cure rate to a patient. If he/she has recurrence and/or dies.... he/she had a 100% death rate. A thoracic surgeon may perform 100-400 lobectomies per year. He/she thus has that experience to draw from and recommend from when dealing with the individual patient. Each patient, like yourself, and God willing, will only have that single lobectomy experience in their life. It is potentially the most significant experience in their life and so that single experience may affect their perspective. It is not uncommon to have a patient at a one year follow-up mention not understanding or not realizing important components of our discussion as to their operative care. In my experience, patients spend years gaining an understanding of their individual experience.

soccerfreaks's picture
soccerfreaks
Posts: 2801
Joined: Sep 2006

Thank you for what had to be a rather time-consuming explanation for many of my questions. It is greatly appreciated.

As for the term cardiopulmonologist, I found more than 1,300 hits for it using Google and am sure that some reference to my doctor as one was made during my time with him (it is not a word I am apt to make up :)), but I admit that in searching for his data explicitly, he is listed as a cardiothoracic surgeon.

Again, thanks for clarifying some issues for me.

Take care,

Joe

mylungs
Posts: 5
Joined: Oct 2009

I really appreciate your participation and everyone else, in this blog and your attention to my concerns. Your comments are very helpful. I apologize for not responding sooner but have been traveling and dealing with 2 family hospitalizations.

I will definitely take into your consideration about consult with a thoracic surgeon and fully understand the need to work with certified/fellowship trained specialists.

In terms of my overall lung health. I had the flu last in 1999; the only year I did not get a flu shot. I have not had a cold in more than 10 years. I actually bike ride for exercise 3 times a week and at the age of 59 can bike 5 miles in 40 minutes on a nonstop bike trial. Everything else on my physical was AOK. I am proud to say my total cholesterol adds up to 148 and my BP is normal.

Like I said, I will update everyone in late January when I have my 3 month follow-up chest xray. Until then Happy Holidays to everyone.

mylungs
Posts: 5
Joined: Oct 2009

Thanks for your thoughtful and thorough overview of this issue. It is very reassuring and expressed the gut feeling I had. I am glad to learn about your experience and results. It is helpful.

I will keep this board updated on my progress.

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