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Multiple nodules and Adenocarcinoma in Situ

bonaya
Posts: 10
Joined: Aug 2014

Hello everyone,
I am 56-year old former smoker (quit 7 years ago) and was just diagnosed with Adenocarcinoma In Situ based on needle biopsy done on a 1.3cm nodule in my right middle robe.  Multiple pulmonary nodules in my lung were first discovered by CT (taken because I was feeling shortness of breath) in 2005 and they were monitored every 6 months for three years and every year after that and no change in size was observed in any of the nodules until the last CT taken two weeks ago.  It turned turned out 3 of the nodules have grown and the largest was 1.3cm. Here is the relevant section of the pathology report:

----------------------------------------
FINAL PATHOLOGIC DIAGNOSIS
RIGHT LUNG MASS CORE NEEDLE BIOPSY:
- ADENOCARCINOMA IN SITU. (SEE COMMENT)

Comment
Multiple deeper sections into the paraffin block were obtained in
this case. Only adenocarcinoma in situ is identified in the
histologic sections examined. Adenocarcinoma in situ was previously
known as bronchioloalveolar carcinoma. No invasion is identified in
the tumor present for evaluation.
----------------------------------------
Summary of the size and location of the nodules based on the last CT is shown below:
----------------------------------------
"There is a 5 mm groundglass nodule in the LEFT upper lobe on series 3, image 15. There is a 5 mm nodule in the LEFT upper lobe on series 3, image 18. There is a 5 mm groundglass nodule in the LEFT upper lobe and 3 mm nodule in the LEFT upper lobe on series 3, image 28 and 29 respectively. There is a 4 mm groundglass nodule in the RIGHT upper lobe on series 3, image 21. There is an additional 1 cm groundglass nodule in the RIGHT upper lobe and an additional 13 mm irregular elongated nodule in the RIGHT middle lobe on series 3 image 27 and 29. The 2 largest nodules in the RIGHT upper lobe and RIGHT middle lobe are increased in size."
----------------------------------------
I have PET scan scheduled for tomorrow August 5 and appoint with thoracic surgeon on Thursday.  I am deeply stressed and don't know what to expect.  I would like to hear from people who may have been in my kind of situation.  

Thanks
Bonaya

dennycee
Posts: 836
Joined: Mar 2011

Very sorry for the necessity that drew you here.  This link is compiled by the Am Cancer Soc and its pretty comprehensive.  Print it out.  There is room to write the answers if you print it out.  If possible, have someone come with you to take notes.  If you miss something or don't quite understand what they say, ask them to repeat it in plain English.  If you think of it after the appt, don't worry.  Call the office back with the question.  The drs. nurse will call back with the info.  

If you have to have lung cancer, this is the slowest growing cancer which is fairly good news.  There are fewer options for treatment at this time but with the advent of the newer targeted therapies in clinical trial, chances are very good that they will have several options in use before you need it.  If they recommend lobectomies or wedges or both, you may never need further intervention. 

This may be overwhelming at first, but, it is survivable.  Please let us know what the drs say. Don't be afraid to get a second opinion.  If it sounds like I am trying to put a positive spin on it-I am.  My adenocarcinoma (fast growing, high grade) was diagnosed when my primary was 14cm (almost 6 inches).  My metasteses were diagnosed by additional biopsy, I was staged at 4 and told I had 10-15 months to live in October 2010.  You can do this, the first step is believing it is possible.  

http://m.cancer.org/cancer/lungcancer-non-smallcell/overviewguide/lung-cancer-non-small-cell-overview-talking-with-doctor

bonaya
Posts: 10
Joined: Aug 2014

Dennycee,
Thank you for the information and for the advice.  I have my PET scan tomorrow and my first appointment with y thoracic surgeion on Thursday.  I will let you know what I find out. 

Bonaya

bonaya
Posts: 10
Joined: Aug 2014

I had my PET today and I just received the report from my doctor.  The PET scan shows thee is no malignancy in the nodules and this conflicts with the biopsy report.  I like the PET result but what if the biopsy result is more reliable?  Which one am I supposed to believe.  Has anybody been in my situation? 

Here is the PET Report in full:
----------

PET/CT BASE OF SKULL TO MID THIGH

** HISTORY **:
Multiple pulmonary nodules.

** FINDINGS **:
Procedure:

Blood glucose (mg/dL): 109
IV dose (mCi FDG): 11.0
Injection time: 1255
Scan time: 130

The patient was in the supine position for 30 minutes after
administration of radiopharmaceutical. A non-diagnostic quality
CT scan, used only as a transmission scan for attenuation
correction and anatomic map for the PET scan, from the base of the
skull through the pelvis was acquired followed immediately with an
emission PET scan of the same area.

The data was reconstructed in transaxial, coronal, and sagittal
views and displayed as PET non-attenuation corrected, PET
attenuation corrected, and PET/CT coregistered images. The CT
scan obtained was a low energy acquisition and a non-diagnostic
quality study used for the purposes of anatomic mapping and
attenuation correction of the PET scan.

Findings:

A 1 cm nodule in the lateral right upper lobe (maximal SUV 1.0).
Adjacent inferiorly and medially is a 1.1 cm nodule in the right
middle lobe without hypermetabolism. A 4 mm nodule in the left
upper lobe is also without hypermetabolism.

Prominent uptake at or near the porta hepatis is probably
non-malignant. A small lesion just anterior to the right iliac
crest (2.4) may be due to trauma. Diffuse, linear uptake in the
abdomen and pelvis is representative of gastrointestinal and
genitourinary tract activity. No lesions are identified to
indicate malignancy as clinically questioned.

** IMPRESSION **:
1. No malignant disease identified. Multiple nodules involving
both lungs without hypermetabolism. The sensitivity of PET for
lesions less than 1 cm may be reduced.

2. Aortic atherosclerosis.

dennycee
Posts: 836
Joined: Mar 2011

Your confusion is understandable. It helps to understand that a malignancy is a cancer that is spreading into other organs and places within the lungs.  A PET scan reads the amount of metabolic activity in the tissue.  The higher the number the more likely the activity is related to a cancer.  There are many things that can cause metabolic activity including healing from injury, irritation from caustic fumes, cleaning fumes, allergies and even bronchitis, colds or flu. A high percentage of nodules go away on their own (95%).  For that reason we remind ourselves that its not cancer until a biopsy says its cancer. 

In your case the biopsy has confirmed it is cancer.   The PET has confirmed that it is unlikely that the nodules are metastases.  The type of cancer you have is very slow growing, so it registers very low on the uptake reading.  That said, there is no guarantee that there are not mets- just a very low likelihood.  Until a cancer reaches a certain critical mass it will not appear on the PET scan.  

In all, this is an excellent report.  Except for the recent cancer diagnosis, I would say its worthy of a happy dance.  Your dr will follow this up with regular ct scans to measure any progress.  Have they discussed a treatment plan yet?   

bonaya
Posts: 10
Joined: Aug 2014

Thanks Dennycee,
I am having my first meeting with a throacic surgeon tomorrow and I hope he will bring up whatever treatmentoptions are available to me.  I will keep you posted. 

dennycee
Posts: 836
Joined: Mar 2011

Meeting with surgeon means  the tumor board thinks they can possibly remove a section of the lung and effect a cure (possible in early stages).  I've had the pleasure of meeting an 18 yr survivor of stage one lung cancer.  He's still going strong.  

bonaya
Posts: 10
Joined: Aug 2014

I had my very first constultation meeting with my surgeion on Thursday.  He said he can remove the 1.3cm malignant tumor in middle right lobe by VATS and will try to remove the 1cm nodule using VATS as well but may have to go to open chest surgery for that due to its location.  These were the only two nodules that grew in size over the last 9 years but there are others that have not shown any change during this time.  The surgeion thinks all of them are most likely the same as the one proven to be malignant by biopsy and I am wondering if that has been proven by other patints and doctors. 

A big question I have now is this:  How can I be sure that the surgeon I have is the best doctor I can get with the health plan I have?

dennycee
Posts: 836
Joined: Mar 2011

Get a second opinion at a teaching hospital.  This is a list of comprehensive cancer care centers as designated by the NIH/NCCN. Ask lap ask your primary care dr who she/he would want operating on their own moms.   That can be quite telling.  Also, ask your surgeon how many of each of the surgeries he has done.  

bonaya
Posts: 10
Joined: Aug 2014

Thank you Deenycee. I have asked a referal for a second opinion.

bonaya
Posts: 10
Joined: Aug 2014

I had my first ever surgery (VATS) exactly a week ago and I received the pathology report yesterda. Two adenocarcinomas (one in right upper lobe and antother in right middle lobe) each 1 cm in size were removed.  These are now defined as adenocarsinomas and not adinocarcinoma in situ as had been thought from in the pre-surgery needle biopsy studies. 

The post surgery pathology report is shown below.  Is there anybody here who has had similar diagnosis?  Please help. 

Surgical Pathology Report
FINAL PATHOLOGIC DIAGNOSIS
A. RIGHT MIDDLE LOBE LUNG, WEDGE RESECTION:
- INVASIVE WELL DIFFERENTIATED ADENOCARCINOMA (SEE SYNOPTIC REPORT
AND COMMENT).
- SURGICAL MARGINS NEGATIVE FOR CARCINOMA (CLOSEST IS 1.0 CM FROM
RESECTION MARGIN).
- TUMOR SIZE: 1.0 CM IN GREATEST DIMENSION.
- TUMOR INVADES VISCERAL PLEURA.
- 9 BENIGN LYMPH NODES (0/9) FROM PARTS C-F.
- PATHOLOGIC STAGE: mpT4 N0 (BECAUSE OF SEPARATE TUMOR NODULE IN A
DIFFERENT LOBE OF IPSILATERAL LUNG - PART B).
- ADDITIONAL PATHOLOGIC FINDINGS: ATYPICAL ADENOMATOUS HYPERPLASIA.

A. LUNG, WEDGE BX, INCLUDING OPEN - RIGHT MIDDLE LOBE WEDGE
RESECTION:
Specimen: Lobe(s) of lung: Right middle lobe
Procedure: Wedge resection
Specimen Integrity: Intact
Specimen Laterality: Right
Tumor Site: Middle lobe
Tumor Focality: Separate tumor nodules in different lobes, sites: Right
middle lobe (above) and right upper lobe (part B)
Histologic Type:  Adenocarcinoma
Histologic Grade: G1: Well differentiated
Tumor Size: Greatest dimension: 1.0 cm
Additional dimension: 0.5 cm
Visceral Pleura Invasion: Present
Tumor Extension: Not applicable
All Margins Uninvolved By Invasive Carcinoma:
Distance of invasive carcinoma from closest margin: 10 mm
Margin closest to invasive carcinoma:: Resection margin
Bronchial Margin: Bronchial margin-Not applicable
Vascular Margin: Not applicable
Parenchymal Margin: Uninvolved by invasive carcinoma
Parietal Pleural Margin: Not applicable
Chest Wall Margin: Not applicable
Other Attached Tissue Margin: Not applicable
Treatment Effect: Not applicable
Lymph-Vascular Invasion: Not identified
TNM Descriptors:
m (multiple primary tumors)
Primary Tumor (pT):
pT4: Tumor of any size that invades any of the following:
mediastinum, heart, great vessels, trachea, recurrent laryngeal
nerve, esophagus, vertebral body, carina; or Tumor of any size with
separate tumor nodule(s) in a different lobe of ipsilateral lung
Regional Lymph Nodes (pN):
pN0: No regional lymph node metastasis
Number of nodes examined: 9
Number of nodes involved: 0
Distant Metastasis (pM):
Not applicable
Additional Pathologic Findings: Atypical adenomatous hyperplasia
*Best TUMOR Block(s) If Further Studies Are Needed: A2,A3

--------------------------------------------------------

B. RIGHT UPPER LOBE LUNG, WEDGE RESECTION:
- INVASIVE MODERATELY DIFFERENTIATED ADENOCARCINOMA.
- SURGICAL MARGINS NEGATIVE FOR CARCINOMA (CLOSEST IS 2.0 CM FROM
RESECTION MARGIN).
- TUMOR SIZE: 1.0 CM IN GREATEST DIMENSION.
- 9 BENIGN LYMPH NODES (0/9) FROM PARTS C-F.
- PATHOLOGIC STAGE: mpT4 N0 (BECAUSE OF SEPARATE TUMOR NODULE IN A
DIFFERENT LOBE OF IPSILATERAL LUNG - PART A).

B. LUNG, SEGMENTAL RESECTION/LOBECTOMY - RIGHT UPPER LOBE WEDGE
RESECTION:
Specimen:
Lobe(s) of lung: Right upper lobe
Procedure: Wedge resection
Specimen Integrity: Intact
Specimen Laterality: Right
Tumor Site: Upper lobe
Tumor Focality: Separate tumor nodules in different lobes, sites: Right upper
lobe (above) and right middle lobe (part A)
Histologic Type: Adenocarcinoma
Histologic Grade: G2: Moderately differentiated
Tumor Size: Greatest dimension: 1.0 cm
Additional dimension: 0.7 cm
Visceral Pleura Invasion: Not identified
Tumor Extension: Not applicable
All Margins Uninvolved By Invasive Carcinoma:
Distance of invasive carcinoma from closest margin: 20 mm
Margin closest to invasive carcinoma:: Resection margin
Bronchial Margin: Bronchial margin-Not applicable
Vascular Margin: Not applicable
Parenchymal Margin: Uninvolved by invasive carcinoma
Parietal Pleural Margin: Not applicable
Chest Wall Margin: Not applicable
Other Attached Tissue Margin: Not applicable
Treatment Effect: Not applicable
Lymph-Vascular Invasion: Not identified
TNM Descriptors:
m (multiple primary tumors)
Primary Tumor (pT):
pT4: Tumor of any size that invades any of the following:
mediastinum, heart, great vessels, trachea, recurrent laryngeal
nerve, esophagus, vertebral body, carina; or Tumor of any size with
separate tumor nodule(s) in a different lobe of ipsilateral lung
Regional Lymph Nodes (pN):
pN0: No regional lymph node metastasis
Number of nodes examined: 9
Number of nodes involved: 0
Distant Metastasis (pM): Not applicable
*Best TUMOR Block(s) If Further Studies Are Needed:
B2,B3

C. LYMPH NODES, 4R, DISSECTION:
- 1 BENIGN LYMPH NODE (0/1).

D. LYMPH NODES, 2R, DISSECTION:
- 1 BENIGN LYMPH NODE (0/1).

E. LYMPH NODES, LEVEL 7, DISSECTION:
- 5 BENIGN LYMPH NODES (0/5).

F. LYMPH NODES, LEVEL 9, DISSECTION:
- 2 BENIGN LYMPH NODES (0/2).

G. RIGHT MIDDLE LOBE LUNG, WEDGE RESECTION #2:
- SMALL FOCI OF ATYPICAL ADENOMATOUS HYPERPLASIA.

IPR (A1-A3, B2, B3): JSH

ROBERT WILLIAM BRINSKO M.D.
** Report Electronically Signed by RWB **
Comment
In addition to the invasive carcinoma in part A (right middle
lobe), there is also a mucinous lepidic growth pattern component
(formerly mucinous bronchioloalveolar carcinoma).

In addition to the invasive carcinoma in part B (right upper lobe),
there is also a lepidic growth pattern component (formerly
bronchioloalveolar carcinoma).

dennycee
Posts: 836
Joined: Mar 2011

A) the margins were clear so nothing was left behind.  A tumor comprised of well differentiated cells is a low grade tumor.  As the tumor advances it becomes more distorted and resembles the primary tissue less and less.  So a well or moderately differentiated tumor is less aggressive.  

There was no evidence of metastatic disease in the lymph nodes or distant organs.  

You may want to ask one of the drs that monitor cancergrace.org th help translate into plain English.   

bonaya
Posts: 10
Joined: Aug 2014

Thank you for the explanation Dennycee.  I appreciate it and I will checkout cancergrace.org as well.

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