UPDATE NODULE CHECK (PART 2)

[Dazy]

Whew!! Yes, that is a BIG difference - the difference 'tween a mass, and a nodule I believe (3.0 - 3.5 cm is the threshold, I think) Well, glad that it is only mm's, but do keep an eye on it.

Good info, Carol. I've read that same article. There is an updated version (2003)at the following site: http://www.postgradmed.com/issues/2003/08_03/sullivan.htm

The site below will assist any math challenged nodule watchers in determining volume doubling times (VDT's) if you have had interval growth on CT, and also has excellent info on variants/limitations in CT reading, and interpretation, etc.

http://www.chestx-ray.com/SPN/DoublingTime.html

The article below has good info regarding types of LC and their average VDT's, however, it fails to mention BAC, which has a significantly longer doubling time than the average adenocarcinoma VDT, often longer than the 450-500 days considered for suspicious for malignancy. It also has good information regarding other indicators for malignant versus benign nodules. It is a bit long, but I posted it here for those NW's who are unable to pull it up online:

http://www.indianchestsociety.org/

Solitary Pulmonary Nodule

Solitary pulmonary nodule (SPN) represents a single discrete intrapulmonary nodule(Fig 1) with any contour (smooth, lobulated, umbilicated), with or without calcification, cavitation, satellite lesions, and symptoms.

Differential Diagnosis:

Infections:

a. Mycobacterial -- Tuberculoma

b. Bacterial: Lung abscess, Round pneumonia.

c. Parasitic -- Echinococcus granulosus

d. Fungal - Histoplasmosis, Coccidiodomycosis

Tumors:

a. Malignant -- Bronchogenic carcinoma, metastatic nodule.

b. Benign -- Bronchial adenoma.

Developmental:

a. Bronchogenic cyst.

b. Sequestration.

Traumatic:

a. Hematoma

b. Traumatic lung cyst

Immunological disorders:

a. Rheumatoid nodule

b. Wegener's granulomatosis

Vascular: Pulmonary arteriovenous malformations (PAVM).

Pleural disorders: Round atelectasis.

Approach to diagnosis:

At the outset it is important to confirm that the nodule is indeed intrapulmonary and not a chest wall lesion. Hence a lateral view is mandatory to confirm this and also to exactly localize the nodule.

Also keep in mind that 40-50% of all solitary pulmonary nodules are malignant, hence the probability of the nodule being malignant should be assessed.

To ascertain the cause of the SPN, the following characteristics on a chest radiograph or CT scan should be taken into account.

Margins: Lobulated margins, umbilication, notching, strand like pseudopodal projections, "sunburst" appearance all indicate malignancy. Well defined margins indicate a benign nodule.

Patterns of calcification on chest radiograph or CT densitometry: Central, popcorn like, laminated or diffuse patterns all suggest benign nodules, while an eccentric or a stippled pattern suggest malignancy.

Satellite lesions: Tuberculomas.

Rib erosions suggest a malignant nodule.

Comet tail or vacuum cleaner effect due to crowded vessels, in round atelectasis.

In addition it is important to review the older radiographs and calculate the doubling time.

Doubling time (DT) is the interval of time required for the nodule to double in volume. It is calculated as the time required to increase the diameter 1.28 times or 28% increase in the diameter. DT can be calculated if two radiographs showing the nodule are available and there is sufficient interval of time between them to allow detectable growth.

If prior chest films show no tumor, an upper limit doubling time (ULDT) can be calculated by assuming that the nodule was present and was just 8millimetres in diameter (which is the lower margin of detectability) in the most recent negative film.

The ULDT detected in this way is the maximum possible for this nodule. The actual DT may be much lower.

DT helps in assessing the likelihood of malignancy as

DT< 20-30 days -- Acute infectious process

DT> 450 days -- Benign nodules

DT= 60-80 days -- Squamous cell carcinoma, large cell carcinoma.

DT= 120 days -- Adenocarcinoma

DT=30 days -- Small cell carcinoma.

Assessment of probability of carcinoma includes evaluation of the following factors:

Age: More than 35 years of age increases chances of the nodule being malignant.

Smoking either current or past is a risk factor.

Calcification pattern as mentioned before.

Calculation of the doubling time, as a DT of between 1 to 18 months suggests malignancy.

After assessing the probability of carcinoma, a decision may be taken to perform thoracotomy and excision of the nodule or Image assisted Fine Needle Aspiration Biopsy. Alternatively if the probability of carcinoma is very low the patient can be kept under observation and radiographs can be taken at frequent intervals to assess for an increase in size.

*****************************************************

Note: I noticed the article above does not mention the complete lack of calcification when discussing calcification patterns. Complete lack of calcification is usually seen more in malignancies, but can also be the case with some granulomas...

Hope this will help some of you NW Clubbers out there!

As for me...I go tomorrow a.m. for my 3 month CT... Wish me luck!

Prayers for HOPE & Health to All!

~Stacey

[Kasey]

Thank you Miss Dazy !!!!!

Your research is much appreciated here.

A BIG GOOD LUCK to you, Stacey on your CT scan. May those nodules be just sitting there the same as always OR even smaller, ya know?????

Prayers many times over for good results.

Love,

Kasey

[Connie B]

Hey Stacey,

GOOD INFORMATION, and thanks for sharing it with us.

GOOD LUCK tomorrow on your CT Scan. Drop a line and let us know how it goes. Sending Positive Vibes for GOOD NEWS!!

[Dazy]

Thanks so much for the well wishes! Kasey, when you were saying you hoped they were "sitting there, doing nothing" I had this bizarre image of a three-ring-circus going on in my lungs - ya know, 2 nodules on the highwire, one getting shot out of a cannon, you get the picture...

My CT results are in - it appears I've grown yet another little booger in the L lung. It appears to be subpleural, and in the upper lobe. But, it is teeny (<5mm). The 1.1cm nodule is reported to be relatively unchanged for a year. So, whatever this is, it is slow growing. I just wish I knew why these new nodules are slowly appearing. The dr.s keep telling me that they will no longer test for VF, and we've run out of differential dx's as far as I know.

Maybe I'm panicing, again, but I really wish they could get a piece of the larger one in the L, at least. We've done "wait & watch" for a year, and all I'm seeing is more of them slowly developing. I guess if the SOB/coughing, etc. weren't progressing as well, I might not be so concerned - but at my age, to run out of breath doing simple household chores is unnerving ('tho I always joke with my doc that ANYone would be out of breath chasing my three year old around)...

I don't know...I've had many family members w/ adeno, or adeno/BAC - this is how they say it starts. I know Fay could relate to the need to be a bulldog with some docs. But I get so tired of having them brush me off when I'm looking for answers. Unless you arrive armed with journals of research, they don't give you the time of day. Simply scratch their heads, and say "hmmmm....let's watch more..."

Alright...that is my rant of the day. If anyone out there (especially those with BAC) have any suggestions, they would be so appreciated. The slow growing, indolent nature of BAC tumors can often leave them overlooked by today's Nodule Observation Protocol (so to speak )because their doubling time can fall outside of the standard 2 year watch. (Again, I'm reminded of Fay A. and the very delayed dx of her first tumor after an extended period of watching)

I will see my doc on Wednesday - guess I'll know a little more then.

Thanks for listening & caring!!!

[carolhg]

I know that non cancerous nodules can light up on a PET scan-mine did. I have been told that if a nodule is non cancerous that it does not become cancerous. My question is when the doctor does not know and they are doing a watch and wait procedure to see if the nodule grows. If it is cancer can it spread or mestastisize while it is growing before the doctor finds out it is cancer?

[Guest Narda99]

Do only malignant nodules light up on the scan? And how large do they have to be before they can biopsied?

[Connie B]

That I know of, they do NOT biopsy mm nodules. They are too toooooo small. And trust me, YOU DON'T WANT TO GO THROUGH A BIOPSY. It's not fun!

As far as what lights up on a scan. Are you talking a PET scan? Well, it doesn't matter. The anwser to your question is: Other things can light up on a PET scan and they DON'T HAVE TO BE MALIGNANT or CANCER. There are things they call hot spots that can and DO light up a PET scan. Again these can be infections, or scar tissue.

Please keep in mind there is NO Scan PET, CT, Etc., that is 100% when it comes to being dx.d. They are the best tool we have at this time, but they are NOT 100%.

[Guest Narda99]

Thanks, Connie, you are so helpful. My nodules are 2mm and 2.3mm, so perhaps they are just going to watch them, if they are too small to biopsy. Will know in a week or so what the doctor will do. The waiting is horrible! My granuloma is 6mm. Wonder if they will do anything with that?

[luvmydog2]

I saw my pulmonary doctor for my nodule. He felt, by looking at films, that it was nothing. He did a bronscopy to be sure. He took some culters while he was in there. He told my wife he did not see anything but I see him in 2 weeks to get results of the cultures etc. Don't know if he actually touched the nodule or what. Perhaps since a biopsy is not possible then maybe a bronscopy is way to go.

[Connie B]

Bruce, I was told there is no way to biopsy a (mm) nodule, and that included with a bronscopy.

I was told that 3 years ago when they were going to remove my nodule while I was having my heart surgery. They were going to do a double whammy. Needless to say, I never got my nodule removed, but the surgeon along with 2 other surgeons said they FELT my 6mm nodule and they were very sure it didn't feel like a cancerous nodule. They all said they could tell by the texture of it that it wasn't cancer. I had a lot of hands in my chest that day!

I have a small area of emphysema in my lung and during that surgery one of the doc's brushed against the emphysema and they had to close me so I wouldn't bleed to death. So they never removed my nodule or the tumor in my heart that time.

I went back 10 weeks later and had the tumor in my heart removed but they left the nodule alone. We have watched it for well over 3 years and now they say it's Scar Tissue.

I also just went through all this heart stuff again 7 weeks ago at Mayo Clinic, and for the lark of it, I asked what they thought of my nodule after they did ton's of tests on me. The surgeon said the nodule was nothing to worry about. He looked at my CT scans and he felt it was scar tissue also. He said it was a nodule between 4mm to 6mm in size.

I ask questions when ever I can, to who ever I can, and so far all the doc's that I have talked to regarding nodules say they are nothing to panic about but something in the case of a lung cancer patient that should be watched closely. But for the most part they do watch nodules in those that are dx.d with them for a period of time.

I'll be interested in hearing what your doc has to say about them. More info is ALWAYS BETTER!

Hell, we're going to be nodule doctor's before long!

[Dazy]

For carolhg:

Nodules that are being observed can potentially metastasize during the observation period IF they turn out to be cancerous. The article below comes from a study out of Duke Univ. regarding tumor size and metastatic potential.

http://dukemednews.duke.edu/news/article.php?id=5149

DURHAM, N.C. – A fundamental assumption of lung cancer screening is that small tumors are less likely to have metastasized -- spreading to other organs -- than large tumors. But a new study by researchers with Duke's Department of Radiology and the Comprehensive Cancer Center, shows that size does not necessarily indicate the severity of cancer.

The authors of the study -- based on the stage distribution of cancer in 620 men and women with primary non-small cell lung carcinomas -- caution physicians who have begun to use computed tomography (CT) scans for screening and early lung cancer detection not to assume that small tumors represent early-stage cancers. They advise physicians against the widespread use of CT scans for screening and early detection of lung cancer until further data become available.

"Our study found no statistically significant relationship between the size of small tumors and the stage of cancer," said Dr. Edward F. Patz Jr., professor of radiology at the Duke University Medical Center and senior author of the article appearing in the Dec. 15, 2001, issue of the journal Cancer.

The study focused on patients with tumors that measured from less than one centimeter to three centimeters in size. The researchers concluded from their data relating stage to tumor size that even the smaller tumors could represent an advanced stage of the cancer. They said that their study suggests that the size of tumors less than or equal to three centimeters plays only a limited role in the biology of lung cancer. Patients with a primary lesion that is three centimeters or smaller in diameter will have an approximately 80 to 85 percent chance of having stage I lung cancer and an approximately 10 percent chance of having stage IV lung cancer, regardless of tumor size at detection. Lung cancer stages range from stage I, in which the cancer has not metastasized, to stage IV, in which the cancer has spread.

In recent years, low-dose "spiral" CT scans -- in which an imaging machine rotates rapidly around the body taking more than 100 images in sequence -- have been proposed as a potential method to screen for lung cancer. Proponents of CT scans have argued that these scans could detect smaller lesions not visible with chest X-rays, that these smaller tumors represented an early stage of cancer and detecting them would lead to reduced lung cancer mortality, the Duke researchers said.

"Our study emphasizes the fact that size alone does not appear to determine a cancer's metastatic potential and ultimate stage distribution," the researchers wrote. "While it is reassuring to believe there is a size threshold below which there is minimal or reduced risk of a tumor having metastasized, and thus that lung cancer screening can reduce mortality, there is no conclusive data to support this notion. Early detection with imaging alone may not be enough to impact the natural course of lung cancer."

The researchers also wrote that while larger tumors presumably have more time to grow and metastasize, it has become increasing clear that size alone may not predict the biological behavior of lung cancer. Other studies have reported improved survival in patients with tumors less than three centimeters as compared to patients with tumors greater than three centimeters, said the researchers. However, in contrast, one recent study found no correlation between the size of stage I lung cancers and survival.

The Duke researchers concluded by saying, "At this time there is no clinical or experimental evidence to confirm that the critical time for metastases is when lesions measure five to 10 millimeters, which is generally the targeted size of CT screening, as opposed to one to three centimeters, when a lesion is visible on a chest X-ray. How size truly relates to metastatic potential and the natural history of the disease remains to be seen."

The study's co-authors were Dr. Philip Goodman, Dr. Laura E. Heyneman and James E. Herndon.

Hope that helps... I have a TON of nodule info lying around. Let me know if ya need more. (I should almost qualify for a doctorate degree by now )

Oh, and a benign nodule cannot turn cancerous, BUT, adenocarcinomas have been referred to as "scar carcinomas" because of a tendency to sometimes engulf a granuloma, scar, etc. I believe that is what accounts for the occurrence of "eccentric" calcification patterns in some nodules/tumors. I'll see what I have on that, as well.

Yours in watch

~ Stacey

[carolhg]

Thank you so very much for the info Stacey. it certainly does answer my question.

[Connie B]

Great Information Stacey! I have heard of people that have a tumor the size of a football and yet he cancer had NOT spread anywhere else, it was totally contained in/on the lung.

This cancer stuff is a mystery with little rhyme nor reason to how or why it does what it does.

[karen335]

Thanks Stacey for sharing...

Karen

I love people who research and are knowledgable....

[luvmydog2]

I posted this in the GENERAL Forum and Connie reminded me to post in this thread. Thanks Connie. Since I was not feeling well today, I was not thinking straight. Perhaps the outcome of my nodule will ease the fears of the "unknown" and help someone else. If it does then that is what my purpose is for posting.

Some of you may remember me talking about a nodule on my CT a few weeks back. Oncologist told me it could be anything from scar tissue to an infection.

Went to pulmonary doctor on Wednesday of last week for a broncoscopy. Thursday I started chilling bad. Temp was 100.5. Talked to Pulmonary doctor on Friday... my doctor was not in so talk with one on call. He said probably flu since I had no other symptons but if I needed to he would meet me at ER. Still toughed it out and decided to go to ER on Monday. Felt this was faster then getting an appt and such. By now my temp was 102.

ER doctor determined I had pneumonia. Also stuck that thing up my nose to check for flu. Believe that to be the worst test since dx. Anyway I am home with an antibodic plus the IV antibodic at ER. Never was one to run to doctor but I think from now on if temp reaches 100.5 I will go. Temp is down to around 99 today but still miserable.

My question to each of you is this... How do we keep from getting the flu or pneumonia besides staying indoors and hybernating for the winter. I don't go out much except to mailbox and occasional trip to store etc. I have had flu shot and pneumonia shot. How do the rest of you avoid this situation?

[Connie B]

I asked my Pulmonogist about Calcified nodules and non-calcified nodules and here is what he replied to me.

A calcified nodule almost always implies a benign process, usually it represents an old fungal infection. A non-calcified nodule is a non specific finding and could be benign or malignant but requires further evaluation.

[carolhg]

Are nodules normal? I mean do people get nodules but never get lung cancer?

[Connie B]

You Got It! In this thread we have discussed nodules right down to the nitty gritty. Great information has been shared by many. When a person is informed that they have a Nodule, of (mm) size the doctor isn't telling you that you have lung cancer, but he's just telling you that you have a nodule of sort. Nothing more then that.

Again, Nodules can be INFECTIONS, SCAR TISSUE, VALLEY FEVER, or just NODULES THAT DO OR BECOME NOTHING! MOST nodules are NOT cancer related.

The studies that are going on at this time, indicate CT scans tend to detect nodules when looking for an early detection method for lung cancer. HOWEVER, most of these nodules are scar tissue from a person that may have had pnemonia, or bronchitis, etc.... or they are infections or fungus. And these nodules can sit there for years and years and years and never ever become anything.

Lung Cancer patients need to be concerned about nodules, more so then a person that has never had cancer.

When a person has been told they have a nodule, the doctor's will suggest keeping an eye on it via CT scan's for a year or so,(every 4 or 6 months) depending on the persons history.

Are nodules normal? I mean do people get nodules but never get lung cancer?

[Connie B]

I just want to share again, that I have a 6mm nodule. I have had this 6mm nodule for going on 4 years come April of this year. This nodule has done nothing but sit there. They are very sure at this time that this nodule is Scar tissue and nothing more.

I also have a friend in Iowa who is a soon to be 8 year LC Survivor and she has nodules. 5-1/2 years ago they noticed 5 nodules in her lung. They have watched these nodules for 5-1/2 years. She now has only 2 nodules left that are in the (mm) range and they have not done anything in all that time. Three of them just disappeared. Poof Gone! She did chemo only 7-1/2 years ago and has been cancer free ever sence.

The doctor's told her they feel these last two nodules are scar tissue. She is watched via CT scan on a yearly basis.

Just thought I would share that with you.

[carolhg]

Thank you so much Connie. I guess nodules can be like fibroid tumors. I have had those for years. My doctor said if they don't grow or cause you pain they are no problem. I am going to think of nodules the same way.

[snow]

All the info iam getting here is great,going to see doc on March 13 for 6mm nodule,I am not a smoker..and not having syptoms so I guess that is all in my favor...but as we all nknow lc can get a nonsmoker too. I am a very nervous person so this wait and watch thing is REALLY hard for me,my hubby has 3 nodules and taking it in stride!!! Wish I was more like him LOL love DEb

[Guest Narda99]

I have a couple of questions. Is it possible to biopsy a 2mm nodule with any accurate results? Also, do they biopsy a granuloma? I have two 2mm nodules in the right lower lung, along with one 6mm ground-glass granuloma in the same area. These were found when I had a particularly bad case of pneumonia in January. I am seeing the lung doctor tomorrow and just wondering (or guessing) what the next step will be. I have read that it is impossible to get an accurate diagnosis on nodules smaller than 8mm and that the procedure is to follow up with 3-6 month CT scans. Does this sound correct?

[Connie B]

I think you need to talk to your doctor about your nodules. I have a feeling he is going to tell you they are pneumonia related. But, you'll find that out when you talk to him. Please take some time and read over all the posts regarding Nodules. Your answers I'm sure are in one of those posts.

Also, you might want to go into the search area at the top of the page and type in NODULE. You'll get all the posts that make mention of nodules. All that your asking about nodules has been talked about in length.

I have a couple of questions. Is it possible to biopsy a 2mm nodule with any accurate results? Also, do they biopsy a granuloma? I have two 2mm nodules in the right lower lung, along with one 6mm ground-glass granuloma in the same area. These were found when I had a particularly bad case of pneumonia in January. I am seeing the lung doctor tomorrow and just wondering (or guessing) what the next step will be. I have read that it is impossible to get an accurate diagnosis on nodules smaller than 8mm and that the procedure is to follow up with 3-6 month CT scans. Does this sound correct?

[Guest Narda99]

Connie, thanks for the info. I did see my lung doctor today (first time.) I was thoroughly impressed with her. A very kind, thoughtful (and beautiful) young lady. She spent one hour with me going over all my x-rays and CT scan in great detail. Everything was carefully explained to me in terms I could understand. I was made to feel very comfortable with her and felt she was very competent. Her suggestion is to follow up with 3 month scans (next one at the end of April) and she feels that nothing stands out as being alarming to her. I must say she was one of the nicest and most thorough doctors I have come across and I have every confidence in her. Bless you all!

[teresasuesan]

Hello Everyone,

I came in new last week. My mind is starting to dwell,( the waiting ) and I'm thinking that I need some options. Don't we all?

When a nodule has grown, what else could it be? I've researched the "valley fever" thing, and it just doesn't seem to fit.

Thanks,

Teresa