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Possible Lobectomy after radiation?


Minh

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Hello all,

I have lung cancer with a 1.6cm nodule on right lower lobe. Yesterday I was offered an option between lobectomy or SBRT. During my meeting with radiation oncologist, I asked “If I get radiation now can I get lobectomy later”. Oncologist avoided the question with another question “Why would you get lobectomy after radiation has killed all cancer cells?”. I asked what would you do if a recurrence nodule comes back on the same lobe? He said he will repeat radiation on the new recurrence nodule. I am not satisfied with this answer.

Could anyone here please help answer this question if I get radiation now can I get lobectomy later if recurrence comes back on the same lobe? why and why not?

Thank you,

 

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Hi, Minh, 

SBRT is generally done in lieu of surgery when a patient can't tolerate surgery. Surgery is really the gold standard for making sure the tumor is removed in its entirety.  So even though SBRT is very effective, unless there's some reason you can't/shouldn't have surgery (e.g., poor lung function), I'd go with the lobectomy. 

I don't know of any reason you COULDN'T get a lobectomy after SBRT, just haven't heard of its being done. Maybe there's a medical reason. Either way I'd want to go with my best shot out of the gate, and that would be a lobectomy.

Another advantage of the lobectomy is they can take a sample of lymph nodes at the same time, to see whether it has spread. Most lobectomies today are done via VATS (laparoscopic surgery). There are three tiny incisions on your back/side. You are usually in the hospital only 2-3 days and I was out with friends to a concert and dinner just a week or so after getting out of the hospital.

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Minh,

I don't know of a reason why you couldn't have a lobectomy after SBRT either. You could but that would likely be driven by a new tumor find in your right lower lobe. I tend to side with your oncologist. There is a very, very high probability that the 1.6cm nodule would be "fried" by the SBRT.

However, I note you are not reporting a type of lung cancer. Have you had a biopsy? if not, Lexie's suggestion offers an additional benefit: resected tumor cells can be biopsied to determine your type of lung cancer. 

Stay the course.

Tom

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I had a biopsy and it indicated I have lepidic predominant adenocarcinoma. I had two separate appointments with thoracic oncologist surgeon and radiation oncologist. I had meeting with the thoracic oncologist first and asked him the same question “can I get lobectomy after radiation?”. And his answer was typically surgeons DONOT want to operate on radiated lungs due to potential radiation damages scattered all over in the lungs which could negatively impact surgical benefit. But they may perform salvage surgery as last resort which can be challenging for surgeons. He said it also depends on how radiation is done and I should ask radiation oncologist. He was really engaged, patient and tried his best to answer all my random questions. And I really appreciated that! So I went and ask the radiation oncologist in the following meeting with the same question which he didn’t appear to want to explain. I guess he thinks I don’t have mental capacity to understand the medical complexity of cancer treatments. I was not able to ask some of questions on my list.

After reading some of the messages in this forum, from Lexie and additional googling, I told them couple hours ago I would like to have surgery instead of radiation if I am eligible. I did passed PFT test this morning. Also had a PET/CT scan done this morning and result should come out soon!

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Minh,

There’s always an opportunity to obtain an second opinion.  I’m not sure where you’re being treated but if it’s not a a major academic center with a NCI or CCC designation, it’s well worth your time to get another opinion.  
 

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Minh,

Well I had surgery after radiation, but this treatment was fractional general radiation (widely spaced across the tumor area). That form of radiation did hamper suture healing and I had two follow-up surgeries to address that problem.

I also had precision radiation (SBRT) to my left lung after recurrence. This type is very focused on the specific tumor and would be less likely to cause the type of radiation concern expressed by your surgeon.

But, you've got a suitable treatment plan in place and I do hope surgery goes well.

Stay the course.

Tom

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Thank you all for helping with my confusion!

Help!!! Now I am even more confused than before. I just received pet/ct scan report minutes ago. And it reported that

a) my supposed to be cancerous 1.6cm nodule has now shrunk to 1.3cm in 4 weeks.

b) nothing lit up in my body. Not even the supposed to be cancer nodule. 

c) there are two new 2.6cm nodules showed up that weren’t in the ct scan 4 weeks ago. And they are not lit up either.

The biopsy said the nodule is cancerous. And now pet/ct scan said nothing lit up. Could anyone please help explain this? What should I do now?

 

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Minh,

I assume your pathologist tissue examination resulted in your diagnosis of lung cancer. Sometimes, small nodules do not display uptake of radioactive iodine during a PET. 

Stay the course. 

Tom

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Just to add to what Tom said, the nodule didn't necessarily "shrink" in size. CTs take images of a "slice" of your anatomy at a time. Depending on the angle of the machine or your body, nodules may appear slightly different in size from one scan to another.  A biopsy is more reliable than a PET CT for diagnostic purposes. 

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I had a small, slow growing nodule that did not light up on the PET. It turned out to be adenocarcinoma. It's my understanding that these slow litlle cancers sometimes don't have enough metabolic activity to register on the PET.

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Another question I have is when I asked if they have done the molecular testing after completing the biopsy, they claimed that they don’t have enough sample. I don’t understand why they did not get enough sample! Isn’t it part of the process? And how could they miss the opportunity to definitively determine the mutant genes?

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Depending on the location of the nodules, it’s pretty common there isn’t enough tissue collected for biomarker testing.  There’s two types of tissue biopsies.  Needle and core.  Needle biopsies are most common and least invasive but there is a risk of inadequate sampling.  This happened to my mother during a lung biopsy.  The area of concern was so small the oncologist took a watch and wait approach.  The second biopsy also failed to obtain a tissue sample and it was the third biopsy 18 months later that we finally had an answer.   It’s a good news/bad news situation with slow growing adenocarcinomas.  
A liquid biopsy can be an alternative so you can ask about that.  My mother had those as well yet it was a similar problem, there wasn’t enough circulating tumor DNA to yield a result.  Eventually we did discover her endometrial cancer did have a mutation  so she was able to start targeted therapy.    
 

As frustrating as this is sometimes the process is watch, wait and reevaluate under the close supervision of an oncologist.  

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Thank you all for sharing your experiences and advices.

Learning about your experiences helps me feel like I made a right decision to go with surgery. They said the earliest available surgery date would be around first week of Nov.  And I don’t want to miss having Thanksgiving and Christmas with family because of recovery period of about 4 weeks at the minimum. Since my cancer is slow growing, should I delay to second week of January? Am I pushing my luck for potential metastasis? How much of the risk if I delay surgery?

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I don't know what having Thanksgiving and Christmas with family involves for you. If you are planning to travel or put together a holiday gathering for everybody, I'd say you probably wouldn't be up to it. But if you are just going to someone else's home and they do the major work, chances are you'd be fine. I was out to a concert and dinner with friends only a week or two after I got out of the hospital. And hospital stay for a VATS lobectomy is only 2-3 days, generally. 

The other thing is the further out you plan to have surgery, the less certainty there is about what the COVID situation will be--whether hospitals will be overcrowded, etc. 

Personally, I think I'd do it sooner rather than later, but it's something you should decide after discussing with your surgeon.

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Hi Lexie,

I typically host holiday celebrations. I guess I can skip them this year if I have to.

Did you have choices for VATS and lobectomy? The nurse told me it’s up to the surgeon. He can do VATS or full open and lobectomy or wedge. It all depends on what he sees when he is in there. You think I can specifically ask for VATS and lobectomy?

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Here's how it was explained by my surgeon. He starts off with VATS. If some emergency situation occurs during surgery (e.g., uncontrolled bleeding; some unexpected finding) then he would switch to an open procedure. IOW, it's all planned to be VATS, but  if the unexpected happens, he will do what he has to do. And he started off with a wedge and sent that out for examination to see if the nodule was cancerous--assuming it was, he would then remove the lobe. He explained to me that it's safest to remove the whole lobe if there is cancer--it's more likely to remove all of the cancer so it doesn't spread. Incidentally, there's also RATS--robotic assisted surgery. It's virtually identical to VATS, but they use a robot. My doc said which they do--VATS or RATS--was a matter of the surgeon's preference and the availability of the equipment. He said one of his colleagues loved using the robot, while he preferred hands-on. Everything I've read indicates one is as safe/effective as the other.

Since you already have a biopsy-confirmed cancer (I did not), I doubt the surgeon needs to do a wedge resection first. I think ultimately, based on everything I've read, a lobectomy is more likely to be effective at removing all the cancer than a wedge resection is.

I'm sure your family/friends will understand if you have to skip the host duties this year (another option to consider, if your guests are nearby and you're comfortable with the idea, would be to have others prepare the meal at your house and clean up after). And by Christmas you should have no difficulty hosting (though you might ask for help putting a 20-lb turkey in the oven). 

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My surgery experience  was similar to Lexie's. My surgery was planned to be VATS. My surgeon explained to me that if something unexpected occured he might have to switch to open surgery. It was completed as VATS, thankfully.

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Help again. Now I am more confused and scared!

Yesterday surgeon called me and discussed about pet/ct scan results from couple of days ago on Sep/29/2021. He told me I have an irregular 2.6 cm nodule in the lingula. What is the lingula? And an irregular opacity on the upper right lobe. He wanted me to have another biopsy to determine if these two are cancerous. What I don't understand is they had a ct scan on Aug/27th and none of these were in the reports. And they already done one biopsy on Aug/30th. Why didn't they biopsy everything then. Now after they did the pet scan, all kind of nodules showed up. Seems like they are going diagnose me to DEATH prior to any treatments. This is really upset me because now I have 3 nodules ranging from 1.3cm to 2.6cm and located in both left and right lungs. This automatically stage 3b right?

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I assume they didn't biopsy the new nodules back in August because they didn't know they were there--you said these just showed up on the PET-CT, right? After the biopsy was already done.

Staging depends on whether either of the new nodules is cancerous. If one in the other lung is, then you would be Stage IV and treated with radiation and/or chemo/immunotherapy, unless you have a targetable mutation.

The lingula is just a specific area of the left lung. Supposedly it resembles a tongue, which is why it's called that.

I'm sorry, Minh, I know how frustrating this must be. It's important, though, to find out whether those other nodules are cancerous, too. If they are, surgery would not do you any good, so they want to find out what they're dealing with before you get any surgery.

Did the doctor say how soon they could do the biopsy?

 

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Thanks Lexie for quick response! 

CT scan in August (30 days ago) said I only have one 1.6cm nodule on the right lower lobe (nothing else!). So they went in and did a biopsy (couple days after CT scan) and confirmed it is adenocarcinoma. Then they gave me the PET/CT scan couple days ago and then called me back and told me I have more new nodules showed up in PET/CT scan. And yes, these new nodules just showed up in PET/CT scan. They did not show up the the CT scan in August. And now they want me to do more biopsy and testings. 

They want to do more biopsy ASAP. But because I have some liquid in the left lung since my heart surgery in April, and I am on Warfarin because of mechanical heart valve, they want me to drain more fluid from left lung which will take at least 2 weeks because I have to be off Warfarin for 5 days. And then they want make sure the left lung fluid is not cancerous and lowered to acceptable level before they can do the biopsy on the lingula nodule and other nodule on the upper right lobe. If everything moves fast, I don't expect to get new biopsy get done in another 4 to 6 weeks. This is too long of a wait, don't you think! Cancer could be spreading everything by the time they done with the diagnosis phase!

So I could go from stage 1 (they told me 30 days ago) to stage 4 in a blink of an eye! With these many new nodules showed in the PET/CT scan, I should have a lot of symptoms now, right? I don't have any symptoms. When will I expect to have more symptoms?

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No, you wouldn't necessarily have any symptoms. If the nodules are not blocking any of your airways and aren't pressing on nerves or anything, they could continue to grow/spread for a while before you would have any symptoms. 

You can always seek another opinion, though it may not speed things up any. You could do that while proceeding with the recommended testing where you are now. A second opinion is often useful. Even if it results in the same recommendation, it is reassurance that your providers are on the right track.

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Minh,

Oh no! I wish things were different but nodules seem to make surprise appearances. 

I can't specifically address the complexity of your mechanical heart valve but believe a biopsy of the drained fluid is a best practice. Often fluid in cardiopulmonary effusions contains cancer cells and it is important to learn if yours does.

I have a history of "phantom" nodules that appear and disappear from scan to scan. The PET scan these days is, more often than not, a combination PET/CT. While the CT portion of the scan can show nodules, the resolution is not sufficient to be a diagnostic image. The PET portion of the scan differs from a CT in one important way. It measures the uptake of glucose by cells in the body factoring that metastatic cancer cells demand much more glucose than surrounding cells. You mentioned these new nodules are not "lit up." Can you recall the SUV or standard uptake value numbers cited in the PET/CT report for the new nodules? Anything greater than 4 can be indicative of metastatic cancer. Values between 3 and 4 can be suspicious finds that might be cancer but could be explained by other causes (inflammation). Values less than 3 are presumed not to be cancer.

I do note it is your surgeon who is suggesting further biopsies. Perhaps that indicates a desire to be very sure these new nodules are not metastatic before surgery. I wonder what your medical oncologist's opinion of your PET scan results would be.

As for symptoms, normally lung cancer is asymptomatic until late stage or metastatic involvement to bones that can cause pain. That is what makes it so dangerous. So new nodule discovery would not necessarily involve symptoms.

Stay the course.

Tom

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Hi Lexie and Tom,

Please look below at my chronological tests and results and give me your opinions of what you think of my situation. There is so much info. that I cannot digest fast enough. There is no mentioned of SUV numbers in PET/CT scan. My thoracic surgeon is also an oncologist. Also please keep in mind that these tests are from MD Anderson, so I expect their standard is higher than average (I would hope!). Can a new nodule grow to 2.6cm in 4 weeks without causing any symptoms?

08/25/2021 – Got CT scan done for suspicious of right lower lobe 1.6cm ground glass nodule and result as shown below.

08/27/2021 – Got left lung fluid drained (850ml) and fluid tested negative for cancer, fungus, and infections.

09/03/2021 – Got right lower lobe lung biopsy done. Pathology result from biopsy confirmed 1.6cm groundglass nodule is lung adenocarcinoma and most like lepidic predominant adenocarcinoma.

09/27/2021 – Met with both thoracic oncologist surgeon and radiation oncologist. I was offered to select surgery or radiation. I elected for surgery option.

09/28/2021 – Got PET/CT scan done for suspicion of right lower lobe 1.6cm ground glass nodule and result as shown below.

10/01/2021 – Received a phone called from thoracic oncologist surgeon. He said PET/CT scan found a new nodule of 2.6cm in the lingula.  He wanted me to drain more fluid from left lung and then have a biopsy for this new nodule. Keep in mind previous CT scan on 08/25/2021 did not show 2.6cm nodule. Can a new nodule grow that fast to 2.6cm in 4 weeks?

===================

CT scan 08/25/2021 result

Findings:

There is a stable in size 1.6 cm groundglass nodule in the right lower lobe on image 117. New moderate in size left pleural effusion. There are atelectatic changes involving the lingula and left lower lobe. No mediastinal, hilar or axillary adenopathy. Changes after CABG. A small pericardial effusion is identified. No mediastinal hilar or axillary adenopathy. Sternotomy wires are in place. The adrenal glands are within normal limits. There is a cyst in the left kidney. No hydronephrosis.There are degenerative changes of the spine. There a new fracture involving the left third rib, that is likely related to a previous surgical procedure. Small radiolucency at T1 and proximal right second rib are stable and consistent with benign etiology.

======================

PET/CT scan 09/28/2021 result

Impression

There is a 1.3 cm right lower lobe nodule presumably the patient's primary lung cancer and does not show increased metabolic activity over background.

A left upper lobe 2.6 cm nodule does not show increased metabolic activity may be due to scarring. Follow to exclude an underlying neoplastic lesion can be performed.

Stable moderate-sized left pleural effusion. Small pericardial effusion.

Narrative

FULL RESULT:

Examination: FDG PET/CT, 9/28/2021 8:01 AM

Clinical History: Non-small cell lung cancer. Adenocarcinoma the right lower lobe. Clarify initial treatment strategy. Right lower lobe biopsy, suspicious for adenocarcinoma, 9/3/2021

Indication: Non-small cell lung cancer. Adenocarcinoma the right lower lobe. Clarify initial treatment strategy.

Comparison: CT scan 8/25/2021.

Technique: F-18 fluorodeoxyglucose (FDG) 10.9 mCi was administered intravenously via left antecubital fossa. To allow for distribution and uptake of radiotracer, the patient was asked to rest quietly for approximately 60-90 minutes. PET/CT imaging was performed from the top of the skull through the thighs. Serum blood glucose at the time of the injection was 89 mg/dL. CT scanning was done for attenuation correction, image registration, and diagnosis with scan parameters optimized to minimize radiation exposure to the patient. SUV measurements are reported as maximum SUV based on body weight unless otherwise specified. Intravenous contrast media was administered.

Findings:
Head and Neck: No enlarged nodes in the head and neck region showing increased FDG activity to suggest nodal metastatic disease. The thyroid gland appears unremarkable.

Chest: Central airways are patent.

An irregular nodule in the lingula, image 152, 2.6 cm in diameter persists and does not show increased metabolic activity over background and may be due to an area of scarring or atelectasis. Follow-up can be performed.

Linear band opacities in left lung likely areas of atelectasis or scarring.

1.3 cm right lower lobe nodule presumably the patient's primary lung cancer, image 167, does not show increased metabolic activity over background.

Irregular opacity in the right upper lobe persists probably due to scarring, image 118 and follow-up is recommended.

Moderate-sized stable left pleural effusion. No right pleural effusion.

No enlarged hilar, mediastinal, or axillary nodes.

Moderate coronary artery calcification. Surgical changes compatible with aortic valve replacement and coronary artery bypass graft. Small pericardial effusion. Cardiac chambers are not enlarged.

Abdomen and Pelvis: No focal liver lesions. The spleen is not enlarged. No focal pancreatic lesions.

No adrenal gland nodularity. There is a cyst involving the upper pole of the left kidney, 4.4 cm in diameter. Renal activity is physiologic.

Musculoskeletal: No sign of bony metastatic disease. Sternotomy.

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The report says the "new" nodules do not have uptake in excess of the background--IOW, there is nothing in the FDG to suggest they are cancerous. In fact, the report suggests these "new" nodules might be due to scarring or atelectasis (lung collapse).

It sounds to me as if the surgeon is, as Tom suggested, wanting to be absolutely sure those other nodules are benign--especially given that your confirmed cancerous nodule also shows no uptake. 

I don't think any of us here are any better equipped to answer your questions than your doctors are.  I don't know what else to suggest other than, as I said, a second opinion if you aren't satisfied with the answers your doctors are giving you. Have you asked them the same questions you're asking us? If what they are telling you isn't making sense, tell them you don't understand and ask them to explain it again. Sometimes the answer is simply, "We don't know." There are limits to what the testing can tell them (and you).

 

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Minh,

I agree with Lexie. I note "There are atelectatic changes involving the lingula and left lower lobe." reported on your 8/25 CT scan and both of these findings are also called out on your PET/CT but are now defined as nodules. Moreover, none of your nodules are showing FDG uptake (metabolic activity) in the PET/CT. This is not unusual. Small nodules do not reliably show uptake on PET scans.

As Lexie said, I really think you need to get answers to questions you are posing to us from your doctors. Does your surgeon have a patient portal where you can pose your questions?

I don't know if nodules can grow to a given size in a given time period. I think the factors governing nodule growth are complicated. I'm sorry I couldn't be more helpful.

Stay the course.

Tom

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