a question or two about diagnosing cancer

[tgif i guess]

is a biopsy of your lungs the only way to diagnose lung cancer?

i never had a biopsy of my lungs.  but i did have a surgeon go in under my arm pit and snag a lymph node in my chest.  that was sent to pathology.

i had 2 different genetics tests done but do not have a copy of the results

i have had no radiation or surgeries, just the chemo and immuno

from my oncologist's notes

Principal Dx
• Non-small cell lung cancer (disorder) (Lymph Node Involvement: Cervical; Lymph Node Involvement: Axillary; Lymph Node Involvement: Hilar; Lymph Node
Involvement: Pectoral; Lymph Node Involvement: Mediastinal; Metastatic Sites: Bone; Metastatic Sites: Spinal cord;
ICD-10:C34.12 ;Malignant neoplasm of upper lobe, left bronchus or lung )

Diagnosis date was about September of 2022

history

CT Chest with contrast- Stable partially calcified mediastinal and holar adenopathy which could be due to prior granulomatous
exposure. Irregular parenchymal density in the left apical region which appears minimally thicker than on the previous study. PET
recommended

found an ENT that ordered a pet scan

Extensive mediastinal and left hilar lymphadenopathy is redemonstrated. The adenopathy is FDG avid. In the superior mediastinum the nodes measure up to 5.9 SUV. Right paratracheal nodes measure up to 8.5 SUV. At the aorto pulmonary window than lymph nodes measure up to 6.3 SUV. At the left hilum maximum SUV of 6.1 is recorded and in the subcarinal nodes maximum 7.9 SUV is demonstrated. Left subpectoral and left axillary lymphadenopathy is also demonstrated and is FDG avid. The largest node at the left axilla measures 2.1 cm with maximum 7.4 SUV. The tiny 1 cm spicular focus in the left upper lobe demonstrates intermediate FDG activity with maximum 2.2 SUV. At the L4 body there is a focal area of intense activity in the right pedicle measuring 7.1 SUV suspicious for metastatic lesion.

IMPRESSION:

1. Extensive mediastinal and left hilar FDG avid lymphadenopathy most concerning for lymphoma or metastatic disease. Left subpectoral and axillary FDG avid adenopathy are also demonstrated. The largest node is at the left axilla measuring 2.1 cm.

2. 1 cm spicular lesion in the left upper lobe with intermediate FDG activity may be inflammatory or neoplastic.

3. Focal FDG avid lesion in the right pedicle of L4 concerning for metastatic lesion.

chemo (carbo and alimta) and keytruda for 6-8 months - then carbo discontinued

latest pet scan (but they have all been the same for about a year, when carbo was discontinued)

Brain: Visualized brain has normal physiologic uptake.

Pharynx: No abnormal uptake.

Larynx: No abnormal uptake. Stable left vocal cord paralysis.

Lungs, pleura and trachea: No abnormal uptake. No nodules or masses. No pleural effusion.

Heart: Normal physiologic uptake. There is no cardiomegaly. There is no pericardial effusion. No coronary artery calcification is visualized.

Mediastinal space: No abnormal uptake.

Liver: No abnormal uptake. Stable simple cysts measuring up to 1.5 cm.

Gallbladder and biliary ducts: No abnormal uptake.

Pancreas: No abnormal uptake.

Spleen: No abnormal uptake. No splenomegaly.

Adrenal glands: No abnormal uptake. No nodules.

Kidneys and ureters: Normal physiologic uptake. No hydronephrosis.

Stomach and bowel: No abnormal uptake. Mild diverticulosis of the sigmoid colon.

Vasculature: No abnormal uptake.

Lymph nodes: No abnormal uptake. No lymphadenopathy in the head, neck, chest, abdomen, pelvis, and extremities.

Skeleton: No abnormal uptake in the visualized axial and appendicular skeleton.

Soft tissues: No abnormal uptake in the visualized head, neck, chest, abdomen, pelvis, and extremities.

IMPRESSION:

Stable exam with no abnormal radiotracer uptake.

my oncologist used the remission word when the pet scans cleared up.  still doing the alimta and keytruda

 

[LouT]

So you’re saying that treatment was instituted based on the PET results.  Perhaps when they did the chest they took a sample.  
Biopsy is normally considered the gold standard in concluding whether tissue is malignant or not.  They can do it a number of ways depending on the position of the growth, patient’s condition, and the history.  In my case they were going to do a “CT-Guided Biopsy” where a CT scanner helps them to locate the correct place for the needle to enter and obtain the sample.  Some have been done via the esophagus, and others using a blood biopsy.  In my case the CT-Guided one wouldn’t work because of the size and placement of my nodule.  Instead the surgeon decided to do a resection, test the tissue, and remove the lobe if it was malignant.  It was and I had my lobectomy.
At the end of the day, regardless of the method the biopsy is the “final word” on malignancy.  If/when you have one done please insist they also test the tissue for any biomarkers.  That information can be important in deciding the mode of treatment either initially or in the case of a recurrence.

Lou

[edivebuddy]

No a biopsy of the lung is not necessary.  The lymph node they retrieved was sufficient.  If it came back clean it would not have been sufficient because the cancer may not have spread to the lymph node.  If it came back positive, unless there was some huge clerical error you have cancer.

They should be able to tell where the cancer came from no matter where they get the tissue.  First by looking at the cell and it's properties.  Different types of cells have difficulty features.

Then they will do immunohistochemical staining.  It takes immune cells that attach to specific proteins expressed in different types of cancer. These are the colorful pictures you see that look like Paisley.  There are many different kinds and even different lung cancers will stain differently.  The biggest of these is probably  TTF1 , Thyroid Transcription Factor 1. It's highly expressed in lung cancers.  Napsin A is another man one. Small cell, large cell, squamous cell and adenocarcinoma all will stain differently.  Taken together with your other medical information is how they will discuss you with lung cancer .  There are times when lung cancer is diagnosed without any lung tumors.  It still lung cancer just classified as cancer of unknowns primary or CUP.

You will have a pathology report for the biopsy of your lymph node. It will show how they determined it was lung cancer and it's subtype.

 

 

 

[Tom Galli]

Agree. A biopsy of a lymph node is sufficient to yield a lung cancer diagnosis.

To clarify Lou's intent, a tissue biopsy, obtained in any number of ways and places, is required to produce a lung cancer diagnosis. It is unusual to have a lung cancer diagnosis without a primary lung tumor but it happens.

Best information is your oncologist using the word "remission" in your case.

Stay the course.

Tom

[tgif i guess]

thanks for the replies. i was curious about that since my diagnosis.  

the first surgeon i talked to said he could not get to the area.  the second surgeon said he'd try.  from his operative report

An axillary incision was made.  I dissected into the deep axilla and there was a hard, firm, matted node deep in the axilla.  I dissected down to that and resected the lymph node and used a 3-0 Vicryl pop-off suture to secure the vascular inflow to lymph node.  The node was sent fresh for analysis and the pathology department was made aware of our concerns.

from the pathology report

Final Diagnosis
MICROSCOPIC EXAMINATION AND DIAGNOSIS:
LEFT AXILLARY LYMPH NODE, EXCISIONAL BIOPSY:

 - METASTATIC CARCINOMA MOST CONSISTENT WITH  PRIMARY LUNG
ADENOCARCINOMA.

 - TUMOR IS PRESENT IN LYMPHOVASCULAR CHANNEL LUMENS.

 - THE CANCER IS PRESENT AT THE EXTERIOR MARGIN OF THE SPECIMEN.

i should have paid closer attention

 

[edivebuddy]

I don't know  about that.

  I paid attention and I still missed/forget a ton.  So much is tossed at you it's hard to catch up especially when the most important decisions of your life are being made from  30 to 60 minute conversations.  You get your head wrapped around One idea or term,the doc has covered 3 more. 

As soon as you hear I'm sorry...., your mind is going to be hard pressed to move on from there. Add new appointments new terms, treatments, new side effects, and their terms It's a lot to learn and remember in such a short time.

 

 

[Karen_L]

I recently went back and re-read my genetic studies. It gave me great food for thought. That report was extensive, i.e., pages and pages, with information about different mutations and the potential treatment paths for each one. 

All of my test results are available to me online, through a program called MyChart. I download and keep copies of all tests and notes from doctor visits. 

The more information we have about our individual situations, the better able we are to advocate for ourselves. I hope you'll call your doctor's office and ask for access to all those results. 

Keep us posted.

[TJM]

Karen. Well said!