Lung met question

Raquel · 09-20-2011, 05:23 AM

Has anyone out there had lung surgery for a met?I have one that is 1.5cm and is not shrinking after 3 months of Tykerb and Herceptin. Any advice or experinces are appreciated!

Joan M · 09-21-2011, 09:07 AM

Raquel,

I had a lung wedge resection for a 9 mm tumor in April 2007. It recurred a year later, and I had an RFA in August 2008. Nothing in the lungs since then. Patients often get more time of N.E.D. from a wedge resection. After the procedure it may be best to continue on some chemo. I didn't do that, but wish I had, even though I've been N.E.D. since October 2008 (I had a brain tumor removed in October 2008 and then targeted radiation to the brain tumor bed in December of that year. All part of the same treatment.)

Joan

Raquel · 09-21-2011, 05:44 PM

Joan,
What is an RFA?Was the lung surgery painful?My tumor is deep in and they can't get to it to biopsy it.How did they know for sure what yours was,they told me that my tumor didn't light up til it was 1cm and they don't worry until it lights up.They knew about it a year before they told me it was even there.I go Monday for a second opinion at a larger center with another oncologist.He told my Dr that we need to get it out of there.I did not meet the criteria for the trial he wanted me to be in three months ago.

09-21-2011, 06:01 PM

how do they know what a tiny nodule is? I have 6 mm nodule on left lung. Dr wants to wait three months and rescan. I already have a chest wall met so I believe it to be cancer. But how do they know?

Raquel · 09-21-2011, 06:08 PM

That's a good question.Have you gone for a second opinion?It doesn't hurt and maybe you'll get an answer.I think it's frustrating to know something is there but they just wait to see.Sorry your going throgh this too.

Joan M · 09-21-2011, 08:26 PM

Raquel,

An RFA, or radiofrequency ablation, is a minimally invasive procedure done by an interventional radiologist. It uses radio waves (NOT radiation) to burn a tumor. It is less invasive than surgery.

RFAs have been done very frequently in the liver for both primary liver disease and liver mets. Lung RFA is a newer procedure.

The IR doc makes a very small slit in the back usually and inserts a probe about the thickness of a pencil.

I was put out under general anesthesia.

Most oncologist do not take to these procedures. If you are interested, mention it to your onc, who will probably not be interested. If you'd like to know more go directly to an interventional radiologist to find out whether the procedure can be done. For a lung RFA it would be better to be in a major medical center where they have a lot of experience doing lung RFAs.

Lung surgery is usually also minimally invasive, called VATS, or video-assisted thorasic surgery. The surgeon makes three, two inch slits. Mine were on my upper flank. One slit is for a camera, and instruments are put in the other two. I was put out under general anesthesia.

The lung does not hurt at all in either of these procedures, and there is really no pain with an RFA. With VATS there was some pain at first when I coughed, sneezed, etc., but I was on painkillers in the hospital. The pain didn't last a long time. Maybe less than a week. I can't exactly remember, but it was not unbearable.

I had a similar experience of my 5 mm lung tumor appearing in the CT scan part of the PET/CT and not being reported. When it reached 1 cm it lit up and was reported. Generally, with a PET/CT a nodule has to usually be about 1 cm to light up.

It's very difficult to biopsy a 1 cm lung tumor. That is, to get enough tissue to give a meaningful answer. My biopsy report said it was an adenocarcinoma. But both lung and breast cancers are adenocarcinomas ... My oncologist suggested that the pathologists compare the biopsy to my original breast cancer slides, and based on that comparison they decided it was probably bc and not lung cancer.

Doctors often wait when a tumor is small, or less than 1 cm, is see how quickly it is growing over a certain time period. They look at doubling time. Not to get into the details of that, docs can sometimes determine the probability of whether a tumor is benign, malignant, or an infection based on this measure. However, a CT scan can sometimes show directly whether a nodule is benign or malignant (but not a PET scan). That is, my tumor had spiculated edges, and that's a sign of malignancy, regardless of a PET scan lighting up. A PET scan can light up for benign processes as well, like tuberculosis, etc.

Joan

Pmoore · 09-22-2011, 10:14 AM

Joan, have you had both procedures done,RFA and VATS?I have mets on my lungs and onc does not want me having any type of surgery on them.She believes in the systematic approach.I would like to do both.My mets have shrunk since I was diagnosed at stage IV last year.I am on Hercetin only ,so far it is working.I would like to get rid of them completely.Looking at my options

anna4969 · 09-22-2011, 01:42 PM

Raquel and Joan M.

Raquel, thank you for this post. I have 3 nodules showing up on July's ct scan, the largest being 7mm. Of course, I am worried sick about this but my onc has also taken the rescan approach and that date is coming up Oct. 10th. Thus any sort of lung met question...I read immediately. Thank you for posting

Joan M. Thank you for the education on this matter. I think I understand a bit more why he is taking the waiting and rescan approach now. He has told me the very thing that they are too small to light up on the Pet and too small to biopsy. I am thinking that October's scan will be a deciding factor. My additional worry is that I have pain when I take a deep breath where the 7mm nodule was spotted at the outer edge near the lining of the lung. So not sure. I had my rad. onc followup appointment last week and she took one look at the ct scan from July and said that I have something going on in that lung where the 7mm nodule is but it's not cancer. Period. I didn't have a chance to ask more about why she was so sure. I guess I was too comforted to ask. Maybe you answered that question too in that maybe the outer edges were not what is typically seen with lung cancer? Anyway, any thougts on that?

Joan M · 09-22-2011, 02:23 PM

I have had both VATS and lung RFA.

If your oncologist is not interested in these procedures, my only suggestion is that if you are, you should go directly to both a thorasic surgeon (VATS) or an interventional radiologist to get their opinion (IR doc for an RFA, or in the case of the liver, RFA and cryoablation, or freezing the tumor instead of burning it). However, keep in mind that a surgeon wants to do surgery and an IR doc wants to do RFA and in the liver, cryoablation.

When my bc advanced, I was getting Herceptin in a local hospital and consulting at a major, world-renown cancer center in NYC, and the breast oncology service there is dead set against these procedures (my local onc was not. And she is not only an onc, but also has a doctorate in molecular biology in cancer. Perhaps she has another perspective because of that). I went on my own directly to the surgeon and IR docs bypassing the doc I was consulting with. In the 11th hour, the oncologist who I was consulting with however found out that I was having a lung RFA and tried to stop it, saying to the IR doc, "what are you doing? This is not standard of care for metastatic breast cancer." The IR doc told me that he and the onc "agreed" that this is what the patient wants to do. (I had the VATS at another major hospital in NYC, but not at the world-renowned one.) In my own humble opinion, I'm not dead set against any of our options, but feel that each patient should be evaluated on a case-by-case basis until a systemic cure is found.

I eventually switched over to the world-renowned hospital with another onc on the breast service (the consultant is one of the top dogs in that service), but during the year I was worrying so much about not having these options that I switched to the major hospital where I had the VATS. The onc I have there is a top, metastatic doc. And now I don't have to worry and dread discussing these treatment options on my cancer advancing.

On that note, for a lung RFA it's better to be in a major cancer center where the procedure has been done many times. However, major cancer centers are known to be very conservative in treatments (generally following NCCN guidelines) even though they are outstanding in research, have the latest equipment, and employ oncs, docs, and technicians who know how to use that equipment.

If you are interested in RFA send me a PM, and I will ask the IR doc for a referral in your area.

Anna, I do not have any thoughts about the questionable area on the outer edges. However, I would get a copy of that report and then ask your oncologist to explain what that means. And keep asking until you get an answer that you're satisfied with. I get copies of every scan and blood work results, just in case I have any questions.

And ask the Lord for strength because we cancer patients often need that in not only coping with our advanced cancer but dealing with oncs and hospitals. At times it has been extremely distressing for me.

Joan

Pmoore · 09-22-2011, 02:42 PM

Thank your so much for your reply.I live in the Washinton DC area and have seen a IR at a major hospital center.I am thinking about seeing a thorasic surgeon also to look at all my options and figure out what is best for me.Thanks again for your knowledge in this area.

BonnieR · 09-22-2011, 03:47 PM

I hope you will refer to my response in your other thread on the same subject. First one needs to be sure it IS cancer. As I recall, you have not had a biopsy to determine that. In my case, the areas lighting up on scans were only old pneumonia. But I found out too late. I would have been better off seeing a pulmonolgist first who would have treated things like an infection to see if there was response to antibiotics. Instead I ended up having a surgical biopsy that ended up as a lobectomy due to the incorrect diagnosis of cancer....
Try to have somone outside of the cancer/surgery world evaluate you too
Keep the faith

Raquel · 09-24-2011, 05:14 PM

Thank you all for your input, now I have many good questions to ask Monday when I go for my second opinion. I asked my nurse how they knew for sure it was cancer and she said it showed a high metabolic activity.I don't know if they have a specialist there that does the radioactive ablasion. I am going to the Hershey medical center so if anyone knows of a good Dr. in PA please let me know! I think I will see a lung specialist first, I have known other people too who have undergone lung surgery and found out later is wasn't cancer. The dr I am going to see wasn't in favor of surgery three months ago but agreed with my Dr that it needs to come out. I'll let you know what he says, and thanks for all your replys! It helps!

BonnieR · 09-24-2011, 10:02 PM

My lesions also showed high metabolic activity but they still were not cancer. Other things can cause that reaction. I am proof.

Are they sure it cannot be reached for biopsy? Even a surgical biopsy? Mine would have gone fine if the pathologist had not made a diagnostic mistake. The biopsy would have been negative and no further treatment needed.
Keep us posted and keep the faith.

Raquel · 09-26-2011, 08:09 PM

I went for my second opinion and didn't find out much, he is sending my scans to a surgical board to review to see if a biopsy is possible or surgery.He suggested a brand new study too but I'd rather see what I'm dealing with first.He mentioned a circulating cancer cell blood test that he was going to check into for me.The new trail included Xeloda which I'm not real fond of taking.I told him I'd rather hold off on chemo and get rid of whatever this thing is in my lung.We'll see what they come up with and I am going to look for a lung specialist on my own.Thanks for the advice!This is so frustrating and everyone keeps asking me how I made out and why I don't have any answers! I wish I knew!

anna4969 · 09-27-2011, 05:50 PM

Raquel

Thank you for the update. Please keep us informed when you go for the second opinion or what the board has to say about it.

Raquel · 10-19-2011, 07:00 PM

HI Everyone! Just checking in,I go Fri to meet with a surgical oncologist to see what he says. I want to meet with an rfa Dr too but they seem to want me to meet with the surgeon first.Joan,your inbox is full now so I can't send any messages! Hope you read this! Thanks for helping me with Dr's who do Rfa's! The only good news is they are sending me for a chest CT scan, finally!I'm tired of waiting on Dr's!

Joan M · 10-24-2011, 01:40 PM

Hey Raquel,

Andi also just told me my PM in-box is full. I've been away for 21 days and just returned home. I need to clean it up!

I hope your appointment with the surgeon went well, and I'm glad to hear that you'll be getting a chest CT scan. Generally, surgeons want to do surgery when it's possible, and interventional radiologists want to do RFAs. And the patient is left wondering what to do! I hope you're getting answers on how to proceed.

If you consult with the RFA docs, let them know the name of the doc who recommended them, as this generally can help with getting an appointments quicker, etc.

Joan

CoolBreeze · 10-24-2011, 02:10 PM

My cancer was in the liver, not the lung. But, for some of us with metastatic breast cancer it only appears in one place and doesn't grow anywhere else - we are considered oligiometastatic. We are only 3% of women with mets, but in us, surgery can be curative. The best thing to do is a resection and the 2nd best thing is an ablation technique. Both can give you years, if not cure you.

But, you have to have cancer in only one area, and have had enough time since original dx so that they know it's only in one area, and it has to be in a resectable place and you have to be healthy.

The older thinking is that metastatic breast cancer is a systemic disease that can only be treated with chemotherapy - newer thought is that multimodal methods of treatment are helpful, including surgery.

I had half my liver removed October 3rd and there was a very tiny tumor in the other half that was ablated using the microwave technique. I will start chemo again mid-November. It is possible that I am cured.

I hear they are doing something similar for patients who have mets only in their lungs. Google oligometastatic and lung mets for more info.

Raquel · 10-25-2011, 06:35 AM

Thanks for the replys!They have been a huge asset in my decisin making on this. I am waiting for a call for a biopsy and we'll go from there.This Dr wants to investigate how many scans ago this showed up and find out exactly what it is before we do anything.Why in your opinion do you think surgery is a better option?He is leaving the decision up to me so I am weighing the pros and cons of both ways out.I have not met with the rfa Dr yet.I also got a circulating cancer cell blood test Fri so that may help in determining if it is truly cancer.I feel we are making progress!

Joan M · 10-25-2011, 12:23 PM

Raquel,

Good to hear that you're making a lot of progress, and you seem in good hands.

I had both a lung resection and a lung RFA. In both cases the tumor was 9 mm-1 cm, so they were small.

I did the resection first and the margins were clean. When the tumor reappeared a year later I did the RFA. So, I personally did not get a lot out of the resection, but that varies from patient to patient.

I had the sense after the lung tumor recurred that doing surgery was like doing a lumpectomy, but without radiation. And that's a big "but." Perhaps I should have checked into following up with radiation, but at the time it didn't dawn on me, and nobody suggested it. And I'm not that sure I'd want to radiate my lungs, even though that's done for lung cancer.

With the RFA, I felt that at least the tumor was burned, with a margin, as well. And the IR doc told me afterward that there was also 2 mm tumor in the area, and he ablated that, as well. As Cool Breeze said, "there was a very tiny tumor in the other half that was ablated using the microwave technique." IR docs do that technique. So there may have been an IR doc also in the operating room. Cryoablation is also done in the liver. That's encasing the tumor in an ice ball to ablate it.

The size and location of the tumor matter. RFA is done for tumors up to 3.5 cm.

Joan