Uh-oh! New test results have me worried

[Becky]

Dear Erin

I am sorry about having to have additional tests. They might do a PET/CT as it may be able to see lesions smaller than 7mm. In the case of mets, there tends to be more than one nodule. In the case of a new primary, there tends to be just one nodule. You are right about "spiculated" as that tends to be not a good thing.

If I were you, I would push for biopsy unless your doc thinks otherwise. Also, call your onc and fax your report to him and ask what he thinks and how you should proceed.

[Joan M]

Erin,

I relate to you and understand your anxiety because I had the same experience.

I too had a CT scan of the chest, which showed a 9 mm spiculated nodule in the apex of my left lung (the scan was a routine scan of the chest, abdomen and pelvis). A single nodule is known as a solitary pulmonary nodule or SPN.

The good news is that if it is a bc met, it's small and can be removed by minimally invasive surgery, as was the case with my nodule, which has been shown to give a good survival benefit.

Here's what I suggest from my experience, and also some information that might be helpful to you in making decisions about this.

You should have a PET/CT scan. However, at 7 mm, the nodule may not "light up" on PET (it's borderline). The guideline for PET imaging is about 1 cm to give an accurate reading, but smaller nodules have been shown to light up depending on how strong the signal is, and of course if they light up they shouldn't be ignored.

So what this means is that it may or may not light up even if it is a bc met. If it doesn't light up, you have the option of getting a biopsy or waiting out the nodule to see whether it gets bigger, and if it does grow to have another PET/CT scan. The reason for waiting is because it's hard to get an accurate biopsy of a nodule that is less than 1 cm.

I went through this. I had two thorasic surgeons, two oncologist, and one pulmonoligist say that it was not possible to get a good reading on a biospy from a nodule less than 1 cm. But a third surgeon said to try for the biopsy and I did. All three surgeons "swore" I had lung cancer ("the position of the nodule, the look of it," etc.).

The results of the biopsy showed an adenocarcinoma. As it turns out, both lung cancer and breast cancer are adenocarcinomas, and the doctor could not get enough biopsy tissue for a differential diagnosis. However, this was important because the treatment for each diagnosis is different. If it had been lung cancer (and I'm a former smoker), the surgery would have been a lobectomy. But for a lung metastasis, the treatment is a wedge resection, which is taking a slice of pie taken from the lung.

My onc suggested that the lab compare my original bc slides with the biopsy, and the result was that the lab thought it looked close to my bc. But, of course, this was just their gross observation after the fact. It was still inconclusive.

I decided on a wedge resection via VATS (video-assisted throsic surgery) because I wanted the nodule out.

At 9 mm, if the nodule had been lung cancer it would have been "tiny, tiny, tiny," as all three thorasic surgeons said. In the lung cancer world, the nodule would have been stage I, and I probably would not have had any other treatment (chemo or radiation).

This leads back to your cough. In my opinion, a 7 mm nodule would not be the cause of your cough. The nodule's not big enough. That's what's so devastating about lung cancer: by the time you have symptoms, the tumor is large, much bigger than 7 mm.

However, if your nodule turns out to be either lung cancer or a bc met, you could say it was good to have been found so small.

Another thing. A CT scan can see nodules much smaller than a PET/CT. Sounds surprising, right? A CT scan can see a nodule that's as small as 2 mm. But a PET can't see it.

Here's the difference. A CT scan is looking at the morphology of the nodule. That is the form of the nodule (like the size, whether is spiculated, whether it's opague, etc.), but a PET measures metabolic activity. Cancer cells involve a lot of glucose metabolism, much more so than normal cells, and that's what a PET scan measures -- metabolic activity.

With a PET/CT there's a radioactive tracer for the PET (a shot in the vein), but no tracer for the CT part (that is, no intravenous dye in the arm), so the picture isn't perfect on the CT part of the scan, and the scan is just used for attenuation purposes, giving a picture of all your organs to give perspective to the PET part, which is just measuring a signal.

I've been there and I understand how anxious you must be. I was very upset.

You should first start by getting a PET/CT, to see whether the nodule is PET positive.

My prayers are with you. Please let me know if I can help in anyway.