Imaging in Lung Cancer

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Wonder if someone can translate this to English. Like our doctor but her accent is difficult to understand and I think she doesn't like to tell us negative things. From the PET: There is a small cavitary focus within the left apex with pleural thickening and soft tissue density. In the posterior aspect of the left apex, there is a soft tissue density meausring apx. 2.3 centimeters. This demonstrates marked hypermetabolism with standard uptake values up to 15 (mediastinal blood pool 1.5). Ther eis a second 5 millimeter density along the medial aspect of the cavitation in the left apex. This is noted medially and posteriorly and also demonstrates hypermetabolism with standard uptake value at 5. This may represent posturgical change, however, residiual on recurrent tumor cannot be exluded. There is also a small pleural-based density in the posterior aspect of the upper hemithorax, measuring (copy but I think it says) 12 x 7 millimeters, this is hypermetabolic and has standard uptake values of 9. There's more but these were, I think, the areas of concern. The comments were well, some of this could be scar tissue, surgical related, or emphysema but it could be cancer. Can anyone clarify a bit - I prefer to know what we're dealing with here.

The imaging results are only part of the story. First, a report is only a summary of what is actually seen, and it can be very helpful for the doctors who know the situation to actually look at the images: you can get more information than a summary report will provide. Meanwhile, the context of what's going on is critical: is this a setting of prior surgery for known disease? A question of a new diagnosis of lung cancer? Any significant risk for infection or inflammation?

It's fair to say that when the PET scan shows several areas of increased metabolism (abnormal uptake on the scan) in someone with a known history or high risk of cancer, we're concerned that this may represent active cancer. At the same time, you can absolutely see increased uptake after surgery from normal post-treatment inflammation or from an infection, which wouldn't be welcome, but it's almost always better than recurrent cancer.

You can't actually diagnose cancer from a PET scan, even though the PET scan can raise or lower your level of concern. If there is any doubt about the diagnosis based on the overall scenario and the imaging, a biopsy is the way we can say something more conclusive.

Online discussions of scan results are actually a poor substitute for input from someone more directly involved. I think it would be appropriate to press for more information about what these results mean. Even if the oncologist involved may be uncomfortable talking about possibly negative results, a good discussion is part of the job and can't be sidestepped.

Good luck.

-Dr. West

what is a small density found in the posterior medial aspect of the right lower lung field mean?

It means that there is a nodule in the back of the right lung, toward the center part of the chest, that is abnormal. It doesn't mean that it is cancer vs. some benign nodule, because it can't tell -- only a biopsy can really do that. But it does suggest that there is something that merits at least being followed and perhaps worked up more actively than that. A doctor reviewing the results could provide more context.

-Dr. West

what is a small pleural density

It's a little nodule on the lining around the lung and chest wall.  This could be just a benign little area of scar tissue, or it might represent an area of cancer.  The overall context of whether there are other areas of benign findings or known cancer in the chest could raise or lower the level of suspicion, as could the result of a PET scan (if it's got high metabolic activity on PET scan, that suggests a cancer; if it's got low or no metabolic activity, cancer is very unlikely).  In the end, though, only a biopsy can truly clarify what it represents, though we wouldn't necessarily pursue that if we have enough clues from other variables.

Good luck.

-Dr. West

Please help. Can you explain what the following report means? "...there are numerous sub centimeter mediastinal nodes as well as a relatively flat precarinal node measuring 1.7 cm, slightly larger then on previous study. There is a 9-mm opacity in the lingual again seen, unchanged. No other nodules are identified and there are no infiltrates." my dad got a ct chest scan a year ago and The doctor said that he found an "iIl-defined opacity in the medial aspect of the left lung base and also in the inferior aspect of the left hemidiaphragm" Ever since then he told my dad to get ct chest scan every 3 months so they can watch more closely what is happening. The report above is from the last scan. The doctor said that he doesn't know what it is. My dad is scared -every 3 months going to the doctor to find out if he has lung cancer or not. I asked the doctor if there are other tests that he could perform on my dad and he said "no we just got to wait."

   Seeing enlarging lymph nodes and/or lung nodules on a chest CT makes us concerned about the possibility that a person has lung cancer or another medical issue that could benefit from treatment.  If the progression is convincing, we often do a biopsy or consider a PET scan, which looks for increased metabolic activity in the areas that are suspicious.  If you see higher than normal metabolic uptake in a nodule or enlarged lymph node, that raises our concern for cancer.  But the only definitive way to really get an answer is from a biopsy.

   Good luck.

-Dr. West

My maternal GF died of lung cancer at age 69. He was a heavy smoker. My mom died of it at age 88. She was a light smoker many decades ago. I have never smoked but am concerned there may be a genetic component in our family. Should I get a CT screening?

Because lung cancer is both very common and well associated with smoking (though certainly not invariably), we don't leap to concluding that there is a significant hereditary component when someone has a couple of relatives who aren't first degree relatives develop lung cancer after previously smoking. Hereditary lung cancers are disproportionately in younger patients and never-smokers.

Your situation definitely falls outside of the range for which the risk of lung cancer is high enough to recommend CT screening. We know that chest CT scans are very likely to identify small lung nodules, which are far more likely to be benign than cancer, but they can cause a lot of anxiety and need for subsequent tests just the same. That's generally considered an acceptable risk when a person has a sufficiently high risk of cancer, but if someone has a lower risk of cancer, it's overwhelmingly likely that screening will identify nodules that often cause a lot of anxiety and need for subsequent testing, but that will ultimately turn out to be nothing significant.

Good luck.
-Dr. West

Hello,What are the opinions of your experts on the use of low dose CT scans as a strategy for early detection of lung cancer?

An annual low dose chest CT is the evidence-based screening approach for lung cancer that has been proven to improve survival in higher risk people. The screening population is defined as those with a smoking history of at least 30 pack-years (the product of average number of packs smoked per day x number of years smoking), continues to smoke or has quit in the last 15 years, and is age 55-74 and otherwise fit enough to pursue the treatment for a detected early stage lung cancer (generally surgery).

Though screening programs haven't yet been widely implemented, the data really support it, and because we need to balance the value against the risk from the screening test, a low dose screening chest CT is the scan of choice.

-Dr. West

My husband (49) had a CT scan done at the local VA in, I think, April of this year. The dr. (I use that term loosley because I think what he has done is unprofessional in my opinion) looked at the scan for only a few minutes, my husband asked if it was cancer & the dr. said Yes. This is a general dr. who is not a specialist -- the scan showed 2 small abnorbalties. My husband has been 'freaking' over this ever since then... In my opinion I don't believe that the dr. should have told him it was definitly cancer without doing any other testing -- blood work, biopsy, specialist, etc.! Since then there has been several other 'questionable' happenings that has taken place at the VA regarding the way my husband has been treated that he will now Not go back to any VA again. He is a veteran who served for 14+ years in the service & was in Operation Desert Storm in the '90's! My question is this: Where can he go to get another scan (we do not have insurance) done in the Kansas City area? Also, is this normal procedure for a dr. to tell his patient that he definitly has cancer when there is no biopsy, etc done?Thank you in advance

I'm sorry I can't answer your question about where to go, since that's really a practical question that can be best addressed by someone in the area, and I'm about 1400 miles away.   I don't know the lay of the land there, but the local university usually has a wide range of specialists and should be charged with seeing people throughout the community.

I agree with your point that it isn't chemo unless a biopsy proves it to be that.  Seeing new lung nodules is always a concern, but it really depends on the characteristics of both the nodules and the person they're found in how likely they are to be cancer.  We know from screening studies looking for lung cancer that small, ambiguous lung nodules are VERY common, and most often they're benign.  The larger a nodule is, and the more of a smoking history a person has, the higher the risk that a nodule is actually a cancer. Nevertheless, even in people with very worrisome scans and a history that highlights a high risk of cancer, all experienced doctors have encountered patients in whom they were all but convinced a cancer was present, but it turned out to actually be infection or inflammation.  Consequently, you're right to want to have biopsy confirmation of what you're actually dealing with before making any declarations or starting treatment plans.

Good luck.

-Dr. West

Chiropractor saw what he describes as a pancoast tumor. Are these invasive tumors and what is a prognosis for these tumors?

This is some introductory information on Pancoast tumors:

http://cancergrace.org/lung/2007/10/12/pancoast-tumor-intro/

http://cancergrace.org/lung/2007/10/15/pancoast-trimodality-rx/

Though these posts are 6 years old, neither the treatment nor our general understanding have changed appreciably in that interval.

However, I would be very wary about drawing any conclusions before a proper workup that includes a biopsy and full staging has been done.

Good luck.

-Dr. West

I am a radiation therapist. On a routine cxr my mom was said to have a mass in her lt lung done 1-9-14. Her prev cxr 10-11-13 makes no mention of this. She had multiple complications with a biv-icd (lead perforation and blood around heart, lead change, infected pocket, removal and replament of icd-pacemaker not biventricular within a few weeks in May 2013 and had pneumonia with plueral effusion. They were checking on the plueral effusion again with this cxr and found the mass. I know usually something this fast appearing would indicate infection. My worry is oat cell cancer or neuroendocrine or metastatic disease (read following please). Is there information regarding tumors that would progress this quickly. She is to have a CTA in a few days. She is 55. Smoker since 14 about half a pack a day. HPV positive history of partial vaginectomy/vulvectomy Sept 2012 with bilateral inguinal lymph node removal (1 microscopically positive out of 9 rt side. 0 out of 7 on lt side. Nov 2012 re-excision vagial/vulvar area to obtain clear margins that were not achieved prior. Laser ablation Oct 2013 of vaginal cuff for dysplasia.

I consider the interpretability of a chest x-ray to be extremely minimal, in this setting primarily only useful for highlighting the need for a real imaging study that will provide some actual detailed information.

I agree that the new finding in a short interval is highly consistent with infection or inflammation rather than cancer, but you're right that lung cancer, especially small cell, can progress out of nowhere pretty rapidly.

It may be helpful, if there is going to be an interval between imaging studies, to start an antibiotic and see if that possibly leads to any apparent improvement. Obviously, cancer isn't going to shrink with antibiotics, so that's a reassuring finding if you see it.

Good luck.

-Dr. West

How long does it take standard chemo to work (carbo and taxol)? I had 2 treatments in 6 weeks and the cancer continued to grow. My doctor recently switched me to Xalkori a chemo pill 2 weeks ago. Today I had my CT scan,but don't know the results yet.

We usually assess response to chemotherapy or a targeted therapy like XAKLORI (crizotinib) after about 6-8 weeks. You don't tend to see a dramatic response to chemo in less time than that -- at least 3-4 weeks, in most cases. In contrast, you can SOMETIMES see a significant response to a targeted therapy (if you have the right biomarker) within days or under 2-3 weeks, but we generally don't presume that to be the case and typically re-scan after 6-8 weeks to assess response to a targeted therapy as well.

Good luck.

-Dr. West

Husband had upper right lobectomy for stage 2a adenocarcinoma in 2012. Apparent success but being having Ongoing investigations for significant abdominal pain. On ct enlarged lymph nodes showed has had ultrasound guided lymph node biopsy for supraclavicular node but when we went for results it said no lymph tissue found, why would this be, the radiologist said she could see the node and it looked enlarged? They are going to repeat, but is there any point?

It's possible that the biopsy missed the lymph node or that the enlarged area that was presumed to be a lymph node actually wasn't one. His doctor may be able to provide more insight based on the specifics of the imaging and the biopsy report.

Good luck.

-Dr. West

Had a lobectomy upper right and vat lower right 2 years ago. Also numerous nodules on left lung that they would "watch very closely". Recommend CT every 4 months. Now my insurance is denying this saying once a year is sufficient. Is this worth appealing?

If lesions haven't changed over two years, an annual CT would probably be considered not only sufficient but plenty, because you're trying to balance vigilance with cumulative radiation exposure. If the lesions are growing, then more frequent follow-up is very indicated. The person who recommended every 4 month follow-up should be able to clarify why more frequent follow-up is necessary. If not, it probably isn't.

Good luck.

-Dr. West

Six months ago I had a ct scan and they found a 5mm nodule non clarifed on my left lung. We recently had another scan 6 months later and it is now 7mm so it had grown 2 mm in 6 months should i be worried. Im a smoker. Thank you

It is of greater concern when a lung nodule is growing. If that nodule is accessible, I suspect that the doctor following you and your scans will favor a biopsy, potentially even removal of the nodule, or possibly additional follow-up imaging to see if it grows larger. 7 mm is on the small side to biopsy reliably, but it raises our suspicion for cancer when a lung nodule is growing over time.

Good luck.

-Dr. West

I have not been dx with lung cancer. July 2013 went to dr for mid back pain that did not seem right. Dr assumed muscular pain. Took pain meds did not do anything to pain. So for months, just dealt with it. Jan 2014 woke with headache, and just did not feel right. Later in the day, my chest became heavy feeling, like someone sitting on my chest. Took bp and it was 172/109. Went to ER, put me back on another bp med (have had bp issues before). During my early morning walking I would become more tired..just blamed it on not a good nights rest. March 2014, thought I was coming down with the flu, but this pain under right rib that connected with my previous back pain did not seem right. Went to dr, did all kinds of gall bladder testing which came back ok. Referred to GI doctor, who did upper GI. Had small polyp (non cancerous), and all looked great. Pain continued and now then felt in my chest and radiated to shoulders. This is now the weekend, so went back to ER. Same ER doctor was shocked that still having issues. Sent me to cardiac dr. Explained that my pain was on my right side under rib and behind right breast bone that connects to my back pain. Did many heart tests, and found myocardial bridge. Felt I would feel better when bp and heart rate was lower. But did not affect anything. Recommended to be re-evaluated by family doctor. She ordered more blood work and chest xray. Bloodwork and pulmonary function tests ruled out asthma, COPD, sarcoidious, infection, pneumonia, thyroid, lupus, and others that I was not familiar with. Chest xray shows right rardiac margin is minimally is tear in the lateral view there is increased density anteriorly projecting of the right middle lobe. No mediastinal or hilar lymphadenophathy. The trachea is midline. No focal airspace disease or pleural effusions. Impression: Questionable infiltrate or partial atelectasis of the right middle lobe. Recommend clinical correlation and follow up chest xray. Family doctor put me on doxy-cycl hycl 100 mg. Almost done with it, and no change. Appointment with pulonmalogist and another xray next week. Symptoms that I have are chest pain, shortness of breath, occasional nausea under sternum, pain under right chest bone, mid back pain, and pain under right rib. (Pain feels deep in chest)and a cough has come on in the past 5 to 6 weeks. Dry cough. I asked dr if it could be lung cancer, and she said could be, but there is infiltrate not a mass. My friend past of lung cancer at 33yr, so it is fresh in my mind of her experience. I am 37yr, non smoker, was active, hair stylist of 17yrs. Can you give me some insight on my past that I have missed. Are we finally on the right path, or is cancer ruled out because the chest x ray showed infiltrate and not a mass? Thank you.

Cancer is not likely in someone under 40, especially without a mass, but as you saw with your friend, it is possible. It is not ruled out by there being no mass, as some lung cancers can appear as an infiltrate. If it were to improve over time, that would be very uncharacteristic of cancer, but otherwise a biopsy is the only way to definitively clarify that there is no evidence of cancer.

Good luck.
Dr. West

My boyfriend who is 49 is a heavy smoker. My father died of lung cancer and I know how a ct lung cancer screening is the best make sure he does not have any tumor etc. His doctor gave him the script to get donw and when he called hospital they said he had to be 55 that was the health care criteria? He was going to pay this out of pocket, can you help where he can get this done We live in Edgewood Kentucky thank you Tracy and Jimmy

I'm sorry, but the evidence upon which screening is based is for patients from age 55 to 75, so guidelines don't favor screening for younger patients at this time. I don't know of a center that routinely favors and covers screening for patients younger than that covered by the screening recommendations.

Good luck.

-Dr. West

Hi. My mom finished chemo from lung cancer a little over two years ago. She was having CAT scans every 3 months and it was always clear. She recently moved to scans every 6 months. There was a "spot" on the other (healthy) lung that they had seen, but it wasn't changing. We just found out that it did grow just a tiny bit since her last scan 6 months ago. It's a small spot. She has a PET scan tomorrow with follow-up next week. Obviously, my family is in panic mode. Can it be anything else besides cancer? I know you obviously can't diagnose and I'm not asking that. But are there other options of things it could possibly be? They're doing a pet scan due to her hx of lung and kidney cancer. Thank you so much.

Yes, something very small and changing minimally over 6 months could be many other things, aside from recurrent cancer. Most notably, a spot of inflammation or some infection or even just a small area of lung that doesn't inflate well -- called atalectasis -- could appear but not be a threat at all.

I'd also highlight that even if this spot is found to be cancer (and I'm not saying it is/will be), if it's a solitary small area that has demonstrated minimal change over 6 months, it has a very significant probability of being able to be managed with a very good prognosis.

Good luck.

-Dr. West

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