Lung Nodules - any advice welcome

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roadrunner
Posts: 240
Joined: Sun Jan 12, 2020 8:46 pm

Re: Lung Nodules - any advice welcome

Postby roadrunner » Thu May 12, 2022 6:33 pm

Utahgal7:

I’d add the following:

(1) This is not clearly a met. Instead, there’s a chance it is, and a chance it isn’t. Nodules this small rarely are, but of course the odds change in a rectal cancer patient with nodal spread, and the growth does raise questions. And as I mentioned, your onc is doing it right—wait until it grows (or doesn’t). Also, biopsy is usually reserved for 10mm+. It’s nerve-wracking, but there are reasons not to rush treatment. One is that you need to get enough tissue for genomic testing if it is a met. (7mm is I think is about minimum for this.) You asked about genetic differences between mets and primary tumors. You’re right that they can differ. This is why you need to test the nodule if it’s eventually found to be malignant—some 5% respond to immunotherapy. I did this, but my genomic testing was delayed by a communication issue, so I don’t yet know the results.

(2) IF this is a met, SOC is to wedge it out (metasectomy) all other things equal. You will see references to SBRT and other therapies like cryoablation or radiation-frequency ablation, but these are still alternative therapies for alternative situations (bad location, low fitness/performance score, etc.). First choice is VATS wedge resection because it is highly successful at local control and gets you tissue to test. I chose SBRT for my second nodule because it was central and would likely have been a lobectomy (LUL). I and my team wanted to preserve healthy lung tissue in case I end up playing whack-a-mole.

(3) Adjuvant chemo after pulmonary metasectomy is hotly debated. I have seen studies that it increases PFS (progression-free survival) but not OS (overall survival). But that’s not the whole picture, and this is a very subtle issue that you should talk to sophisticated oncologists about. Most generally, chemo delays progression of pulmonary mets but does not eradicate them (thus the surgery). Exceptions occur—Claudine’s DH is one (perhaps a journal article, there! : ) Also, if you can do immunotherapy that will increase your odds if you need systemic therapy (the 5%). Finally, in most cases pulmonary CRC mets (without other disease) are associated with longer survival. That may be material, because there are numerous promising technologies and treatments now in trials that could provide rescue in a few years. But these are questions for down the road.

(4) Next—this is great news—you’re relatively far out from your primary surgery, and nothing else has appeared. This is now termed oligometastasis, and its prognosis is relatively favorable. It’s no guarantee, but a good sign even if this is a met.

(5) Finally, there’s IMO a tricky balance here. Even if you have a met, your immune system is doing a good job of containing it. It would be worth trying to maintain the situation (with local control, of course—e.g. metasectomy). Both standard chemo and some alternative therapies can interfere with the immune system. The bet is with chemo generally that it hurts the cancer more than it hurts you. Here, if it’s an easy wedge, it’s not crazy to simply try to promote immune health and watch and wait. But not necessarily right for you. I would be careful in particular about unproven alternative therapies that might impact immune health. But since chemo is not usually curative with pulmonary mets, the choice is hard there too. That’s part of the reason for a strong second opinion. My only view would be that immune health is key, with or without chemo. I am not currently on chemo, but if something pops up I’m not against it.

These are just my perspectives. Others may have different ones. Happy to try to answer any other questions you may have.

Oh, and no guilt! No reason for it. You’re right on schedule with no mistakes or unhelpful delays so far even if it’s a met.

And now I have to go run three miles. It’s a nice evening : )
7/19: Rectal cancer: Staged as IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/reduced size est. 70-75%)
neoadjuvant chemorad 11/19
4 rounds of FOLFOX July-August 2020
ncCR found 10/20; biopsies negative
TAE 11/20, tumor cells removed, lung nodules orig id’d 6/20 stable Nov 2020
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear

Rock_Robster
Posts: 679
Joined: Thu Oct 25, 2018 5:27 am
Location: Brisbane, Australia

Re: Lung Nodules - any advice welcome

Postby Rock_Robster » Thu May 12, 2022 8:30 pm

Excellent, balanced advice from roadrunner above.

The only other comment I’d add is that while wedge resection is indeed currently the gold standard treatment, there is a rapidly growing body of evidence that SBRT could potentially be at least as good for single, isolated lung mets - with a much lower risk profile and shorter recovery period. I’m not saying it would be a done deal for me, but it’s definitely worth discussing with a radiation oncologist who is on top of the latest research. Given the need to play the “long game” in stage IV CRC, anything which preserves the maximum lung tissue for future options should get serious consideration.

Good luck,
Rob

PS: I’m also not sold on chemo for recurrent oligometastic disease if it’s radically treatable. There is only underwhelming evidence around this, and the oncology community is divided. My onc’s approach generally is not to use chemotherapy in the absence of detectable disease after oligometastatectomy, other than for the initial post-op adjuvant chemo.
40M Australia
2018 Dx RC, 12cm high
Mod diff, EMVI, LVI. 4 liver mets
pT3N1aM1a Stage IVa. MSS NRAS G13R
CEA: Nov-18= 14; then ~2. Nov-21: 5.4
11/18 FOLFOX x6
3/19 Liver resection
5/19 25x pelvic IMRT radiation
7/19 ULAR & ileo, 1/27 LN
8/19 Liver lesion
8/19 FOLFOX, FOLFOXIRI, FOLFIRI x7
12/19 Liver resection
NED
2/20 Ileo reversed
11/21 Liver met & celiac node; 2-3 tiny lung things, indeterminate
12/21 PVE
3/22 Nodal spread & 3 liver lesions. Lymphadenectomy
4/22 Liver SBRT x 5

utahgal7
Posts: 80
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Fri May 13, 2022 7:04 am

roadrunner:

Thank you for all of your helpful information. It has given me a lot to ponder and thank you for helping me to get my head straight. It is really easy to "go down the rabbit hole" of constant worry and second guessing.

Have a great day and thank you again :)
02/20 Rectal Cancer dx - 4 cm mass; located 9 cm from AV
03/20 CEA 2.7; 0.9; 1.4; 0.9; 0.9; 1.2; 1.0; 0.9; 0.8; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy
04/20 ypT3N1bM0; MSS; moderately differentiated adenocarcinoma
05/20 CAPEOX
08/20 Ileostomy reversal
09/20 CT scan; suspicious areas in liver; 10/20 MRI liver; dx hemangioma
12/20 CT scan; lung nodules (watch and wait);
07/21, 10/21, 1/22, 5/22 CT scan; (1) lung nodule (right lower lobe 6mm X 7mm)

utahgal7
Posts: 80
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Fri May 13, 2022 7:12 am

Rob,

Thank you for the advice. I get your point about not being sold on chemo for recurrent oligometastatic disease. It is important to have the chemo option "in your back pocket" so to speak, if you have additional metastases elsewhere.

Have a great day and thank you again!
02/20 Rectal Cancer dx - 4 cm mass; located 9 cm from AV
03/20 CEA 2.7; 0.9; 1.4; 0.9; 0.9; 1.2; 1.0; 0.9; 0.8; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy
04/20 ypT3N1bM0; MSS; moderately differentiated adenocarcinoma
05/20 CAPEOX
08/20 Ileostomy reversal
09/20 CT scan; suspicious areas in liver; 10/20 MRI liver; dx hemangioma
12/20 CT scan; lung nodules (watch and wait);
07/21, 10/21, 1/22, 5/22 CT scan; (1) lung nodule (right lower lobe 6mm X 7mm)

prayingforccr
Posts: 320
Joined: Sun Jun 28, 2020 4:44 pm

Re: Lung Nodules - any advice welcome

Postby prayingforccr » Fri May 13, 2022 3:14 pm

prayingforccr wrote:
utahgal7 wrote:prayingforccr:

Thank for that tip. I will have to look into that.

Just curious, with regard to the supplements that you use, do you feel like the tippens protocol worked best on your lung nodules?


Well. I’m only as good as my next scans but there has been no growth in my nodules for six months and almost all have holes (cavitation).

I’m on day 18 of curt michael graydon’s artemisinin protocol which I wholeheartedly recommend, and will resume the fenben at its conclusion.

My regimen is posted and updated in detail here:

viewtopic.php?f=1&t=66082

I have scans scheduled for june 13, and am hoping for the best.

I’m happy to answer any and all questions via DM.
11/19: colonoscopy
12/19: diagnosed with stage 3 rectal cancer 6+cm tumor
1-3/20: 20 sessions of radiation, mon-fri capecetibine+clinical trial drug m3814
7/20: 8 treatmentsFOLFOX
11/20: Primary tumor had complete response. Possible tumor deposits on latest mri. Biopsy negative for cancer.
5/21: Multiple lung nodules (3-6mm) on ct scan
10/21: md anderson gives me 1 year without treatment/3 years with folfiri/avastin (refused)
3/22 No growth in nodules 6 months…..most showing cavitation.

utahgal7
Posts: 80
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Fri May 13, 2022 3:20 pm

prayingforccr:

Thank you for the information!

Have a nice evening:)
02/20 Rectal Cancer dx - 4 cm mass; located 9 cm from AV
03/20 CEA 2.7; 0.9; 1.4; 0.9; 0.9; 1.2; 1.0; 0.9; 0.8; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy
04/20 ypT3N1bM0; MSS; moderately differentiated adenocarcinoma
05/20 CAPEOX
08/20 Ileostomy reversal
09/20 CT scan; suspicious areas in liver; 10/20 MRI liver; dx hemangioma
12/20 CT scan; lung nodules (watch and wait);
07/21, 10/21, 1/22, 5/22 CT scan; (1) lung nodule (right lower lobe 6mm X 7mm)

Utwo
Posts: 278
Joined: Mon May 23, 2016 10:14 am
Location: T.O.

Re: Lung Nodules - any advice welcome

Postby Utwo » Mon May 16, 2022 3:54 pm

utahgal7 wrote:So most recent CT scan showed growth in (1) lung nodule (right lung lower lobe). Most recent measurement shows that nodule has grown to 6mm x 7mm. I am beyond a little frustrated. At one oncology appt. the nodule will be stable. Then at next oncology appt. 3 months later, the CT will show that nodule has grown. So, the nodule has tripled in size since CT scan from (3/2021 - nodule measured 2mm x 3mm then).
So, my oncologist wants to wait 2 months and do an additional scan ...
I had a few "density anomalies" in my lungs.
After a brief period of growth they have became stable.
I understand that watching them is rather "entertaining".
However you need to understand that at our age (I assume your age based on your broken hip) people typically have quite a few such "density anomalies" in lungs, liver etc.
If I were you I would follow your doctor's advice and wait for one more CT scan.
If this is CC metastasis, it grows rather slow and a few extra months doesn't present a lot of additional risk.
58 yo male at diagnosis: T1bN0M0, 0/15 nodes, low grade/moderately differentiated adenocarcinoma
03/2016 colonoscopy: 2 small polyps removed in left colon; CEA = 1.3
04/2016 colonoscopy: caecum sessile 3.5 cm polyp piecemeal removed with kind of clear margins
05/2016 "prophylactic" laparoscopic right hemicolectomy - bleeding, leak, infection
06/2017 CT scan, colonoscopy OK; CEA = 1.6
A lot of funny stuff discovered by CT scans in liver, kidney, lungs, arteries, gallbladder, lymph node, pancreas


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