As you can see from my signature, I just went through something similar. I’ll try to provide some general background, but feel free to PM me if you want to talk more.
Determination of whether a nodule like this is a met is tough because it is so small. My known (sub-pleural) met was 7mm when wedged out, the other (more central) nodule was “5mm or 6mm” when I had SBRT on it. Factors include the appearance on scans and the growth rate. Mine were also very slow, closing on max (the central one seemed to stall) for CRC mets even well off chemo. My were frequently designated “stable” as well, but keep in mind that there’s substantial inter-observer and even some infra-observer variation in size estimates on CT (also depends on contrast and machine), so when nodules are this small evaluation takes time. Most generally, pulmonary nodule growth is evaluated by calculating “doubling time,” which basically means how long it takes the diameter to increase by .26. So a 7mm met will have “doubled” at 8.82mm. If I recall correctly, the range for doubling of CRC mets is about 30-120 days, assuming no systemic therapy intervened. But none of that is definitive. As I said, at this size the possible error is large versus the nodule size. But the growth over time is concerning.
Since you don’t have everything in your signature, I couldn’t calculate anything, but I share your concern based on what you included. Wedge resection is a real surgery, but quite a light one, comparatively. I went home the same day, was 100% and back to running in a few weeks. SBRT was far less of an event. Really nothing at all in terms of immediate side effects. I will have to look at it, but I don’t think biopsy is usually done for such small nodules, and I think is generally disfavored because by the time it’s practical it’s generally unnecessary (because of radiological evidence and growth pattern).
So I can’t recall if this would be your first potential evidence of metastatic disease, but if it is, yeah, that can be scary. My team was able to tell from the images and growth rate that it was a met, so I knew that going into surgery. But things get better. If you do have an isolated pulmonary met, that is highly treatable and survivable. There are a number of posters on here many years out from that situation. Moreover, you should NOT feel guilty about not getting a biopsy earlier. I believe it would have been too small (I think it still is), and the approach for nodules this size is nearly always to watch and wait. You did nothing wrong here that I can see. You’re right about the next stage, though. A second opinion would be good (I know it’s rural Utah but many major centers will take transmitted scans and do remote consults in cases like yours). There are, however, other things to consider strategically, such as whether to do chemo down the road if it’s a met (debated, as your onc intimated), what approach to take to the nodule if intervention is called for, how long to wait, etc.
So my bottom line is: I understand the fear and stress, but you did zero wrong so far (don’t beat yourself up unnecessarily), it still may not be a met, but even if it is it’s nearly certainly very treatable. This may be a very high-leverage strategic point though (so you should get full info). Fortunately you have some time to do that.
As I mentioned, happy to chat more if you wish.
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 for remaining nodule 1/22
CT 3/22: Clear