Lung Nodules - any advice welcome

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utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 7:47 am

Sorry that I haven't posted in awhile. I had a fractured right hip, so I have been dealing with that.

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 before deciding upon biopsy. He says he is not convinced the growth is cancer, which I think is crap. I had expressed concern over the past year about this nodule. He kept telling me not to worry, blah blah blah. In addition, he told me that my cancer had only a 1% chance of reoccurrence, which I now believe is bs. He also said that if the nodule is cancerous, he is certain that either SBRT or VATS could treat it. I don't know whether to believe this either. My oncologist is not a surgeon and only a radiologist and/or surgeon could confirm that the nodule could be safely treated with either SBRT or VATS.

Also, he said that chemo might not be necessary. WTH???!!! I know that I should get a second opinion. However, I live in rural Utah, would have to travel far for that 2nd opinion and I am NOT a wealthy person either.

I am really panicking...can't sleep, bouts of crying. In hindsight, I now realize that I should have pushed for lung biopsy sooner and that is on me. Am I totally screwed now?
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

roadrunner
Posts: 460
Joined: Sun Jan 12, 2020 8:46 pm

Re: Lung Nodules - any advice welcome

Postby roadrunner » Thu May 12, 2022 10:06 am

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: RC: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/19-10/19 4 rds.FOLFOX neoadjuvant, 3 w/Oxiplatin (reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
6/20/22 TAE rectal polyp benign)
NED from 3/22 - 3/23
4 cycles FOLFIRI
LUL VATS lobectomy for radio resistant met 7/7/23

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 10:47 am

roadrunner -

Thank you for the kind reassuring words. Also, thank you for providing the information about your wedge resection. It is comforting to know that the lung nodule is treatable.

Yes, this growing lung nodule is my first occurrence of metastasis. I am open to trying chemo again. I had CAPEOX after my LAR surgery. The oxaliplatin caused transient blindness, so the onc stopped oxaliplatin and I continued taking capecitabine. When I pressed my onc about chemo (at the most recent appt.), he did relent and say he would consider allowing me to take capecitabine again for 3 months.

I am trying to not feel guilty. I want to make sure that I am doing everything in my power to stay on top of everything.

Quick question, I don't mean to pry. Did your lung nodules share similar characteristics (i.e. mutations) with your rectal tumor? Secondly, were you given the option of restarting chemo after your wedge resection?

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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

claudine
Posts: 809
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: Lung Nodules - any advice welcome

Postby claudine » Thu May 12, 2022 10:54 am

Utahgal7 I'm sorry about this potential recurrence, but like roadrunner said, isolated lung nodules are eminently treatable. In terms of chemo, my husband had quite a bit of success with Folfiri/Avastin - he had many tiny nodules in both lungs so in his case a systemic treatment was the way to go.
Keep us updated, and hopefully you can get answers and support from your treating team that provide reassurance.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A, no primary

Tumors: L4 04/18; left adrenal gland & small lung nodules 03/19
rectum 02/22 (pT3 pN0 stage 2A); L3 09/22

Surgeries: intestinal resect. 05/18 (no cancer - Crohn's); adrenalectomy 02/20
L3-L4-L5 fusion and corpectomy 05/20; LAR 04/22; ileo reversal 09/22
L2-L3 fusion and corpectomy 09/22

Treatments: EBRT 04/18; SBRT 02/19; Failed adjuvant Xelox ; Folfiri/Avastin 03/19 - 01/20
adjuvant chemorad (Xeloda) 06/22; SBRT 11/22; Xeloda/Avastin since 01/24

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 11:01 am

roadrunner -

I forgot to mention one other thing. I was thinking of getting a 2nd opinion from USC Keck Cancer Center in Los Angeles. I was going to see if I could get an appointment with Dr. Heinz Josef Lenz. My mom is a retired USC employee and knows several of the oncologists there.
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 11:06 am

Claudine,

Thank you for the kind words. Your husband has been through so much. That is good that FOLFIRI/Avastin has worked well for him. I don't mean to pry. Was your husband's tumor KRAS mutant or KRAS wild? The reason that I ask is that I have read FOLFIRI works better than FOLFOX in KRAS wild tumors.
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

claudine
Posts: 809
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: Lung Nodules - any advice welcome

Postby claudine » Thu May 12, 2022 11:20 am

My husband is KRAS G12A, but oxaliplatin didn't work for him, whereas Folfiri did.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A, no primary

Tumors: L4 04/18; left adrenal gland & small lung nodules 03/19
rectum 02/22 (pT3 pN0 stage 2A); L3 09/22

Surgeries: intestinal resect. 05/18 (no cancer - Crohn's); adrenalectomy 02/20
L3-L4-L5 fusion and corpectomy 05/20; LAR 04/22; ileo reversal 09/22
L2-L3 fusion and corpectomy 09/22

Treatments: EBRT 04/18; SBRT 02/19; Failed adjuvant Xelox ; Folfiri/Avastin 03/19 - 01/20
adjuvant chemorad (Xeloda) 06/22; SBRT 11/22; Xeloda/Avastin since 01/24

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 11:43 am

Claudine,

Sorry I missed seeing in your signature that your husband's cancer has KRAS G12A mutation.
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 1:21 pm

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?
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 2:00 pm

prayingforccr:

You have been through so much. I am glad that artemisinin is working well for you. Good luck with your next scan!
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

utahgal7
Posts: 201
Joined: Fri Sep 11, 2020 12:04 pm

Re: Lung Nodules - any advice welcome

Postby utahgal7 » Thu May 12, 2022 2:24 pm

prayingforccr -

I don't want to pry. Did you have any symptoms with your lung nodules (i.e. shortness of breath, cough, etc)?

For the past couple of weeks, I have been coughing and I have trouble breathing. I know definitely that I don't have a cold.
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

roadrunner
Posts: 460
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: RC: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/19-10/19 4 rds.FOLFOX neoadjuvant, 3 w/Oxiplatin (reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
6/20/22 TAE rectal polyp benign)
NED from 3/22 - 3/23
4 cycles FOLFIRI
LUL VATS lobectomy for radio resistant met 7/7/23

Rock_Robster
Posts: 1027
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.
41M Australia
2018 Dx RC
G2 EMVI LVI, 4 liver mets
pT3N1aM1a Stage IVa MSS NRAS G13R
CEA 14>2>32>16>19>30>140>70
11/18 FOLFOX
3/19 Liver resection
5/19 Pelvic IMRT
7/19 ULAR
8/19 Liver met
8/19 FOLFOX, FOLFOXIRI, FOLFIRI
12/19 Liver resection
NED 2 years
11/21 Liver met, PALN, lung nodules
3/22 PVE, lymphadenectomy, liver SBRT
10/22 PALN SBRT
11/22 Liver mets, peri nodule. Xeloda+Bev
4/23 XELIRI+Bev
9/23 ATRIUM trial
12/23 Modified FOLFIRI+Bev
3/24 VAXINIA (CF33 + hNIS) trial

utahgal7
Posts: 201
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles

utahgal7
Posts: 201
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; 0.8; 1.1; 1.0; 1.1; 1.7; 1.8; 1.8
1.9; 2.4; 2.3; 2.8; 2.2, 2.8, 3.2; 3.0; 1.6; 2.0; 1.2
04/20 ST Radiation; 04/20 LAR surgery w/ileostomy; ypT3N1bM0; MSS, KRAS G12A
05/20 CAPEOX; 08/20 Ileostomy reversal
12/20 CT scan; lung nodules (watch and wait);
11/22 lung nodule biopsy positive for RC met;
1/23 VATS right lower lobe wedge resection
FOLFIRI 10 cycles


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