New lung nodules

[L0729]

Recent CT scan shows 3 new sub 4 mm lung nodules. (I already had 3 sub 4mm lung nodules at diagnosis last march) My oncologist not concerned and says we will scan in 3 months. At the time of CT was off chemo for LAR surgery. I feel the appearance of 3 new nodules is suspicious. Just completed 4 more adjuvant folfox and latest scan shows no Change in lung nodules from November but suspicious for metastases since they weren’t there in august per radiologist. Folfox had no effect on them. My questions: should I seek
Out a thoracic surgeon even though they are too small to biopsy? And if they are Mets why did chemo Not affect them. Thank you for advice

[roadrunner]

Your post raises a few questions for me:

1. When you say you had/have “sub 4mm” nodules, is that a catch-all for anything under 4—and are they different sizes—or are they all ~4mm?
2. What has happened to the nodules detected at diagnosis in the interval since they were found?
3. Can you provide a timeline for all scans and for the status of the “new” nodules? When were they first seen on CT? Did they change on subsequent scans? How do you know that “FOLFOX had no effect on them”?
4. Did you have any respiratory infections in the interval before they appeared. Any other respiratory issues, e.g., smoker, job-related?
5. When you say your oncologist “isn’t worried,” did he say why he’s unconcerned about these new nodules?
6. Do you know where they are located?

[L0729]

March 22, original CT showed scattered sub 4 mm right middle lobe, left lower. Non specific. Did not know how many nodules there were- thought there was 3
Had 4 rounds Folfox through April, rectal tumor and liver tumor very responsive. Lung nodules remained unchanged on May CT so assumed chemo did not affect them, possible benign
Off chemo for liver resection in June, did chemo radiation in July. August CT radiologist noted a few sub 3mm lung nodules in both lobes (one was 2 mm)
Lar surgery late October (no chemo since xeloda in July).
November CT noted multiple bi lateral sub 4 mm in right upper, right middle, left lower, a few new since august CT
Started adjuvant 4 folfox in December, march CT show continued liver and bowel clear, chest CT stable since November, however radiologist notes suspicious for metastases since change from august. There was also a notation of calcified granulomas. It seems one of the nodules might be a calcified granuloma?
From the start it’s been difficult to know how many nodules there are. After the new nodules appeared the oncologist said it had only been 4 weeks since my LAR surgery and he’s seen people develop nodules, was not overly concerned. I think until he sees growth he’s not going to do anything. I think the appearance of new nodules would indicate Mets and I should at least meet with a thoracic surgeon. I had not had any lung infections or any situation that might cause the appearance of new nodules (did have Covid but that was the end of dec). Every radiologist reports on the nodules just a bit differently so hard to know for certain how many there are, and exactly what size other than they are under 4mm

[roadrunner]

This seems like a very confusing picture. You’re right that there is variation in the way radiologists report things, and sometimes in the scans themselves (different machines use different “slices,” contrast vs. no-contrast, breath holds, etc.). When nodules are this small, the impact of those variations can be magnified. Here, without knowing the precise history of the original nodules (especially since you went off chemo), and the new ones, it’s hard to assess. The fact that you had FOLFOX for some of the observation period also complicated things. Systemic chemo can have beneficial effects on pulmonary metastases, but these can be subtle—it can result in stable disease as opposed to significant reductions. The new nodules, as your radiologist apparently noted, do cause increased concern, but without a detailed study of the images over time in light of the treatments you had, I suspect the picture may remain cloudy, and may do so even with such a study.

A surgeon could tell you, I think, whether surgery would be an option if some or all of these are metastases, or whether other options should potentially be considered (these may include SBRT, cryo-ablation, radio frequency ablation, and laser-assisted surgery (offered in Europe)). Certain surgeons might give you an opinion on whether the radiological evidence supports consideration of a surgical option. I would note, however, that with multiple uncharacterized nodules of this (small) size, there may be significant resistance to proceeding with surgery now.

I think if it were me, I would get a second opinion from a doctor (could be a specialized surgeon or—more likely—another oncologist) who’s qualified and—importantly—willing to evaluate the whole radiological history/picture as opposed to waiting for definition over time. I’d also be interested in your CEA number (unless it was never a marker). Sorry, I couldn’t be more helpful.

[L0729]

thank you roadrunner for the insights, much appreciated.
I had not considered that Folfox could have kept any of the original nodules stable ( I was looking for shrinkage) if they are indeed mets. The new ones again could have been kept stable from the november CT to the one I had this week, since I was completing 4 rounds of adjuvant folfox.
I am meeting with my oncologist Monday, so will get his take on a plan going forward.
I don't think it would hurt meeting with a thoracic surgeon now? Granted the nodules are too small for biopsy for surgical intervention but if they do grow I can get an idea on the best approach whether it be VATS, SBRT or ablation.
So I guess I have to wait for growth which may happen now that I am off chemo. Can anyone advise what chemo do they usually use for lung nodules? the same as the chemo for the primary?
My CEA was never taken initially unfortunately, as has been 1.8 since August, with the exception of the last draw it was 3.0 (just started the folofx so I don't know if that makes CEA go up). I don't believe CEA is a good indicator for me but I've also seen that sometimes that can change?
Thank you again for the advice, wishing you the best

[rp1954]

We assiduously tracked inexpensive bloodwork to track marker, inflammation and less specific indicators to extend scan and biological information with various hints and guidance for anti-inflammation and immune related treatments.

Commonly unmeasured inflammation, immune deficits and nutrient deficits fuel cancer activity that can be treated, often very inexpensively in the prevention mode. With several 6 mm lung thingies, we were happy to have oral maintenance immunochemo, without heavy chemo cycles, in place.

[L0729]

Thank you for the reply rp1954, happy to hear things have worked out!
what oral maintenance chemo was given, was it xeloda? You mentioned immune oral maintenance and I was curious if the original diagnosis was mss or msi.
Sounds like you were in top of the lung situation, was there other tests besides cea that were used for monitoring? My cea has not been a good marker and oncologist does not make use of signatera ( which I’ve heard is not as useful for lung nodules )

[roadrunner]

I’m definitely not trying to discourage a surgical consult. My guess is that most surgeons will want to wait for more definition over time. A good, patient one may go over potential approaches, but: Thoracic surgeons are busy, and—of course—are focused on surgical patients and therapies. There are multiple potential targets in your case, and all are very small. That’s not an ideal situation for a surgeon. So you may not get a comprehensive or even definitive picture from a surgeon at this point. It’s also the case that other potential therapeutic approaches are often the province of specialized oncologists or even interventional radiologists. (E.g., you’re best off talking to a radiation oncologist about SBRT.) But I agree with you that it might be wise to get a second (or third) perspective on what’s going on now. A good, caring oncologist should be able to do that. Going back to your current oncologist with clear direct questions that demonstrate engagement, understanding, and your desire for clear information is a good move (not saying you didn’t already do this, just stressing it here), but in a complicated Stage 4 context (maybe in any Stage 4 context), second and/or third opinions are nearly a requirement. This feels like an oncologist second opinion to me more than a surgical one, but —definitely—the more the merrier.

By the way, as you can to some extent see from my signature, I had one, and likely 2, pulmonary metastases, and I consulted with my medical oncologist, my radiation oncologist (a wonderful, caring, super capable doctor), my colorectal surgeon (a pioneer in CRC, and with the understanding that we were really just “shooting the breeze”), and two thoracic surgeons. I’m very happy with the information I got and the approach I chose, but there can be lots of options and no perfect path. I like maximal information as a baseline, but I have no problem waiting for definition where that seems best, too. Good luck!

[rp1954]

...what oral maintenance chemo was given, was it xeloda? You mentioned immune oral maintenance and I was curious if the original diagnosis was mss or msi...was there other tests besides cea that were used for monitoring? My cea has not been a good marker

We used UFT, a mild 5FU prodrug, developed in Japan ca 1984. Ineffectively marketed and applied, it is not available in the US and Canada. Xeloda is what is available and ADAPT++++ is closer to what we did.

Some members have had more CA199 marker activity but CA199 is more affected by inflammation and should be used with inflammation markers like hsCRP, ESR, fibrinogen. LDH and GGTP are nonspecific markers that take on new meanings and ranges after a CRC diagnosis. Take a look at my posts with IM64 and how has he posted blood data, although I prefer a worsheet.

[L0729]

Thanks roadrunner. You make some good points about thoracic surgeons being busy and I’m not there yet with needing a consult. I like to have a plan, and fall back plans, it helps me process all of This even when things don’t go to plan. I am going to reach out to radiation oncologist and speak with my oncologist as well. Will try to get a second opinion with an oncologist at Sloan Kettering regarding lung nodules. I see you had some time between when your lung nodules grew and when you treated them, typically lung nodules slow growing?
Happy to see you have the worst behind you!

[L0729]

Thank you for the information rp1954, will check this out. You’ve been very helpful. Appreciate the reply

[beach sunrise]

I also have a few small nodules. I track all Rp said plus I would like to add to it: IL-6, IL-8, IL-2. The IL's also relate to lung inflammation. My IL-8 has been high since the beginning while I also had one nodule just sitting there. Now I have 3-4 potentionally so the IL-6 is beginning to climb out of normal range.

[roadrunner]

LO729:

I think your plan of multiple consults is great. Take good notes, of course! That will help when/if you get to a surgeon. These are complicated issues and choices, and keep in mind that consults (especially surgical consults) are like a job interview. Best to seem informed, rational, focused, straightforward, etc. My 2 cents is: Channel an airline pilot. Totally fine to freak out later.

As far as my timing is concerned, my team suggested a wedge early based on pretty limited growth. If I recall right, mine were 4-5mm at that point. But one was sub-pleural, and thus an easy wedge. I was concerned about the more central one, and, frankly, may have been hoping the nodules would turn out to be benign given their size and limited/unclear growth. They went through the next scan (3 mo.) cycle with no observed growth, but then the sub-pleural nodule showed growth, so it was definitely time to act.

Generally, yes—CRC pulmonary mets are slow-growing, but that’s all relative. If I recall right, the range is about 30-120 days for volume doubling. That translates to size on a scan as follows: a nodule “doubles” when the scan size increases by .26X. Thus, a 4mm nodule has “doubled” when it reaches 5.04mm. Small nodules like yours are tricky, though—there’s comparatively large inter- (and even intra-) observer variability, machine variables, etc. that are magnified by the comparatively small size. Also, they’re below the PET threshold. I worry a bit that I left them in there for a few months when I “shouldn’t have,“ but it was within a reasonable approach (I think), and metastasis from metastases is not a clear thing, especially with such limited disease. I guess I’ll find out in a few years ; )

And as far as “the worst is behind me” goes, I appreciate the good wishes, but I’m certainly not out of the woods yet. I’ve got a decent shot at continued good health, I hope, but it’ll be a few years before I get comfy at all, and I won’t really breathe easy until I die of something else ; )