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Forum Name: Lung Cancer

Question: Lung mass - conflicting diagnosis


 TITASGIRL - Wed Jan 25, 2006 3:48 pm

I took my grandmother to the ER a 3 weeks ago and the ER doctor did a CTscan and an Xray and determined that she had malignant lung cancer. She was a smoker for 50 years and quit in 1997. This diagnosis was a surprise since she had seen her pulmonologist 2 weeks prior to that and he did the same tests. The pulmonologist has put her on 2 heavy antibiotics (AFTER THE ER VISIT) and wants to see her tomorrow, which will have been 2 weeks since she started them. In the CT scan, the mass was very jagged and had black lines which the pulmonologist seems to believe are air pockets. When she initially went to the pumonologist and had these scans done, he mentioned TB or some other infectious disease. He said cancer was a remote possibility. She had a breathin test done last week and all of her numbers were in the 90s except the one where she exhales which was in the 40s. I just got her blood work from the hospital back and the results are as follows. Does any this give any indication on whether this might just be an infection or if it is lung cancer?

WBC 9.9
RBC 5.06
HEMOGLOBIN 14.2
MCV 28.0
MCHC 32.6
RDW 14.7
PLATELET 307
MPV 8.0
NEUTROPHIL # 6.7
NEUTROPHIL 67.7
LYMPHOCYTES 23.2
LYMPH 2.3
MONOCYTE 6.4
MONO 0.6
EOSINOPHIL 2.5
EOSINOPHIL # 0.3
BASOPHIL 0.2
BASOPHIL # 0.0
PT 12.4
INR 1.06
APTT 27.8
D-DIMER 437.8
MAGNESIUM 2.0
MYOP 74.4
SODIUM 140
POTASSIUM 471
CHLORIDE 107
CO2 22.5
HCT 43.5
GLUCOSE 22.5
CREAT 1.5
BUN 1.5
CALCIUM 23
TOTAL BILI 0.8
ALT (SGPT) 17
AST (SGOT)19
GAMMA GT 13
ALK PHOS 74
LDH 222
TOTAL PROTEIN 7.8
ALBUMIN 3.1
TRIGLYCERIDES 145
CHOLESTEROL 123
HDL 39
LDL 58
LDL CALCULATED 55
VLDL CALCULATED 29
A/G RATIO 0.6
TROP 0.0
 Dr. A. De la Guerra - Mon Jan 30, 2006 6:51 pm

User avatar Hi Titasgirl,

I will be glad to help you, though some important information is missing (why did your grandmother went to the pulmonologist the first time, why was admitted to the ER, where is the “mass” localized and what size is it, does she has or has had any pulmonary disease, and her age).

Regarding your question about the possibility that a blood work might rule out cancer, unluckily lung cancer can not be diagnosed with any type of laboratory test (neither breathing tests). Lung cancer can only be confirmed by a trained pathologist after microscopic examination of a sample of the lung lesion. Therefore, a biopsy is required to obtain that sample. However, blood tests are very useful to bear out infectious diseases, like pneumonias. The results you have posted appear to be inside acceptable ranges, and do not suggest any infection. About her breathing test, smoking is not only responsible for 90% of lung cancer (and more than 30% of all cancers), but also causes (and much more often) COPD, a chronic pulmonary and irreversible disease, that impairs lung functions (showed by the “exhalation” value in the 40s).

Typically, almost 90% of young adults with pneumonia have fever, chills, cough with phlegm, shortness of breath, and chest pain; less than 40% of elderly patients have those symptoms. That’s the reason why diagnosis of pneumonia in the elderly is not an easy task, and 30% of the patients are initially misdiagnosed as not having pneumonia. Another problem is that chest X-rays (CXR) may not return to normal after appropriate treatment; only 50% have normal CXR after 2 weeks, 75% after 6 weeks, and it may take up to 3 months in elderly individuals.

As well, unfortunately, sometimes pneumonia is a complication of an underlying lung cancer. About 4% of adults with a diagnosis of pneumonia are found to have lung cancer on investigation. In current or ex-smokers, aged over 50, cancer is found in as much as 16% of the cases.

I don’t have enough information to estimate the likelihood of a pneumonia, but I feel one of the reasons why the pulmonologist considered that chance is the presence of black lines within the lung “mass” (based on the description you made of it), which is a CXR feature commonly associated with pneumonias and other lung infections. But unfortunately, while chest CT is extremely specific for certain benign lesions, most abnormalities remain indeterminate and lung cancer cannot be excluded, and patients may then proceed to an invasive procedure for diagnosis.

What do experts recommend about pneumonia:

1. Patients who still have symptoms or physical signs or who are at higher risk of underlying cancer, especially smokers and those over 50 years, should have a CXR done after 6 weeks of finishing treatment.
2. Further investigations, which may include bronchoscopy or biopsy, should be considered when signs, symptoms, and radiological abnormalities persist at around 6 weeks after completing treatment.

Although I said that symptoms and radiologic signs are not always reliable to assess pneumonia in the elderly patient, considering it has been more than 6 weeks without a consistent diagnosis, and most important because of your grandmother’s risk factors for lung cancer (age, I guess she’s over 50, smoking history and COPD), my advice is to think in the possibility of lung cancer and try to rule it out by whatever method is easiest. Sputum cytology is a reasonable first step when the tumor is centrally positioned, but diagnostic accuracy depends on many factors (acquisition, handling, and interpretation of samples), and flexible bronchoscopy is more useful in those cases, whereas in peripheral lesions, transthoracic needle biopsy is the best method.

I will be looking forward to the results.

Best luck,

Dr Torax
 TITASGIRL - Mon Jan 30, 2006 8:43 pm

Hello Dr. Torax,
We took her to the ER on 1/10 because we thought she might have pnemounia. The doctor there did a chest x ray and a CT scan and diagnosed her with malignant lung cancer which was a shock seeing as we just had seen her pulmonologist 2 weeks ago and had the same tests. We took her to see a pulmonologist because she is a former smoker (50) years probably and she has emphysymia and COPD. on the 12th her pulmonologist prescribed 2 heavy antibiotics for her thinking that the mass was an infection and wanted to see her in 2 weeks to do a chest x ray. That was this past Thursday. He did the x ray, but there was a lot of fluid on the right lung and he said he could not really see the mass, but he thought it had shrunk. He gave her lasiks and wanted her to take 1 pill that day and 1 the next and get another CT scan the following day. She ended up being allergic to the lasiks. She had the CT scan and here is the report.

FINDINGS: Again noted is a ill defined right apical pleural-based mass with adjacent pleural thickening. Pleural mass measures approximatly 1.9x4.5 cm, (back in September it was 2.5cm) not significantly changed. Extensive underlying pulmonary emphysematous changes are noted. Multiple small bilateral pulmonary nodules are present. 2 right lower lobe nodules are increased in size with the largest measuring 1.3x0.7. Punctate left lower lobe nodule appears new. Mediastinal and right hilar lymphadenopathy is not significant changed with subcarinal node measuring 4.4x2.7 cm. The right effusion is increased.

IMPRESSION: 1. Right upper lobe pleural based mass likely representing primary bronchogenic neoplasm. This is amenable to CT guided biopsy.
2. Mediastinal lymphadenopathy without significant interval change.
3. Additional pulmonary nodules concerning for metastatic disease. Several are increased in size.


Today she had thoracentesis and they removed 1 liter of fluid. Her oxygen level went up 10 points immediatly. I spoke with her doctor and than later the radiologist and he said that the pleminary findings on the fluid were inflammatory. The radiologist said this was very good news suggesting infection not cancer.

Does this sound plausable to you and should I have any hope???? Thanks for your previous response :)
 Dr. A. De la Guerra - Tue Jan 31, 2006 1:32 am

User avatar Hello again Titasgirl,

Thank you for the additional information.

The CT scan findings don’t look very well, and the radiologist’s impression is consistent with lung cancer. Compared with the scans done in September it shows more and bigger lung lesions. I think the probability of lung cancer is very high. In addition, lung cancers can cause fluid to collect in the sac surrounding the lung; this is called pleural effusion. Sampling this fluid can confirm the presence of cancer, however, malignant effusions can be diagnosed by pleural fluid alone in only 60% of cases, so if the first pleural cytology specimen is negative, this should be repeated a second time. Certainly many other pulmonary and systemic diseases can be the origin of a pleural effusion, thus, regarding the preliminary findings on the fluid, as I point out on my previous post, definitive diagnosis of cancer is made under a microscope, therefore, is better to wait an see what does the cytopathologist has to say.

I saw you posted a question in a new thread here:
http://www.doctorslounge.com/oncology/forums/viewtopic.php?t=11960
I will answer it with more detail in a few hours, but remember to keep all related posts in a single thread. In advance I can tell you that doctors have said it might be inoperable because lung cancer patients who have pleural involvement, mediastinal lymph node enlargement and other tumors somewhere else in the lungs are not good candidates for surgery. There are other options of treatment.

I truly hope it is not cancer, I wish the best for you and your grandmother.

Sincerely, Dr Torax.
 TITASGIRL - Tue Jan 31, 2006 2:50 am

Thanks Dr. Torax for your help and analysis. Sorry about the other thread, I thought that each subject should be a separate thread...lol. So since we are looking at most likely a diagnosis of lung cancer, based on what you have seen, does she have a reasonable chance of survival for the next few years??? I know there are different types, and staging is important too, so I don't know if this is a question that can be answered at this time. Also, is there anything indicitive to you in these reports that would cause you to believe that this is an infection? We are seeing a pulmonologist who has a wonderful reputation and came highly reccomended and I am just not sure how he could look at the same films as the radiologists keep looking at and up until last Friday he was still pretty certain this was an infection. Sigh.
 Dr. A. De la Guerra - Tue Jan 31, 2006 9:38 pm

User avatar Hi Titasgirl,

Even though your recent posts are pretty clear, as you can imagine is not easy to be convinced of any diagnosis based only in the information provided. Basically, a patient with a heavy smoking history, aged over 50, with a lung “mass” that was not present on a previous CXR (or if no CXR are available to compare), symptomatic or not, needs to be evaluated to exclude lung cancer, unless the “mass” has unmistakably characteristics of benignity on a CT scan. The same is true when the “mass” was present on a CXR, and has grown. PET scan is a non-invasive test, highly sensitive for identifying malignant nodules, but is not always available. Observation and follow-up is a valid option, but in my opinion, too risky. In these situations I recommend a biopsy, either by transthoracic fine needle aspiration or through a bronchoscopy (except for tumors only reachable by open surgery). My opinion not only relies on your grandmother’s age and past medical history, but on the duration of her disease, and on the fact that although she has been under broad-spectrum combination therapy, her condition has worsened, as deduced from the radiologist report. An unusual lung infection could have a similar outcome, but in that case, also a more aggressive approach to diagnosis will be justified, which may include bronchoscopy and even needle aspiration of the lesion.

Regarding your question if something indicates this can be an infection, as I said somewhere else on this thread, diagnosis of pneumonia in the elderly is not an easy task. As well, I’m missing an important piece of information to answer: the CXR and CT films. Sometimes pulmonologists and thoracic surgeons can have a very clear approach to diagnosis after meticulous examination of the CXR. At this time, with this information I cannot tell this is not pneumonia, nor it is. So, if the pulmonologist is still pretty certain this is an infection, we should trust him and wait for the cytology test.

About your question on survival (if it’s cancer), you are right, can’t be answered at this time. To decide on the appropriate treatment and give a prognosis we need to know the stage of the disease and the performance status of the patient. Furthermore, even for the most experienced cancer expert it’s complicated to predict how long someone will live; patients are unique individuals and diseases affects them differently.

I will be waiting for the results.

Sincerely,

Dr Torax.
 TITASGIRL - Tue Jan 31, 2006 9:39 pm

Hi Dr. Torax,
I am a little confused. You indicated that the mass has grown since September. In September it was measured at 2.5 cm and recently it was measured at 1.9x4.5 Am I looking at the wrong numbers? They didn't have a second number for September. Thanks as always for your help!!!!!
 TITASGIRL - Wed Feb 01, 2006 10:34 am

Hello Dr. Torax,
I'm not sure what happened to my response to your post last night. The one that is after yours...we must have posted at the same time...lol! I am waiting on the results of the fluid. She feels a lot better and her breathing is a lot easier. Could you please define for me what you meant by "unmistakably characteristics of benignity on a CT scan" Despite how everything turns out we have scheduled her for a bioposy on 2/13. Thank you again for all of your time and analysis.
 Dr. A. De la Guerra - Thu Feb 02, 2006 1:12 am

User avatar Hi Titasgirl

Yes, we posted at the same time (1 min), lol.

About your concerns on the size of the “mass”. Mainly. there are two ways to evaluate if a lung lesion has grown: one is determining its growth rate by comparing its size on a current image with that on prior images, using the maximum diameter; the other is to judge against volumes. On September the diameter was 2.5 cms, and on the last report it was 1.9 x 4.5 cms, being 4.5 the largest. Anyway, I was not talking about that particular value, the radiologist reported more lung lesions that where larger than previous ones:

FINDINGS: Again noted is an ill defined right apical pleural-based mass with adjacent pleural thickening. Pleural mass measures approximately 1.9 x 4.5 cm, (back in September was 2.5 cm) not significantly changed. Extensive underlying pulmonary emphysematous changes are noted. Multiple small bilateral pulmonary nodules are present. 2 right lower lobe nodules are increased in size with the largest measuring 1.3 x 0.7. Punctuate left lower lobe nodule appears new. Mediastinal and right hilar Lymphadenopathy is not significant changed with subcarinal node measuring 4.4 x 2.7 cm. The right effusion is increased.

IMPRESSION: 1. Right upper lobe pleural based mass likely representing primary bronchogenic neoplasm. This is amenable to CT guided biopsy. 2. Mediastinal Lymphadenopathy without significant interval change. 3. Additional pulmonary nodules concerning for metastatic disease. Several are increased in size.

About explaining what are "unmistakably characteristics of benignity". There are some highly reliable findings of benignity on CT scans, like degree of enhancement of the lesion, type of margins and contours, and other internal characteristics, like presence of fat inside the lesion, some patterns of calcification inside the tumor (central calcification in benign tumors), etc.

Hope you find the information useful.

Good luck,

Dr Torax
 TITASGIRL - Mon Feb 06, 2006 10:41 pm

Hi Dr. Torax,
Well, it turns out she does have lung cancer. They believe that it is either stage 3B or stage 4. They are thinking stage 4 since there were cancer cells in the pleural effusion. Do you know anything about that new drug Tarceva abd if it would work for her? We go to our first Oncologist appointment tomorrow. Wish us luck! Any advice as we go further?

Thanks
 Dr. A. De la Guerra - Tue Feb 07, 2006 10:33 pm

User avatar Hi Titasgirl,

I’m really sorry to hear they confirmed it is lung cancer.

About the stages of lung cancer, if the pleural fluid shows malignant cells it is IIIB, but if a pleural biopsy is positive it is stage IV. Also, if the CT shows other lung tumors, even if they are small, it is also classified as stage IV disease.

Patients with stage IIIB or IV do not benefit from surgery and are best managed by chemotherapy, radiotherapy, or a combination of both, depending on the sites of tumor involvement, and most important, on the patient’s performance status (general health condition). That’s because, even though there can be many treatment alternatives, the patient may not be able to tolerate them. Patients with excellent performance status can have combined therapy; however, patients with malignant pleural effusion are not always candidates for radiotherapy and usually are treated like stage IV patients, with chemotherapy.

Currently, in patients with inoperable stage IIIB or IV disease, specialists recommend as first-line chemotherapy (initial drug preference) a combined drug regimen (platinum-based or not). For patients with adequate performance status who have failed on first-line, platinum-based therapy, Docetaxel (brand name: Taxotere), is recommended as second-line therapy.

Unfortunately, treatment with those kinds of drugs may be contraindicated in elderly patients because of age-related impairment of organ functions and/or the presence of other diseases. Doctors must evaluate performance status and other illness co-existence rather than age when choosing treatment options for elderly patients.

Erlotinib (brand name:Tarceva) is recommended for the treatment of patients after failure of both platinum-based and docetaxel chemotherapies. This drug has a different mechanism for stopping cancer cells from growing and multiplying than those of chemotherapy and hormonal therapy. Erlotinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.

Because elderly patients with advanced lung cancer typically have few treatment options, investigators carried out clinical trials using Erlotinib as single therapy in elderly patients without prior chemotherapy; studies demonstrated tumor shrinkage good enough to help restore quality of life so that patients can carry on recreational activities. Other benefit of the drug is it can be taken once a day by mouth.

Age itself should not preclude an elderly patient from receiving chemotherapy. Currently, single-agent chemotherapy and nonplatinum or platinum-based doublets can all be considered as appropriate treatment for elderly patients with good performance status. Doctor’s judiciousness, drug toxicity profiles, presence of other diseases, and patient preferences are fundamental to decide on which drug to use.

If your grandmother’s health condition isn’t good enough to tolerate regular chemotherapy regimens, Tarceva is a good choice.

I wish luck to you and your grandmother,

Dr. Alberto de la Guerra

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