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Monitoring a lung nodule - when to biopsy?
I've had rheumatoid arthritis (RA) for 20 years and never had any lung involvement. I have not been on any RA treatment for two years due to low white counts and persistent infections. I had a 9 mm solid nodule found on a CT scan in January which was done for epigastric pain. The nodule is along a lung fissue and has several smaller satellite nodules. It's atypical in shape. There's no calcium in the nodules or surrounding thoracic lymph nodes which are also enlarged. Had a second CT scan in May. Depending on how one measures the nodule, it looks to have changed shape and increased in size to 1.2 - 1.5 cm over a three month period (screenshot of latest scan attached). I have no noticeable symptoms and have never been a tobacco smoker.
I first saw a pulmonology Physcian Assistant (PA) at the local hospital who got me in rather quickly after I called to triage the case. She reviewed the case with her supervising interventional pulmonologist and she said it might be sarcoidosis or RA nodules with malignancy being further down as a possibility. She ordered a follow up CT which is scheduled for Aug 14.
I also got an appointment with a Duke Interventional Pulmonologist. It was at their Thoracic Cancer Clinic, a world class clinic, which feels quite daunting on a first visit. But everyone was amazing and the system ran like clockwork. I first spent time with the Fellow who was very professional and knowledgeable. He went over my scans and talked about algorithims used to gauge risk calling my case "moderate". He then shared everything with the main Pulmonologist who came in and spent considerable time with me. He said that he didn't think it was sarcoidosis because of a lack of calcium deposits on the nodule and lymph nodes. He said it could be RA nodules or a mycobacterium infection. If either were the case, he said the nodule might start getting encapsulated killing off that section of the lung and would show up on future scans. Malignancy is a possibility but he felt less likely. The only way to rule out malignancy is through a biopsy which he said might need to be done using robotic broncoscopy or even open surgery given the location of the nodule. He ordered a CT scan for three months out with a follow -up appointment the same day (benefit of a huge cancer center). This scan and appointment is Oct 18.
Long background to get to my questions...
1. Should I get both CT scans from separate hospitals - one Aug 14 and one Oct 18? Or should I just stick with one scan? If one, which?
2. At what point do I insist on a biopsy? The first PA said that if at anytime I wanted to just stop and request a biopsy, to say the word and they'd schedule it. The Duke doctor did not offer that and said let's wait until the next scan before making a decision. If a biopsy is done, I'd prefer to have the Duke people do it.
3. Anything else I need to consider in this situation?
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@happydappy
Welcome to Mayo Clinic Connect!
Any lung nodules seem to be confusing. Having RA adds another factor to consider.
I think it’s great that you have been seen at Duke!
As to which CT to do I would have it done at Duke.
After the CT you will get the result the same visit and get an opportunity to discuss options with the Pulmonologist.
I have been followed for pulmonary nodules for 2-3 years now. The last CT showed one had grown and looked suspicious for adenocarcinoma.
I’m having a biopsy in a week.
In general, most lung nodules are benign.
I’m sure Duke is going to help you making a decision.
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1 ReactionThanks for the reply. Here's hoping that your biopsy goes smoothly and they find nothing of concern.
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1 ReactionI just got visit notes from the Duke pulmonologist...
"This is a 62 y.o. male who presents with a 2 cm solid peri-fissural right middle lobe lung nodule, enlarged by comparison to 01/2023 when first (incidentally) detected on CT abdomen and pelvis. My overall clinical pre-test probability for malignancy is low-moderate, and I favor possible diagnosis of atypical or mycobacterial infection (noting history of immune suppression, though he should not be at asymmetrical risk for this at this time given hiatus from DMARDs and Biologics). Differential includes rheumatoid nodule, sarcoid (would be an atypical picture for sarcoidosis but still possible), and/ or malignancy.
Biopsy would prove challenging from any angle, noting peripheral location (likely outstripping even robotic capabilities), peri-fissural position (rendering CT-guided biopsy more risky). In this setting, favor close follow up in 3 months time with same-day CT chest. If enlarging, could consider referral to thoracic surgery for excisional biopsy."
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1 ReactionI would stick with the Expert Center - experience is critical. Lung biopsies are not to be taken lightly.
And the experienced center will specifically set up scan machines to pick up nodules.
I had similar situation. I had abnormal chest x-ray, and first saw local Pulmonologist (MD not a PA!). She ordered CT scan and then PET scan which both "screamed" cancer (I read the reports). Her main interest was asthma and not lung cancer. She wanted to do diagnosis there and ordered a needle biopsy, but their Radiologist refused to do it as it was too risky and would not get enough sample to warrant risk. I had my scans sent to Mayo Clinic and they called me immediately. They gave me biopsy/surgery date. They were setting up a program to do biopsy and surgery in the same procedure. If it looks suspicious, they take it out at the same time so one does not have to come back a second time. And mine was cancer. And Mayo could offer me Video Assisted Thoracic surgery which is a heck of a lot easier for the patient than open chest!!!
One wants a Specialist with lots of experience in the specific area - in a center that can offer you full range of procedures. The others follow the "guidebook" but without experience to understand that there is risk in certain procedures, and it may not be warranted to take such risk.
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3 ReactionsThanks for the advice. It sounds like expert medical centers are worth the effort. Glad the Mayo Clinic took your case and hope you're doing well now.
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1 ReactionI always look for people with knowledge no matter what I need. I have saved lots of money by checking things out!
In my case, I was fortunate. Because I have a complex type of cancer (multifocal) and it never really ends. Going directly to Mayo saved me time and unnecessary procedures.
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2 ReactionsGood Luck. Hope the nodule is benign. I have Sarcoidosis and my nodules come and go
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