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?