Biopsy results following CT and Pet

[kri312]

Thoughts on how to assess this? Had routine CT scan in November and there was slight changes to the site of the scarring from my R UL wedge resection (also had R LL lobectomy at the same time) 5 years prior. Scans prior to this were all clear. MD wasn't concerned but said to come back in 6 months vs. a year, as it was the responsible thing to do. Below you will see the findings from the April CT scan- similiar findings with very slight increases from Nov CT.

He suggested to do a PET to rule out anything ( he knows I am an emotional mess). See the PET results - he also wasn't super concered and suggested a biopsy - again more to help with my anxiety over what might be there.

Biopsy results are listed - he said they are good but not great due to the miminal findings of rare atypical cells. He said this could be due to small infection that has just been brewing (put me on antiobiotics), residual issue with COVID diagnosis last June, changing scar tissue which is normal OR very early recurrence. He is repeating PET in 3 months- feel like just kicking the can down the road.

Of course I now how SOB - aniexty? Wild fire air quality issues in northeast? Relentless humidity? Mild morning cough but do have post nasal trip issues and just got over a mild upper respiratory infection (sore throat, cough, stuffy nose). For those who have dealth with recurrenes, did you know before the scan definitively picked it up.??? He reassured me that EVEN if it was a recurrence, it is very treatable and he again said he is not concerned! His calm demeanor is always very reassuring however....it takes work to redirect ones thought process to doom and gloom with more tests!

CT FINDINGS:

Lungs and pleura: Status post right lower lobectomy. Postsurgical changes in the right upper lobe with predominant stable thickening and nodularity along the suture line. Along the medial aspect of the suture line (4:61) there has been mild thickening dating back to 2019 but stable as compared to the most recent exam. Mildly increased ground-glass changes are noted adjacent to this thickening (4:60). No new or enlarging pulmonary nodules.

PET CHEST:

Lungs: Postsurgical changes status post right lower lobectomy and right upper lobe wedge resection. Thickening and nodularity along the suture line, increased since 2019, with heterogeneous mild radiotracer uptake most predominant snteromedially with SUV max 2 (3:83). Adjacent ground-glass changes are stable compared to the most recent CT(4:82).

Airway: The trachea and central bronchi are patent.

Mediastinum, hila and lymph nodes: No FDG avid mediastinal node.

Heart, vascular structures and pericardium: The heart, major vessels and pericardium are normal.

Soft tissue: The other soft tissues / organs do not demonstrate abnormal radiotracer uptake.

SURGICAL PATHOLOGY

**See Addendum/Procedure**

SPECIMEN: Lung, RUL, navigational cryobiopsy

DIAGNOSIS(ES):

Lung, RUL, navigational cryobiopsy:

Lung parenchyma with focally minimal fibrosis, no explanation for a nodule is seen, no granulomata or carcinoma seen. Awaiting 6 additional levels.

Date Dictated: 6.14.22

INTERPRETATION:

ATYPICAL

Thin Prep slide and cell block section show:

Rare atypical epithelial cells; there are too few cells present for a definitive diagnosis.

Few pulmonary alveolar macrophages and predominantly blood.

NON-GYN CYTOLOGY

**See Addendum/Procedure**

SPECIMEN:

Respiratory, right, bronchial lavage

GROSS DESCRIPTION:

One CytoLyt solution received. 1 ThinPrep and 1 cell block prepared. Acid fast, Pneumocystis and Gomori methenamine silver staining performed on cell block sections.

CLINICAL HISTORY: Lung nodules.

DIAGNOSIS(ES):

SPECIMEN ADEQUACY:

NON-DIAGNOSTIC

There are too few cells present for diagnosis.

INTERPRETATION:

NO DIAGNOSIS RENDERED

ThinPrep slide and cell block section show:

Rare neutrophils.

Few red blood cells.

ADDENDUM

Six additional levels of blocks A1 and A2 of the lung biopsy have been examined and again unremarkable fibrovascular tissue and lung parenchyma is seen. No inflammation, granulo

mata or neoplasm is identified.

[JanetteR57]

Anxiety is natural in such situations but not our friend as it can add to or create symptoms including shortness of breath which as you rightly say, could also have a number of other causes.

I had upper left lobectomy (thoracotomy) in Dec 2010 and 7cm adenocarcinoma removed. After about 18 months, I had symptoms including SOB, wheezing, inability to climb stairs despite having relatively good fitness when swimming so my consultant did what yours did - and investigated further with bronchoscopy and scans but what had been thought to be potential recurrence turned out to inflammation on the scar/stump area from surgery. I read the book 'cancer is a word not a sentence' by Dr Rob Buckman which helped me stop thinking that every symptom must be related to the cancer diagnosis.

I have had some nasty chest infections between 2015 and 2019 which hospitalised me every year - including pneumonia, pseudomonas and RSV - all with much worse symptoms than my original cancer diagnosis and had bronchial lavage which found the pseudomonas. Thankfully none turned out to be serious but that didn't take away how scared I felt at the time when it was hard to look forward to the future.

Since 2013 I've been involved in lung cancer research and screening committees and so pleased in the UK we've now got recommendation to screen for those most at risk of lung cancer although as a never smoker and 52 at the time, I would never be eligible - but it's a great start. From that work, I've learnt that many many people have lung nodules including ground glass opacities and most do not develop into anything but there are strict pathways in place to monitor them. Reading your post, it appears your clinician is doing everything possible to investigate and reassure you - fingers crossed that things improve for you soon. We often think things on imaging reports sound serious - I remember being quite panicked reading 'atelectisis' and the hand surgeon I was being treated by wouldn't agree to nerve release surgery until the respiratory consultant had given him the ok. the respiratory consultant said it was a natural reaction to anyone who'd had a bronchoscopy whereas I was imagining the worst! If you've had respiratory or chest infections or any infection recently, that can lead to inflammation which can make the appearance of existing scar/fibrosis worse and can also inflame lung nodules and lymph nodes but as the infection settles, often so do the other aspects which is why they rescan a few months later. the addendum to the latest report sounds reassuring to me - 'unremarkable', 'no inflammation, granulomata or neoplasm evident and too few irregular cells to identify anything. '

Sounds to me as if he has eyes all over your case and keen to reassure you - so hope you can take some comfort from that and live your life with more hope. worrying about the 'what if' saps life and energy - physical and emotional from us. better to focus on the 'what is'.

good luck.

[kri312 in reply to JanetteR57]

I’m curious to hear about the scare 18 months that turned out to be inflammation from the scar / surgery. Did that light up on a pet scan? That worries me more than the changes in the CT scan.

[JanetteR57 in reply to kri312]

it wasn't caused by the surgery - but inflammation/infection that had affected the stump/surgery. I didn't have another PET - the CT showed the area so the respiratory physician did the bronchoscopy and found the inflammation at the 'stump/scar' site.

PET scans can have false positives and negatives hence using it in conjunction with other tests - no imaging test on its own can confirm malignancy.

The point of explaining my experiences was to highlight the many incidences I've had that I could have assumed were sinister. Thankfully in my case none turned out to be and I've lived a generally active life, working, travelling and swimming despite these. I also went onto swim much further than the 130 x 25m lengths 2-3 times a week that I did pre-surgery.

Having lost 2 sisters and a niece - none from cancer - all unexpectedly and prematurely has only added to my outlook to try and live live as it is rather than worrying about 'what if' wherever possible.

thinking of you. good luck.

[kri312 in reply to JanetteR57]

Thank you...the mental aspect has been the bigger challenge here for sure! Physically I feel great!

[Denzie Moderator Volunteer]

what struck me most about your posting was your oncologist responsiveness to your concerns. It appears that they listened to you.

What I am curious about on the CT report came at the end , what are the changes to the ground glass nodules? Are they increasing in size or developing solid portions?

I think the SUV rate is borderline and with the recent history of Covid and the respiratory infection can easily account for that. It’s good that your follow up will be short term.

[kri312 in reply to Denzie]

Unclear about the ground glass. He said that wasn’t concerning to him and felt it was more of a changing sca4 tissue and he had many people look at the ct scans- because he was so unclear as to it’s findings.. COVID was last June. Recent respiratory infection was sadly after all these tests. He says he could go in and surgically remove but until convinced it’s a recurrence doesn’t want to remove more lung . Biopsy didn’t show definitive anything.

[Denzie Moderator Volunteer in reply to kri312]

Sorry I misunderstood. Thank you for clarifying. The next couple months while you anticipate the next test is going to be tough. Do you do something specific to help with anxiety? Do you meditate? Exercise? Something else?

[kri312 in reply to Denzie]

Yes I exercise daily. Have tried meditation however can’t redirect my thoughts during that time - clearly a mediation failure 🤪! The closer the time gets , the harder it gets. 🤞