Pulmonary Nodule Screening in Smoker by Jeffrey Dach

A friend who has been a heavy smoker for many years underwent
screening Lung CAT scan and a small spiculated density in the upper
lobe was detected. The density was thought to represent either a small
spiculated cancer or perhaps merely inflammatory scarring about 12 x
16 mm in size.

There was no mediastinal adenopathy, and the lungs showed mild COPD.
A PET scan showed only very slight activity in the nodule, so there
was still some question about whether the nodule should be removed
surgically, or adopt a wait and see approach.

The patient waited 12 weeks and had a follow up PET scan which showed
again very slightly increased activity in the nodule compared to the
first PET scan.

I found this to be unusual to follow a nodule with serial PET scans as
the standard method is to follow with serial high resolution CAT scans
at 12 week intervals to assess change in size and growth. Although
the PET scan comes with an accompanying CAT scan, this is a non-
diagnostic CAT for anatomic localization of the PET findings and not
considered adequate for accurate assessment of change in size of the
nodule.

On the basis of the second PET scan, the surgeon recommended
thoracotomy. The patient (who was age 75) declined and opted for a
second high resolution CAT scan to be performed at the 12 week follow
up mark to assess size.

Any Comments?

Jeffrey Dach MD www.drdach.com

Screening for lung cancer:

Radiology. 2005 Apr;235(1):259-65. Epub 2005 Feb 4.

Full Text:

http://radiology.rsnajnls.org/cgi/co...full/235/1/259

CT screening for lung cancer: five-year prospective experience.

Swensen SJ, Jett JR, Hartman TE, Midthun DE, Mandrekar SJ, Hillman SL,
Sykes AM, Aughenbaugh GL, Bungum AO, Allen KL.
Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905, USA. swensen.stephen@mayo.edu

PURPOSE: To report results of a 5-year prospective low-dose helical
chest computed tomographic (CT) study of a cohort at high risk for
lung cancer.

MATERIALS AND METHODS: After informed written consent was obtained,
1520 individuals were enrolled. Protocol was approved by institutional
review board and National Cancer Institute and was compliant with
Health Insurance Portability and Accountability Act, or HIPAA.
Participants were aged 50 years and older and had smoked for more than
20 pack-years. Participants underwent five annual (one initial and
four subsequent) CT examinations. A significant downward shift was
evaluated in non-small cell lung cancers detected initially from
advanced stage down to stage I by using a one-sided binomial test of
proportions. Poisson regression and Fisher exact tests were used for
comparisons with Mayo Lung Project.

RESULTS: In 788 (52%) men and 732 (48%) women, 61% (927 of 1520) were
current smokers, and 39% were former smokers. After five annual CT
examinations, 3356 uncalcified lung nodules were identified in 1118
(74%) participants. Sixty-eight lung cancers were diagnosed (31
initial, 34 subsequent, three interval cancers) in 66 participants.
Twenty-eight subsequent cases of non-small cell cancers were detected,
of which 17 (61%; 95% confidence interval: 41%, 79%) were stage I
tumors. Diameter of cancers detected subsequently was 5-50 mm (mean,
14.4 mm; median, 10.0 mm). Analysis for a more than 50% shift in
proportion of stage I non-small cell cancer detection did not show
statistical significance. Forty-eight participants died of various
causes since enrollment. Lung cancer mortality rate for incidence
portion of trial was 1.6 per 1000 person-years. There was no
significant difference in lung cancer mortality rates of cancers
detected in subsequent examinations between this trial and Mayo Lung
Project after separation of participants into subsets (2.8 vs 2.0 per
1000 person-years, P = .43).

CONCLUSION: CT allows detection of early-stage lung cancers. Benign
nodule detection rate is high. Results suggest no stage shift.

References:

Evaluating Pulmonary Nodules, Radiology Rounds, Massachusetts General
Hospital Department of Radiology

http://www.massgeneralimaging.org/newsletter/July_2004/

The following articles are the basis for the belief that screening
with CXR and/or sputum cytology don't improve mortality. Many have
expressed concern about the quality of these studies.

Fontana RS, Sanderson DR, Taylor WF, et al.

Early lung cancer detection: results of the initial (prevalence)
radiologic and cytologic screening in the Mayo Clinic study.
Am Rev Respir Dis 1984;130:561-5. Also includes a summary of the
combined results of the Mayo, Sloan-Kettering, and Johns Hopkins study
sites on pp 565-70.

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6091507

Melamed MR, Flehinger BJ, Zaman MB, et al.

Screening for lung cancer: results of the Memorial Sloan-Kettering
study in New York. CHEST 1984;86:44-53.

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6734291

Frost JK, Ball WC, Levin ML, et al.

Early lung cancer detection: results of the initial (prevalence)
radiologic and cytologic screening in the Johns Hopkins study. Am Rev
Respir Dis 1984;130:549-54

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6091505

Kubik A, Parkin DM, Khlat M, et al.

Lack of benefit from semi-annual screening for cancer of the lung:
follow-up of a randomized controlled trial on a population of high-
risk males in Czechoslavakia.

Int J Cancer1990;45:26-33.

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=2404878

The following articles address screening with chest CT scans.

Henschke CI, McCauley DI, Yankelevitz DF, et al.

Early lung cancer action project: overall design and findings from
baseline screening. Lancet 1999;354:99-105.

Study of annual low dose CT in detecting lung cancer in 1000 heavy
smokers identified noncalcified nodules in 23% of patients and 12% of
nodules were malignant. The yield was extraordinarily high, as 27 of
28 biopsies were positive for malignancy, and 87% of these were stage
I. Large scale study to confirm findings and assess long-term survival
benefit and costs is in progress.

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10408484

Swenson SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer:
Five-year prospective experience.

Radiology 2005;235:259-65.

Updated results from Mayo's screening study of 1,520 subjects age > 50
with tobacco use > 20 pack-years. After 5 years, 74% of subjects had
at least 1 uncalcified nodule and 2.6% were diagnosed with stage I non-
small cell cancer. Compared to previous studies, adenocarcinoma
(including bronchioloalveolar carcinoma) was over-represented, which
raises the possibility of earlier diagnosis without reduction in
mortality. 96% of nodules identified on the prevalence scan and 96% of
nodules identified on an incidence scan proved to be benign based on
observation or resection. 69% of all participants had at least 1 of
these "false-positive" nodules.

http://www.ncbi.nlm.nih.gov/entrez/q...=pubmed_docsum

Solitary pulmonary nodule

Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. NEJM
2003;348:2535-42.

Concise review of risks and yield of the currently used diagnostic
modalities, including PET scans. Unlike some recently published
guidelines, the authors consider both clinical suspicion for
malignancy and operative risk in making management recommendations.
The authors advocate the use of serial CT scans in patients with low
probability of cancer as well as patients with intermediate
probability with negative additional workup.

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12815140

Torrington KG, Kern JD.

The utility of fiberoptic bronchoscopy in the evaluation of the
solitary pulmonary nodule. CHEST 1993;104; 1021-4.

Study found low yield for use of FOB in the work-up of radiographic
Stage I lung cancer. FOB confirmed the diagnosis of cancer in 30% of
cases (no higher yield with use of fluoroscopic guidance), but this
did not affect surgical management. Unsuspected synchronous tumor
found in only 1% of cases. Study population skewed in that a high
proportion (87%) of SPNs were malignant.

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8404158

Henschke CI, Yankelevitz DF, Naidich DP, et al. CT screening for lung
cancer: suspiciousness of nodules by size. Radiology 2004;231:164-8.
Based on data from 2897 high-risk subjects in the ELCAP study, non-
calcified nodules < 5mm diameter should be followed with a repeat scan
in 12 months rather than shorter-term follow-up.

http://www.ncbi.nlm.nih.gov/entrez/q..._uids=14990809

Risk factors

Tockman MS, Anthonisen NR, Wright EC, et al.
Airways obstruction and the risk for lung cancer. Annals Intern Med
1987;106:512-8. This study found smokers with COPD had about a 5-fold
risk of developing lung cancer compared to smokers without COPD. The
more severe the COPD, the greater the risk.

http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=3826952

<postman123a@gmail.com> wrote in message
news:1175262740.015078.229050@r56g2000hsd.googlegr oups.com...
>A friend who has been a heavy smoker for many years underwent
> screening Lung CAT scan and a small spiculated density in the upper
> lobe was detected. The density was thought to represent either a small
> spiculated cancer or perhaps merely inflammatory scarring about 12 x
> 16 mm in size.
>
> There was no mediastinal adenopathy, and the lungs showed mild COPD.
> A PET scan showed only very slight activity in the nodule, so there
> was still some question about whether the nodule should be removed
> surgically, or adopt a wait and see approach.
>
> The patient waited 12 weeks and had a follow up PET scan which showed
> again very slightly increased activity in the nodule compared to the
> first PET scan.
>
> I found this to be unusual to follow a nodule with serial PET scans as
> the standard method is to follow with serial high resolution CAT scans
> at 12 week intervals to assess change in size and growth. Although
> the PET scan comes with an accompanying CAT scan, this is a non-
> diagnostic CAT for anatomic localization of the PET findings and not
> considered adequate for accurate assessment of change in size of the
> nodule.
>
> On the basis of the second PET scan, the surgeon recommended
> thoracotomy. The patient (who was age 75) declined and opted for a
> second high resolution CAT scan to be performed at the 12 week follow
> up mark to assess size.
>
> Any Comments?
>
> Jeffrey Dach MD www.drdach.com
>


I think either approach is perfectly justifiable

<postman123a@gmail.com> wrote in message
news:1175262740.015078.229050@r56g2000hsd.googlegr oups.com...
>A friend who has been a heavy smoker for many years underwent
> screening Lung CAT scan and a small spiculated density in the upper
> lobe was detected. The density was thought to represent either a small
> spiculated cancer or perhaps merely inflammatory scarring about 12 x
> 16 mm in size.
>
> There was no mediastinal adenopathy, and the lungs showed mild COPD.
> A PET scan showed only very slight activity in the nodule, so there
> was still some question about whether the nodule should be removed
> surgically, or adopt a wait and see approach.
>
> The patient waited 12 weeks and had a follow up PET scan which showed
> again very slightly increased activity in the nodule compared to the
> first PET scan.
>
> I found this to be unusual to follow a nodule with serial PET scans as
> the standard method is to follow with serial high resolution CAT scans
> at 12 week intervals to assess change in size and growth. Although
> the PET scan comes with an accompanying CAT scan, this is a non-
> diagnostic CAT for anatomic localization of the PET findings and not
> considered adequate for accurate assessment of change in size of the
> nodule.
>
> On the basis of the second PET scan, the surgeon recommended
> thoracotomy. The patient (who was age 75) declined and opted for a
> second high resolution CAT scan to be performed at the 12 week follow
> up mark to assess size.
>
> Any Comments?



I agree that it's unusual to follow a nodule of that size with serial PET
scans instead of CAT. However, the fact that the nodule increased in size is
the important part and demonstrates that needle biopsy of the mass is
indicated. HOW the increase in size was detected doesn't matter at this
point.

I would not recommend a thoracotomy without a diligent attempt to ascertain
the histology first. IOW, thoracotomy as a next step is appropriate only if
the actual diagnosis can't be made by bronchoscopy, transthoracic needle
biopsy, or thoracoscopy.

HMc



HMc

postman123a@gmail.com wrote:

> <snipped> Any Comments?
>
> Jeffrey Dach MD www.drdach.com

Spammers come in different colours.
http://tinyurl.com/2rewg9 doing similar things on other newsgroups.

Plus he's an idiot.
This was his first try.
Note the CC instead followups

Subject: Pulmonary Nodule Screening in Smoker by Jeffrey Dach
Date: 30 Mar 2007 06:34:28 -0700
From: postman123a@gmail.com
Organization: http://groups.google.com
CC: sci.med.diseases.cancer, alt.support.cancer, alt.smokers
Newsgroups: sci.med.radiology

Folowups set to sci.med.diseases.cancer

Keep that name in mind and ignore, in the future, is my suggestion.
J

On 30 Mar 2007 06:52:20 -0700, postman123a@gmail.com wrote:

>A friend who has been a heavy smoker for many years underwent
>screening Lung CAT scan and a small spiculated density in the upper
>lobe was detected. The density was thought to represent either a small
>spiculated cancer or perhaps merely inflammatory scarring about 12 x
>16 mm in size.
Spiculated is usually associated with cancer. Many cancers don't have
much of an increased FDG uptake until they get larger than about 25mm.

The rule of thumb in someone with a history of tobacco use, is that
the nodule should be assumed to be cancerous until or unless proven
otherwise.

About 40% of such pulmonary lesions are Cancerous, however if you have
no history of tobacco use, or other carcinogenic exposure, the odds on
the lesion being malignant are very low. If you have a history of
tobacco use, the odds on the lesion being malignant are very high.

At 12 x 16mm is still quite small. Lesion larger than 30mm are
considered malignant regardless of tobacco history unless proven
otherwise.

I have a 13mm pulmonary nodule, so I've been through this. Fortunately
I have a good understanding of where it came from, and mine turned out
to be downright 'COLD', i.e. FDG uptake was lower than normal. It also
is as the radiologist put it, smoothe as a baby's bottom. I need to
have it CT scanned again in May, but the odds are overwhelming that it
is the ghost of a Coccidiodomycosis infection about 20 years ago. The
lesion wasn't spotted earlier because the the same infection ate a
golf ball sized hole in my other lung, and that was pretty striking on
an Xray, and prevented anyone from noticing anything slightly out of
the ordinary on the other side. So I've been Xray'd, CT Scanned, PET
Scanned....

YOur friend has a ticking bomb in his lung, and if it isn't removed,
it is very likely to kill him sooner or later.
>
>There was no mediastinal adenopathy, and the lungs showed mild COPD.
>A PET scan showed only very slight activity in the nodule, so there
>was still some question about whether the nodule should be removed
>surgically, or adopt a wait and see approach.
>
>The patient waited 12 weeks and had a follow up PET scan which showed
>again very slightly increased activity in the nodule compared to the
>first PET scan.
>
>I found this to be unusual to follow a nodule with serial PET scans as
>the standard method is to follow with serial high resolution CAT scans
>at 12 week intervals to assess change in size and growth. Although
>the PET scan comes with an accompanying CAT scan, this is a non-
>diagnostic CAT for anatomic localization of the PET findings and not
>considered adequate for accurate assessment of change in size of the
>nodule.
>
>On the basis of the second PET scan, the surgeon recommended
>thoracotomy. The patient (who was age 75) declined and opted for a
>second high resolution CAT scan to be performed at the 12 week follow
>up mark to assess size.
>
>Any Comments?
>
>Jeffrey Dach MD www.drdach.com
>
>Screening for lung cancer:
>
>Radiology. 2005 Apr;235(1):259-65. Epub 2005 Feb 4.
>
>Full Text:
>
>http://radiology.rsnajnls.org/cgi/co...full/235/1/259
>
>CT screening for lung cancer: five-year prospective experience.
>
>Swensen SJ, Jett JR, Hartman TE, Midthun DE, Mandrekar SJ, Hillman SL,
>Sykes AM, Aughenbaugh GL, Bungum AO, Allen KL.
>Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester,
>MN 55905, USA. swensen.stephen@mayo.edu
>
>PURPOSE: To report results of a 5-year prospective low-dose helical
>chest computed tomographic (CT) study of a cohort at high risk for
>lung cancer.
>
>MATERIALS AND METHODS: After informed written consent was obtained,
>1520 individuals were enrolled. Protocol was approved by institutional
>review board and National Cancer Institute and was compliant with
>Health Insurance Portability and Accountability Act, or HIPAA.
>Participants were aged 50 years and older and had smoked for more than
>20 pack-years. Participants underwent five annual (one initial and
>four subsequent) CT examinations. A significant downward shift was
>evaluated in non-small cell lung cancers detected initially from
>advanced stage down to stage I by using a one-sided binomial test of
>proportions. Poisson regression and Fisher exact tests were used for
>comparisons with Mayo Lung Project.
>
>RESULTS: In 788 (52%) men and 732 (48%) women, 61% (927 of 1520) were
>current smokers, and 39% were former smokers. After five annual CT
>examinations, 3356 uncalcified lung nodules were identified in 1118
>(74%) participants. Sixty-eight lung cancers were diagnosed (31
>initial, 34 subsequent, three interval cancers) in 66 participants.
>Twenty-eight subsequent cases of non-small cell cancers were detected,
>of which 17 (61%; 95% confidence interval: 41%, 79%) were stage I
>tumors. Diameter of cancers detected subsequently was 5-50 mm (mean,
>14.4 mm; median, 10.0 mm). Analysis for a more than 50% shift in
>proportion of stage I non-small cell cancer detection did not show
>statistical significance. Forty-eight participants died of various
>causes since enrollment. Lung cancer mortality rate for incidence
>portion of trial was 1.6 per 1000 person-years. There was no
>significant difference in lung cancer mortality rates of cancers
>detected in subsequent examinations between this trial and Mayo Lung
>Project after separation of participants into subsets (2.8 vs 2.0 per
>1000 person-years, P = .43).
>
>CONCLUSION: CT allows detection of early-stage lung cancers. Benign
>nodule detection rate is high. Results suggest no stage shift.
>
>References:
>
>Evaluating Pulmonary Nodules, Radiology Rounds, Massachusetts General
>Hospital Department of Radiology
>
>http://www.massgeneralimaging.org/newsletter/July_2004/
>
>The following articles are the basis for the belief that screening
>with CXR and/or sputum cytology don't improve mortality. Many have
>expressed concern about the quality of these studies.
>
>Fontana RS, Sanderson DR, Taylor WF, et al.
>
>Early lung cancer detection: results of the initial (prevalence)
>radiologic and cytologic screening in the Mayo Clinic study.
>Am Rev Respir Dis 1984;130:561-5. Also includes a summary of the
>combined results of the Mayo, Sloan-Kettering, and Johns Hopkins study
>sites on pp 565-70.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6091507
>
>Melamed MR, Flehinger BJ, Zaman MB, et al.
>
>Screening for lung cancer: results of the Memorial Sloan-Kettering
>study in New York. CHEST 1984;86:44-53.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6734291
>
>Frost JK, Ball WC, Levin ML, et al.
>
>Early lung cancer detection: results of the initial (prevalence)
>radiologic and cytologic screening in the Johns Hopkins study. Am Rev
>Respir Dis 1984;130:549-54
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=6091505
>
>Kubik A, Parkin DM, Khlat M, et al.
>
>Lack of benefit from semi-annual screening for cancer of the lung:
>follow-up of a randomized controlled trial on a population of high-
>risk males in Czechoslavakia.
>
>Int J Cancer1990;45:26-33.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=2404878
>
>The following articles address screening with chest CT scans.
>
>Henschke CI, McCauley DI, Yankelevitz DF, et al.
>
>Early lung cancer action project: overall design and findings from
>baseline screening. Lancet 1999;354:99-105.
>
>Study of annual low dose CT in detecting lung cancer in 1000 heavy
>smokers identified noncalcified nodules in 23% of patients and 12% of
>nodules were malignant. The yield was extraordinarily high, as 27 of
>28 biopsies were positive for malignancy, and 87% of these were stage
>I. Large scale study to confirm findings and assess long-term survival
>benefit and costs is in progress.
>
>http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10408484
>
>Swenson SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer:
>Five-year prospective experience.
>
>Radiology 2005;235:259-65.
>
>Updated results from Mayo's screening study of 1,520 subjects age > 50
>with tobacco use > 20 pack-years. After 5 years, 74% of subjects had
>at least 1 uncalcified nodule and 2.6% were diagnosed with stage I non-
>small cell cancer. Compared to previous studies, adenocarcinoma
>(including bronchioloalveolar carcinoma) was over-represented, which
>raises the possibility of earlier diagnosis without reduction in
>mortality. 96% of nodules identified on the prevalence scan and 96% of
>nodules identified on an incidence scan proved to be benign based on
>observation or resection. 69% of all participants had at least 1 of
>these "false-positive" nodules.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...=pubmed_docsum
>
>Solitary pulmonary nodule
>
>Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. NEJM
>2003;348:2535-42.
>
>Concise review of risks and yield of the currently used diagnostic
>modalities, including PET scans. Unlike some recently published
>guidelines, the authors consider both clinical suspicion for
>malignancy and operative risk in making management recommendations.
>The authors advocate the use of serial CT scans in patients with low
>probability of cancer as well as patients with intermediate
>probability with negative additional workup.
>
>http://www.ncbi.nlm.nih.gov/entrez/q..._uids=12815140
>
>Torrington KG, Kern JD.
>
>The utility of fiberoptic bronchoscopy in the evaluation of the
>solitary pulmonary nodule. CHEST 1993;104; 1021-4.
>
>Study found low yield for use of FOB in the work-up of radiographic
>Stage I lung cancer. FOB confirmed the diagnosis of cancer in 30% of
>cases (no higher yield with use of fluoroscopic guidance), but this
>did not affect surgical management. Unsuspected synchronous tumor
>found in only 1% of cases. Study population skewed in that a high
>proportion (87%) of SPNs were malignant.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8404158
>
>Henschke CI, Yankelevitz DF, Naidich DP, et al. CT screening for lung
>cancer: suspiciousness of nodules by size. Radiology 2004;231:164-8.
>Based on data from 2897 high-risk subjects in the ELCAP study, non-
>calcified nodules < 5mm diameter should be followed with a repeat scan
>in 12 months rather than shorter-term follow-up.
>
>http://www.ncbi.nlm.nih.gov/entrez/q..._uids=14990809
>
>Risk factors
>
>Tockman MS, Anthonisen NR, Wright EC, et al.
>Airways obstruction and the risk for lung cancer. Annals Intern Med
>1987;106:512-8. This study found smokers with COPD had about a 5-fold
>risk of developing lung cancer compared to smokers without COPD. The
>more severe the COPD, the greater the risk.
>
>http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=3826952

On Mar 30, 4:18 pm, matt weber <matth...@qwest.net> wrote:
> On 30 Mar 2007 06:52:20 -0700, postman1...@gmail.com wrote:
>
> >A friend who has been a heavy smoker for many years underwent
> >screening Lung CAT scan and a small spiculated density in the upper
> >lobe was detected. The density was thought to represent either a small
> >spiculated cancer or perhaps merely inflammatory scarring about 12 x
> >16 mm in size.
>
> Spiculated is usually associated with cancer. Many cancers don't have
> much of an increased FDG uptake until they get larger than about 25mm.

Benign inflammatory scarring can also have a spiculated appearance.

>
> The rule of thumb in someone with a history of tobacco use, is that
> the nodule should be assumed to be cancerous until or unless proven
> otherwise.
>
> About 40% of such pulmonary lesions are Cancerous, however if you have
> no history of tobacco use, or other carcinogenic exposure, the odds on
> the lesion being malignant are very low. If you have a history of
> tobacco use, the odds on the lesion being malignant are very high.

Do you have the reference handy for the odds of malignancy being
higher in smokers vs. non-smokers for the same lesion? Would like to
see it.

>
> At 12 x 16mm is still quite small. Lesion larger than 30mm are
> considered malignant regardless of tobacco history unless proven
> otherwise.
>
> I have a 13mm pulmonary nodule, so I've been through this. Fortunately
> I have a good understanding of where it came from, and mine turned out
> to be downright 'COLD', i.e. FDG uptake was lower than normal. It also
> is as the radiologist put it, smoothe as a baby's bottom. I need to
> have it CT scanned again in May, but the odds are overwhelming that it
> is the ghost of a Coccidiodomycosis infection about 20 years ago.

As Coccidiomycosis is most prevalent in the southwestern desert areas
of the US, I would assume you must have lived in Arizona or New
Mexico, or San Juaquin Valley 20 years ago.

> The
> lesion wasn't spotted earlier because the the same infection ate a
> golf ball sized hole in my other lung, and that was pretty striking on
> an Xray, and prevented anyone from noticing anything slightly out of
> the ordinary on the other side. So I've been Xray'd, CT Scanned, PET
> Scanned....
>
> Your friend has a ticking bomb in his lung, and if it isn't removed,
> it is very likely to kill him sooner or later.

What if the lesion is an old scar?

Wouldn't be advisable to preserve lung function by avoiding surgery?

Most studies of screening CAT for lung nodules show that although many
cancers are discovered during screening,
there are also many thoracotomies for benign disease.

Would it not be advisable to first prove via increase in diameter of
the nodule that it has a high chance of malignancy and therefore
justify thoracotomy with loss of pulmonary function?

A follow up high resolution CAT scan would show either an increase in
size in which case surgery would be justified, or no increase in size
in which case watchful waiting would be justified.

regards

>
> >There was no mediastinal adenopathy, and the lungs showed mild COPD.
> >A PET scan showed only very slight activity in the nodule, so there
> >was still some question about whether the nodule should be removed
> >surgically, or adopt a wait and see approach.
>
> >The patient waited 12 weeks and had a follow up PET scan which showed
> >again very slightly increased activity in the nodule compared to the
> >first PET scan.
>
> >I found this to be unusual to follow a nodule with serial PET scans as
> >the standard method is to follow with serial high resolution CAT scans
> >at 12 week intervals to assess change in size and growth. Although
> >the PET scan comes with an accompanying CAT scan, this is a non-
> >diagnostic CAT for anatomic localization of the PET findings and not
> >considered adequate for accurate assessment of change in size of the
> >nodule.
>
> >On the basis of the second PET scan, the surgeon recommended
> >thoracotomy. The patient (who was age 75) declined and opted for a
> >second high resolution CAT scan to be performed at the 12 week follow
> >up mark to assess size.
>
> >Any Comments?
>
> >Jeffrey Dach MDwww.drdach.com
>
> >Screening for lung cancer:
>
> >Radiology. 2005 Apr;235(1):259-65. Epub 2005 Feb 4.
>
> >Full Text:
>
> >http://radiology.rsnajnls.org/cgi/co...full/235/1/259
>
> >CT screening for lung cancer: five-year prospective experience.
>
> >Swensen SJ, Jett JR, Hartman TE, Midthun DE, Mandrekar SJ, Hillman SL,
> >Sykes AM, Aughenbaugh GL, Bungum AO, Allen KL.
> >Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester,
> >MN 55905, USA. swensen.step...@mayo.edu
>
> >PURPOSE: To report results of a 5-year prospective low-dose helical
> >chest computed tomographic (CT) study of a cohort at high risk for
> >lung cancer.
>
> >MATERIALS AND METHODS: After informed written consent was obtained,
> >1520 individuals were enrolled. Protocol was approved by institutional
> >review board and National Cancer Institute and was compliant with
> >Health Insurance Portability and Accountability Act, or HIPAA.
> >Participants were aged 50 years and older and had smoked for more than
> >20 pack-years. Participants underwent five annual (one initial and
> >four subsequent) CT examinations. A significant downward shift was
> >evaluated in non-small cell lung cancers detected initially from
> >advanced stage down to stage I by using a one-sided binomial test of
> >proportions. Poisson regression and Fisher exact tests were used for
> >comparisons with Mayo Lung Project.
>
> >RESULTS: In 788 (52%) men and 732 (48%) women, 61% (927 of 1520) were
> >current smokers, and 39% were former smokers. After five annual CT
> >examinations, 3356 uncalcified lung nodules were identified in 1118
> >(74%) participants. Sixty-eight lung cancers were diagnosed (31
> >initial, 34 subsequent, three interval cancers) in 66 participants.
> >Twenty-eight subsequent cases of non-small cell cancers were detected,
> >of which 17 (61%; 95% confidence interval: 41%, 79%) were stage I
> >tumors. Diameter of cancers detected subsequently was 5-50 mm (mean,
> >14.4 mm; median, 10.0 mm). Analysis for a more than 50% shift in
> >proportion of stage I non-small cell cancer detection did not show
> >statistical significance. Forty-eight participants died of various
> >causes since enrollment. Lung cancer mortality rate for incidence
> >portion of trial was 1.6 per 1000 person-years. There was no
> >significant difference in lung cancer mortality rates of cancers
> >detected in subsequent examinations between this trial and Mayo Lung
> >Project after separation of participants into subsets (2.8 vs 2.0 per
> >1000 person-years, P = .43).
>
> >CONCLUSION: CT allows detection of early-stage lung cancers. Benign
> >nodule detection rate is high. Results suggest no stage shift.
>
> >References:
>
> >Evaluating Pulmonary Nodules, Radiology Rounds, Massachusetts General
> >Hospital Department of Radiology
>
> >http://www.massgeneralimaging.org/newsletter/July_2004/
>
> >The following articles are the basis for the belief that screening
> >with CXR and/or sputum cytology don't improve mortality. Many have
> >expressed concern about the quality of these studies.
>
> >Fontana RS, Sanderson DR, Taylor WF, et al.
>
> >Early lung cancer detection: results of the initial (prevalence)
> >radiologic and cytologic screening in the Mayo Clinic study.
> >Am Rev Respir Dis 1984;130:561-5. Also includes a summary of the
> >combined results of the Mayo, Sloan-Kettering, and Johns Hopkins study
> >sites on pp 565-70.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Melamed MR, Flehinger BJ, Zaman MB, et al.
>
> >Screening for lung cancer: results of the Memorial Sloan-Kettering
> >study in New York. CHEST 1984;86:44-53.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Frost JK, Ball WC, Levin ML, et al.
>
> >Early lung cancer detection: results of the initial (prevalence)
> >radiologic and cytologic screening in the Johns Hopkins study. Am Rev
> >Respir Dis 1984;130:549-54
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Kubik A, Parkin DM, Khlat M, et al.
>
> >Lack of benefit from semi-annual screening for cancer of the lung:
> >follow-up of a randomized controlled trial on a population of high-
> >risk males in Czechoslavakia.
>
> >Int J Cancer1990;45:26-33.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >The following articles address screening with chest CT scans.
>
> >Henschke CI, McCauley DI, Yankelevitz DF, et al.
>
> >Early lung cancer action project: overall design and findings from
> >baseline screening. Lancet 1999;354:99-105.
>
> >Study of annual low dose CT in detecting lung cancer in 1000 heavy
> >smokers identified noncalcified nodules in 23% of patients and 12% of
> >nodules were malignant. The yield was extraordinarily high, as 27 of
> >28 biopsies were positive for malignancy, and 87% of these were stage
> >I. Large scale study to confirm findings and assess long-term survival
> >benefit and costs is in progress.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Swenson SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer:
> >Five-year prospective experience.
>
> >Radiology 2005;235:259-65.
>
> >Updated results from Mayo's screening study of 1,520 subjects age > 50
> >with tobacco use > 20 pack-years. After 5 years, 74% of subjects had
> >at least 1 uncalcified nodule and 2.6% were diagnosed with stage I non-
> >small cell cancer. Compared to previous studies, adenocarcinoma
> >(including bronchioloalveolar carcinoma) was over-represented, which
> >raises the possibility of earlier diagnosis without reduction in
> >mortality. 96% of nodules identified on the prevalence scan and 96% of
> >nodules identified on an incidence scan proved to be benign based on
> >observation or resection. 69% of all participants had at least 1 of
> >these "false-positive" nodules.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Solitary pulmonary nodule
>
> >Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. NEJM
> >2003;348:2535-42.
>
> >Concise review of risks and yield of the currently used diagnostic
> >modalities, including PET scans. Unlike some recently published
> >guidelines, the authors consider both clinical suspicion for
> >malignancy and operative risk in making management recommendations.
> >The authors advocate the use of serial CT scans in patients with low
> >probability of cancer as well as patients with intermediate
> >probability with negative additional workup.
>
> >http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> >Torrington KG, Kern JD.
>
> >The utility of fiberoptic bronchoscopy in the evaluation of the
> >solitary pulmonary nodule. CHEST 1993;104; 1021-4.
>
> >Study found low yield for use of FOB in the work-up of radiographic
> >Stage I lung cancer. FOB confirmed the diagnosis of cancer in 30% of
> >cases (no higher yield with use of
>
> ...
>
> read more »- Hide quoted text -
>
> - Show quoted text -

Hi, Oh goodie,,,,the postmans here...
Fetch it out of the box lil Billy and bring it over to me....
Hummm It's from.....
<postman123a@gmail.com> wrote in message
news:1175262740.015078.229050@r56g2000hsd.googlegr oups.com...

And it such a mouthfull I'm a gonna have to insert replies....
HWOS

>A friend who has been a heavy smoker for many years underwent
> screening Lung CAT scan and a small spiculated density in the upper
> lobe was detected. The density was thought to represent either a small
> spiculated cancer or perhaps merely inflammatory scarring about 12 x
> 16 mm in size.
>

Uh Huh Ok....

> There was no mediastinal adenopathy, and the lungs showed mild COPD.
> A PET scan showed only very slight activity in the nodule, so there
> was still some question about whether the nodule should be removed
> surgically, or adopt a wait and see approach.

Ok...If you say so, but I think I'd just butcher em up and have a look
see....

>
> The patient waited 12 weeks and had a follow up PET scan which showed
> again very slightly increased activity in the nodule compared to the
> first PET scan.
>
I'm not really in the medical field but I'll give er a go....
it's not good to keep pets inside you though.


> I found this to be unusual to follow a nodule with serial PET scans as
> the standard method is to follow with serial high resolution CAT scans
> at 12 week intervals to assess change in size and growth. Although
> the PET scan comes with an accompanying CAT scan, this is a non-
> diagnostic CAT for anatomic localization of the PET findings and not
> considered adequate for accurate assessment of change in size of the
> nodule.
>
Sheesh...where's my can a chew....
(hoggin 1/2 can it in the lip)

> On the basis of the second PET scan, the surgeon recommended
> thoracotomy. The patient (who was age 75) declined and opted for a
> second high resolution CAT scan to be performed at the 12 week follow
> up mark to assess size.
>
the orac to my.....? what?
Good god..the guy's 75 and you want to get his pets out and a
swallered a
cat too?
Then mark his asses sizes?
> Any Comments?

Any comments you say !!!!!
Good god... what are you look in here for advice for....
None a these trolls got any sense...cept Nizo1 and he's begged off.
Shame~ none of them medical people got book learning and now
look to the usernet trolls for a scalpel lesson.

>
> Jeffrey Dach MD www.drdach.com
>
Thanks for writting !

> Screening for lung cancer:
Don't need none, mines fine...but thanks...


>
> Radiology. 2005 Apr;235(1):259-65. Epub 2005 Feb 4.
>
They got TV now you know....Why not,...god all the money you guy's
charge....

> Full Text:
>
Uhhh huh...
> http://radiology.rsnajnls.org/cgi/co...full/235/1/259
>
> CT screening for lung cancer: five-year prospective experience.
>
I'm only gonna give you a couple more minutes of my time...
5 years ain't in my plans feller, no wonder Dr.'s charge so
mauch these day...1 look at somethin and you got a 5 year job...


> Swensen SJ, Jett JR, Hartman TE, Midthun DE, Mandrekar SJ, Hillman SL,
> Sykes AM, Aughenbaugh GL, Bungum AO, Allen KL.
> Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester,
> MN 55905, USA. swensen.stephen@mayo.edu
>
I' ve got cable TV long time now...not going back to radio....


> PURPOSE: To report results of a 5-year prospective low-dose helical
> chest computed tomographic (CT) study of a cohort at high risk for
> lung cancer.
>
Do you trust the data from a win 98 system??
My cohort's would never let me insert nothing in them....you guy's are
weird.


> MATERIALS AND METHODS: After informed written consent was obtained,
> 1520 individuals were enrolled. Protocol was approved by institutional
> review board and National Cancer Institute and was compliant with
> Health Insurance Portability and Accountability Act, or HIPAA.
> Participants were aged 50 years and older and had smoked for more than
> 20 pack-years. Participants underwent five annual (one initial and
> four subsequent) CT examinations. A significant downward shift was
> evaluated in non-small cell lung cancers detected initially from
> advanced stage down to stage I by using a one-sided binomial test of
> proportions. Poisson regression and Fisher exact tests were used for
> comparisons with Mayo Lung Project.
>
if they smoked, they sound like good blokes to me...
most people don't like downward shifts..



> RESULTS: In 788 (52%) men and 732 (48%) women, 61% (927 of 1520) were
> current smokers, and 39% were former smokers. After five annual CT
> examinations, 3356 uncalcified lung nodules were identified in 1118
> (74%) participants. Sixty-eight lung cancers were diagnosed (31
> initial, 34 subsequent, three interval cancers) in 66 participants.
> Twenty-eight subsequent cases of non-small cell cancers were detected,
> of which 17 (61%; 95% confidence interval: 41%, 79%) were stage I
> tumors. Diameter of cancers detected subsequently was 5-50 mm (mean,
> 14.4 mm; median, 10.0 mm). Analysis for a more than 50% shift in
> proportion of stage I non-small cell cancer detection did not show
> statistical significance. Forty-eight participants died of various
> causes since enrollment. Lung cancer mortality rate for incidence
> portion of trial was 1.6 per 1000 person-years. There was no
> significant difference in lung cancer mortality rates of cancers
> detected in subsequent examinations between this trial and Mayo Lung
> Project after separation of participants into subsets (2.8 vs 2.0 per
> 1000 person-years, P = .43).
>
1000 person years only happened in the bible...
I think they measured time differently..In the Bc era


> CONCLUSION: CT allows detection of early-stage lung cancers. Benign
> nodule detection rate is high. Results suggest no stage shift.
>
Look Conclusion means the end...this letter goes on and on....
4-5 scroll downs, and still more...

Look that's all the time I allot for most writters,
Robert like's to write real long boring disortations for those
of you that know what them's is....
My keyboard sticks too much to keep up with you here
so just write back little by little as you open the guy up.

Then we' ll try & walk you through it...
Just tell they guy before you start ....
Huge wad of spit is pulling fer ya....

robert no.e@mail
or
HossManua could help you better than me...

Nah...no more...I'm bugg outa here...

HWOS

Sheewww...
Good luck to the ol timer..

Get ready a tome of bull crap follows:


> References:
>
> Evaluating Pulmonary Nodules, Radiology Rounds, Massachusetts General
> Hospital Department of Radiology
>
> http://www.massgeneralimaging.org/newsletter/July_2004/
>
> The following articles are the basis for the belief that screening
> with CXR and/or sputum cytology don't improve mortality. Many have
> expressed concern about the quality of these studies.
>
> Fontana RS, Sanderson DR, Taylor WF, et al.
>
> Early lung cancer detection: results of the initial (prevalence)
> radiologic and cytologic screening in the Mayo Clinic study.
> Am Rev Respir Dis 1984;130:561-5. Also includes a summary of the
> combined results of the Mayo, Sloan-Kettering, and Johns Hopkins study
> sites on pp 565-70.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Melamed MR, Flehinger BJ, Zaman MB, et al.
>
> Screening for lung cancer: results of the Memorial Sloan-Kettering
> study in New York. CHEST 1984;86:44-53.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Frost JK, Ball WC, Levin ML, et al.
>
> Early lung cancer detection: results of the initial (prevalence)
> radiologic and cytologic screening in the Johns Hopkins study. Am Rev
> Respir Dis 1984;130:549-54
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Kubik A, Parkin DM, Khlat M, et al.
>
> Lack of benefit from semi-annual screening for cancer of the lung:
> follow-up of a randomized controlled trial on a population of high-
> risk males in Czechoslavakia.
>

The air's worse in Mexico City I hear !

> Int J Cancer1990;45:26-33.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> The following articles address screening with chest CT scans.
>
> Henschke CI, McCauley DI, Yankelevitz DF, et al.
>
> Early lung cancer action project: overall design and findings from
> baseline screening. Lancet 1999;354:99-105.
>
> Study of annual low dose CT in detecting lung cancer in 1000 heavy
> smokers identified noncalcified nodules in 23% of patients and 12% of
> nodules were malignant. The yield was extraordinarily high, as 27 of
> 28 biopsies were positive for malignancy, and 87% of these were stage
> I. Large scale study to confirm findings and assess long-term survival
> benefit and costs is in progress.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Swenson SJ, Jett JR, Hartman TE, et al. CT screening for lung cancer:
> Five-year prospective experience.
>
> Radiology 2005;235:259-65.
>
> Updated results from Mayo's screening study of 1,520 subjects age > 50
> with tobacco use > 20 pack-years. After 5 years, 74% of subjects had
> at least 1 uncalcified nodule and 2.6% were diagnosed with stage I non-
> small cell cancer. Compared to previous studies, adenocarcinoma
> (including bronchioloalveolar carcinoma) was over-represented, which
> raises the possibility of earlier diagnosis without reduction in
> mortality. 96% of nodules identified on the prevalence scan and 96% of
> nodules identified on an incidence scan proved to be benign based on
> observation or resection. 69% of all participants had at least 1 of
> these "false-positive" nodules.

I gave up on MAYO years ago Miracle Whip is better...


>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Solitary pulmonary nodule
>
> Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. NEJM
> 2003;348:2535-42.
>
> Concise review of risks and yield of the currently used diagnostic
> modalities, including PET scans. Unlike some recently published
> guidelines, the authors consider both clinical suspicion for
> malignancy and operative risk in making management recommendations.
> The authors advocate the use of serial CT scans in patients with low
> probability of cancer as well as patients with intermediate
> probability with negative additional workup.
>

Geeze...Now you want management recomendations......
Just get a job....Cutting meat...then slowly work yer
way up the ladder.


> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Torrington KG, Kern JD.
>
> The utility of fiberoptic bronchoscopy in the evaluation of the
> solitary pulmonary nodule. CHEST 1993;104; 1021-4.


>
> Study found low yield for use of FOB in the work-up of radiographic
> Stage I lung cancer. FOB confirmed the diagnosis of cancer in 30% of
> cases (no higher yield with use of fluoroscopic guidance), but this
> did not affect surgical management. Unsuspected synchronous tumor
> found in only 1% of cases. Study population skewed in that a high
> proportion (87%) of SPNs were malignant.





That poor guy, when I got the flourscope thank god there were no
taste buds in there just those roids...

>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Henschke CI, Yankelevitz DF, Naidich DP, et al. CT screening for lung
> cancer: suspiciousness of nodules by size. Radiology 2004;231:164-8.
> Based on data from 2897 high-risk subjects in the ELCAP study, non-
> calcified nodules < 5mm diameter should be followed with a repeat scan
> in 12 months rather than shorter-term follow-up.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...
>
> Risk factors
>
> Tockman MS, Anthonisen NR, Wright EC, et al.
> Airways obstruction and the risk for lung cancer. Annals Intern Med
> 1987;106:512-8. This study found smokers with COPD had about a 5-fold
> risk of developing lung cancer compared to smokers without COPD. The
> more severe the COPD, the greater the risk.
>
> http://www.ncbi.nlm.nih.gov/entrez/q...eve&db=pubmed&...

Good God almighty you ani't got nothing but time on your hands.
At 75 years old looks like he'd be better off buying a box
down at the local funeral parlor.

Maybe try the preventable death method and don't cut him
all up. A couple more years is better than later on today.
Eh?

HTH

I'll give you my best advice....

Don't take anyone's advice off the internet.

On 30 Mar 2007 14:39:19 -0700, postman12345@gmail.com wrote:

>On Mar 30, 4:18 pm, matt weber <matth...@qwest.net> wrote:
>> On 30 Mar 2007 06:52:20 -0700, postman1...@gmail.com wrote:
>>
>> >A friend who has been a heavy smoker for many years underwent
>> >screening Lung CAT scan and a small spiculated density in the upper
>> >lobe was detected. The density was thought to represent either a small
>> >spiculated cancer or perhaps merely inflammatory scarring about 12 x
>> >16 mm in size.
>>
>> Spiculated is usually associated with cancer. Many cancers don't have
>> much of an increased FDG uptake until they get larger than about 25mm.
>
>Benign inflammatory scarring can also have a spiculated appearance.
But if it is scar tissue, the FDG uptake is very low, unless the
inflamation is active.
>

On Mar 31, 4:38 pm, matt weber <matth...@qwest.net> wrote:
> On 30 Mar 2007 14:39:19 -0700, postman12...@gmail.com wrote:
>
> >On Mar 30, 4:18 pm, matt weber <matth...@qwest.net> wrote:
> >> On 30 Mar 2007 06:52:20 -0700, postman1...@gmail.com wrote:
>
> >> >A friend who has been a heavy smoker for many years underwent
> >> >screening Lung CAT scan and a small spiculated density in the upper
> >> >lobe was detected. The density was thought to represent either a small
> >> >spiculated cancer or perhaps merely inflammatory scarring about 12 x
> >> >16 mm in size.
>
> >> Spiculated is usually associated with cancer. Many cancers don't have
> >> much of an increased FDG uptake until they get larger than about 25mm.
>
> >Benign inflammatory scarring can also have a spiculated appearance.
>
> But if it is scar tissue, the FDG uptake is very low, unless the
> inflamation is active.
>
>

Follow up on this case:

After 14 weeeks a follow up Hi Res CAT Scan shows no change in the
size of the nodule. Since there was no change, the patient and
surgeon decided to treat the nodule with "watchful waiting" and get a
follow up CAT scan after another 12-24 weeks. (drdach)

Jeffrey Dach