Multiple lung nodules in two lobes both sides of chest

[whspurr222]

I recently went to the er for chronic nausea/vomiting.I have a spinchter of oddi disorder and I was admitted for that but they did a chest xray..not sure if anything was on it, but on the ct scan of my abdomen my lungs showed & a ct scan done. On the ct scan of my abdomen a 6mm nodule posterolateral aspect rt lower lobe. Significant mediastinal and hilar adenopathy. Impression: rt lowr lobe pumonary nodule significant intrathoracic adenopathy. On the chest ct scan: at least 4 nodules..I think all were smaller than 2 mm..maybe the total was 6 mm I can't find the ct impression but here is basically what it said: At least 4 nodules on the right lower lobe, solitary nodule (very small) on the left lower lobe and suspected metastatic disease. I've only smoked about 3 total packs of cigarettes in my entire life..socially in my 20s. I just turned 44 last week. I've never been exposed to anything that I know of but I took dilantin for a seizure disorder from may 06 until sept 08 when I was found to have had a poisonous amount in my system for some reason. I was taking 100 mg tid and I quit taking it at that time. I read on the internet that dilantin can cause non hodgkins lymphoma. Does this automatically mean that if it's cancer it's advanced since it's in both lungs? I have no spleen due to a mva in 93 and a lot of health problems. I had stage one melanoma in 2001 and it was removed with a biopsy then I went to duke as a precaution and that took more tissue away and I needed no furthur treatment. It was on the inside of my left lower thigh most likely from the tanning bed. I have followed up with my dermatologist ever since and not been in the sun or tanning been and it will be 8 yrs this june. In your opinion, since my lymph nodes are pretty huge in the middle of my chest what are the most likely diagnosis? Mediastinoscopy is being done this thursday. Non hodgkins, scarcoidosis, or lung cancer?

[Kamal S Saini, MD, MRCP (UK), DM]

Hi,
As of now, there is no firm evidence of any malignancy. Any suspicion of this will be ruled out or confirmed when the mediastinal biopsy report becomes available.
With multiple auto-immune issues in the past, it may just turn out that these nodules and lymph nodes too are related to this same problem.
Lymphoblastic lymphoma related to dilantin is a rather far-fetched possibility.
Please try to relax. I understand that this is a difficult wait for you, but worrying will not help either. Have faith, and all will be well.
Good luck.

[whspurr222]

I would also like to add the following that was listed on the ct scan of my abdomen:
There is patchy air-space disease right middle and lower lobe. This is nonspecific. It may reflect compressive atelectasis. It is slightly suspicious for patchy pneumonia. The only symptoms that I have related to my lungs is occassional wheezing lying flat and I do have sleep apnea. The spirometry was said to be detrimental or something like that..at the time I was on IV dilualdid for my herniated disc in my back and that usually affects my breathing but I'm not sure. I don't have any trouble breathing at all no night sweats, no itching or anything like that..I do have a dysphagia/chronic gastric problems and i've had the swallowing disorder since at least 06. My chest xrays were clear last sept 08. I also had a ct abdomen at that time that showed nothing in my lungs. I had the start of an infection when I was initially hospitalized  on march 14th 2009 and it cleared up with iv antibiotics. I'm going out of my mind waiting on this mediastinocopy and cannot sleep and I'd just like to know the most likely culprit. They also followed up with a CT scan of my head and it was normal..would it have shown my neck as well? Also there was nothing else abnormal on the ct scan of my abdomen execpt a small cortical cyst on my lower pole left kidney that's been there several years.The radiologist didn't remark about it.

[Kamal S Saini, MD, MRCP (UK), DM]

Hi,
You have tiny (about 2 mm) nodules in your lung, about 4 in number, along with mediastinal and hilar lymph nodes.
Lymphoma can present with mediastinal and hilar lymph nodes, but usually not with multiple, tiny lung nodules.
I also doubt if this is a recurrence of melanoma, as you have not described any skin changes in your left thigh, nor any lymph nodes in your left inguinal area.
Lung cancer usually presents with a single lung mass, at least initially. To have multiple tiny foci in the lung is distinctly uncommon in this setting.
Sarcoidosis again present with lymph node enlargement within the mediastinum, but usually also have some skin or other immune system disorders. Lung involvement of the kind described by you is uncommon.
You said you had a chronic problem with the sphincter of oddi. What exactly was the problem, and has the area been biopsied?
Please dont worry too much about your diagnosis yet. We dont even know if we are dealing with a malignancy or not. The mediastinal sampling of the lymph nodes should reveal the diagnosis. I think that a PET-CT would give us plenty of useful information also.  
Pl feel free to post additional questions / doubts.
All the best, and God bless.

[whspurr222]

I don't have any skin changes that I know of. I just got the ct scan of my abdomen and my lungs and a chest x-ray from last sept (neg) that was also compared to 2006 & 2007 and there were all negative (lungs) until this march 14. I have been vomiting/severe nausea/severe gerd/dry heaves, pancreatitis (3 times), elevated liver enzymes that all seem to be related to the spinchter of oddi since June 06.

The biopsy they did with the ercp in January was normal but they didn't do a chest xray at the time or maybe I would have had the procedure done early feb. I don't know what could have grown so quickly in 6 mos time that the radiologist would already suspect metastatic disease. Left inguinal area was not mentioned and the scar from the melanoma still feels normal.

I do have chronic irritation from the nausea/vomiting and I hope that maybe this has something to do with it. I have Sjogren's syndroma as far as an autoimmune disorder and fibromyalgia, osteoporosis, but I don't know what else to mention. I've had at least 6 to 8 endoscopies in the last 10 years, one ercp (jan 29, 09), gallbladder surgery, spleenectomy, hysterectomy, and my immune system might be compromised since I don't have the spleen. I've had health problems that may or may not be related since then. I have hypertension, interstitial cystitis (which is also supposed to be automimune), I don't actually have any large mass just the 4 nodules on rt lower lobe and one on left lower lobe. I'm worried that it will be the agressive non hodg lymp called lymphoblastic lymphoma  b/c of this sentence that I found on a website. (Involvement of hilar and mediastinal lymph nodes is less common than in Hodgkin lymphoma. Mediastinal adenopathy, however, is a prominent feature of lymphoblastic lymphoma and primary mediastinal B-cell lymphoma, entities primarily found in young adults). My report said that there was significant and mediastinal adenopathy??? Any opinion on that? Thanks for answering. I'm just not ready 2 leave at 44. I'm having some improvement w? the nausea/vomiting and now this :(

[whspurr222]

I just found the CT scan of the chest and I have the report as follows:

Axial enhanced
There is extensive medistinal adenopathy involving the anterionr mediastinum, ap window, distal pretracheal, tracheobronchial angle, subcarinal and both hilar areas. There are at least 4 subcentimeter nodules scattered through the right lower lobe. There is a solilatary one on the left. In view of the adenopathy these likely reflect metastatic disease. There is mild nonspecific adenoopathy both axillary areas.
Impression: Significant mediastinal adenopathy. Malignancy suspected. Mulptiple pulmonary nodules likley reflecting metastatic disease.

(how much larger is the subcentimeter from what was originally listed as 6 mm on the CT scan of the abdomen). Is your opinion still the same or after reading this do you have any suspicions? Thank you doctor :)

[whspurr222]

Below: Does this mean on both sides left and right of the chest or does this mean above and below? (for example above the breast and below as in the abdomen..can anyone figure this out? I have nodules on both sides of my lungs in lower right lobe and lower left lobe..this confuses me. It's the difference between stage 2 and 3 lymphoma's...


Stages of cancer:
Cancer is found in two or more groups of lymph nodes on the same side as the diaphragm. (The diaphragm is a thin muscle below the lungs that helps in breathing and separates your chest from the abdomen). In addition, an organ not in the lymph system may be involved close to the involved nodes.

[Kamal S Saini, MD, MRCP (UK), DM]

Hi,
The chest CT does show lymph node enlargement, and also some "subcentimeter" nodules within the lung.
"Subcentimeter", as the name implies, refers to any size less than 1 centimeter. It is not possible to compare "6 mm" and "subcentimeter" and comment on their relative size.
The radiologist is suspecting some malignancy based on the CT criteria, but we will know for sure only after a biopsy or FNAC. Do you have any risk factors for tuberculosis?
All the best!