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Lung Cancer Metastasis to Right Adrenal Gland
I just got the (2) two page written report of a PET SCAN taken at NYU on 0-8/25/08, that doesn't seem kosher.
IMPRESSIONS:
1. Intense activity in the right adrenal mass is consistent with metastasis.
2. Moderate activity in the right lower lobe pleural based nodularity, likely post surgical inflammation
although residual viable malignancy cannot be excluded.
3. Intense activity in the right hilar node is inflammatory verses malignancy.
Beside the right adrenal mass that is metastatic, is there another are of malignancy?
IMPRESSIONS:
1. Intense activity in the right adrenal mass is consistent with metastasis.
2. Moderate activity in the right lower lobe pleural based nodularity, likely post surgical inflammation
although residual viable malignancy cannot be excluded.
3. Intense activity in the right hilar node is inflammatory verses malignancy.
Beside the right adrenal mass that is metastatic, is there another are of malignancy?
Hi,
The term aggressive is meant to distinguish which cancers would require additional treatment like chemotherapy (to be delivered after surgery), not to distinguish which cancers are not amenable to surgery. Even if you started with metastatic lung cancer to the adrenal gland, even this does not automatically mean that there is zero chance for surgery, but you are correct that majority of these cases are not surgical candidates.
It is possible to develop a metastasis after a few months. This is due to the limitations of the imaging tests, there is a threshold size for the CT scan to be able to “see” the cancer.
The term aggressive is meant to distinguish which cancers would require additional treatment like chemotherapy (to be delivered after surgery), not to distinguish which cancers are not amenable to surgery. Even if you started with metastatic lung cancer to the adrenal gland, even this does not automatically mean that there is zero chance for surgery, but you are correct that majority of these cases are not surgical candidates.
It is possible to develop a metastasis after a few months. This is due to the limitations of the imaging tests, there is a threshold size for the CT scan to be able to “see” the cancer.
Sorry to bother you again. To assist you in any evaluation/reply to my last post of 08/31/08, I just noticed that the PET SCAN taken at NYU was compared only to the NYU Emergency Room CT Chest Scan takon on 02/20/08, during my Emergency Room admittance for complications - blowing up like a baloon. The cardiothoracic surgeon who performed the lung surgery viewed the (6) six month postop CT Chest Scan dated 08/13/08 and said that the NEW right adrenal mass was not adrenal cancer but still lung cancer. If the NEW right adrenal mass is malignant, and it seems so with an FDG uptake of 9.3 max. Size: 4.0 x 2.5 cm. , then the primary lung carcinoma was at the outset an aggressive cancer. Nothing can be done about then and now. The size of this NEW right adrenal mass actually grew in between the (6) month postoperative CT Chest Scan dated 08/13/08, Size: 3.2 x 2.0 cm - viz a viz - the NYU Pet Scan dated 08/25/08 - Size 4.0 x 2.5 cm. Is that at all possible? And if so, how aggressive is this suspicious metastasis? Anthony590
I get the gist of what you are saying about then and now. The surgeon was a cardiothoracic surgeon. If surgery fo the adrenal is performed, it will be by a surgeon who specializes in laparoscopic surgery. Let me clarify a little more. The cat scan dated 08/13/08 states again that there is a "stable" left adenoma. A stable 1.5 cm left upper pole renal cyst is reidentified. A stable low density nodule is seen n the left lobe of the thyroid gland, likely representing an adenomatous nodule.
The Pet Scan dated 08/25/08: chest: The heart and pulmonary vasculature are within normal limits. Abdomen: Evaluation of the abdomen demonstrates normal physiologic uptake within the bowel, liver, kidneys and urinary collecting system. No abnormal radiopharmaceutical uptake is seen along the lymph node chains of the abdomen, pelvis, or retroperitoneum. On unenhanced CT images, the liver is normal. The spleen is unremarkable. Pancreas well visualized and normal. The kidneys are normal. No upper abdominal or retroperitoneal lymphadenopathy is visualized. Scans of the pelvis
reveal no side wall adenopathy or central mass. The urinary bladder is normal. Prostatic calcifications are visualized. The Pet Scan - viz a viz - the Cat Scans does not mention a stable left adrenal adenoma, nor do they mention the left adrenal at all. I'm a layman and this is still very confusing. The natural progression, as you said, from right to right ensued after the non-agrressive mass on the lung turned out to be aggressive. I never mentioned to you that I had a serious, life threatening complication after the lung lobectomy. I returned from the hospital after being drained with chest tubes for six days and the same day I returned home, I blew up like a baloon. Rushed back to hospital emergency and drained again for seven days. The trauma was scary. I undersatnd that laparoscopic surgery also utilizes the infusion of air during the procedure. I dread another complication. Any comments you may be able to post will be appreciated. Anthony590
The Pet Scan dated 08/25/08: chest: The heart and pulmonary vasculature are within normal limits. Abdomen: Evaluation of the abdomen demonstrates normal physiologic uptake within the bowel, liver, kidneys and urinary collecting system. No abnormal radiopharmaceutical uptake is seen along the lymph node chains of the abdomen, pelvis, or retroperitoneum. On unenhanced CT images, the liver is normal. The spleen is unremarkable. Pancreas well visualized and normal. The kidneys are normal. No upper abdominal or retroperitoneal lymphadenopathy is visualized. Scans of the pelvis
reveal no side wall adenopathy or central mass. The urinary bladder is normal. Prostatic calcifications are visualized. The Pet Scan - viz a viz - the Cat Scans does not mention a stable left adrenal adenoma, nor do they mention the left adrenal at all. I'm a layman and this is still very confusing. The natural progression, as you said, from right to right ensued after the non-agrressive mass on the lung turned out to be aggressive. I never mentioned to you that I had a serious, life threatening complication after the lung lobectomy. I returned from the hospital after being drained with chest tubes for six days and the same day I returned home, I blew up like a baloon. Rushed back to hospital emergency and drained again for seven days. The trauma was scary. I undersatnd that laparoscopic surgery also utilizes the infusion of air during the procedure. I dread another complication. Any comments you may be able to post will be appreciated. Anthony590
Hi,
Your latest post seems to clear things up. Let me summarize: post operatively, the new imaging studies done only showed a suspicious adrenal mass.
The basis for advice generally rests on the estimate of cancer behavior. During the time of initial surgery, if the cancer is limited to the lung and has reached nodes near the heart – then the assumption is that the cancer is not very aggressive and is indeed limited. Hence, the surgeon was correct AT THE TIME. Further treatment wouldn't likely make much of a difference.
At the present time that there seems to be involvement of the adrenal gland (regardless of lateralityor put another way – the lung cancer and the adrenal need not be on the side of the body, left lung with cancer with new left adrenal mass or right lung with cancer with new right adrenal mass), there is no need to demonstrate that the cancer followed an orderly progression (or put another way, we cannot make a rule that we will only consider it as likely to be cancer if there is a clear mass on the nodes around the heart, then probably nodules in the liver, then a new adrenal mass). Hence, the adrenal mass if proven malignant speaks against the assumed behavior that the cancer was not aggressive and was limited to the chest.
Your latest post seems to clear things up. Let me summarize: post operatively, the new imaging studies done only showed a suspicious adrenal mass.
The basis for advice generally rests on the estimate of cancer behavior. During the time of initial surgery, if the cancer is limited to the lung and has reached nodes near the heart – then the assumption is that the cancer is not very aggressive and is indeed limited. Hence, the surgeon was correct AT THE TIME. Further treatment wouldn't likely make much of a difference.
At the present time that there seems to be involvement of the adrenal gland (regardless of lateralityor put another way – the lung cancer and the adrenal need not be on the side of the body, left lung with cancer with new left adrenal mass or right lung with cancer with new right adrenal mass), there is no need to demonstrate that the cancer followed an orderly progression (or put another way, we cannot make a rule that we will only consider it as likely to be cancer if there is a clear mass on the nodes around the heart, then probably nodules in the liver, then a new adrenal mass). Hence, the adrenal mass if proven malignant speaks against the assumed behavior that the cancer was not aggressive and was limited to the chest.
Perhaps I should explain more precisely. The PET SCAN dated 08/25/08 shows and FDG uptake of 9.3 max for the right adrenal gland. Size 4.0 x2.5 cm. The areas of inflammation verses malignancy have FDG uptakes of 3.2 SUV and 3.3 SUV. Again, the lung surgeon said that chemo or radiation after the lung surgery was not necessary.
It was a cure, he said. The Cat Scan dated 08/13/08 does not show any areas of inflammation verses malignancy. The adrenal laparascopy surgery, I was told by an oncologist/hematologist, will need chemo and/or radiation after surgery. I am perplexed by the areas that still show surgical clips. What is their importance, if any?
Anthony590
It was a cure, he said. The Cat Scan dated 08/13/08 does not show any areas of inflammation verses malignancy. The adrenal laparascopy surgery, I was told by an oncologist/hematologist, will need chemo and/or radiation after surgery. I am perplexed by the areas that still show surgical clips. What is their importance, if any?
Anthony590
Thanks for your comments on the PET SCAN. I was told by the lung surgeon that chemo or radiation was not necessary after the lung operation. It was a cure, he said.
The six month postop Cat Scan taken on 08/13/08, shows uptake to the adrenal mass.
3.2 x 2.0 SUV. The Cat Scan does not show the other inflammation sites verses malignancy viz a viz residual lung cancer. The SUV uptake on the PET SCAN taken
on 08/25/08 was 4.0 x 2.5. This mass actually grew in between tests. I gess you are right about a value judgment. The adrenal surgery will probably be necessary. This will be done by laparoscopic surgery. There are still surgical clips in the mediastinum.
Any significance? Anthony590
The six month postop Cat Scan taken on 08/13/08, shows uptake to the adrenal mass.
3.2 x 2.0 SUV. The Cat Scan does not show the other inflammation sites verses malignancy viz a viz residual lung cancer. The SUV uptake on the PET SCAN taken
on 08/25/08 was 4.0 x 2.5. This mass actually grew in between tests. I gess you are right about a value judgment. The adrenal surgery will probably be necessary. This will be done by laparoscopic surgery. There are still surgical clips in the mediastinum.
Any significance? Anthony590
Hi,
Your concern about the possibility of residual tumor in the lung is valid. Your case also hits upon one of the weaknesses of the PET scan. Since you had surgery in January, and this PET was done in August, this is more than a 6 month interval. The PET may have changes due to treatment from chemotherapy within 2 weeks after the treatment and so a repeat during this time may make the PET less reliable. For radiation, the effect may be at least 2 months or 3 months or MORE. For surgery, I haven’t found any specific data.
If you still have some symptoms in the lung, some breathlessness, then this may indicate that there is still some healing going on (which would explain the PET) though the opposite argument for symptoms from lung cancer could also be made. A practical way to look at it would be to see what the CT scan showed. If the area in the lung described as PET positive is virtually invisible to CT, then any symptoms would be unlikely due to cancer.
As what I have mentioned before, this all seems to boil down to a value judgment. If you are risk averse, then you may want to observe over time for any changes and withhold any surgery for the adrenal. On the other hand, if you are willing to take the risk (and chances are this would be less risky than the initial lung procedure), then this report doesn’t really convince against the possibility of cure – so the surgery may still be something to consider.
Your concern about the possibility of residual tumor in the lung is valid. Your case also hits upon one of the weaknesses of the PET scan. Since you had surgery in January, and this PET was done in August, this is more than a 6 month interval. The PET may have changes due to treatment from chemotherapy within 2 weeks after the treatment and so a repeat during this time may make the PET less reliable. For radiation, the effect may be at least 2 months or 3 months or MORE. For surgery, I haven’t found any specific data.
If you still have some symptoms in the lung, some breathlessness, then this may indicate that there is still some healing going on (which would explain the PET) though the opposite argument for symptoms from lung cancer could also be made. A practical way to look at it would be to see what the CT scan showed. If the area in the lung described as PET positive is virtually invisible to CT, then any symptoms would be unlikely due to cancer.
As what I have mentioned before, this all seems to boil down to a value judgment. If you are risk averse, then you may want to observe over time for any changes and withhold any surgery for the adrenal. On the other hand, if you are willing to take the risk (and chances are this would be less risky than the initial lung procedure), then this report doesn’t really convince against the possibility of cure – so the surgery may still be something to consider.
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