10mm lung nodule, non smoker

[jsr51]

I am a 51 year old female who has never smoked.  I went to the doctor 2 months ago with shoulder pain that was diagnosed as tendonitis.  When my shoulder was x-rayed a small spot showed on me right lung.  I was then given a chest x-ray that showed several small spots on both lungs.  I then had a chest CT scan.  This showed multiple irregular-shaped nodular densities in both lungs.  The largest being approximately 10mm.  There is no pleural effusion or pleural mass.  I have had abdominal and pelvic CT scans, a colonoscopy, a EGD, endometrial biopsy, pap test, pelvic ultrasound and various blood tests all which have been normal.  I am extremly worried about this and would like any input on what I should expect.  I am scheduled to have a VATS in 3 days.  Other than this problem I am an extremely healthly person and have never had any health problem.  There is no history of lung cancer in my family other than my maternal grandfather who smoked most of his life.

[National Jewish Health]

You might want to have a mammogram, also, but the first thing you should do if you have not already done so is to locate any previous chest x-rays or even x-ray reports for comparison.  These "spots" may have been present for a long time.  Without prior films, you should proceed with the VATS.

Good luck

[roent]

First of all, pulmonary nodules could be due to multiple things.  The most concerning would be a primary lung cancer that has spread to both lungs or metastatic disease from some other cancer.  Benign (noncancerous) sources would primarily include infection and granulomatous disease.  A granulomatous disease process may occur from exposure to fungi such as histoplasmosis, which is endemic in the Ohio River valley (which means many people are exposed and many get nodules).  Depending on where you live, you may have been exposed at some time in your life and may have developed nodules.  Sometimes these nodules accumulate calcium which shows up on a CT scan and, essentially, indicates a benign nodule.  It would be helpful to know if these nodules were calcified or noncalcified.  If you live in or have traveled to an area such as the southeast/Ohio river valley (histoplasmosis) or to the Southwest (coccidiomycosis) would also be helpful information.  Granulomatous nodules can also be seen in sarcoidosis.  Some autoimmunine diseases (rheumatoid arthritis) can produce nodules.

With the information you have provided, I find it interesting that you are already scheduled for VATS.  While the VATS should give you the answer, it is also lung surgery, although less invasive than open lung surgery.  A PET scan (preferably PET/CT) scan would potentially be very helpful in your workup. A PET scan may indicate that these nodules are likely benign or may suggest malignancy and be helpful as a guide for biopsy (ie. which nodule is most suspicious).  If this is metastatic disease, PET scan may be helpful in finding the source, as well. If a PET scan is negative, the etiology of the nodules are most likely benign.  However, they would still need to be followed for 2 years with CT of the chest to make sure they are stable.  There are a few instances where PET can be abnormal in a benign process and normal in a malignant process.  PET can also be limited by the size of the nodules.  A 10mm nodule should be able to be visualized on PET.  PET scans should be interpreted by a qualified Nuclear Medicine physician or Radiologist.

A CT guided biopsy with a needle is also a consideration.  It is less invasive that a VATS.  A Radiologist would perform this procedure as an outpatient and would explain the risks.  Depending on the size and location of the largest nodule, this may or may not be an option.

You also did not mention bronchoscopy.  With broncoscopy, a pulmonologist (lung doctor) would look into your airway with a scope and try to take material which could give information as to whether this is due to a benign or malignant process.  Again this may or may not be an option in your case.

Followup CT can also be useful to see if the process is getting better or worse before proceding to VATS

You have many options.  Of the options available, VATS is the most invasive and carries the most risk.  It also is probably best at giving you a definitive answer.  CT biopsy can also give an answer and is less invasive.  Further imaging with PET/CT is noninvasive and could help determine whether you want to follow this or procede with biopsy.  Bronchoscopy and follow-CT are other options.  You should discuss these with your doctor if you have not done so.  Only you and your doctor can determine the best next step for you.  He/she may have very specific reasons why VATS may be the best next step for you.