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Forum Name: Lung Cancer

Question: MULTIPLE TINY PULMONARY NODULES: CT ARTIFACTS? PLEASE ADVISE


 Nomad - Mon Jan 12, 2009 10:11 pm

I am a 47 year old female with good general health and fitness levels. Last October I had a CT scan for ongoing swallowing problems, which found a 'large substernal mass' which was subsequently removed. It was ectopic thyroid tissue and there was no cancer. I then had a neck lymph node biopsy, again no cancer.

The CT scan also found a small mass in my uterus which, from U/S follow-up, my OB/GYN believes is a fibroid. So far, so good!

My question concerns another incidental finding from the CT scan...
'On lung windows in the right hemithorax there are multiple non-calcified tiny pulmonary nodules (it then lists 5 image numbers) to 3mm. Recommend close CT follow-up in three months to ensure decrease in size or resolution'.

From researching this I understand these are extremely small and typically folllowed-up with regular CT scans to monitor size etc. I used to smoke cigarettes - a pack/day for 18 years - but gave up in 1997. I have had bronchitis twice (in 1997 and 2005) and used to have exercise-induced asthma occasionally (I am a recreational runner). My father had fatal esophagal cancer (with matastases but unsure where located) and my mother had cervical cancer.

I discussed this report with my thoracic surgeon (who operated as above) and he seems pretty confident that I may not even have any lung nodules! He suggests it is some kind of effect from how the CT images are taken or 'sliced' (he used another term). He says I should wait 5/6 months for my first repeat CT scan. My specific questions are:-

- Any ideas re what he may mean re the slicing or endings of the images?
- How concerned should I be?
- What follow-up do you recommend?
- Has anyone reading this actually had lung cancer develop from 'multiple non-calcified tiny pulmonary nodules' such as this?

I would appreciate any help/experience because I am concerned and surprised by my doctor's laid-back recommendation.

Many thanks.
 Dr. Tamer Fouad - Tue Jan 13, 2009 9:47 am

User avatar Hello,

New CT techniques (eg, Helical CT) use computer aided techniques and may also compress the image (similar to what happens with a computer image). This and many other things can lead to artifacts. A CT scan as you know takes serial x-ray 'slices' in the area being scanned.

Certain characteristics can help in determining the nature of a nodule. The small size of the nodules of course favors a benign nature. The multiplicity of the nodules and their location can help also. Lung cancer usually presents with a dominant mass. Lung metastasis usually presents with multiple nodules of variable size that are located at the periphery of the lung field.

I really don't think you have reason to worry since you do not have any other symptoms. I understand your concern but I think active surveillance is the right approach. During the 6 month period should you feel any complaints you should report them immediately to your doctor.

Best of luck!
 Nomad - Tue Jan 13, 2009 1:42 pm

Thank you for such a fast reply and explanation re the 'slicing' effect!

My main concern is that my Dr advises a 6-month wait before a follow-up scan, whereas the report says 'Recommend close CT follow-up in three months to ensure decrease in size or resolution'. Just to clarify, do you suggest a 6 month wait too?

Many thanks.
 Dr. Tamer Fouad - Tue Jan 13, 2009 2:31 pm

User avatar Thank you for your question.

I am not really in a position to recommend a certain time period for follow up. However, if you are anxious about ]your CT that alone may be a good enough reason to conduct a follow up sooner. Usually when I am faced with a patient is anxious I tend to compromise and do the CT sooner than later ie, for example at 4 months.

Again, I haven't seen the CT. Sometimes, it's so obvious that there is no reason for concern.

I think you should discuss your concerns again with your doctor. I think your concerns are legitimate. I'm forwarding this for referral to our Radiology Team!

Good luck!
 dyagernpc - Wed Jan 14, 2009 2:59 pm

Re: REFERRAL: MULTIPLE TINY PULMONARY NODULES: PLEASE ADVISE
Sent at: Wed Jan 14, 2009 2:34 pm
by dyagernpc

I conferred with one of the interventional radiologists I am working with and as far as artifacts causing 3mm nodules to appear, I don't know of any. However, main artifacts are streak artifacts causing linear rays, and rings which are like target rings from a blown detector. Then there is motion artifact, again not likely to cause the appearance of nodules. Volume averaging is another phenomenon but that is not an artifact and usually results in missing 3 mm nodules when the slice thickness is 5mm for example.

Small nodules like that can be granulomas, related to sarcoidosis, mets, miliary TB or a whole host of things. Nodular interstitial disaeses are also included.

Hope this helps!

Deb Yager, NP-C
 Nomad - Thu Jan 15, 2009 9:16 pm

Thank you for taking the time to discuss and respond. Are you suggesting it is unlikely to be artifacts and more likely to be something actually there? And that the 'something' could be anything from sinister to harmless? That makes me favour a 3-month follow-up. Any thoughts/comments? Thank you.
 Dr. Tamer Fouad - Sat Jan 17, 2009 9:16 am

User avatar Hi,

Please remember we are in no position to recommend anything since we haven't actually seen your scans. But from a theoretical point of view nodule artifacts are not likely. It may be that the 'artifacts in your scan are not exactly 'nodules'. As you can see it's very confusing.

You need to discuss this again with your doctor and if needed seek a second opinion.

Please remember to keep us updated!
 Nomad - Mon Feb 23, 2009 5:04 pm

I just got the report from my follow-up scan. It reads:

'The lung parenchymal window settings show no acute or focal infiltrates or effusions. Scattered nodules previously described appear stable'.

So this is good news! I think may wait six months before my next scan.
Thank you again for your help.
 Dr. Tamer Fouad - Tue Feb 24, 2009 5:18 am

User avatar Congratulations! Thanks for posting an update!

Best regards,
 mtstreet - Thu Mar 26, 2009 7:51 pm

Hi,

Nomad, I'm glad you posted this thread because I had a similar question.

I recently had my second CT scan due to an ascending aortic aneurysm. New in this year's report was the appearance of "3 tiny less than 5mm noncalcified pulmonary nodules." They are in the apical segment of the right upper lobe, the anterior segment of the right upper lobe, and "what is probably" the left lower lobe.

So I got concerned until I read the bottom of the report, which says that they are of "doubtful significance." I won't have another CT until next year but frankly, I wish they'd check these again before then.

However, Dr. Fouad made me feel better when he said the fact that they are small favors a benign nature.

I have a question for the doctor, though. Both my father and grandfather (who were smokers) died from lung cancer. I have never smoked due to heart problems but was around second hand smoke while growing up. What are the chances that a non-smoker can get lung cancer? Is it fairly rare?

Thanks in advance for any information and good luck, Nomad.
 Dr. Tamer Fouad - Fri Mar 27, 2009 5:15 am

User avatar Hello,

Good question regarding second hand smoke while growing up.

There is a point I would like to make before I forget, there is a familial risk especially with first degree relatives who are diagnosed at a younger age.

Regarding your question it is hard to determine the individuals risk of developing lung cancer from second hand smoke. There is a dose response relationship and estimating the amount of exposure is obviously difficult to determine.

That said, several studies give us a general idea about risk in the case of second hand smoke (also known as environmental tobacco smoke).

Environmental tobacco smoke is estimated to be the cause of 2% of all lung cancers.

According to the U.S. Environmental Protection Agency (EPA), approximately 3,000 nonsmoking adults die from lung cancer each year because of breathing the smoke of others' cigarettes.

Analysis shows that sidestream smoke emitted from a smoldering cigarette between puffs contains virtually all the carcinogenic compounds that have been identified in the mainstream smoke that is inhaled by smokers. Beside nicotine, side stream smoke contains one of the highest environmental exposures of benzene (a risk for leukemia).

The risk of lung cancer is doubled after exposure to household smoke for over 25 smoker years. The risk of mortality from lung cancer was 30 fold higher in one report for a nonsmoker living with a smoker compared to a nonsmoker living with a nonsmoker. Whereas, less than 25 years of exposure was not associated with an increased risk. This may answer your question. In addition to that lung cancer that occurs in nonsmokers has been attributed to childhood exposure to second hand smoke in 17% of these cases.

The risk may also be influenced by genetics. Risk increases in those with polymorphisms of GSTM1 gene (which detoxifies carcinogens in tobacco).

Lots of numbers but I hope this gives you a general picture of the complexities of estimating risk.

Best regards,
 mtstreet - Fri Mar 27, 2009 8:20 am

Hi again,

Thanks so much for the very interesting reply. The good news is that the risk does seem relatively small. On the other hand, my father was 53 when he passed, which is a fairly young age.

I do have a couple of other questions, if you don't mind.

Last year's CT scan did not show the nodules but did show "califications within the lung and spleen consistent with old granulomatous disease." Is there any kind of a relationship between these nodules and granulomatous disease noted last year?

Also, prior to my scan I had either a cold or sinus infection that caused me to do a lot of coughing. This may sound stupid, but could this have caused the nodules?

Thanks in advance for any information.

Cheers!
 Dr. Tamer Fouad - Sat Mar 28, 2009 11:22 am

User avatar Hi,

It can be very misleading to give an opinion about a CT that I haven't actually seen. So please be cautioned about taking anything I say except in the most general sense.

Calcifications are unlikely to be confused with nodules unless these calcifications appear within nodules. That said there should be some mention of the calcifications in the new CT.

Its the questions that our guests call 'stupid' that are usually the most scientifically challenging! :)

But to answer again in the most general terms, coughing can lead to congestion which would cause an increase in vascular markings. Sometimes, vascular markings when viewed head on can mimic a nodule. However, my opinion is no this is usually something a radiologist would keep in mind.

Good luck to you!
 mtstreet - Sun Mar 29, 2009 10:32 am

Thanks for your reply, even to my "stupid question." : )

Yes, the granulomas were noted on this year's report as well. I'll have another CT scan in a year and just keep in mind what the radiologist said in his report - they are "tiny" and of "doubtful significance."

Take care and thanks again.

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