Lung Cancer or PCa Mets....only taking out the lower left lobe will tell :-(

Cryoablation 2006; pca slowly growing since...until Sept 2016, where it grew from 7.9 in Feb, 2016 to 13.4 in Sept.

Bone scan showed two small spots; one on a right rib and one at the back of left shoulder. Urologist followed up with an additional CT scan to the chest to see if anything more could be shown about the bone spots...CT scan found bones clean but showed a 17 mm, malignant appearing, nodule in lower left lung.

Biopsy followed which confirmed malignancy, favoring adenocarcinoma, but couldn't determine what kind of cancer (primary lung cancer or PCa mets).

Lung surgeon wants to be totally conservative, believing it is more likely lung cancer, due to smoking history (even though I have not smoked in 11 years) and will take out entire lower left lobe on Jan 9. The only good news is that the nodule appears to be totally isolated and even the surgeon believes that if it is lung cancer, the surgery may be curative. PET scans show little else, other than some limited uptake in lymph nodes around the throat, which likely are due to a bout with an upper respiratory infection. However, right before the major surgery, the surgeon will have those nodes analyzed.

I have been through so many tests, the latest being a four hour heart stress test that the lung surgeon ordered; the results of which I still don't know due to the holiday. On a lighter note, the PET scan showed the muscles where I was injected with Lupron having a significant uptake.

The last three months have been surreal and yes, I am scared.

The possibility of having two cancers is frightening, especially that the possible "second" cancer is much more aggressive by nature. However, there is always hope and it is hope that keeps me going right now.

Thank you all for reading this. We all have our stories and it is nice that there is a place where we can put our feelings out, where others have similar feelings, similar hope and similar fears.

Post Edited (Joefrompgh) : 1/2/2017 2:03:38 PM (GMT-7)

Hi Tall Allen,

I appreciate your questions and will answer them as best I can.

I am seeing an oncologist specializing in prostate cancer at UPMC Pittsburgh, who, contrary to the lung surgeon, believes it is more likely prostate cancer mets. The biopsy samples were too small to do any adequate testing. The best they could tell was it is "carcinoma, favor adenocarcinoma." There is a chance that a larger biopsy sample would provide more and better information but if more time is spent on trying to identify this, the less chance that if this is lung cancer that surgery could be curative. This is part of all the stress as time is not on my side.

As to this being small cell cancer, lung or prostate, that also wasn't indicated by the biopsy. It is nearly impossible that this could be small cell lung cancer due to its positioning very far away from the upper lung, where substantially all small cell lung cancers reside. And, if this were small cell PCa, at a size closing in at 2 cm, I would probably have many signs already and possibly be nearing death, as small cell PCa moves rapidly. The rise in psa since February is also not indicative of small cell prostate cancer. Of course, I still harbor some concern about that but I have to think that feeling absolutely fine in all respects, save an upper respiratory infection, which has since cleared, does not point to a rapidly moving morbidity throughout my body, which small cell cancer is noted for. BTW: if either my surgeon or my oncologist thought this was a small cell cancer, they would not operate to take it out as that would not be either curative or in any way, helpful. Again, I do share some concerns here as the biopsy only "favored" adenocarcinoma (which is never small cell) but lack of symptoms or noted spread would seemingly be on my side. I would hate to find out a week after surgery that I have 6-9 months to live but am confident to a good, but not unqualified degree, that will not happen.

The lupron depot shot showed up as uptake on the PET scan in the muscle of the buttocks where it was injected. No one thought that was an issue. However, my prostate bed, which is now calcified, did show uptake that my oncologist did not believe was abnormal.

I had the normal glucose-based PET scan.

I will not be getting my 4 month psa test since my first lupron shot until March. I am also on bicaludamide (Casodex), 50mg, daily.

Post Edited (Joefrompgh) : 1/2/2017 2:01:52 PM (GMT-7)

Thanks for explaining that. You might want to go ahead and get that second opinion from Epstein. Of course, the definitive way of telling if it is prostate cancer is if it shrinks after your Lupron shot. With small cell PC, it is often a "mixed type." As you know, the small cell component doesn't put out much PSA and doesn't respond to hormone therapy, but the adenocarcinoma component does. At any rate, it's very easy to see under a microscope, so if the pathologist didn't ID any, it's something you can, thankfully, rule out.

I have no idea why an FDG PET scan would show uptake at the site of an IM Lupron injection -- is that common? FDG PET scans are not much used for prostate cancer because prostate cancer cells don't metabolize glucose at an accelerated rate until it is very advanced. (The FDA-approved PET indicators specific for prostate cancer are C-11 Choline and fluciclovine, with several others in clinical trials.) The uptake in the prostate shows that the cryoablation was incomplete and the residual cancer there is advanced. I guess there is little point in worrying about that now. Your lung met, whatever it is, is your main concern.

Joe and Allen
The radiologist notes from my scans regularly show uptake in the site of my injections. I have had these notes as recently as this year in my stomach muscles/fat from the firmagon injections I received for much of 2013. I have also seen these notes about the injection sites in my rear from Lupron. It is also usually noted as inconsequential or indeterminate but it is noted as showing uptake just the same.

Tall Allen said...
Thanks for explaining that. You might want to go ahead and get that second opinion from Epstein. Of course, the definitive way of telling if it is prostate cancer is if it shrinks after your Lupron shot. With small cell PC, it is often a "mixed type." As you know, the small cell component doesn't put out much PSA and doesn't respond to hormone therapy, but the adenocarcinoma component does. At any rate, it's very easy to see under a microscope, so if the pathologist didn't ID any, it's something you can, thankfully, rule out.

I have no idea why an FDG PET scan would show uptake at the site of an IM Lupron injection -- is that common? FDG PET scans are not much used for prostate cancer because prostate cancer cells don't metabolize glucose at an accelerated rate until it is very advanced. (The FDA-approved PET indicators specific for prostate cancer are C-11 Choline and fluciclovine, with several others in clinical trials.) The uptake in the prostate shows that the cryoablation was incomplete and the residual cancer there is advanced. I guess there is little point in worrying about that now. Your lung met, whatever it is, is your main concern.

Tall Allen, it is too late to send the biopsy for a second reading (surgery in 6 days) and there is no time to see if the nodule shrinks (which could take months) as the Lupron takes effect. I wish there was.

From my understanding there may be various "likely reactive" sites on a PET scan, most notably lymph nodes that are fighting inflammation or infection. I would imagine that the Lupron-depot shot would possibly cause some glucose uptake by virtue of inflammation, alone. I will ask my oncologist about this when I see him after the surgery, along with the uptake in my prostate bed, which as you said, is really meaningless at this point.

Both my oncologist and I noted that the SUV reading of 3.86 at the nodule sight was not as high as might be expected if this was lung cancer (the SUV readings range from 0-15) and could very well be indicative of PCa, which as you noted, does not give off very high readings on the glucose PET test. However, one cannot use that reading alone to make a decision, as an SUV of 3.86 is not a low reading either and either cancer could well give off that reading.