Unidentified Mass In My Lungs

[wpcoe]

I developed acute bronchitis just after having one of Bangkok Hospital-Hua Hin's packaged physicals which included a chest X-ray. Because the X-ray was handy, my physician looked to see if any irregularity appeared with my bronchia, and noticed a round "object" adjacent to my left bronchial tube that she couldn't identify. A fresh X-ray was no clearer, so she sent me for a CT scan for clarification.

The CT scan revealed the round object was merely a blood vessel (aorta, I think?) showing up. HOWEVER, a small (3 cm?) mass was noticed on my lower left lung, or possibly on the diaphragm. My doctor was *quite* concerned about it, but since Bangkok Hospital Hua Hin is brand new, they don't yet have a pulmonary doctor on staff, so she sent me to Bangkok for a biopsy. I chose BNH over Bangkok Hospital.

I met with the BNH pulmonary physician on Tuesday, and he gave me three diagnostic options:

(1) bronchoscopy -- sending a tube down through my throat and into the lungs to snip a tissue sample

(2) needle biopsy -- plunging a needle from outside my body into the lung to snip a sample

(3) old-fashioned surgery to just open me right up.

He listed those options as being in the order of least invasiveness and risk. He said a problem with the needle biopsy was that the mass was not adjacent to the rib, so would have to disturb healthy lung tissue to get to the mass.

I had the bronchoscopy on Tuesday, and today he called to say some initial TB test came back negative as well as the test for malignant cells being negative. Results are still pending for a fungus test as well as some lengthy (three month?) TB test.

He's already pushing me to return for the needle biopsy. I asked him why, since the bronchoscopy biopsy showed no malignant cells. He said there is concern for a "false negative" on that test.

I *think* what he's concerned about is that since they don't know what the mass is, they want to keep testing until they find out what it is.

I'm of the mindset that, if it ain't broke, don't fix it. i.e. It's not TB nor malignant, so what harm is it doing? In my distant past, I was convinced to have a liver biopsy due to a high bilirubin count. Turns out I simply have a (congenital) liver abnormality, and there was no need for concern. I wonder about this mass being similar: I might have had it for a long time, and it's not causing any problems, so why not just let it be? I also want to at least wait until the fungus test results are in.

How much risk do you all think there'd be if I wait a couple months, then do another CT scan to see if the mass has changed?

Part of my reluctance in continuing with more procedures is my cynical opinion that I'm viewed by the Bangkok Hospital conglomerate, at least partially, as a farang cash cow to be milked of yet more money. e.g. The B9,000 CT scan and the B45,000 procedure at BNH.

[FBN]

This is an extremely difficult question to comment on. Perhaps clarification of some of the salient aspects..

If the mass is not inside the bronchus or connected to the lung space that can be accessed by the bronchoscope, the test sample may not be completely accurate for obvious reasons. This lung mass seems to be isolated from the airway and is clearly a solid mass within perhaps a capsule of fibrous tissue. Only an open (surgical) biopsy or a needle biopsy will give the definite answer. This is unfortunately now the point we are at. The BNH doc had the correct approach ie from the least invasive to the most even if the least invasive was not guaranteed to give a final answer.

This lesion is very unlikely TB which occurs clasically in the upper lung regions and rarely results in a solid lesion. Fungal it could be but there is unlikely any association with the liver problem before. The reason for the delay in the TB results is the time it actually takes to grow a TB bacterium in a culture medium; this is a very slow growing bug. Intitial tests are only a stain of the sample with a special tecnique that shows the presence of the bacterium. So, unlikely that postponing by three months will get a definite diagnosis.

It is actually "broke" because there is a mass but what it is and how to fix it is yet unknown. Far be it, I think for anyone on this forum to advise on how long this can wait. Best to get a second opinion and then go with the best medical advice. I would not let cost be the determinator here...

[jimmym40]

If it were me, I'd be extremely concerned. I didn't know much about lung cancer until one of my relatives and a close friend had it. The relative passed away after around 9 months, and luckily, the close friend survived after after cemo and radiation. But any form of lung cancer is serious and the prognosis is usually not good. Do some research (google) on lung cancer. I agree, I think the doc's approach was right on. I'd keep going with the testing until something is definitive or keep ruling things out - ALL JUST MY OPNION

Wish you the best.

[wpcoe]

If the mass is not inside the bronchus or connected to the lung space that can be accessed by the bronchoscope, the test sample may not be completely accurate for obvious reasons.

So I wonder what the bronchoscopy snipped off as a sample, if not from the unknown mass? I had thought the bronchosopy was like a colonoscopy where a camera was used to see and to to direct the tool. If the camera did not actually see a mass, why even take a sample?

This lung mass seems to be isolated from the airway and is clearly a solid mass within perhaps a capsule of fibrous tissue. Only an open (surgical) biopsy or a needle biopsy will give the definite answer. This is unfortunately now the point we are at. The BNH doc had the correct approach ie from the least invasive to the most even if the least invasive was not guaranteed to give a final answer.

Makes sense. But, again if the mass is isolated and out of reach of the bronchoscope, what was the sample taken?

It is actually "broke" because there is a mass but what it is and how to fix it is yet unknown. Far be it, I think for anyone on this forum to advise on how long this can wait. Best to get a second opinion and then go with the best medical advice.

Thanks. Regarding consultation with another pulmonologist: I fully expect nothing less than the recommendation to follow with a needle biopsy. Where there is any remote possibility of doubt, the doctor would almost *have* to err on the side of caution, wouldn't s/he?

I value the input from you folks here on the forum as a valuable resource, as well. Mostly it seems like it's westerners with medical knowledge & experience here, and the way information and opinions are presented and explained is easy for me to understand. I seem to sometimes struggle with Thai doctors' explanations, even though the English is fluent.

[moe666]

Western dr. would be treating you the same and yes they see a cash cow as well. Any one in their own business only makes money if you buy what they are selling. Good luck on your health issue.

[Beechboy]

Being in the medical profession myself (sem-retired now) and yes I have worked in various private Bkk hospitals, please folks play down the money making angle.

Honestly, it is hardly as rife as is made out, and usualy concerns prescibing and minor stuff and becomes less common the more serious the problem

Most Thai doctor's are excellent and taking advantage of patients is the last thing on their mind. The Hippocratic oath still dominates, not the Thaksin oath.

There are some hospitals that cash in at every opportunity, usually for cosmetic stuff. These are usually well documneted on boards such as this.

Of course hyped up American ladies from California and the wives of wealthy sheiks are asking for it, to the Thai way of thinking

Your average John will be treated more or less fairly.

Please remember, medical care is extremely expensive, from the operating theatre right down to the dispensary.

Some superficial stuff for the O/P to consider;

If you feel well in yourself,then this would be encouraging.

If you retain your appetite, then this would be encouraging.

If your weight is constant, then this would be encouraging.

If you remain active and have no breathlessness over minor activities ,then this would be encouraging.

And the chestnut, do you or did you ever smoke?

Your specialist would have asked all these questions at your initial consultation, as such small changes indicate problems in the making.

[wpcoe]

Some superficial stuff for the O/P to consider;

If you feel well in yourself,then this would be encouraging.

If you retain your appetite, then this would be encouraging.

If your weight is constant, then this would be encouraging.

If you remain active and have no breathlessness over minor activities ,then this would be encouraging.

And the chestnut, do you or did you ever smoke?

As recently as three weeks ago I was literally fat, dumb and happy. Since then, I have spent B80,000+ on health care. (I've had two other questionable issues that could warrant threads of their own...) Yes, money should not be the primary focus, but it does give me pause.

Other than still coughing up a bit of blood, I feel like I'm back to normal. My appetite has remained pretty constant for years now. Weight loss is not an issue. I'm not really active, but that's a lifestyle choice I've made since I retired last year. I fully enjoy sleeping long hours, just puttering around the house, and spending way too much time online. My left-brain lectures me about getting exercise, but my right-brain lets me be lazy. Definitely no breathlessness. I have never smoked.

I just got an e-mail from my BNH doctor. When we talked on the phone earlier he mentioned he had sent me a couple e-mails, but turns out he had the wrong e-mail address for me. So, as of this evening:

"TB smear and PCR - negative

: cytology - no malignant cell

: biopsy - no TB or cancer

I am waiting for the rest - culture for bacteria (this takes 3 days), culture for fungus (2 weeks) and culture for TB (2 months)"

I will wait until the bacteria and fungus culture results are in before deciding what to do next.

[moe666]

Beechboy has good words for thought. I spent 10 days in Chiang Mai Ram Hospital in Jabuary. I will say the treatment was fantastic and the Dr. was very competent, if a bit consevative in his treatment(cellulitus in leg). 3/4 cost of the stay was for anti-biotics and 1/3 was for the hospital and Dr. fees which were very reasonable. The same treatment and stay in a hospital in the states would have been 10 times what I paid in Thailand and the care not as good.

Good luck on your treatment and I hope all turns out well for you.

[wpcoe]

I should have mentioned that included in that B80,000+ in health care charges was about B13,000 for a pre-packaged physical to which I added a few extra tests (STD panel, HIV, testosterone). I was not feeling ill, just that I'm 56 and it had been about six years since I had a full physical.

I also intended to establish a rapport with a Hua Hin physician whom I could consider my "primary care" doctor to whom I would report with any malady and have her make referrals to specialists, as appropriate. I wanted her to know my particular idiosyncrasies, like that my normal resting body temp is 36 C/96.8 F so that if I show up and my temp reads 37.5, she'll know I am already running a fever. Things like my bilirubin count is "high," but that it's "normal" for me. Things just kind of went downhill from there.

[Beechboy]

Beechboy has good words for thought. I spent 10 days in Chiang Mai Ram Hospital in Jabuary. I will say the treatment was fantastic and the Dr. was very competent, if a bit consevative in his treatment(cellulitus in leg). 3/4 cost of the stay was for anti-biotics and 1/3 was for the hospital and Dr. fees which were very reasonable. The same treatment and stay in a hospital in the states would have been 10 times what I paid in Thailand and the care not as good.

Good luck on your treatment and I hope all turns out well for you.

Thank you for your kind words moe666 and I am pleased that your treatment went so well.

One thing, I would have thought that your hospitalisation (10 days) would have been more expensive than the antibiotics. These are now relatively cheap drugs and cellulitus, a medium-level infection problem, would normally respond to single drug IV, two at the most.

The thing is, most Thai hospitals now use cheaper generic products rather than the official brands and thus save a lot. Possibly, they make a lot too because you are most certainly charged for the "real" stuff.

There is nothing wrong with generics as long as they come from a reputable source. They are legal, as the franchise held by the drug company who developed the medicine in the first place should has lapsed.

Ciallis is, I believe, a generic of Viagra, much cheaper and much to the chagrin of Pfizer, the developing drug company. Whether or not Pfizer deserve to be upset is a matter for debate. They were developing a heart drug at the time but this was proving ineffective. When they asked for a re-call from the local population of men who were paid to be guines pigs for this drug, few pills came back. It was only when they sought to find out the reason for this that the extraordinary "side-effect" of the drug was realised. Hence the Worldwide institution known as Viagra. Pfizer have made £billions.

Local myth has it that there was a baby boom in nearby Ramsgate (Pfizer is at Sandwich) at about this time.

The main thing Moe is that you were well-treated and are now better.

Sorry O/P I am digressing. It is good to hear that your prognosis improves by the day.

[Sheryl]

• Coughing up blood
• a mass in the lung the nature of which has not been established
• bronchoscopy findings negative

the bacterial culture will most likely be negative as if yoiu had a bacterial infection there would have been findings such as fever, high white blood cell count. Fungal is possible.

if the fungal culture is also negative then any doctor in the world would tell you to proceed to needle biopsy at once. It is the only way to get a definitive answer.

Lung cancer is curable only in early stages, so there is a great deal to lose by waiting. Yes, if it turns out to be benign then the test may not have been necessary, but if it is malignant and you delay it could easily cost you your life.

[wpcoe]

JOOC, if a needle biopsy also shows negative for everything (TB, bacteria, fungus, malignant cells), will it be okay to just leave the mass? If it's "none of the above," could it be something else dangerous?

The liver biopsy I had some 30 years ago was just a big old needle plunged into my chest cavity while I lay on my side, and while the pain was not too bad, the sound it made as it entered the cavity kind of grossed me out.

For a needle biopsy of my lungs, would any type of anaesthesia (sedative, local, general, you-won't-remember-a-thing) be involved?

FYI, I'm no longer coughing up much blood. Before this whole odyssey (about four weeks ago) I wasn't coughing at all...

[Sheryl]

It is normally done under local anesthesia only. But I think you can request a mild sedative, telling the doctor you feel anxious about it. You have to be awake and able to follow instructions so knocking you out is not an option.

The biopsy should yield a definitive diagnosis. If it's negative for malignant cells then it should be positive for some type of benign tumor, i.e. you'll know what the mass is and based on that, the need for treatment can be determined. Some benign lung tumors do require treatment, "benign" just means not cancerous, it does not always mean harmless. Depends on the tumor type and also its location.

[wpcoe]

Between the very informative posts on this thread and my other one about regaining recall of "awakening" during the procedure, I think I was given the type of anaesthesia (I don't want to mis-use terminology I don't totally understand) where I was at least semi-alert during parts the procedure to be able to follow instructions, but after the procedure I was not supposed to recall.

Next time I talk to my doctor, I will ask about the biopsy "yielding a definitive diagnosis," and not simply "negative for malignant cells."

I'm still not clear about the possibility that maybe the bronchoscope was not able to reach the suspect mass. If the bronchoscope didn't reach the mass, why snip a tissue sample? If the bronchoscope DID successfully reach the mass which then tested negative for malignant cells, then what further benefit would another (needle) biopsy yield?

[FBN]

The doctor should be able to indicate where and why the biopsy was taken. It may have been a suspicious area only, not the mass itself. At least this shows that there was no invading malignant cells in the sample.

The needle biopsy will be done under local as, same as with the liver biopsy, you may asked to hold your breath at some point etc. This is usually done under ultrasound or CT scan guidance so that the surgeon knows when the needle is in the mass when the biopsy is taken.

[wpcoe]

FYI, I sent an e-mail to my doctor, including (heavily drawing on Sheryl's post...):

"Did the biopsy yield a definitive diagnosis? The test was negative for malignant cells, but was it positive for some type of benign tumor?"

The relevant part of his reply:

"For bronchoscopy with biopsy, it is not definite in case of negative result as the tissue might be too small or not from the site."

Soooo. I guess the only definitive outcome of the bronchoscopy would be if the biopsy found malignant cells. Apparently, not finding malignant cells is not to be trusted. I wonder why he failed to comment on my query about a "benign tumor?"

Oh, well. More and more, I'm accepting the inevitability of a needle biopsy in my near future.

[Gary A]

My uncle had some sort of growth in one of his lungs. He is a truck driver and frequently hauled grain. They removed the growth and found out that it was a grain of wheat that he apparently aspirated. His body encapsulated it and it appeared as a growth. He is fine and there are no further problems.

[wpcoe]

@Gary A: THANK YOU! What a nice potential outcome to hope for.

[wpcoe]

The needle biopsy will be done under local as, same as with the liver biopsy, you may asked to hold your breath at some point etc. This is usually done under ultrasound or CT scan guidance so that the surgeon knows when the needle is in the mass when the biopsy is taken.

Yuck. I never really thought about combining the needle insertion with ultrasound/CT scan or other guidance. That means the needle will need to remain embedded in my lungs while they look to see if it's at the correct place.

CT scan: I envision being slid into the tunnel with the needle poking out. My last CT was not exactly speedy.

Ultrasound: Sure hope this time they use a lighter touch than the last time. I would think substantial pressure against my body where the needle is could be unpleasant.

The doctor did mention having to coordinate with radiology. Are CT and/or ultrasound considered to be radiology? When I think radiology, I think old-fashioned X-ray.

[Tywais]

Are CT and/or ultrasound considered to be radiology? When I think radiology, I think old-fashioned X-ray.

CT does use x-rays (radiation source), ultrasound is just as it appears - high frequency sound waves that propagate through the tissue and reflect (bounce) back to a sensor similar to radar.

[Sheryl]

Nowadays these departments/services in hospitals are termed Imaging as that encompasses all of it..Xray (whihc as noted above, VT is a type of), MRI, ultrasound etc.

Wpcoe: ultrasound guided needle biopsy is nothing to fear, indeed it is likely to make for a quicker/less painful procedure and certainly more likely a successful one. The ultrasound is applied first and then the needle inserted according to where the mass shows on the ultrasound, the needle immediately becomes visible as it enters and it is then comparatively easy to hit the mass.

Ultrasound application does not require much pressure.

The liver biopsy you had in the past was probably also ultrasound guided, even 30 years ago.

Nobody would undergo a needle biopsy for fun,obviously, but it is not that bad and usually pretty quick. You can request some sedation for it, but as FBN explained you do need to be awake and able to follow commands which will include holding your breath briefly at various points.

[wpcoe]

Ultrasound application does not require much pressure.

You should tell that to the gal that did my lower abdominal ultrasound a few weeks ago. Geez, I half expected to see red track marks, if not some bruises, where she guided the thing. I've had two other ultrasounds in the past (one part of a routine physical, and once to investigate DVT), and those operators just glided the thing along my skin. Fingers crossed for a repeat of the latter!

The liver biopsy you had in the past was probably also ultrasound guided, even 30 years ago.

No, they just had me turn on my side and *thunk* in went the needle. I guess they pretty much knew where my liver was, so no precision needed vs my current predicament.

Nobody would undergo a needle biopsy for fun,obviously, but it is not that bad and usually pretty quick. You can request some sedation for it, but as FBN explained you do need to be awake and able to follow commands which will include holding your breath briefly at various points.

It was a combination of the noise the needle made piercing the cavity and the (admittedly small bit of) pain. Of course, I was a teenager then...

It sounds like the ultrasound won't slow down the process as much as I had feared.

[FBN]

It sounds like the ultrasound won't slow down the process as much as I had feared.

The best route here is really to sit down with the doctor who will actually (potentially) be carrying out the procedure. Doing so will give you a much better picture than we can at this point on the forum.

Clearly this is not all doom and gloom; there may be many reasons for such a mass as you have noted earlier but the only way to know for sure, is to bite the bullet..

[wpcoe]

Well, for any brave (or maybe extremely bored?) folks reading this far down in the thread, I'll update what has happened.

All the test results (bacterial, fungal, TB and malignant cells) from the bronchoscopy came back negative, so after long consideration I finally accepted that a needle biopsy was in my future. It turns out my pulmonary doctor at BNH doesn't do them. From an e-mail from my doctor:

"At BNH, we have a doctor called x-ray interventionist who can do needle biopsy. He is a faculty @ Chulalongkorn Hospital but he works at BNH only on Saturdays. I will check if he works on this Saturday (Aug 13) because it is 3-day weekend and let you know ASAP.

The procedure takes 30-40 minutes and is done under CT scan. You will be injected with the anesthetic. If there is no complication, you can be released after 2-3 hours. The complication like bronchoscopy - air leakage if normal lung is cut or pricked."

So, I made an appointment for 0900 this past Saturday. After a chest X-ray and a blood test that took about an hour for results (clotting and some other test?), I was sent to the CT scan room. The scan showed the mass had shrunk *considerably* and a needle biopsy was no longer recommended.

Such a relief. The curious cat in me still wants to know what the mass was, but I wasn't about to endure the needle biopsy just for a definitive diagnosis!

Now, the politics of medicine and insurance companies: I was finished and back in my street clothes before noon. I wasn't able to leave the hospital until 500pm! In order for BUPA insurance to cover the expenses, I couldn't be discharged for six hours after my 0900 admission, so BNH couldn't submit any paperwork until 1500. Then, it took 1.5 hours to get it all sorted out, apparently.

Oh, well. Bottom line, is I've been given a reprieve with the mass. And, I'm quite pleased with that.