Lung Cancer

[Opl]

BanK

Each case is specific, the decision is not made by a single specialist, but by a pool of different specialists in thoracic surgery working in team.

They need a pannel of tests results to study if surgery is possible or not : PET scan, cerebral MRI, they may need an EBUS ( endobronchial ultrasound http://health.ucsd.edu/specialties/pulmonary/procedures/Pages/endobronchial.aspx - in the same time they may pose in advance the Implantable Catheter-Port System the chemo) , and tests of the mediastinal lymph nodes, etc...

" Having thought about the time I have before my Health Insurance needs renewing (23 March 2016), and being cynical, I would like to get as much as possible done before that time."

Yes it's quite possible because once you've had your appointment with the specialist in hospital, then his service coordinates the agenda for the tests so that the surgery / or any other treatment can be scheduled within 2 or 3 weeks.

you've already made big steps on the way to resolve the problem, go on and don't panic

Edited December 23, 2015 by Opl

[banK]

BanK

Each case is specific, the decision is not made by a single specialist, but by a pool of different specialists in thoracic surgery working in team.

They need a pannel of tests results to study if surgery is possible or not : PET scan, cerebral MRI, they may need an EBUS ( endobronchial ultrasound http://health.ucsd.edu/specialties/pulmonary/procedures/Pages/endobronchial.aspx - in the same time they may pose in advance the Implantable Catheter-Port System the chemo) , and tests of the mediastinal lymph nodes, etc...

" Having thought about the time I have before my Health Insurance needs renewing (23 March 2016), and being cynical, I would like to get as much as possible done before that time."

Yes it's quite possible because once you've had your appointment with the specialist in hospital, then his service coordinates the agenda for the tests so that the surgery / or any other treatment can be scheduled within 2 or 3 weeks.

you've already made big steps on the way to resolve the problem, go on and don't panic

As I understood it from the Pulmonologist, the only relevant test is the needle biopsy whether it's benign or malignant. The internal lung one/s are only accessible through the rib cage (major surgery). They are unable to navigate down the throat then up through the lung, it's just too far and too small to find and snip a bit off.

Thinking about it, it's almost preferable to have the needle biopsy to come back malignant (100 percent certain), because at that point there will be no need for surgery, just Chemo. Because of the risk of a false negative (quite a high risk), surgery could be done and the internal one/s turn out positive. Then there will be a wait for recovery from surgery, that could set things back a few months before being able to have chemo.

There was also something around the lymphnode (or what ever its called) that could not be defined.

For all anyone knows the lung may not be the primary site, it could have migrated from somewhere else in the body to the lung.

I'm only going on what I have been told - and I have to believe what I am told - although I do question things.

Bit of a nightmare swamp situation.

banK

[Sheryl]

Sent you a PM

[banK]

Have an appointment with Lung Professor Dr. Sawang Saenghirunvattana 26th at 0930, Biopsy either 27 or 28th, results in 5 days - job done.

Then go to the next stage.

banK

[Issangeorge]

Good luck.

[banK]

Good Morning

I am in Bkk hotel Amari (5000B) night next to the Bangkok Bangkok hospital. Does anyone know of a less expensive one not to far away from this location.

Tks for any info

banK

[Thanyaburi Mac]

BanK

You might check this one:

A-One Bangkok Hotel

9 Soonwijai 4, New Petchburi Rd., Ratchadaphisek, Bangkok, Thailand

About $30 a night.

Mac

[Sheryl]

+1

A One is much less expensive and located right behind the hospital

[banK]

BanK

You might check this one:

A-One Bangkok Hotel

9 Soonwijai 4, New Petchburi Rd., Ratchadaphisek, Bangkok, Thailand

About $30 a night.

Mac

+1

A One is much less expensive and located right behind the hospital

Thanks for that - I'm now installed there,1600 Baht.

Today spent about 6 hours at the hospital. The professor explained the procedure clearly and more than willing to answer any questions.

Was then cleared by the heart doctor for the procedure to be done.

Procedure - EBUS - TBNA + GS under intravenous anesthesia.

I was given several sheets of paper with the explanation , risks, how is will be done, cost etc. Estimated cost 290,000 - 340,000 baht. The blood tests, evaluations etc. was a separate cost (20,000 Baht).

When I was at the KK Bkk hospital I was told that where the needle biopsy would be done is actually the site of pneumonia. Also, I was told that to biopsy the spatulated thing at the back of the lung and the nodule at the site of the lymph node would entail an operation. However, the doctor said that he can navigate to the sites with his camera thingy and get the specimens for biopsy.

This greatly speeds things up for me, no recovery time from an operation chemo can be done straight away. As regards that, he says that it is quite likely that I would be able to take Targets nullifying the need for intravenous drip chemo. Of course he will only be sure once the tissue is biopsied, this can be done at home.

All above is the upside of the rollercoaster. Now for the down side.

Before seeing the consultant this morning, I phoned the insurance company and asked whether it would be ok to go ahead with the procedure. I was told not to worry and go ahead with whatever is necessary - they would foot the bill.

The consultant said that I could have the procedure done tomorrow morning at 0800.

At one o'clock the Hospital insurance dept phoned me to say that they are still waiting for the insurance company to guarantee the payment and until that time or I give them the 300,000 baht nothing would be happening. The UK time being 0600 I phoned them and asked what was the problem - I was told that

the "medical team" needs to sanction the procedure, due to the time difference and the time of year I didn't have much hope of anything turning out right.

The Bkk hospital insurance dept closes at 1900 local time (midday UK time), so there was only a few hours to get it right.

As time went on I phoned back the insurance company and explained that at this end, on the weekend, there was no way I could access 300,000 baht from my account and that the procedure is to take place at 0800 tomorrow morning (0100 UK time).

The insurance person was very understanding but it wasn't her call - I must have sounded forlorn or something but she asked me when and how did I suspect that I what I have - Told her and after the story she said that she would guarantee the payment to the hospital, she duly sent the required information to the hospital. - So there are some kind and understanding people even insurance ones!

So that's the story so far - to be continued tomorrow

banK

[Sheryl]

My experience with Cigna Global is that they are nice enough folk but their office very inefficient so some persistence is needed in dealing with them. Should be OK in the end, but will likely need many a phone call etc before this is all squared away.

Given the situation, very fortunate that you have this coverage.

[Opl]

Thanks to you BanK, for keeping us update - it's great, you're in reliable hands, be confident!

[banK]

Well I woke up and wasn't in heaven!

Procedure done and now in for an overnighter. Very nice room.

No one has come to see me but I gather that all went well - Bringing up a bit of light coloured blood - not the same colour as before, it was darker.

Apparently this is normal due to the foreign object shoved down my throat.

banK

[Sheryl]

Yes, it is normal.

The doctor will likely come by at some point but truth to tell, until the pathology result is in (which takes some days), not much to tell.

I trust the doctor is aware if your recent endocrine (thyroid) issues - it could be relevant as there is a type of tumor (carcinoid) which can secrete hormones. Also, regular lung cancers (both small cell and non-small cell) can sometimes metastatsize to the thyroid - so some more scrutiny of the thyroid gland may be warranted.

If the biopsy results show malignancy, and especially if any of the lymph nodes are positive, scans of other body organs may be advised to rule out metastasis (to or from the lung).

[banK]

Yes, it is normal.

The doctor will likely come by at some point but truth to tell, until the pathology result is in (which takes some days), not much to tell.

mI trust the doctor is aware if your recent endocrine (thyroid) issues - it could be relevant as there is a type of tumor (carcinoid) which can secrete hormones. Also, regular lung cancers (both small cell and non-small cell) can sometimes metastatsize to the thyroid - so some more scrutiny of the thyroid gland may be warranted.

If the biopsy results show malignancy, and especially if any of the lymph nodes are positive, scans of other body organs may be advised to rule out metastasis (to or from the lung).

Hi

All are aware of the thyroid problem that I have

Before starting the procedure this morning I spoke with the doctor, I think it was me that mentioned to him about having a PET-CT scan, he said He could arrange for on to be done tomorrow. Would this be normal to have one at this stage? I ask that because I expect I to have to inform Cigna insurance and request permission

for it to be done.

banK

[Opl]

BanK,

Having a PET scan now , will give a precise idea of the actual extension of the problem. Also if you have chemo or surgery or radiotherapy, they'll need to see where and what they have to focus, or if more investigations are needed.

After the treatment, you will have again ( nearly 1 year after) , scan and PET scan to check that everything is ok , by comparison before / after.

[Sheryl]

You have already had a CT scan. As mentioned a low dose spiral CT is the test of choice for this. However I note you say it was done without contrast, which is a little odd as when looking for tumors contrast is important (shows how vascular the lesion is).

I would be guided by your doctor - does he think a PET scan will give additional useful information at this stage?

PET scans can help determine if a lesion seen on CT is likely malignant but this is moot since in your case they were able to access the lesions for biopsy, and biopsy is of course more definitive than any imaging study.

To me it would make more sense to wait until you have the biopsy results, which might also indicate need for scan on parts of the body other than the lung depending on results. PET scans are useful in identifying whether there has been lymph node spread, but that becomes an issue only if the biopsy comes back malignant. So again I would have thought waiting for the biopsy first would make more sense, but see what your doctor says. The insurance company will want to know why it is considered necessary.

[banK]

You have already had a CT scan. As mentioned a low dose spiral CT is the test of choice for this. However I note you say it was done without contrast, which is a little odd as when looking for tumors contrast is important (shows how vascular the lesion is).

I would be guided by your doctor - does he think a PET scan will give additional useful information at this stage?

PET scans can help determine if a lesion seen on CT is likely malignant but this is moot since in your case they were able to access the lesions for biopsy, and biopsy is of course more definitive than any imaging study.

To me it would make more sense to wait until you have the biopsy results, which might also indicate need for scan on parts of the body other than the lung depending on results. PET scans are useful in identifying whether there has been lymph node spread, but that becomes an issue only if the biopsy comes back malignant. So again I would have thought waiting for the biopsy first would make more sense, but see what your doctor says. The insurance company will want to know why it is considered necessary.

Thanks for that info. I need to take a breath and think logically - its so obvious what you say. I have to be a bit patient and wait.

As matter of interest I did enquire the cost.- 58,000 baht.

banK

[banK]

Hi again,

I came back to the village a couple of days ago.

The Doctor who did the biopsy procedure telephoned me this morning with the results. Plainly speaking, the 2 suspicious nodes at he lymph node were soft and he said that they are non-malignant (100%). The tumor RUL spiculated border nodule also turned out to be non-malignant (he took 6 samples in this area). This had a 70% chance of malignancy.

He arranged for the investigations and results to be sent to me by e-mail which I now have. This is also being sent to Cigna as well.

In his recommendations he put "PET CT scan is highly recommended. He is referred to a cardio thoracic surgeon for further management and possible surgery if PET CT scan result revealed stage 1 malignancy.".

The surgeon who will carry out the operation if required will be available despite it being New Year - (so would I if I could earn a few bob!)

So armed with this information I will shortly phone the insurance company - hopefully a good outcome.

banK

[Sheryl]

Thanks for the update.

Given the surprising results, PET scan is definitely indicated to fully rule out an early malignancy.

The negative lymph nodes is an encouraging finding. It is looking like if there is a malignancy (and there might not be), it is probably quite early. So I think you can be cautiously optimistic.

[banK]

Thanks for the update.

Given the surprising results, PET scan is definitely indicated to fully rule out an early malignancy.

The negative lymph nodes is an encouraging finding. It is looking like if there is a malignancy (and there might not be), it is probably quite early. So I think you can be cautiously optimistic.

Looks like I may have dodged a few bullets there.

Could it be that early that the tissue samples taken show up negative but a PET CT scan could show a positive result?

If the PET CT scan does show up negative for malignancy - What is the normal procedure? Are the nodules/tumor left in situ. and thereafter ignored, if so, could these turn malignant in the future?

Or

Is surgery then done to cut them out?

Go on Sheryl - educate me!

banK

[Sheryl]

It could be possible if there is a very small, early malignancy that the sample taken slightly missed the malignant cells. Probably not, but as you are high risk should make sure.

Assuming the PET is negative, next steps depend entirely on what the pulmonologist thinks the nodule and infiltrate are. (The lymph node enlargement, now that we know it is benign, will just be secondary to whatever the infiltrate is, maybe pneumonia or early COPD. Mediastinal lymphadenopathy just means some sort of interstitial lung disease, it is not specific to cancer).

For a benign single pulmonary nodule in someone high risk (based on your age and smoking history) usual management would be just to recheck in 12 months to compare size and consider surgical removal only if size has increased.

The path report should indicate what the RUL nodule is, and this will be helpful. If it is a granuloma it may be the result of some sort of infective process and some investigations along those lines (non-surgical) may be indicated.

Bear in mind I am no pulmonary specialist so see what your doctor says. But I cannot imagine surgery being indicated at this time.

May find this useful http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507065/figure/F10/

[banK]

It could be possible if there is a very small, early malignancy that the sample taken slightly missed the malignant cells. Probably not, but as you are high risk should make sure.

Assuming the PET is negative, next steps depend entirely on what the pulmonologist thinks the nodule and infiltrate are. (The lymph node enlargement, now that we know it is benign, will just be secondary to whatever the infiltrate is, maybe pneumonia or early COPD. Mediastinal lymphadenopathy just means some sort of interstitial lung disease, it is not specific to cancer).

For a benign single pulmonary nodule in someone high risk (based on your age and smoking history) usual management would be just to recheck in 12 months to compare size and consider surgical removal only if size has increased.

The path report should indicate what the RUL nodule is, and this will be helpful. If it is a granuloma it may be the result of some sort of infective process and some investigations along those lines (non-surgical) may be indicated.

Bear in mind I am no pulmonary specialist so see what your doctor says. But I cannot imagine surgery being indicated at this time.

May find this useful http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507065/figure/F10/

The path report was brief: "Microscopic Examination - Section shows a few pieces of alveolar tissue with some hemorrhage. The alveolar wall is not remarkable"

In the Doctors report - "Results revealed unremarkable alveolar tissue with recent hemorrhage. Negative for malignancy. Fluid culture revealed moderate growth of klebsiella pneumoniae ssp pneumoniae. PET CT is highly recommended. (etc. as in previous post).

banK

[Sheryl]

OK, so you have a pneumonia which explains both the infiltrate and the mediastinal lymph node enlargement.

The recent hemorrhage seen likely accounts for the blood you saw.

Not sure why the nodule, I suspect the doctor also is puzzled and the concern would be that possibly the needle missed the nodular tissue, hence the PET scan.

Should note that pulmonary nodules are not an unusual finding even in asymptomatic people and non-smokers, and usually are not due to cancer. In fact standard treatment algorithms in the West would not go straight to biopsy unless the nodule were fairly large, otherwise would follow up after 12 months with another scan. Not saying it was wrong to do the biopsy (if it were me and I was a smoker for many years, I wouldn't be able to tolerate just waiting a year knowing there was a nodule). But just to let you know that your doctor is already being plenty aggressive in his approach.

He will likely order an antibiotic for the klebsiella

[banK]

OK, so you have a pneumonia which explains both the infiltrate and the mediastinal lymph node enlargement.

The recent hemorrhage seen likely accounts for the blood you saw.

Not sure why the nodule, I suspect the doctor also is puzzled and the concern would be that possibly the needle missed the nodular tissue, hence the PET scan.

Should note that pulmonary nodules are not an unusual finding even in asymptomatic people and non-smokers, and usually are not due to cancer. In fact standard treatment algorithms in the West would not go straight to biopsy unless the nodule were fairly large, otherwise would follow up after 12 months with another scan. Not saying it was wrong to do the biopsy (if it were me and I was a smoker for many years, I wouldn't be able to tolerate just waiting a year knowing there was a nodule). But just to let you know that your doctor is already being plenty aggressive in his approach.

He will likely order an antibiotic for the klebsiella

I was prescribed MEIACT 200mg tablets before the biopsy was performed, so it was not known the pneumonia type was klebsiella during the initial consultation, is MEIACT a general antibiotic able treat all types of pneumonia? Have enough tablets for a 7 day course.

banK

[Sheryl]

It is a third generation cephalosporin, very broad spectrum and usually effective against Klebsiella.

[banK]

It is a third generation cephalosporin, very broad spectrum and usually effective against Klebsiella.

Thanks for that - and by the way - Happy New Year

banK

[NeverSure]

Happy New Year BanK, and the best to you in all of this.

[banK]

Happy New Year

Finally getting somewhere with Cigna, a bit of an uphill struggle but finally got the guarantee of payment for the PET-CT but need to make an appointment for it before the letter is issued - chicken and egg situation - too far from the airport to find out availability and pay for flight (cannot use my debit card over phone, made it that way for security)., but need to book appointment for PET-CT, won't know that till tomorrow (dept. shut till tomorrow morning.)

So will hopefully make appointment for Tuesday 5th, this gives me time to get a flight comfortably / drive down.

It would also seems that the pneumonia is now gone - close run thing as took the last tablet morning.

banK

[Sheryl]

Good. If you aren't able to get the appointment till a few days latet don't sweat it, a few days or even a week or two will not matter. (Though I can understand your desire to get it done ASAP).

[banK]

Had the PET-CT scan yesterday 5th.

Lots of information about the whole body, but the main thing is: "most likely diagnosis is RUL cancer with multiple lymph nodes enlargement at mediastina and RML."

I still have a bit of an infection (pneumonia), but the surgeon said its not best to wait for the infection to be gone by antibiotics , he said he wants to cut out RUL tumour and at the same time cut out the infection bits.

Also "Accidental finding of 6.8cm INFRE RENAL ABDONMINAL ANEURYSM in AP diameter found". But this is for another day soon.

I feel like I'm falling to bits!!

The cost 850,000 - 1,060,000Baht ( It will more than that because it does not include "expenses for medical clearance and PMR : + blood component"

and "Expense for special consultation: + home medication".

I'm now waiting for the Insurance company to send the Guarantee of payment - for me this is the hard bit, waiting on the insurance company to OK procedures - time seems to be clocking on.

banK