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Is A 6 Mm Cerebellar Nodule Of The Brain A Cause For Concern?
Question: Thank you for taking the time to read about my case. I am going to provide you with a lot of information so you can have as clear a picture as possible of my situation without actually being able to see my MRI pictures, in the hopes that you can calm me down a bit in what I am finding to be a potentially very scary situation. I got my MRI (of the brain) results back recently and the report said that I have "an enhancing nodule present at the medial aspect of the left cerebellum measuring 6 mm." However, in the impression, the radiologist does not mention the cerebellum and says "6 mm enhancing nodule within the medial left temporal lobe. Differential could include metastatic disease or primary brain tumor. Correlate clinically. Consider neurosurgical consultation." The report also said "there is mild associated hyperintense T2 signal within the surrounding white matter. The brain parenchyma is otherwise normal." This "lesion", as the radiologist calls it, was discovered because I already have a 1.6 X 1.2 cm vestibular schwannoma (on the right side) that I have known about for 17 years. Every year or so since 2000 I have had follow-up MRIs and they have always indicated no change/significant change, and no new lesions/abnormalities found. This is the first time something new has been seen on an MRI.
I find something rather confusing----the report said that this small nodule is in the medial left temporal lobe, which I had believed to be in the cerebral cortex, which is where I understand most brain metastasis occurs. However, the report ALSO refers to the same area as the "medial aspect of the left cerebellum", and I understand that brain metastasis is NOT common in the cerebellum. Why is the radiologist referring to the same nodule as seemingly being in two different places? Is not the "left temporal lobe" in a different spot than the cerebellum? And would the location of this small nodule in the cerebellum be a good sign that it is probably not brain metastasis? My research has indicated that 85 percent of brain metastasis localize to the cerebral hemispheres and 15 percent localize to the cerebellum, so I am somewhat calmed by the fact that it is in the cerebellum...although since the cerebrum is much larger, and it would make logical sense for more metastasis to be found there, are these statistics reassuring in and of themselves??
It has now been just over two weeks since I had the MRI and just over one week since I met with my PCP and learned the findings, and it has been a terrifying week, to say the least. I am trying to arrange an appointment with a neurosurgeon quickly but every second is making me more concerned. Since the PCP is not a specialist he was very vague - he said it could be anything from a harmless cyst to a benign brain tumor to a malignant tumor. Based on the information I gave you, is there anything you can tell me that may reassure me somewhat? He did say that 6 mm is very small - is that a good sign? I am a 48 year old male and my maternal grandfather died from a malignant brain tumor at 43 - however, that was in 1955 when medical technology was obviously far less than it is today. I do not really have any symptoms except for occasional headaches, but I have had those off and on for my entire life, and they are no worse now. I have also never been a smoker. I don't know what "the brain parenchyma is otherwise normal" means, but is the fact that it is "normal" a good sign? But does "mild hyperintense T2 signal within the surrounding white matter" mean something potentially troubling? I read that hyperintensity on a T2 sequence MRI basically means that the brain tissue in that particular spot differs from the rest of the brain. Is that alarming? I do know that malignant tumors can invade the surrounding tissue...could that be what this means?? I have also been extremely troubled with the phrase "could indicate metastatic disease", thinking that I might have cancer somewhere else in my body. I am trying to narrow down as many possibilities as I can. From what I have researched, some of the most likely cancers to travel to the brain are kidney, colon, breast, and especially lung, among others. I am a male, so I assume I do not have to worry too much about breast cancer?? I did have an uncle who actually had breast cancer, but I have no abnormal lumps in that area, so I hope I am fairly safe in that regard. I had a colonoscopy ten years ago and that came back perfectly clean, not even a single polyp - I believe it is time to schedule another one, but since the last one was perfectly fine and I was told I would be OK to wait until around age 50 to have the next one, and I have had no symptoms of colon cancer, I am hoping that I do not have to worry too much about having that?? I also have no symptoms of kidney cancer - there is a fairly minor pain in my back that I have had for about three weeks, but it came on suddenly after shoveling, and felt like a pulled muscle, as I was fine before that, and it seems to be coming directly from my back rather than radiating from the abdomen or anywhere else, and it has been notably lessening during the past week, so I am assuming this is muscle strain - I do not seem to have any abdominal pain, and from what I understand, back pain as a result of kidney cancer, or even liver or pancreatic cancer, generally starts as pain in the abdomen and radiates to the back - this feels like strained, tight muscles, and does not appear to be radiating from anywhere.
I had a cold for two weeks - which finally has gotten better - and I had a chest X-ray done and the results came back very good, saying "Heart and mediastinal structures are within normal limits. Lungs are clear. Vascularity is normal. There is no visible pleural fluid. Normal study." I am hoping that will help to rule out possible lung cancer - in fact I am guessing that the reason the back pain/strain is still not completely gone (though better) is at least partly due to the coughing and nose-blowing I did for two weeks because of the cold - other than occasional minor coughs, I was not coughing before the cold started. So hopefully that reduces the likelihood of lung cancer? Indeed, if I had any cancer that was advanced enough to have spread to the brain, wouldn't I most likely be having some symptoms by now from the primary cancer? Since I don't (as far as I can tell) seem to have any overt symptoms of any other kind of cancer, I am hoping that whatever this is on my brain is isolated and is NOT related to metastasized cancer from another location. I did get results of blood work back and most results were perfectly normal, including the white and red blood cell count, which I am taking as a good sign...?? My triglycerides were somewhat elevated at 229, which I understand could mean kidney disease, but from what I have researched, 229 is not that terrible, and my BUN and creatinine levels were good, and as I said, I don't seem to have any signs of kidney cancer, so I am hoping that that triglyceride level does not necessarily indicate a likelihood of kidney cancer. My protein level was also slightly high at 8.6, and I understand that could potentially indicate multiple myeloma, but from what I understand, 8.6 is not really that abnormal, and as I said, my white and red cell blood levels were fine, so wouldn't the blood count have probably been off somewhat if I had multiple myeloma? I should also add that I am about 25 pounds overweight, and I realize that these somewhat elevated levels are probably being caused by that - my HDL cholesterol, for instance, is 35, which I know is a little low, but I am hoping that is just due to being overweight and is not necessarily indicative of anything disastrous - for the record, my LDL cholesterol is 85.
Back to the brain nodule - I have done research that indicates that it could be a brain cyst - however, I also read that many brain cysts are present from birth and are just not discovered until adulthood. Since I have had regular MRIs for the past 17 years, I know that I have not had this from birth - my most recent MRI was in May, 2015, and this 6 mm nodule was apparently not present at that time (unless it somehow went unnoticed then??). That means that whatever this is seems to have appeared during the last year and nine months. So does that lessen the possibility that it is a cyst? I am hoping that it is a cyst because, from what I understand, they are almost always benign, and often don't require treatment beyond "watchful waiting". As you can see, I have done some research on my own, which is all that I can do while I agonizingly wait for an appointment with a neurosurgeon to get further explanations and answers. I am driving myself nearly crazy with how serious this could be - it would be great if I could find out that there is an equal or greater chance that it is something harmless as well. I wanted to tell you as much as I possibly could in order for you to be able to give me the most detailed information you can give me, given the fact that you have not actually seen the MRI scan. From what I detailed above, is there any way you can indicate that what I have is probably NOT metastasized brain cancer, but could just as well be a benign brain tumor or cyst? I understand that the shape of the nodule can help clarify things also - from what I've read, if the edges are smooth there is more of a likelihood that it is benign, and if the edges are more rough, it could be malignant, so hopefully the edges ARE smooth, and this is something the neurosurgeon I see will be able to decode??? I am somewhat troubled that the radiologist made no reference to the shape on the report...if he had mentioned that the nodule had smooth edges, I'd be feeling much less nervous. I also know that even benign brain nodules/cysts/tumors are not necessarily without problems of their own, but I am hoping and praying that I can, at the very least, get the word "cancer" out of the equation, or at least limit its likelihood.
I should also mention that I have read that nodules on the brain can also be as a result of a blow to the head, and I DID bump my head, and I believe it was after the May 2015 MRI---but it was more on the left TOP of my head, rather than the left lower side, where the cerebellum is...but it WAS pretty hard, and left a lump, and gave me a headache that lasted for a day, but I didn't think it was THAT hard (no bleeding, loss of consciousness, etc., and I didn't seek medical treatment) - but I DID bump it fairly hard, so could it have left this nodule on my brain, even though I didn't hit my head in that exact spot, and would it still be there well over a year later??? Perhaps it could be some kind of scar tissue or remnant from this incident? The radiologist made no such suggestion on his report that this could be a possibility, but I understand that they usually prefer to address the worst case scenarios in order to rule those out first.
I am also at least mildly reassured by research that has indicated that only 10-20 percent of brain metastasis arise as a single tumor, whereas 80-plus percent arise as multiple tumors, and I only have one small nodule (very small, it would seem, as "small" seems to mean 3 cm or less, and this is 6 mm). But, being the nonprofessional that I am, I really have no idea what it all could/could not mean.
Could you please give me as much detailed information as you can based on what I have written? You are my only hope of having my fears somewhat calmed until I can actually talk with the neurosurgeon. And thank you very very much in advance!! Thank you.
XXXXXXX XXXX
I find something rather confusing----the report said that this small nodule is in the medial left temporal lobe, which I had believed to be in the cerebral cortex, which is where I understand most brain metastasis occurs. However, the report ALSO refers to the same area as the "medial aspect of the left cerebellum", and I understand that brain metastasis is NOT common in the cerebellum. Why is the radiologist referring to the same nodule as seemingly being in two different places? Is not the "left temporal lobe" in a different spot than the cerebellum? And would the location of this small nodule in the cerebellum be a good sign that it is probably not brain metastasis? My research has indicated that 85 percent of brain metastasis localize to the cerebral hemispheres and 15 percent localize to the cerebellum, so I am somewhat calmed by the fact that it is in the cerebellum...although since the cerebrum is much larger, and it would make logical sense for more metastasis to be found there, are these statistics reassuring in and of themselves??
It has now been just over two weeks since I had the MRI and just over one week since I met with my PCP and learned the findings, and it has been a terrifying week, to say the least. I am trying to arrange an appointment with a neurosurgeon quickly but every second is making me more concerned. Since the PCP is not a specialist he was very vague - he said it could be anything from a harmless cyst to a benign brain tumor to a malignant tumor. Based on the information I gave you, is there anything you can tell me that may reassure me somewhat? He did say that 6 mm is very small - is that a good sign? I am a 48 year old male and my maternal grandfather died from a malignant brain tumor at 43 - however, that was in 1955 when medical technology was obviously far less than it is today. I do not really have any symptoms except for occasional headaches, but I have had those off and on for my entire life, and they are no worse now. I have also never been a smoker. I don't know what "the brain parenchyma is otherwise normal" means, but is the fact that it is "normal" a good sign? But does "mild hyperintense T2 signal within the surrounding white matter" mean something potentially troubling? I read that hyperintensity on a T2 sequence MRI basically means that the brain tissue in that particular spot differs from the rest of the brain. Is that alarming? I do know that malignant tumors can invade the surrounding tissue...could that be what this means?? I have also been extremely troubled with the phrase "could indicate metastatic disease", thinking that I might have cancer somewhere else in my body. I am trying to narrow down as many possibilities as I can. From what I have researched, some of the most likely cancers to travel to the brain are kidney, colon, breast, and especially lung, among others. I am a male, so I assume I do not have to worry too much about breast cancer?? I did have an uncle who actually had breast cancer, but I have no abnormal lumps in that area, so I hope I am fairly safe in that regard. I had a colonoscopy ten years ago and that came back perfectly clean, not even a single polyp - I believe it is time to schedule another one, but since the last one was perfectly fine and I was told I would be OK to wait until around age 50 to have the next one, and I have had no symptoms of colon cancer, I am hoping that I do not have to worry too much about having that?? I also have no symptoms of kidney cancer - there is a fairly minor pain in my back that I have had for about three weeks, but it came on suddenly after shoveling, and felt like a pulled muscle, as I was fine before that, and it seems to be coming directly from my back rather than radiating from the abdomen or anywhere else, and it has been notably lessening during the past week, so I am assuming this is muscle strain - I do not seem to have any abdominal pain, and from what I understand, back pain as a result of kidney cancer, or even liver or pancreatic cancer, generally starts as pain in the abdomen and radiates to the back - this feels like strained, tight muscles, and does not appear to be radiating from anywhere.
I had a cold for two weeks - which finally has gotten better - and I had a chest X-ray done and the results came back very good, saying "Heart and mediastinal structures are within normal limits. Lungs are clear. Vascularity is normal. There is no visible pleural fluid. Normal study." I am hoping that will help to rule out possible lung cancer - in fact I am guessing that the reason the back pain/strain is still not completely gone (though better) is at least partly due to the coughing and nose-blowing I did for two weeks because of the cold - other than occasional minor coughs, I was not coughing before the cold started. So hopefully that reduces the likelihood of lung cancer? Indeed, if I had any cancer that was advanced enough to have spread to the brain, wouldn't I most likely be having some symptoms by now from the primary cancer? Since I don't (as far as I can tell) seem to have any overt symptoms of any other kind of cancer, I am hoping that whatever this is on my brain is isolated and is NOT related to metastasized cancer from another location. I did get results of blood work back and most results were perfectly normal, including the white and red blood cell count, which I am taking as a good sign...?? My triglycerides were somewhat elevated at 229, which I understand could mean kidney disease, but from what I have researched, 229 is not that terrible, and my BUN and creatinine levels were good, and as I said, I don't seem to have any signs of kidney cancer, so I am hoping that that triglyceride level does not necessarily indicate a likelihood of kidney cancer. My protein level was also slightly high at 8.6, and I understand that could potentially indicate multiple myeloma, but from what I understand, 8.6 is not really that abnormal, and as I said, my white and red cell blood levels were fine, so wouldn't the blood count have probably been off somewhat if I had multiple myeloma? I should also add that I am about 25 pounds overweight, and I realize that these somewhat elevated levels are probably being caused by that - my HDL cholesterol, for instance, is 35, which I know is a little low, but I am hoping that is just due to being overweight and is not necessarily indicative of anything disastrous - for the record, my LDL cholesterol is 85.
Back to the brain nodule - I have done research that indicates that it could be a brain cyst - however, I also read that many brain cysts are present from birth and are just not discovered until adulthood. Since I have had regular MRIs for the past 17 years, I know that I have not had this from birth - my most recent MRI was in May, 2015, and this 6 mm nodule was apparently not present at that time (unless it somehow went unnoticed then??). That means that whatever this is seems to have appeared during the last year and nine months. So does that lessen the possibility that it is a cyst? I am hoping that it is a cyst because, from what I understand, they are almost always benign, and often don't require treatment beyond "watchful waiting". As you can see, I have done some research on my own, which is all that I can do while I agonizingly wait for an appointment with a neurosurgeon to get further explanations and answers. I am driving myself nearly crazy with how serious this could be - it would be great if I could find out that there is an equal or greater chance that it is something harmless as well. I wanted to tell you as much as I possibly could in order for you to be able to give me the most detailed information you can give me, given the fact that you have not actually seen the MRI scan. From what I detailed above, is there any way you can indicate that what I have is probably NOT metastasized brain cancer, but could just as well be a benign brain tumor or cyst? I understand that the shape of the nodule can help clarify things also - from what I've read, if the edges are smooth there is more of a likelihood that it is benign, and if the edges are more rough, it could be malignant, so hopefully the edges ARE smooth, and this is something the neurosurgeon I see will be able to decode??? I am somewhat troubled that the radiologist made no reference to the shape on the report...if he had mentioned that the nodule had smooth edges, I'd be feeling much less nervous. I also know that even benign brain nodules/cysts/tumors are not necessarily without problems of their own, but I am hoping and praying that I can, at the very least, get the word "cancer" out of the equation, or at least limit its likelihood.
I should also mention that I have read that nodules on the brain can also be as a result of a blow to the head, and I DID bump my head, and I believe it was after the May 2015 MRI---but it was more on the left TOP of my head, rather than the left lower side, where the cerebellum is...but it WAS pretty hard, and left a lump, and gave me a headache that lasted for a day, but I didn't think it was THAT hard (no bleeding, loss of consciousness, etc., and I didn't seek medical treatment) - but I DID bump it fairly hard, so could it have left this nodule on my brain, even though I didn't hit my head in that exact spot, and would it still be there well over a year later??? Perhaps it could be some kind of scar tissue or remnant from this incident? The radiologist made no such suggestion on his report that this could be a possibility, but I understand that they usually prefer to address the worst case scenarios in order to rule those out first.
I am also at least mildly reassured by research that has indicated that only 10-20 percent of brain metastasis arise as a single tumor, whereas 80-plus percent arise as multiple tumors, and I only have one small nodule (very small, it would seem, as "small" seems to mean 3 cm or less, and this is 6 mm). But, being the nonprofessional that I am, I really have no idea what it all could/could not mean.
Could you please give me as much detailed information as you can based on what I have written? You are my only hope of having my fears somewhat calmed until I can actually talk with the neurosurgeon. And thank you very very much in advance!! Thank you.
XXXXXXX XXXX
Brief Answer:
Read below
Detailed Answer:
Hello and welcome to HealthcareMagic! Thank you for your detailed explanation.
The temporal lobe and the cerebellum are two different areas of the brain so the radiologist must have obviously made a mistake, they are not adjacent and can't be confused. Perhaps if you provided a copy of the report (just snap a photo with smartphone and upload in report section) might be able to make out by the rest of the terminology where exactly it is.
Regarding the location I am afraid I can not ease your worry as it being in the cerebellum wouldn't help much in excluding metastasis. It is true that 85% are in the cerebral hemispheres, but that is simply because they are bigger and get more blood flow, about 80% of blood flow. So it is natural most metastasis happen there. But when it comes to the possibility of a cerebellar lesion to be a metastasis that is well probable, the older the individual the most likely that is actually (in childhood usually other type of tumors). So it is not reassuring (not alarming either).
While your PCP is right in saying that it is not necessarily a metastasis I fear the possibility of a cyst is unlikely. That is because apart from benign cysts being usually born with, they also do not usually enhance, enhancement means an active lesion with increased blood flow. The surrounding T2 hyperintensity indicates edema, swelling in the adjacent area which also goes against a cyst.
The same applies to the possibility of a consequence of that blow, if that was the case it wouldn't be enhancing or have surrounding edema after so many months.
The "the brain parenchyma is otherwise normal" part is naturally a good thing. It does not exclude metastasis though, they can present as initially solitary in as many as 50% of cases.
The lack of mentioning of the shape perhaps has to do with the fact that it is really small for edges to be evaluated.
The normal X-ray and lack of other symptoms (I wouldn't worry about that back pain) doesn't exclude a metastasis either. It is common for the primary lesion not to cause any symptoms initially (in your case even the brain lesion was found by coincidence, no symptoms) and while it is naturally a good thing for it to be normal X-ray certainly doesn't rule out the possibility of a tumor. The spreading out fact doesn't mean that the primary lesion has to be of a considerable size.
The blood tests are fine I do not see any cause for worry there.
I understand that my answer is not being the calming response you were hoping for. Up to now I have been saying that an old non active benign lesion is unlikely, that the possibility of it being a primary brain tumor or a metastasis is real. A couple of other possibilities to consider from that description might include an infection like an abscess or a demyelinating lesion like in multiple sclerosis. However the first possibility is usually excluded by DWI sequences on MRI (can't say without full report, just assuming) while the second is unlikely at your age and with only a solitary lesion.
So I am afraid the possibility of a tumor will be considered. Perhaps by viewing the lesion him/herself the neurosurgeon may give a more precise estimate on chances of one type of the other being the case. Often that is impossible to determine by imaging alone though and removal of the nodule and biopsy may be necessary.
The good thing that I might say is that the size is really small, it is lucky to have been found at this stage by coincidence having a MRI for other purposes. If a primary brain tumor it can be removed completely without significant damage to healthy brain, may be cured. Even if a metastasis it may allow detection of the primary tumor at a much earlier stage than it would've been found otherwise and if at an early stage more effective treatment may be employed.
I remain at your disposal for other questions.
Read below
Detailed Answer:
Hello and welcome to HealthcareMagic! Thank you for your detailed explanation.
The temporal lobe and the cerebellum are two different areas of the brain so the radiologist must have obviously made a mistake, they are not adjacent and can't be confused. Perhaps if you provided a copy of the report (just snap a photo with smartphone and upload in report section) might be able to make out by the rest of the terminology where exactly it is.
Regarding the location I am afraid I can not ease your worry as it being in the cerebellum wouldn't help much in excluding metastasis. It is true that 85% are in the cerebral hemispheres, but that is simply because they are bigger and get more blood flow, about 80% of blood flow. So it is natural most metastasis happen there. But when it comes to the possibility of a cerebellar lesion to be a metastasis that is well probable, the older the individual the most likely that is actually (in childhood usually other type of tumors). So it is not reassuring (not alarming either).
While your PCP is right in saying that it is not necessarily a metastasis I fear the possibility of a cyst is unlikely. That is because apart from benign cysts being usually born with, they also do not usually enhance, enhancement means an active lesion with increased blood flow. The surrounding T2 hyperintensity indicates edema, swelling in the adjacent area which also goes against a cyst.
The same applies to the possibility of a consequence of that blow, if that was the case it wouldn't be enhancing or have surrounding edema after so many months.
The "the brain parenchyma is otherwise normal" part is naturally a good thing. It does not exclude metastasis though, they can present as initially solitary in as many as 50% of cases.
The lack of mentioning of the shape perhaps has to do with the fact that it is really small for edges to be evaluated.
The normal X-ray and lack of other symptoms (I wouldn't worry about that back pain) doesn't exclude a metastasis either. It is common for the primary lesion not to cause any symptoms initially (in your case even the brain lesion was found by coincidence, no symptoms) and while it is naturally a good thing for it to be normal X-ray certainly doesn't rule out the possibility of a tumor. The spreading out fact doesn't mean that the primary lesion has to be of a considerable size.
The blood tests are fine I do not see any cause for worry there.
I understand that my answer is not being the calming response you were hoping for. Up to now I have been saying that an old non active benign lesion is unlikely, that the possibility of it being a primary brain tumor or a metastasis is real. A couple of other possibilities to consider from that description might include an infection like an abscess or a demyelinating lesion like in multiple sclerosis. However the first possibility is usually excluded by DWI sequences on MRI (can't say without full report, just assuming) while the second is unlikely at your age and with only a solitary lesion.
So I am afraid the possibility of a tumor will be considered. Perhaps by viewing the lesion him/herself the neurosurgeon may give a more precise estimate on chances of one type of the other being the case. Often that is impossible to determine by imaging alone though and removal of the nodule and biopsy may be necessary.
The good thing that I might say is that the size is really small, it is lucky to have been found at this stage by coincidence having a MRI for other purposes. If a primary brain tumor it can be removed completely without significant damage to healthy brain, may be cured. Even if a metastasis it may allow detection of the primary tumor at a much earlier stage than it would've been found otherwise and if at an early stage more effective treatment may be employed.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you, Dr. Taka, for your detailed answers. I relayed word for word what the radiologist's report said, there was nothing more - just that he mentioned the 6 mm nodule as being in the medial aspect of the left cerebellum, and then later referred to the same area as the medial temporal lobe. I assume he must have made a mistake, as you said.
If the best case scenario I'm obviously hoping for doesn't take place then I at least hope that I can have the better end of a worse-case scenario. You did say that it is a good thing and I am lucky that it was found small, but that doesn't rule out brain metastasis. So what would the next step be? If the neurosurgeon can't rule anything out just by looking at the MRI pictures then I assume a biopsy would be next? I read from someone who had been through one that it is not as bad as one would think - that a small hole is drilled into the skull, and if the tumor is small enough, it might be able to be completely removed during the biopsy. This person said that he was out of the hospital in less than a week. Does that sound realistic? Do you think that 6 mm is small enough that the entire thing could be removed during a biopsy? Are they fairly easy procedures, and would I be able to get back to my regular routine within a week or two? You mentioned that if it's a primary tumor it could be removed completely without "significant" damage to healthy brain...does that mean that there would be SOME damage? Since it is so small is it possible it could be removed with no damage to the brain? I am a pianist and organist and could not afford to lose any mobility in my fingers, in addition to my fear of losing any other brain functions.
After removal, if the tumor ends up being benign, is that the end of it, and it is considered a cure? If there is a biopsy and it is malignant, what then? Would scans be able to tell if there was any cancer in the brain beyond the tumor site, and would it be able to be treated with radiation?
I also read from one person that she was told to wait 6 months for a follow-up MRI. In your opinion, is this something I would even want to do, even if I was given the option? The goal of cancer treatment is to catch it as early as possible, and if the nodule is malignant, how much could it potentially spread in three months? Since, at this point, I know nothing about how serious this may or may not be, how quickly could it grow and/or spread? I have read that some aggressive tumors can grow in a matter of weeks. It has now been over two weeks since the MRI, on which it appeared at 6 cm. Could it have already grown larger than that just by now? How fast could it grow if I do not have it treated quickly? I still have no symptoms, which I guess is a good sign, but I am naturally concerned that it could be growing very quickly, and that every day could make a difference....
You said that the T2 hyperintensity indicates edema, swelling of the surrounding area, which goes against a cyst, but is it still a very real possibility that this could be a BENIGN tumor?? Am I hopefully looking at just as likely a possibility it is benign as malignant? And if (worst case scenario) it is malignant, am I at least looking at just as likely a possibility that the cancer is contained in that one nodule? I read that secondary brain tumors are more common than primary, which would mean that, in addition to worrying about the brain, I would also have to be worrying about where else I would have cancer.
Again, I do not appear to have any symptoms of any kind of cancer, but you said that it is not uncommon for a primary cancer to spread before it is discovered. So, then, would this bode well for a recovery? I have read the horror statistics on brain cancer, especially metastasis, such as survival rates being less than five years, or in many cases, a year or less. But from what you said, it is good that this nodule is so small...and considering that I have no symptoms of any cancer, do you think that would greatly improve my chances of having a better prognosis? I am trying to move my mind away from the "less-than-five-years" idea, and definitely far away from the one-year-or less idea, but that thought terrifies me. I know you do not have a crystal ball and can not see in the future, but given what I have told you (only one small tumor, no symptoms of any other cancer, non-smoker, otherwise fairly healthy), do you think I would have a pretty good prognosis even if it was a metastasis?? I would take it to mean that if I have cancer anywhere else in my body that it must be in an early stage?? The lung, for instance - you said that just because I had a good chest x-ray does not completely rule out that I have a tumor there, but if there is one there it must still be very small to not show up on an x-ray, correct? And, since there are no symptoms, how would the primary cancer be found, should the tumor end up being determined to be malignant? Early detection is the key to cancer survival, so I would guess that discovering this nodule at such a small size would give me a better chance of beating the primary cancer, but how would I go about being treated so that valuable time is not wasted, allowing for any other cancer in my body to get worse?
You may say that there's no point in speculating about how bad things might be when I don't even know yet if it is a metastasis, but I want to be prepared for a bad scenario, should it arise, rather than being complacent and then having it thrust at me. And you have somewhat reassured me with your statement that a small size is helpful, so I hope you can at least tell me that, while a grim outcome is certainly possible, that it is at least somewhat more likely that I can come out of this OK with the factors that seem to be in my favor?
So, suppose it is discovered that the tumor is malignant, and, hypothetically speaking, that I have a small tumor on my lung, as the primary. What would I be looking at....the surgery and then radiation on the brain, and then surgery on the lung? I understand that chemotherapy is not usually used on brain tumors, but is it possible that a small malignant tumor on the lung could be removed completely without the need for chemotherapy, or with just radiation, and then could I be considered cancer free if no other tumors were found? In other words, if the lung tumor is small (which I guess is likely, if there is one, since I have absolutely no symptoms and the x-ray was clear), could it potentially be successfully completely removed, in addition to the small brain nodule, giving me the life expectancy of someone who had never had cancer? I know there is always the chance of recurrence, and I would probably need to have follow-ups on a regular basis, but given the early stage that I would be in, do you think I would be able to essentially be cured and get on with my life? In your experience, have you had patients with brain metastasis with very small tumors in the 6 mm or so range who have been able to beat that, as well as having their primary cancer caught early enough that they were able to beat that as well and go on with their lives cancer free?
I am also wondering where would be the best place to have surgery. I am in Upstate New York, and I have an appointment on Monday with a neurosurgeon in the Albany area, but I do not believe I would want to have any surgery done there. I have heard good things about XXXXXXX and XXXXXXX as well as Johns XXXXXXX in XXXXXXX but that would be quite a distance - but I would want to go somewhere that offered top of the line treatment. I am about 6 hours north of New York City, where Sloane Kettering is, but I have heard that they do not take all kinds of insurance? And in terms of insurance....would my insurance cover it if I need to have prolonged treatments? I have Excellus Blue Cross/Blue Shield. I would not want to have to worry about going broke due to treatments, in addition to everything else. I have also researched Cancer Centers of XXXXXXX as there is one in XXXXXXX which would be a long drive, but within driving distance. I'd be glad to hear any recommendations from you.
Once again, thank you very much for your answers. I look forward to hearing back from you again.
If the best case scenario I'm obviously hoping for doesn't take place then I at least hope that I can have the better end of a worse-case scenario. You did say that it is a good thing and I am lucky that it was found small, but that doesn't rule out brain metastasis. So what would the next step be? If the neurosurgeon can't rule anything out just by looking at the MRI pictures then I assume a biopsy would be next? I read from someone who had been through one that it is not as bad as one would think - that a small hole is drilled into the skull, and if the tumor is small enough, it might be able to be completely removed during the biopsy. This person said that he was out of the hospital in less than a week. Does that sound realistic? Do you think that 6 mm is small enough that the entire thing could be removed during a biopsy? Are they fairly easy procedures, and would I be able to get back to my regular routine within a week or two? You mentioned that if it's a primary tumor it could be removed completely without "significant" damage to healthy brain...does that mean that there would be SOME damage? Since it is so small is it possible it could be removed with no damage to the brain? I am a pianist and organist and could not afford to lose any mobility in my fingers, in addition to my fear of losing any other brain functions.
After removal, if the tumor ends up being benign, is that the end of it, and it is considered a cure? If there is a biopsy and it is malignant, what then? Would scans be able to tell if there was any cancer in the brain beyond the tumor site, and would it be able to be treated with radiation?
I also read from one person that she was told to wait 6 months for a follow-up MRI. In your opinion, is this something I would even want to do, even if I was given the option? The goal of cancer treatment is to catch it as early as possible, and if the nodule is malignant, how much could it potentially spread in three months? Since, at this point, I know nothing about how serious this may or may not be, how quickly could it grow and/or spread? I have read that some aggressive tumors can grow in a matter of weeks. It has now been over two weeks since the MRI, on which it appeared at 6 cm. Could it have already grown larger than that just by now? How fast could it grow if I do not have it treated quickly? I still have no symptoms, which I guess is a good sign, but I am naturally concerned that it could be growing very quickly, and that every day could make a difference....
You said that the T2 hyperintensity indicates edema, swelling of the surrounding area, which goes against a cyst, but is it still a very real possibility that this could be a BENIGN tumor?? Am I hopefully looking at just as likely a possibility it is benign as malignant? And if (worst case scenario) it is malignant, am I at least looking at just as likely a possibility that the cancer is contained in that one nodule? I read that secondary brain tumors are more common than primary, which would mean that, in addition to worrying about the brain, I would also have to be worrying about where else I would have cancer.
Again, I do not appear to have any symptoms of any kind of cancer, but you said that it is not uncommon for a primary cancer to spread before it is discovered. So, then, would this bode well for a recovery? I have read the horror statistics on brain cancer, especially metastasis, such as survival rates being less than five years, or in many cases, a year or less. But from what you said, it is good that this nodule is so small...and considering that I have no symptoms of any cancer, do you think that would greatly improve my chances of having a better prognosis? I am trying to move my mind away from the "less-than-five-years" idea, and definitely far away from the one-year-or less idea, but that thought terrifies me. I know you do not have a crystal ball and can not see in the future, but given what I have told you (only one small tumor, no symptoms of any other cancer, non-smoker, otherwise fairly healthy), do you think I would have a pretty good prognosis even if it was a metastasis?? I would take it to mean that if I have cancer anywhere else in my body that it must be in an early stage?? The lung, for instance - you said that just because I had a good chest x-ray does not completely rule out that I have a tumor there, but if there is one there it must still be very small to not show up on an x-ray, correct? And, since there are no symptoms, how would the primary cancer be found, should the tumor end up being determined to be malignant? Early detection is the key to cancer survival, so I would guess that discovering this nodule at such a small size would give me a better chance of beating the primary cancer, but how would I go about being treated so that valuable time is not wasted, allowing for any other cancer in my body to get worse?
You may say that there's no point in speculating about how bad things might be when I don't even know yet if it is a metastasis, but I want to be prepared for a bad scenario, should it arise, rather than being complacent and then having it thrust at me. And you have somewhat reassured me with your statement that a small size is helpful, so I hope you can at least tell me that, while a grim outcome is certainly possible, that it is at least somewhat more likely that I can come out of this OK with the factors that seem to be in my favor?
So, suppose it is discovered that the tumor is malignant, and, hypothetically speaking, that I have a small tumor on my lung, as the primary. What would I be looking at....the surgery and then radiation on the brain, and then surgery on the lung? I understand that chemotherapy is not usually used on brain tumors, but is it possible that a small malignant tumor on the lung could be removed completely without the need for chemotherapy, or with just radiation, and then could I be considered cancer free if no other tumors were found? In other words, if the lung tumor is small (which I guess is likely, if there is one, since I have absolutely no symptoms and the x-ray was clear), could it potentially be successfully completely removed, in addition to the small brain nodule, giving me the life expectancy of someone who had never had cancer? I know there is always the chance of recurrence, and I would probably need to have follow-ups on a regular basis, but given the early stage that I would be in, do you think I would be able to essentially be cured and get on with my life? In your experience, have you had patients with brain metastasis with very small tumors in the 6 mm or so range who have been able to beat that, as well as having their primary cancer caught early enough that they were able to beat that as well and go on with their lives cancer free?
I am also wondering where would be the best place to have surgery. I am in Upstate New York, and I have an appointment on Monday with a neurosurgeon in the Albany area, but I do not believe I would want to have any surgery done there. I have heard good things about XXXXXXX and XXXXXXX as well as Johns XXXXXXX in XXXXXXX but that would be quite a distance - but I would want to go somewhere that offered top of the line treatment. I am about 6 hours north of New York City, where Sloane Kettering is, but I have heard that they do not take all kinds of insurance? And in terms of insurance....would my insurance cover it if I need to have prolonged treatments? I have Excellus Blue Cross/Blue Shield. I would not want to have to worry about going broke due to treatments, in addition to everything else. I have also researched Cancer Centers of XXXXXXX as there is one in XXXXXXX which would be a long drive, but within driving distance. I'd be glad to hear any recommendations from you.
Once again, thank you very much for your answers. I look forward to hearing back from you again.
Brief Answer:
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Detailed Answer:
Hello again.
A biopsy is a really easy procedure on the patient and you could be back home that or the following day, returning to normal activity inside the week. As for the possibility of removing it completely that depends, if a tumor is suspected a neurosurgeon wants to make sure he removes all the tumor cells, removing perhaps some of the surrounding tissue. For that purpose a more invasive procedure in order to get a better view might be needed. If he is certain it is a tumor he might decide to skip prior biopsy altogether and remove it completely right away (of course the removed tissue will be biopsied).
I find it a little strange for the report to say only that, usually some more information is added on how it looks on different MRI sequences, whether there is diffusion restriction on DWI sequence (which serves to distinguish from an abscess which might not need surgery at all).
As for the significant damage part, naturally if some brain tissue is removed there is the risk of a neurological deficit. The more tissue is removed the higher the risk. At that size though, even if one is to take into account a rim of normal tissue removed around it, I still think it shouldn't leave any deficit, the amount of tissue should be pretty small and the surrounding tissue should compensate. In the first week there may be some local swelling, but as the swelling subsides and the remaining cells create new connections to compensate for the lost ones you should be able to return to your normal activities very soon. The cerebellum is involved in movement coordination so there is some concern for your line of work. I would still feel optimistic as the lesion is small, you are young and the cerebellar lesions are generally well compensated.
What will be done next if malignant depends on the results of the biopsy, protocols vary depending on tumor type, can't be said whether chemotherapy of radiation will be needed.
As for waiting for a MRI 6 months later I think that shouldn't be done, not unless the neurosurgeon strongly disagrees with the radiologist and think of another diagnosis altogether. As for waiting a few weeks that shouldn't be a problem, while no precise predictions can be done about the rate of growth not knowing the type of tumor, the increase in only a few weeks is not significant.
About whether there is a possibility of it being benign, yes there is, some benign tumors may enhance and have some surrounding edema as well, though more a feature of malignant ones.
Whether it is possible to have just one nodule, yes, if the rest of the brain is normal on MRI it is probable to have only one nodule.
As for the chances and the statistics on brain metastasis, yes generally speaking they are not good, but you are an individual not a statistic. Remember that those are averages and the overwhelming part of patients have been diagnosed when the mass was big enough to develop symptoms. In your case it was discovered by chance way before it reached that stage so one can hope for a much better outcome thanks to an earlier intervention and your young age without other health issues.
Coming to searching for a primary tumor (if the hypothesis of metastasis remains that is) as I said x-ray is commonly not enough, a contrast CT of the thorax and abdomen is the most common investigative tests as well as tumoral markers tests in the blood. In nothing is found but still there is a strong suspicion then a PET-Scan is usually done. Of course the earlier the diagnosis the better chance at a cure, the modalities (surgery, chemo or radio, or a combination) again depend on the type of tumor.
As for your analysis of the hypothetical situation of a single small brain metastasis and a small lung tumor, you more or less gave the answer yourself, yes it is hypothetically possible to be cured, but there would be the fear of recurrence and periodical tests would be done. As for personal experiences, I know a patient in a similar scenario who is fine after 6 years. I am sorry I can't bring other cases with a longer healthy interval but should consider that I started my residency in Neurology in 2008, so my experience can only go back so much. Also it is not common to have a malignant brain lesion detected at your stage, as I said most patients are diagnosed when symptomatic.
As for your last query I am afraid I am not the most suitable person to ask that. That is because I live and exercise in Europe. Health care organisation and insurance systems here are completely different from the US. My knowledge of US centers is limited as well. I might mention Mount Sinai apart from Sloanne Kettering you already know of, but really not the best source. Anyway should not run too far ahead. We are making projections based on a very limited MRI report which is not clear even about the lesion location. Hopefully the neurosurgeon will not agree and it might be something much more trivial.
Read below
Detailed Answer:
Hello again.
A biopsy is a really easy procedure on the patient and you could be back home that or the following day, returning to normal activity inside the week. As for the possibility of removing it completely that depends, if a tumor is suspected a neurosurgeon wants to make sure he removes all the tumor cells, removing perhaps some of the surrounding tissue. For that purpose a more invasive procedure in order to get a better view might be needed. If he is certain it is a tumor he might decide to skip prior biopsy altogether and remove it completely right away (of course the removed tissue will be biopsied).
I find it a little strange for the report to say only that, usually some more information is added on how it looks on different MRI sequences, whether there is diffusion restriction on DWI sequence (which serves to distinguish from an abscess which might not need surgery at all).
As for the significant damage part, naturally if some brain tissue is removed there is the risk of a neurological deficit. The more tissue is removed the higher the risk. At that size though, even if one is to take into account a rim of normal tissue removed around it, I still think it shouldn't leave any deficit, the amount of tissue should be pretty small and the surrounding tissue should compensate. In the first week there may be some local swelling, but as the swelling subsides and the remaining cells create new connections to compensate for the lost ones you should be able to return to your normal activities very soon. The cerebellum is involved in movement coordination so there is some concern for your line of work. I would still feel optimistic as the lesion is small, you are young and the cerebellar lesions are generally well compensated.
What will be done next if malignant depends on the results of the biopsy, protocols vary depending on tumor type, can't be said whether chemotherapy of radiation will be needed.
As for waiting for a MRI 6 months later I think that shouldn't be done, not unless the neurosurgeon strongly disagrees with the radiologist and think of another diagnosis altogether. As for waiting a few weeks that shouldn't be a problem, while no precise predictions can be done about the rate of growth not knowing the type of tumor, the increase in only a few weeks is not significant.
About whether there is a possibility of it being benign, yes there is, some benign tumors may enhance and have some surrounding edema as well, though more a feature of malignant ones.
Whether it is possible to have just one nodule, yes, if the rest of the brain is normal on MRI it is probable to have only one nodule.
As for the chances and the statistics on brain metastasis, yes generally speaking they are not good, but you are an individual not a statistic. Remember that those are averages and the overwhelming part of patients have been diagnosed when the mass was big enough to develop symptoms. In your case it was discovered by chance way before it reached that stage so one can hope for a much better outcome thanks to an earlier intervention and your young age without other health issues.
Coming to searching for a primary tumor (if the hypothesis of metastasis remains that is) as I said x-ray is commonly not enough, a contrast CT of the thorax and abdomen is the most common investigative tests as well as tumoral markers tests in the blood. In nothing is found but still there is a strong suspicion then a PET-Scan is usually done. Of course the earlier the diagnosis the better chance at a cure, the modalities (surgery, chemo or radio, or a combination) again depend on the type of tumor.
As for your analysis of the hypothetical situation of a single small brain metastasis and a small lung tumor, you more or less gave the answer yourself, yes it is hypothetically possible to be cured, but there would be the fear of recurrence and periodical tests would be done. As for personal experiences, I know a patient in a similar scenario who is fine after 6 years. I am sorry I can't bring other cases with a longer healthy interval but should consider that I started my residency in Neurology in 2008, so my experience can only go back so much. Also it is not common to have a malignant brain lesion detected at your stage, as I said most patients are diagnosed when symptomatic.
As for your last query I am afraid I am not the most suitable person to ask that. That is because I live and exercise in Europe. Health care organisation and insurance systems here are completely different from the US. My knowledge of US centers is limited as well. I might mention Mount Sinai apart from Sloanne Kettering you already know of, but really not the best source. Anyway should not run too far ahead. We are making projections based on a very limited MRI report which is not clear even about the lesion location. Hopefully the neurosurgeon will not agree and it might be something much more trivial.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you again for your detailed answers. I have been very pleased with your help so far. Is this the last follow-up that I am allowed??
Yes, I am trying not to think too far ahead, but I need to prepare myself for a bad scenario in case it comes, while hoping for a good scenario. It is true that the MRI report was very limited - I don't know why the radiologist wasn't more specific, in addition to referring to the lesion as being in two different spots. I will assume that the actual spot is in the medial aspect of the left cerebellum, since that was the first place he referred to. Assuming he is correct about that location, does that have any effect on the situation? Easier or harder location to treat? Better or worse sounding in any way? Would that location be right on top of the brain, or deeper inside it, or can you not tell just from that description? If it is deeper inside the brain, does that create a problem, even with such a small nodule as 6 mm? The idea of having to go through the brain to get to it is rather alarming-sounding. Would that raise the likelihood of damaging tissue? You said there would be some concern in reference to my piano playing ability, but that you would still be optimistic, due to the small size, my age, and the fact that cerebellar lesions are generally well compensated. That is good to know, as my main goal would be safeguarding my life, but dexterity in my fingers is extremely important to me, and being left with any kind of paralysis in my hands (to say nothing of other body parts) would be disastrous. So, to confirm, you DO think I could most likely be spared any loss of movement in my fingers, or other mobility issues? What about speech, memory, etc.? Or HEARING.....the vestibular schwannoma near my right ear, while it has not grown in the 17 years since it was discovered, has notably reduced the hearing in my right ear - I can still hear out of it, but higher pitches are greatly reduced, and I have tinnitus in it, which, fortunately, I have learned to live with, and it doesn't bother me too much. Please tell me that surgery to remove this nodule would not affect the hearing in my LEFT ear. One way that I have been able to deal with the loss of hearing in my right ear is knowing that the hearing in my left ear is fine, so I sincerely hope I would not be faced with any loss of hearing in my left ear. I understand that some brain surgeries are performed while the patient is awake so the surgeon can speak to him/her and keep checking to make sure that bodily functions are working properly. I think I would be terrified of having my brain operated on while I was awake - I would imagine that some kind of relaxant must be given, to calm the patient? Would that likely be given to me as an option? And would it be something that you would or would not recommend?
I do like the idea that hopefully the neurosurgeon will not agree and it might be something much more trivial - I am just wondering how wrong the radiologist could have been? Assuming that he is at least correct about it being a 6 mm nodule, what is an example of something much more trivial that it could possibly be? I had hoped that it could be a cyst or a remnant from that bump on the head but you have said that those are both rather unlikely possibilities. Some things someone mentioned it could possibly be include: an erupted or enlarged or inflamed blood vessel, a swelling not related to anything but pressure, a blockage in a vessel, built up calcium deposits, fluid on the brain, abscess, vasculitis, lyme disease, or blood clot. I am also wondering if it could be evidence of a past flare up in the brain, such as a mini-stroke (not that I would want to find out that I had previously had any kind of stroke, but at least it would be an explanation that ruled out a malignancy). You already mentioned the possibility of abscess. Are there any of those things that could likely - or at least potentially - manifest themselves as a 6 mm nodule on a brain MRI, in that location? If you think it could potentially be something much more trivial, as you said, I would love to know about it.
One other thing came to mind...have you ever heard of Caboki? It is a hair enhancement product. It is sprinkled on thin hair like a powder and it gives the impression of a much fuller head of hair. I have been using this product several times a week since XXXXXXX of 2014. It is supposedly made up of all natural ingredients (fibers from plants). It is readily available, has its own website, and apparently has no dangers associated with it, and no major side effects. I had been using it for almost a full year before my May, 2015 MRI, on which nothing suspicious showed up. But, trying to think of any and all potential explanations for why there is a nodule on my brain, I thought of that. Do you think there could be any association? As far as I know, there are no carcinogens or anything harmful in this product. There must be some kind of XXXXXXX to give it its color (the color I use is dark brown), but I can't imagine that would be harmful, as people put XXXXXXX in their hair all the time. Do you think there could be any connection?
I can't help but keep my mind on the worst-case scenario....that it is a metastasis, which would mean I have a malignancy somewhere else. I have been trying to do research to try to reduce the likelihood of as many possibilities as I can. Could you take a look at what I have discovered and let me know if there are any points on which I am way off? If I can lessen the idea that it is a metastasis I can perhaps start to feel a little calmer until I get more specific answers (and hopefully feel much calmer after that if I find out that it is not a worst case scenario situation).
First, as I mentioned, I discovered that lung cancer appears to be the most common kind of cancer to spread to the brain, so that has been on my mind the most. As I told you I had a chest x-ray that came back perfectly fine, with no abnormalities whatsoever - plus I have no symptoms of lung cancer, in addition to never having smoked, and being fairly young, at 48. You did tell me that that does not necessarily eliminate the possibility of a tumor, however, as a CT scan would be needed to do that. I may request one, just to eliminate the possibility of lung cancer - but, even if there is no way to say, at this point, that I definitely do not have lung cancer, would you at least say that - given the information that I have provided you with, that it is at least relatively unlikely that I have lung cancer? And - worst case scenario - if I do, I would assume that it must be a very small tumor, to not have any showing at all on a chest x-ray?
Next, I understand that breast cancer very commonly spreads to the brain, but again, I would imagine that refers mostly to females? As I said, I did have an uncle who had breast cancer (although it did not spread to has brain), but isn't it relatively safe to say that I probably do not have breast cancer? I can feel no lumps or abnormalities in that area either. So hopefully I can rule out breast cancer?
I also read that kidney cancer often spreads to the brain, but that it almost always exhibits at least some symptoms before that point. I have no blood in the urine, no abnormalities that my PCP felt during examination, etc. Plus my creatinine and BUN levels were good on my blood work. So hopefully that means that - while nothing can be totally ruled out - the odds are in my favor that I do not have kidney cancer?
I also read that colon cancer is one of the top cancers that spreads to the brain, but then I read that it only does so in about 5 to 15 percent of cases. So would those statistics - plus the fact that I have no symptoms of colon cancer, and my last colonoscopy was 100 percent clean (even though that was 10 years ago, and I do need to schedule another one) - tend to rule in my favor that it is unlikely that I have a brain metastasis that came from colon cancer?
Melanoma - another cancer that I understand often spreads to the brain, but from what I understand, the most telltale sign of melanoma is a suspicious-looking spot on the skin, and I have none of those. So hopefully I can rule out that?
Liver? I have no signs of that either, and, as I said, my PCP felt no abnormal abdominal lumps.
As I mentioned, my blood work came back fine (white and red blood cells normal), so hopefully that would rule out most (all?) blood cancers?
I also know that overall signs of just about any cancer is loss of appetite and weight loss, and I have neither of those.
And you said you wouldn't worry about my back pain. After over three weeks, it finally seems to be almost entirely gone (just an occasional mild numbness where the pain was before, which hopefully doesn't mean anything in itself, in relation to the nodule?? It is actually similar to other back issues I have had off and on for decades, so I am trying not to relate that to the other situation...)
And of course, I do realize that just about any cancer can potentially spread to the brain, but if I can at least tell myself that it is unlikely that I have any of the ones that most commonly spread, I can possibly relax a bit and let myself believe that the worst I might have to prepare for is that it is a malignant tumor but is at least totally confined to the brain, and its small size makes it very treatable. But then I read that brain tumors tend to be brain metastasis more often than primary, and I start worrying all over again! So, knowing that the odds are in my favor that it doesn't sound likely that I have one of the cancers that commonly spreads to the brain at least makes me feel very slightly less nervous. Your take on my findings would be most appreciated.
I'm glad you say that a biopsy is a really easy procedure and people are often back to normal activity within a week, but doesn't a hole have to be drilled through the skull? Does skull bone regenerate or is one left with a permanent hole in the skull (albeit a small one) after the biopsy? Does one need to be anesthetized for a brain biopsy or do they just numb the area and do it while the patient is awake? Hopefully it is a relatively pain free procedure? The idea of pain scares me! Is there any danger to the brain just as a result of the biopsy?
If I do need to have actual surgery beyond the biopsy I would want to go to a facility where they do nothing but brain surgery. However, if the neurosurgeon that I consult with offers to do the biopsy, do you think it would be OK to let him do it, or should I go to an actual brain tumor center just to have the biopsy? I assume that the biopsy is a far less involved procedure than actual surgery to remove a tumor would be, so I am thinking that it wouldn't necessarily matter if I had a topnotch surgeon for the biopsy, but I would definitely want to go to a top of the line brain tumor facility if I actually need to have the nodule completely removed. Your thoughts?
As for the actual surgery, you said in the first week there may be some local swelling but that it subsides fairly quickly, and I should be able to return to my normal activities fairly soon. Assuming I do need to have surgery, approximately how much time should I plan to need to take off from work, from the time of the surgery to when I would be recovered enough to return? Would you say it should be no more than a month? Or more? One thing I keep thinking about is that I have a trip scheduled in mid-July. If it was decided that surgery was needed, I assume it would be scheduled in the fairly near future? Say the surgery took place by mid April...should I still be able to take my trip in July? Another point is....the trip is to the Florida theme parks. I have always enjoyed riding roller coasters. What would that mean after surgery? If I had the surgery in mid-April, would it be safe for me to ride a roller coaster three months later, in mid-July? Would I be told I would need to wait longer before riding roller coasters? Would I be told I should never ride them again? If I am told I should not ride roller coasters, there are some rides that are fast, and have a few mild drops, but do not violently shake up the body or go upside down. I would hope I would at least be able to ride those, if not the more dramatic and wild rides??
Here is another point altogether, and one that I fervently hope and pray I don't have to face. If it is determined that it is a metastasis, and therefore, I need treatment for another malignancy, as well as the brain, I realize I will need to put my life on hold and discover what additional surgeries, radiation, chemotherapy, etc., I would need - but I keep going back to the fact that it would be being caught early, which you say would greatly brighten my outlook compared to those scary statistics (I was glad to hear about the person you know of who is doing well after six years - since he/she is past the 5-year mark, hopefully he will continue to do well for many, many years to come, with no future complications, and hopefully that would bode well for me if the worst possibility happens). I do wonder, if metastasis was the case, if there would be any possibility of me taking my trip in mid-July. If it is a small lung tumor, for instance, as we hypothetically discussed earlier, do you think it would be conceivable at all that I could have surgery for that, plus the brain, plus start chemotherapy and/or radiation, if needed, and still be able to get away in July for my trip? Obviously if I get that kind of a diagnosis my goal would be to do what I needed to do to get well as quickly as possible, and that would be what I would be concentrating all of my energy on, but I have been looking forward to the trip for months, and that is helping me try to stay optimistic about this entire situation - that whatever treatment I may (or may not) need, I must be enough on the road to recovery by July in order to take that trip, and get on with my life...
As for the surgery---I have also read that gamma knife surgery is sometimes used, but often only if a tumor can not be surgically removed. Would it ever be advisable to do gamma knife radiation if the tumor is able to be surgically removed? I understand that it is possible for some of the tumor to be left behind and later start to regrow, whereas when it is removed surgically it is usually all removed, and, if benign, often not return. Could you give me your opinion on this?
I was glad you said there is a possibility of it being benign, as some benign tumors may enhance and have some surrounding edema as well, but you said that is more a feature of malignant ones. That frightens me, of course. since the radiologist's report said "there is mild associated hyperintense T2 signal within the surrounding white matter." So I am trying to get some reassurance out of that. Does his use of the word "mild" mean anything?? Would there tend to be greater (as in, NOT mild) associated hyperintense T2 signal if it was more likely a malignant lesion? You said that the fact he said "the brain parenchyma is otherwise normal" was a good sign, but does this lessen at all the possibility that it is a malignancy? Since the report was so limited I am trying to find meaning in every word. As I mentioned, I relayed the entire thing to you, so you know everything that the radiologist said. I did find information that said that "any tissue with a high water or protein content will tend to appear very bright on the T2 sequence." Is there anything reassuring to be taken from that?
Once again thanks so much for your detailed answers. Thanks in advance, and I look forward to your next correspondence.
Brief Answer:
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Detailed Answer:
Naturally a mass is more easily removed when close to the brain surface (cortex). Now medial indicates the location of that nodule on one plane, the axial (horizontal) plane where it is close to the center. However, there is no info on the location in the other two planes (high or low, anterior or posterior), it can still be near the cortex, can’t tell. If deeper it is harder to access may be some more damage (I am referring to surgery, biopsy needle is so thin it doesn’t create much issues).
I believe you should conserve mobility and dexterity, certainly for everyday chores, I can’t say it with certainty as in your profession we are speaking of a higher dexterity than normal people, but I am optimistic.
As for hearing, speech and memory there is no reason for them to be affected if it is the case of the cerebellum. If the temporal lobe on the other hand then it is involved in speech and memory, but still for a lesion of that size should recover very well.
I do not think awake surgery is necessary in your case, certainly not for the cerebellum, unlikely for temporal lobe as well. It is done mainly when it is operated in the frontal motor cortex.
As for the other possibilities to be considered I more or less mentioned them, abscess, multiple sclerosis, vasculitis. That is if the description of the radiologist is correct, given the confusion that answer creates one might hope there may be other errors as well. The other diagnoses you mention do not correspond to the provided description.
I had never heard of Caboki. Judging from your description and what I read about its contents I do not think there is any relation at all.
Regarding your understanding on lung and breast cancer, I agree. Lung cancer is unlikely at your young age without a history of smoking. Breast cancer in males is very rare, the fact there is nothing on palpation makes it even more unlikely.
Also agree about melanoma, if you’ve carefully examined your skin.
Do not completely agree about the kidney, liver or colon tumors. Tumors in those organs may manifest symptoms only when reaching a considerable size, but they start to develop long before that happens and can’t be excluded. Of course the percentages are low, but if it is confirmed to be a metastasis everything must be taken into consideration.
Blood cancers generally cause changes in blood count that’s correct, doesn’t completely rule out though, lymphomas may not have major changes at times.
The lack of other signs like loss of appetite and weight loss is encouraging, but doesn’t rule out anything. You do not have any brain related symptoms but there you have a nodule which is a fact. Cases of primary tumors being very small and asymptomatic are common, at times they are not detected even on CT scans and become visible only with time or on PET scan. I am sorry as I know that is not what you wanted to hear, but still remember that you should not run too far ahead with assumptions, try to take things step by step, a diagnosis of the nodule has to come first.
Regarding the biopsy, yes a hole is drilled but it is a very small one, a hole will be left but it is a very small one which will not cause any symptoms or disability. They do it with local anesthesia, just numb the area. It is a relatively pain free procedure. Complication rate (hemorrhage, infection) is very small, under 1%.
Regarding where to do it, of course if a tumor is considered the most likely diagnosis being in a tumor center would be preferable. However, I wonder if that might not lead to losing time for appointments and scheduling. So if that is the case and the current neurosurgeon is confident may consider going to the end with him.
I think one month away from work is enough. You should be able to have that July trip and there is no reason not to ride the roller coaster (of any type) that I can think of.
As for what would happen in the case it was a metastasis and a primary tumor was found, I am afraid it is difficult to answer. Waiting times for appointments and tests may vary where you live. Furthermore, different tumors have different treatment schemes, some need surgery some don’t, have different chemotherapy and radiotherapy protocols (even for the same tumor there may be different alternatives), with different duration and frequency of sessions, depending on type of tumor, staging, treating center etc. The possible combinations are too numerous even for an oncologist and as a neurologist I can’t even claim to know protocols for all tumors outside the nervous system.
As for the gamma knife surgery as you say it is an alternative when surgery is not possible. Since in your case we are speaking about the hope of curing not simply prolonging survival, of course if the tumor was surgically removed it would be better.
The fact that there is mild edema (swelling) is good, usually metastasis have a lot of swelling, but still doesn’t exclude anything, the nodule is very small so the associated changes are naturally small. As the brain parenchyma being otherwise normal that refers only to the presence of other brain metastasis, doesn’t mean much about other brain tumors. It would also render multiple sclerosis unlikely as usually there are many lesions as the term multiple indicates.
I hope to have been of help.
Read below
Detailed Answer:
Naturally a mass is more easily removed when close to the brain surface (cortex). Now medial indicates the location of that nodule on one plane, the axial (horizontal) plane where it is close to the center. However, there is no info on the location in the other two planes (high or low, anterior or posterior), it can still be near the cortex, can’t tell. If deeper it is harder to access may be some more damage (I am referring to surgery, biopsy needle is so thin it doesn’t create much issues).
I believe you should conserve mobility and dexterity, certainly for everyday chores, I can’t say it with certainty as in your profession we are speaking of a higher dexterity than normal people, but I am optimistic.
As for hearing, speech and memory there is no reason for them to be affected if it is the case of the cerebellum. If the temporal lobe on the other hand then it is involved in speech and memory, but still for a lesion of that size should recover very well.
I do not think awake surgery is necessary in your case, certainly not for the cerebellum, unlikely for temporal lobe as well. It is done mainly when it is operated in the frontal motor cortex.
As for the other possibilities to be considered I more or less mentioned them, abscess, multiple sclerosis, vasculitis. That is if the description of the radiologist is correct, given the confusion that answer creates one might hope there may be other errors as well. The other diagnoses you mention do not correspond to the provided description.
I had never heard of Caboki. Judging from your description and what I read about its contents I do not think there is any relation at all.
Regarding your understanding on lung and breast cancer, I agree. Lung cancer is unlikely at your young age without a history of smoking. Breast cancer in males is very rare, the fact there is nothing on palpation makes it even more unlikely.
Also agree about melanoma, if you’ve carefully examined your skin.
Do not completely agree about the kidney, liver or colon tumors. Tumors in those organs may manifest symptoms only when reaching a considerable size, but they start to develop long before that happens and can’t be excluded. Of course the percentages are low, but if it is confirmed to be a metastasis everything must be taken into consideration.
Blood cancers generally cause changes in blood count that’s correct, doesn’t completely rule out though, lymphomas may not have major changes at times.
The lack of other signs like loss of appetite and weight loss is encouraging, but doesn’t rule out anything. You do not have any brain related symptoms but there you have a nodule which is a fact. Cases of primary tumors being very small and asymptomatic are common, at times they are not detected even on CT scans and become visible only with time or on PET scan. I am sorry as I know that is not what you wanted to hear, but still remember that you should not run too far ahead with assumptions, try to take things step by step, a diagnosis of the nodule has to come first.
Regarding the biopsy, yes a hole is drilled but it is a very small one, a hole will be left but it is a very small one which will not cause any symptoms or disability. They do it with local anesthesia, just numb the area. It is a relatively pain free procedure. Complication rate (hemorrhage, infection) is very small, under 1%.
Regarding where to do it, of course if a tumor is considered the most likely diagnosis being in a tumor center would be preferable. However, I wonder if that might not lead to losing time for appointments and scheduling. So if that is the case and the current neurosurgeon is confident may consider going to the end with him.
I think one month away from work is enough. You should be able to have that July trip and there is no reason not to ride the roller coaster (of any type) that I can think of.
As for what would happen in the case it was a metastasis and a primary tumor was found, I am afraid it is difficult to answer. Waiting times for appointments and tests may vary where you live. Furthermore, different tumors have different treatment schemes, some need surgery some don’t, have different chemotherapy and radiotherapy protocols (even for the same tumor there may be different alternatives), with different duration and frequency of sessions, depending on type of tumor, staging, treating center etc. The possible combinations are too numerous even for an oncologist and as a neurologist I can’t even claim to know protocols for all tumors outside the nervous system.
As for the gamma knife surgery as you say it is an alternative when surgery is not possible. Since in your case we are speaking about the hope of curing not simply prolonging survival, of course if the tumor was surgically removed it would be better.
The fact that there is mild edema (swelling) is good, usually metastasis have a lot of swelling, but still doesn’t exclude anything, the nodule is very small so the associated changes are naturally small. As the brain parenchyma being otherwise normal that refers only to the presence of other brain metastasis, doesn’t mean much about other brain tumors. It would also render multiple sclerosis unlikely as usually there are many lesions as the term multiple indicates.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr. Taka? Are you still there? I didn't know if I have used up all of my questions yet but the site said that there is still one day before this discussion closes, so I hope that means I still have one question left...
I wanted to let you know about the meeting I had with the neurosurgeon. He looked at both the MRI I had done a few weeks ago and the one that was done in May of 2015, and he thought he saw evidence of this lesion on THAT scan as well. He said he would consult with his colleague to see what he thought, but I saw the MRI pictures myself, as did a sister that I brought along with me, in addition to the doctor, and it definitely looks like there is something present in that very spot in the 2015 image, and when asked, the doctor said that it looks like there is a good chance this lesion was, indeed, present at that time, just at a smaller size (and even now it is only 6mm, as you know). He did agree with you, that at 6mm it is extremely small, and that almost no abnormality is discovered at such a small size, which would make treating it much easier, if that needs to be done. But it would seem that the very good news with this is that would mean it is almost a guarantee that it is not a malignancy, correct? As far as I understand, no malignancy would grow that slowly in a period of 21 months. The spot was extremely small on the 2015 MRI, and the doctor didn't even try to measure it for size, but he compared the 2015 MRI side by side with the one from recently, and he seemed to think that it was in the exact same spot, which is what it looked like. I also had neglected to mention to you that the radiologist said he compared the most recent MRI pictures to the 2014 MRI - NOT to the most recent one, from 2015 (I don't know if that was another mistake and he meant to write 2015, but if he compared it to the 2014 scan it would make sense that it was not present on that scan, but it was barely visible on the 2015 one). So hopefully I have much cause to feel some relief? Do you think there is any way that this nodule could have been forming in May of 2015 and now only be 6mm and still be a malignancy? The neurosurgeon ordered a full body CT scan which I am having done this week, just to rule out it being a metastasis, and he ordered another MRI in 3 weeks. If that shows no change in size then he said he would order another MRI in one or two months. If that shows no change in size then he said we could watch it regularly and if it doesn't seem to be enlarging, or seems to be enlarging very slowly, we could move the follow ups to longer intervals. This would not change the fact that it would still have to be watched, and if it does, eventually, get to a larger size, it very well may need to be either removed or radiated at that time, but the doctor said that with close watching it could still be dealt with before being anywhere near life-threatening, and rather safely removed if necessary. As for the MRI scan, I am hoping that it was not some artifact on the 2015 scan, as it was a very very small spot - but, considering that it was in the exact same spot as the current nodule, does it seem safe to assume that is what we are seeing on the 2015 scan? My sister (who has had surgery on her head for a benign pituitary tumor) also suggested that it could simply be a case of the contrast being better on the current scan, and it would have been even more visible on the 2015 scan with better contrast. But, in any case, something very small is definitely visible in that same spot on the 2015 scan, so I am taking that to be a very promising sign. Now I just have to hope and pray that the body CT scan comes back good, as does the next MRI. I am very interested in hearing your take on these new findings, so I hope I am still allowed one more question!! Thanks.
I wanted to let you know about the meeting I had with the neurosurgeon. He looked at both the MRI I had done a few weeks ago and the one that was done in May of 2015, and he thought he saw evidence of this lesion on THAT scan as well. He said he would consult with his colleague to see what he thought, but I saw the MRI pictures myself, as did a sister that I brought along with me, in addition to the doctor, and it definitely looks like there is something present in that very spot in the 2015 image, and when asked, the doctor said that it looks like there is a good chance this lesion was, indeed, present at that time, just at a smaller size (and even now it is only 6mm, as you know). He did agree with you, that at 6mm it is extremely small, and that almost no abnormality is discovered at such a small size, which would make treating it much easier, if that needs to be done. But it would seem that the very good news with this is that would mean it is almost a guarantee that it is not a malignancy, correct? As far as I understand, no malignancy would grow that slowly in a period of 21 months. The spot was extremely small on the 2015 MRI, and the doctor didn't even try to measure it for size, but he compared the 2015 MRI side by side with the one from recently, and he seemed to think that it was in the exact same spot, which is what it looked like. I also had neglected to mention to you that the radiologist said he compared the most recent MRI pictures to the 2014 MRI - NOT to the most recent one, from 2015 (I don't know if that was another mistake and he meant to write 2015, but if he compared it to the 2014 scan it would make sense that it was not present on that scan, but it was barely visible on the 2015 one). So hopefully I have much cause to feel some relief? Do you think there is any way that this nodule could have been forming in May of 2015 and now only be 6mm and still be a malignancy? The neurosurgeon ordered a full body CT scan which I am having done this week, just to rule out it being a metastasis, and he ordered another MRI in 3 weeks. If that shows no change in size then he said he would order another MRI in one or two months. If that shows no change in size then he said we could watch it regularly and if it doesn't seem to be enlarging, or seems to be enlarging very slowly, we could move the follow ups to longer intervals. This would not change the fact that it would still have to be watched, and if it does, eventually, get to a larger size, it very well may need to be either removed or radiated at that time, but the doctor said that with close watching it could still be dealt with before being anywhere near life-threatening, and rather safely removed if necessary. As for the MRI scan, I am hoping that it was not some artifact on the 2015 scan, as it was a very very small spot - but, considering that it was in the exact same spot as the current nodule, does it seem safe to assume that is what we are seeing on the 2015 scan? My sister (who has had surgery on her head for a benign pituitary tumor) also suggested that it could simply be a case of the contrast being better on the current scan, and it would have been even more visible on the 2015 scan with better contrast. But, in any case, something very small is definitely visible in that same spot on the 2015 scan, so I am taking that to be a very promising sign. Now I just have to hope and pray that the body CT scan comes back good, as does the next MRI. I am very interested in hearing your take on these new findings, so I hope I am still allowed one more question!! Thanks.
Brief Answer:
Great news
Detailed Answer:
Thank you for the update! Yes your were allowed one more questions, sorry for not saying that in my past answer.
You are correct, that is very very good news. While I confess I have no idea what that is now, the chances of that being a malignant finding are very very small, in 21 months it would have grown much more. Being in the exact same spot I doubt it was an artifact in 2015. The neurosurgeon is being very cautious in his approach anyway scheduling control exams. But you have every reason to feel relieved now that is for sure and I am really happy for you. I am very optimistic body scan will turn out alright (metastasis are aggressive, do not linger for 21 months) and for the next MRI as well.
Wishing you good health.
Great news
Detailed Answer:
Thank you for the update! Yes your were allowed one more questions, sorry for not saying that in my past answer.
You are correct, that is very very good news. While I confess I have no idea what that is now, the chances of that being a malignant finding are very very small, in 21 months it would have grown much more. Being in the exact same spot I doubt it was an artifact in 2015. The neurosurgeon is being very cautious in his approach anyway scheduling control exams. But you have every reason to feel relieved now that is for sure and I am really happy for you. I am very optimistic body scan will turn out alright (metastasis are aggressive, do not linger for 21 months) and for the next MRI as well.
Wishing you good health.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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