Diagnosing lung cancer

Monday 1 December, 2014

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On this page: Chest x-ray | CT scan | PET scan | Sputum cytology | Fine needle aspiration | Bronchoscopy | Endobronchial ultrasound | Mediastinoscopy | Thoracoscopy | Staging | Prognosis | Health Professionals | Key points


Your doctors will perform a number of tests to obtain a diagnosis, determine if the cancer has spread to other parts of your body and develop a treatment plan.

Chest x-ray

A chest x-ray is usually the first imaging test – it is painless and can show tumours 1cm wide or larger. Small tumours may not show up on an x-ray or may be hidden by other organs within the chest cavity. After a chest x-ray, more detailed tests may be required.

CT scan

A CT (computerised tomography) scan is usually the second imaging test. It uses x-ray beams to take three-dimensional pictures of the inside of your body. CT imaging can identify smaller tumours than those found by x-rays, and provide detailed information about the tumour, the lymph nodes in the chest and other organs within the imaging field.

A CT scan is painless and takes about 10 minutes. You will need to lie flat on a table that slides in and out of a large, round scanner. CT scans are usually done at a hospital or a radiology service.

You will receive instructions about preparing for a CT scan. An iodine contrast dye is usually injected into a vein in your arm to make the scan pictures clearer.

Before a CT scan, you may be given an injection or asked to drink a liquid called a contrast to make the images on the computer appear clearer. Tell the doctor if you have any allergies before having this injection.

PET scan

A PET (positron emission tomography) scan is a specialised imaging test that is available at most major hospitals. It is useful in diagnosing lung tumours where a biopsy is inconclusive or not possible. A PET scan can also be used to stage lung cancer (see below) or find cancer that has spread to other parts of the body.

You will be injected with a radioactive glucose solution. It takes 30–90 minutes for the fluid to go through your body, then you will have a body scan. The scan shows ‘hot spots’ in the body where there are active cells, such as cancer cells. Not all PET hot spots indicate cancer. The scan will be carefully evaluated by a PET specialist.

"I had a PET scan and they could tell that the cancer was only one lung and one lymph node nearby." - Jim

Sputum cytology

A sputum cytology test is an examination of phlegm or mucus from your lungs (sputum).

You may be asked to collect sputum samples each morning at home. You can collect a sample by coughing deeply and forcefully.

Collect any sputum that you cough up and store the sample in your fridge until you take it to your doctor, who will check for abnormal cells.

Fine-needle aspiration

A fine-needle aspiration biopsy is one way of obtaining cells used for a diagnosis and is generally used where the tumour is in the outer parts of the lungs.

The doctor will use a CT scanner to identify the best place to insert a needle through your chest wall into the tumour. A small piece of tumour can usually be removed with the needle. Sometimes a slightly thicker needle may be used to give a larger core biopsy.

A fine-needle aspiration is done in a hospital or radiology department. You will be observed for a few hours afterwards, as there is a small risk of the lung partly collapsing during this procedure.

A fine-needle biopsy is less likely to be offered when the tumour is close to the heart or major blood vessels, or if you have a lung condition such as emphysema.

Bronchoscopy

A bronchoscopy allows the doctor to look directly into the airways (bronchi). You will be given sedation, and a local anaesthetic will be sprayed on the back of your throat to numb it. Sometimes a general anaesthetic is given.

The doctor will insert a flexible tube called a bronchoscope into your nose or mouth and down your windpipe (trachea). The bronchoscope may feel uncomfortable, but it shouldn’t feel painful.

During the bronchoscopy, the doctor will take a tissue sample (biopsy). If the tumour is near your main respiratory tract, the cells can be sampled using techniques called washing and brushing. ‘Washing’ means that a small amount of fluid is injected into the lung and withdrawn for further examination, while ‘brushing’ involves the use of a brush-like instrument to remove some cells from the bronchi.

Endobronchial ultrasound

An endobronchial ultrasound (EBUS) is a type of bronchoscopy procedure that allows a doctor to examine the airways (bronchi) and take tissue samples through the airways and windpipe (trachea). Samples may also be taken from a tumour or a lymph node in the middle of the chest or next to the airways. In other cases, samples can be taken from the outer parts on the lung.

The doctor will use a bronchoscope with a small ultrasound probe on the end. The bronchoscope will be put down your throat into your trachea. The ultrasound probe uses soundwaves to create a picture that shows the size and position of the tumour and allows the doctor to measure it.

After an EBUS, you may have a sore throat or cough up a small amount of blood. Tell your medical team how you are feeling so they can monitor you.

Mediastinoscopy

A mediastinoscopy is a less commonly performed procedure that allows a surgeon to examine and sample lymph nodes at the centre of your chest. A rigid tube is inserted through a small cut in the front of your neck and passed down the outside of your trachea. The surgeon will inspect the area between the lungs (mediastinum) and remove some tissue. This is usually a day procedure but some people may need to stay overnight in hospital.

Thoracoscopy or thoracotomy

A thoracoscopy or thoracotomy is an operation performed under a general anaesthetic. It is usually done if other tests are unable to provide a diagnosis. Your surgeon will do this test to take a tissue sample (biopsy) or remove the tumour.

This operation can be done in two ways. The surgeon may be able to make one or two small cuts in your chest to insert a surgical instrument called a thoracoscope, that has a camera attached. If this isn’t possible, the surgeon will open the chest cavity through a larger cut on your back. You will wake up with a drain coming from your side and stay in hospital for a few days.

Further tests

Other tests, such blood and breathing tests, bone and brain scans, or MRI scans may also be required. For information about these tests, talk to your doctor or call Cancer Council 13 11 20.

Staging lung cancer

Staging means finding out if and where the lung cancer may have spread to. Your doctor will assign a staging category to your cancer, which will help determine the best treatment. The staging category is worked out using your medical history and imaging and tissue biopsy information.

Non-small cell and small cell lung cancer
Stage 1
The tumour is in only one lobe of the lung and has not spread.
Stage 2
The tumour has spread to nearby lymph nodes, or has grown into the chest wall.
Stage 3A
Tumours have spread to lymph nodes in the centre of the chest (mediastinum).
Stage 3B
Tumours have spread more extensively to lymph nodes in the mediastinum, or have become attached to major blood vessels or the trachea (windpipe). 
Stage 4
The cancer cells have spread to distant parts of the body, such as the bones, brain or liver. 

Prognosis

Prognosis means the expected outcome of a disease. You will need to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of the illness. Instead, your doctor can give you an idea about common issues that people with the same type of cancer experience.

As in most types of cancer, the results of lung cancer treatment are best when the cancer is found and treated early. See the table above for more information about staging lung cancer.

Assessing prognosis

Important factors in assessing your prognosis include:

  • test results
  • the type of cancer you have
  • the rate and extent of tumour growth
  • how well you respond to treatment
  • your age
  • fitness
  • medical history

Lois' story

"I had been having frequent chest colds and in June, I coughed up blood. My daughter insisted that I go to hospital.

"After having several different types of scans, I was diagnosed with lung cancer. Within a week I had a pneumonectomy to remove my right lung. The surgeon said he got all the cancer but I needed to have chemotherapy to be sure it was gone completely.

"Now I have good and bad days. I do breathing exercises during rehabilitation to stay well. Sometimes I feel so good that I overdo it. I forget that I have one lung and I tire easily. I’m learning to pace myself."

Tell your cancer story.

Which health professionals will I see?

Often your GP will arrange the first tests to assess your symptoms. This can be a worrying and tiring time, especially if you need several tests. If these do not rule out cancer you will usually be referred to a lung specialist, who will arrange further tests and advise you about treatment options.

You will be cared for by a range of health professionals who will generally specialise in different aspects of your treatment. This multidisciplinary team will meet regularly to design and discuss the most appropriate treatment plan for you, and will support you on an ongoing basis.

This team may include some or all of the health professionals listed below.

Health professional

Role

respiratory physician (sometimes called thoracic physician or lung specialist)

diagnoses and stages the cancer and determines initial treatment options

thoracic (chest) surgeon

conducts some diagnostic tests and performs surgery.

medical oncologist

prescribes and coordinates chemotherapy and medications to control the cancer

radiation oncologist

prescribes and coordinates radiotherapy.

nurses and cancer nurse coordinators

supports you through all stages of your treatment and liaises with other staff to help organise care

palliative care doctors 

prescribe or recommend treatment for symptoms of advanced cancer. Liaise with your GP and oncologist to ensure care is well coordinated

dietitian

recommends an eating plan for you to follow while you are in treatment and recovery

speech pathologist

helps with communication and swallowing

physiotherapist and occupational therapist

assist with physical rehabilitation

social worker, counsellor, clinical psychologist, psychiatrist   assist with emotional concerns and in the treatment of depression and anxiety, provide emotional support and link you to other support services  

Key points

  • There are many different types of tests to diagnose lung cancer. Tests will vary, you probably won’t have every test.
  • X-rays and CT scans are painless scans that will take pictures of the inside of your body.
  • If you are coughing up phlegm, your doctor might ask you for a sample to send to a lab for testing (sputum cytology).
  • Sometimes the doctor may insert a needle into your chest to get a tissue sample. This is called a fine-needle aspiration.
  • A bronchoscopy involves a flexible tube being inserted into your nose or mouth and down your trachea to examine your airways.
  • Some people have further tests (such as a blood test, PET scan, brain scan, bone scan, mediastinoscopy or thoracotomy).
  • The doctors will assign a stage to the cancer based on diagnostic tests. This describes the size of the cancer and whether it has spread.
  • Scans and tests can help show if the lung cancer has spread. They can also help your medical team decide on the best treatment plan.
  • Your doctor may talk to you about prognosis. This means the expected outcome of the disease. No one can predict the exact course of the illness.
  • You will probably see many doctors and health professionals who will work together as a multi-disciplinary team to diagnose and treat the cancer. Check to see if a cancer care coordinator or lung cancer nurse is available for you to see.

Reviewed: Prof Kwun Fong, Thoracic and Sleep Physician and Director, UQ Thoracic Research Center, The Prince Charles Hospital, QLD; Clare Brown, Case Manager for Thoracic Surgery, Royal Prince Alfred Hospital, NSW; Glenda Colburn, Director, Lung Cancer National Program, The Australian Lung Cancer Foundation; Prof David Ball, Chair, Lung Service, Peter MacCallum Cancer Centre; Dr Arman Hasani, Medical Oncologist, Sir Charles Gairdner Hospital, WA; Dr Paramita Dasgupta, Viertel Cancer Research Centre, Cancer Council QLD; Carmen Heathcote, Registered Nurse, Cancer Council QLD; Frances McKenzie, Cancer Connect volunteer, QLD.

Updated: 01 Dec, 2014