Diagnosing Lung Cancer

Diagnosing lung cancer early before it spreads leads to better outcomes. Diagnostic tests for lung cancer are often recommended after a person sees their doctor for symptoms that need more evaluation. This can include imaging, or after an abnormal lung cancer screening, a CT scan. It is important that you have additional tests so your care team can make an accurate diagnosis and develop an effective treatment plan. If there is concern about a possible lung cancer, your doctor will refer you to a lung specialist.

Several tests may be used to diagnose a suspicious spot or mass on the lung. Each test may be performed by a different member of our specialty team, including a thoracic surgeon, a radiologist or a pulmonologist. The tests conducted depend on each patient’s individual circumstances.

The diagnostic tool used depends on several factors, including the location and size of the suspicious spot or mass, the patient’s overall health and personal preferences. We tailor the test to the patient as the first step in our comprehensive, multidisciplinary care. Our team members work together closely, from diagnosis through treatment and follow-up, to deliver the best possible care.

Tests to Diagnose Lung Cancer

Diagnostic tests can include imaging scans and a biopsy of lung tissue and fluids around your lungs. Each diagnostic approach has its advantages and disadvantages, and all are based on evidence and research. We review each option thoroughly to help patients make the best choice.

Tests and exams used for ruling out or diagnosing lung cancer include:

Physical Exam

A thorough physical exam and a complete medical history are a key part of the diagnostic process.

Chest X-ray

A chest X-ray done for a different purpose is often the reason a suspicious area on the lungs is identified. X-ray is valuable in identifying masses that need further testing.

CT Scan

A CT scan can be used to identify abnormalities and to monitor changes or growth in a suspicious spot. We also use spiral CT, an advanced technology that uses a continuous spiraling motion to take detailed images quickly.

PET/CT Scan 

A PET/CT scan is similar to CT scan. It is a nuclear medicine test that identifies active cancer cells within the lungs and in other parts of the body. The goal of this scan is to see if there is any metabolic activity within the suspicious area that could indicate that cancer is progressing. The PET/CT scan helps the care team decide on next course of action.

Bronchoscopy

In this procedure, a flexible bronchoscope is passed through the nose or the mouth, to see inside the lungs. It can be done under general anesthesia, or with sedation similar to that used during a colonoscopy. During a bronchoscopy, which can be performed using robotic assistance, tissue samples can be removed for biopsy.

Interventional pulmonologists use a robotic bronchoscope to navigate to suspicious lung nodules. This minimally invasive procedure allows the specialist to biopsy lesions or masses from inside the lungs rather than from the outside. It is especially effective in reaching lesions deep inside the lung and the lymph nodes in the area between the lungs, which may be out of reach of traditional bronchoscopes. Using a robotic bronchoscope, with shape-sensing technology (computer-generated images and GPS-like technology) a physician can steer a catheter into a lesion to biopsy it. The procedure includes real-time confirmation nodule biopsy using cone beam CT.

Image-Guided Needle Biopsy

This test uses CT imaging to guide a needle through the skin into the lung to remove cells or tissue from the suspected mass or lymph nodes for biopsy. It is most effective for tumors located very near the chest wall or the skin.

Robotic-Assisted Thoracoscopic Surgery (RATS)

This minimally invasive surgical approach uses a scope inserted between the ribs to examine the lung. Other small instruments can be inserted for the surgeon to perform any necessary diagnostic or therapeutic procedures, including removing tissue for biopsy or removing the mass itself. RATS procedures typically result in less pain and faster recovery times than traditional open surgical approaches.

Endobronchial Ultrasound (EBUS)

EBUS uses an ultrasound probe at the end of a bronchoscope to help doctors see the mass they are biopsying to improve accuracy. It can be used to look at lymph nodes in the mediastinum (the area of the chest between the lungs). A biopsy can also be obtained by passing a hollow needle through the bronchoscope.

Endoscopic Esophageal Ultrasound (EUS)

This technique uses an ultrasound probe at the end of an endoscope, which is passed down the throat into the esophagus. EUS allows doctors to see some deep lymph nodes and even the adrenal gland to determine if the cancer may have spread. A biopsy can also be obtained by passing a hollow needle through the endoscope.

Thoracentesis 

During thoracentesis, which takes 10-15 minutes, a doctor removes extra fluid from the space between the lungs and the chest wall to help a person breathe more easily or to find out what’s causing the fluid buildup. It involves numbing the skin on a patient’s back or side. Then, the doctor inserts a thin needle or small tube between the ribs to draw out the fluid.

Pathology for Lung Cancer Diagnosis and Treatment Planning

Evaluation by a pathologist experienced in conducting tests on tissues, blood and fluids for thoracic cancers is a critical step before treatment planning. The pathologist’s report will be discussed as part of lung cancer tumor board because it will help your care team decide on the treatments that will be most effective for your specific type of cancer

A pathologist’s analysis will help confirm:

• If you do or do not have lung cancer
• The type of lung cancer (non-small cell or small cell) and if it is non-small cell lung cancer, the subtype
• The stage of your cancer and how aggressive it is likely to be
• The presence of any genetic mutations (if you have non-small cell lung cancer)
• Protein (PD-L1) expression from the tumor cells

Staging Lung Cancer

Staging is a complicated process that helps your care team determine where the cancer is located, if it has spread beyond the lungs, and if so, how far it has spread. With this information, your doctors can plan the best way to treat your cancer. Cancers that have similar stages can have similar prognoses and may be treated in similar ways, although your care team will personalize your treatment to you.

Ask your doctor to explain the particular staging information about your lung cancer in words you can understand.

Non-small cell lung cancer staging

Non-small cell lung cancer (NSCLC) is staged using the TNM system.

• T describes the primary tumor and is based on the size, location and extent of the tumor;
• N describes the number and location of lymph nodes involved; and
• M describes whether the cancer has spread to other areas of the body (metastasis) 

It is further categorized by the numbers 0-IV. The lower the number, the less the cancer has spread.

• Stage I: Early cancer confined to one lung without lymph node spread
• Stage II: Also an early stage cancer, with limited regional spread (usually within the same lung)
• Stage III: A more advanced cancer (larger tumor, more extensive disease, lymph node involvement)
• Stage IV: Advanced cancer that has spread beyond the lungs or chest

Small cell lung cancer staging

Small cell lung cancer is staged as:

• Limited stage: Confined to one side of the chest. The care team anticipates that all of the cancer can be included in the area to be targeted with radiation therapy if radiation treatment is indicated.
• Extensive stage: Spread beyond the area to be targeted with radiation therapy if radiation treatment is indicated. Cancer has spread to both lungs, lymph nodes or to other parts of the body such as the liver, the bones, to the adrenal glands or to the brain.