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Diagnosis

How Is Lung Cancer Diagnosed?

At a patient’s first visit to BMC, he or she will receive highly coordinated, multidisciplinary care that is managed by a thoracic surgeon, a physician who specializes in treating conditions of the lungs, chest wall, and diaphragm.

The patient’s care team will work together to determine a diagnosis.

In collaboration with other specialists, the patient’s physician will likely order a number of diagnostic tests and review the results at a weekly multidisciplinary Thoracic Tumor Board meeting. This interdepartmental review process guides the recommendations for treatment. In consultation with the patient and his or her primary care physician, the BMC care team will plan the best course of treatment based on the type and extent of the patient’s cancer and his or her overall health.

For suspected or confirmed diagnoses of lung cancer, the Cancer Care Center’s physicians will use a variety of diagnostic procedures to stage the disease to determine its severity and spread. The patient’s doctor may request several of the following tests and diagnostic procedures:

Blood Tests

A common tool for disease screening, blood tests provide information about many substances in the body, such as blood cells, hormones, minerals, and proteins.

Computed Tomography (CT) Scan

CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut. Doctors order CT scans when they want to see a two-dimensional image of the body to look for tumors and examine lymph nodes and bone abnormalities. If contrast dye is used to improve the computer image, the patient may need to avoid eating or drinking for 4 to 6 hours before the test. Patients should tell their provider before the test if they have any allergies or kidney problems.

MRI Scan

An MRI is a non-invasive diagnostic imaging that doesn't use ionizing radiation. It is painless and a harmless way of looking inside the body without using X-rays. Instead it uses a large magnet and computer to scan the body. This provides the doctor with information not available from other scans.

Positron Emission Tomography (PET) scan

A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream. Once it has had time to move through your body, you will lie on a table while a scanner follows the radiotracer and sends three-dimensional images to a computer screen. Patients are generally asked to wear comfortable clothing and refrain from eating for 4 hours before the scan. Tell your doctor if you are pregnant or breastfeeding. Patients with diabetes should discuss diet guidelines with their physician for the hours leading up to the scan.

Pulmonary Function Test (PFT)

To understand how well your lungs are working, your physician may order a series of pulmonary function tests. With each breath you take in and breathe out, information is recorded about how much air your lungs take in, how the air moves through your lungs and how well your lungs deliver oxygen to your bloodstream.

Stress Test

A stress test is used to gain more information about how your heart functions during exercise. Your physician will monitor your heartbeat and blood flow as you walk on a treadmill, and will then be able to diagnose any problems as well as plan treatment.

Ventilation and Perfusion Scans

These tests assess breathing and circulation in the lungs. As you inhale a harmless radioactive gas, the ventilation scan monitors your lungs. Next, you receive an injection of radioactive material for the perfusion scan, which monitors blood flow through your lungs. No preparations are needed, but tell your doctor if you are pregnant or breastfeeding. Your physician may also request diagnostic procedures that require sedation.

Bronchoscopy

During a bronchoscopy, your physician will give you a sedative and then pass a small, hollow tube (bronchoscope) through your nose and throat into the main airway of the lungs. He or she can then see any abnormal areas and extract a tissue sample for analysis.

Endobronchial Ultrasound (EBUS)

EBUS is a minimally invasive procedure to assess lymph nodes along the bronchial tubes and frequently complements mediastinoscopy. Your physician will give you a sedative and then insert a bronchoscope through your mouth and trachea and into the lungs and surrounding tissues so that samples can be taken from lymph nodes. EBUS does not require any incisions.

Endoscopic Ultrasound (EUS)

Your physician uses an endoscope (a long, flexible tube) with a small ultrasound transducer on the tip to obtain images of the lymph nodes deep in the chest. This instrument is passed into your esophagus. The transducer sends high-frequency sound waves to the organs to create detailed images of them. You should avoid food and drink for at least 6 hours before the procedure, and you will be sedated, so you should not drive or return to work for 24 hours.

Mediastinotomy and Mediastinoscopy

When performing a mediastinotomy, the surgeon makes a two-inch incision into the center of your chest cavity (the mediastinum) to evaluate and remove tumors in your heart and lung area. This procedure is often performed with a mediastinoscopy, in which the physician inserts a lighted instrument (mediastinoscope) to view the area and take a tissue sample. You will be required to fast in advance and refrain from driving following the procedure.  

Needle Biopsy

Your physician applies an anesthetic (numbing agent) and, guided by CT scan or X-ray, inserts a needle into you to obtain a tissue sample for analysis.

Video-Assisted Thoracoscopic Surgery (VATS)

VATS is a minimally invasive alternative to open chest surgery that involves less pain and recovery time. It is used to both diagnose and treat a variety of thoracic conditions. The physician makes tiny incisions in your chest and inserts a thorascope (a fiber-optic camera) as well as surgical instruments. As the physician turns the thorascope, its views are displayed on a video monitor to guide investigation or surgery.

 

Staging

Staging is the process of determining how extensive the cancer is. It is an important part of diagnosis because it is used to determine the most appropriate treatment options for patients. For patients diagnosed with lung cancer, a multidisciplinary care team will use these diagnostic procedures to stage the disease and to determine its severity and spread. The stage indicates the location and spread of the cancer.

 

Stages of Lung Cancer

Stage I: Cancer is present in the lung tissue but not the lymph nodes
Stage II: Cancer is present in the lymph nodes and the chest wall
Stage IIIA: Cancer is present in the lymph nodes within the center of the chest
Stage IIIB: Cancer is present in local areas such as the heart, blood vessels, esophagus, trachea, or lymph nodes of the collarbone or pleura (tissue that surrounds the lungs)
Stage IV: Cancer has spread to other parts of the body, such as the liver, brain, or bones

Pulmonary Metastasis

When a cancerous tumor that originates in a body part other than the lung spreads to the lung, it is called pulmonary metastasis. These metastases—also called secondary malignancies—are common and occur frequently with cancers of the kidney, bone, skin, breast, and colon, among others. Because the lungs are central to many of the body's systems, and blood and lymphatic fluid are pumped through the lungs, tumor fragments and particles can be transferred to the area. It is estimated that pulmonary metastases are present in up to half of advanced cancers. These tumors may occur as a single metastasis or many may be present.

Symptoms of Pulmonary Metastasis

  • Cough, or coughing up blood
  • Shortness of breath
  • Pain in the chest or rib cage
  • Weight loss with unknown cause
  • Weakness or fatigue

 

How Are Pulmonary Metastases Diagnosed?

Pulmonary metastases are usually detected via one of the following tests:

Chest X-ray

Chest x-rays provide an image of the heart, lungs, airways, blood vessels and bones in the spine and chest area. They can be used to look for broken bones, diseases like pneumonia, abnormalities, or cancer.

Computed Tomography (CT) Scan

CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut. Doctors order CT scans when they want to see a two-dimensional image of the body to look for tumors and examine lymph nodes and bone abnormalities. If contrast dye is used to improve the computer image, the patient may need to avoid eating or drinking for 4 to 6 hours before the test. Patients should tell their provider before the test if they have any allergies or kidney problems.

Positron Emission Tomography (PET) scan

A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream. Once it has had time to move through your body, you will lie on a table while a scanner follows the radiotracer and sends three-dimensional images to a computer screen. Patients are generally asked to wear comfortable clothing and refrain from eating for 4 hours before the scan. Tell your doctor if you are pregnant or breastfeeding. Patients with diabetes should discuss diet guidelines with their physician for the hours leading up to the scan.

 

Treating Pulmonary Metastases

Although lung metastasis can be a discouraging diagnosis to receive, the specialists at BMC are often able to improve survival and a patient’s comfort level via resection or removal. When the lungs are the only site of spread and the number of tumor nodules is small, cure is still possible in many instances.

It is important to preserve as much of the lung as possible, while removing any growths—and BMC’s skilled surgeons are able to do just that.

Wedge Resection

Also known as segmentectomy, this treatment for early-stage cancer removes an area of lung smaller than a lobe—usually the tumor and a small area of healthy lung tissue around it.

Lobectomy

The removal of a lobe, this operation is usually effective at taking out all the cancerous tissue and decreasing the chance of cancer coming back. BMC was the first hospital in New England to perform robotic lobectomies, which require only small incisions. Robotic surgery is less painful and offers faster recovery times than more standard operations for lung cancer.

Chemotherapy

Chemotherapy is a medication or combination of medications used to treat cancer. Chemotherapy can be given orally (as a pill) or injected intravenously (IV). When chemotherapy drugs enter the bloodstream, they destroy cancer cells. Chemotherapy is particularly useful for cancers that have metastasized, or spread. Chemotherapy attacks all quickly-dividing cells, regardless of whether they are cancerous which can cause a number of side effects, including hair loss, mouth sores, loss of appetite, nausea and vomiting, diarrhea, and low blood counts. Low blood counts can increase a patient’s risk of infection, bruising or bleeding, fatigue, and shortness of breath. The side effects of chemotherapy are generally temporary and often go away once treatment is completed. Chemotherapy regimens vary from patient to patient. They are generally repeated several times in cycles, with three to four weeks separating each cycle to allow damaged normal cells time to recover. After the first two or three sessions of chemotherapy, patients may have a CT or PET scan to see if the drug(s) is effective. If the drug(s) is not working, it may be switched out for a new drug(s).

Radiation Therapy

Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Radiation (also called radiotherapy, irradiation, or x-ray therapy) can be delivered internally through seed implantation or externally using linear accelerators (called external beam radiotherapy, or EBRT). Radiation may be used as a solitary treatment or with surgery and/or chemotherapy. The equipment used to deliver the radiation therapy is called a linear accelerator. The linear accelerator has a moveable arm, which enables the radiation to be focused on the part of your body where the cancer is located. Developments in EBRT equipment have enabled physicians to offer conformal radiation. With conformal radiation, computer software uses imaging scans to map the cancer three-dimensionally. The radiation beams are then shaped to conform, or match, the shape of the tumor.

Radiation works by breaking a portion of the DNA of a cancer cell, which prevents it from dividing and growing. Radiation therapy can be systemic, meaning it moves throughout your bloodstream. Systemic therapies are usually given as an injection into a blood vessel or are taken as a pill. Systemic treatments expose your entire body to cancer-fighting medication. Radiation therapy is typically given as a "local" treatment however, meaning it affects only the part of the body that needs therapy.

Microwave Ablation

Microwave ablation is a cancer treatment in which microwave energy is sent through a narrow, microwave antenna that has been placed inside a tumor. The microwave energy creates heat, which destroys the diseased cells and tissue. It is a newer method of treating lung cancer that can target and kill cancerous cells and relieve pain.

Radiofrequency Ablation for Cancer

Radiofrequency ablation (RFA) is a cancer treatment in which radiofrequency energy—derived from electric and magnetic energy—is sent by means of a narrow probe that is placed in the center of a lung tumor. Surgical incisions are not required, and the probes are placed into tumors using CT scan to guide the physician. RFA is a newer method of treating lung cancer, as well as cancers of the liver, kidney, and bone. RFA can target and kill cancerous cells sparing healthy tissues that are close to the cancer. Systemic treatments such as chemotherapy and certain types of radiation are absorbed into both healthy and diseased tissue, whereas RFA is delivered directly into a tumor.

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