Introduction to Lung Cancer - Diagnosis and Staging

In the video below, Thoracic Surgeon, Dr. Jed Gorden provides an introduction to the diagnosis and staging of lung cancer.

Diagnosis and Testing

If an abnormality is found on any chest x-ray, it is important to confirm if cancer is indeed present or if it is possibly another condition, such as an infection. Various tests and procedures may be used to facilitate a diagnosis.

X-rays of the chest (from the back and side) are typically the first test used for patients suspected of having lung cancer. If there is a suspicious finding on the x-rays, patients are then usually asked to get a CT scan.

CT scans show the anatomy of any masses, or tumors, in the lung and chest. If the tumor is malignant, CT scans also help determine if the cancer has metastasized, or spread, to lymph nodes or other organs.

Although imaging technology is one tool in determining if lung cancer is present, the only way to know for certain is to remove and test samples of cells or tissue. This is called a biopsy. Rarely, some patients may need to have surgery to explore the chest area in order to obtain a biopsy. The most important aspect of diagnosis is to obtain adequate tissue from the most appropriate location in the least invasive way possible.

One or more of the following procedures may be used for biopsy. Your thoracic surgeon or interventional pulmonary specialist is often asked to review radiology images and is often asked to recommend the best option based on a patient's specific case. Different tools and technologies are used to sample tissue from different areas of the chest depending on what is most appropriate.

  • Bronchoscopy: A bronchoscope is a viewing instrument inserted through the nose or mouth and into the trachea and bronchial tubes. A bronchoscope is a long flexible instrument with a video camera on the tip which allows your physician to view the large central airway passages leading to the lungs. Flexible video bronchoscopy allows your physician to inspect the central airways look for abnormalities, take biopsy sample and take photographs to communicate information to other members of the team.
  • Endobronchial Ultrasound Bronchoscope (EBUS): EBUS couples two technologies together: traditional bronchoscopy and ultrasound, to allow the operator to see through the airway wall and identify structures like lymph nodes or blood vessels. The use of ultrasound allows the operator to biopsy a lymph node or mass next to the airway under direct vision to safely and accurately obtain tissue for a diagnosis. EBUS is a minimally invasive tool that allows the patient's team to safely and accurately get tissue.
  • Navigation Bronchoscope: When the mass is not in the airway or next to the airway but rather in the lung itself, the patient's team can use navigation bronchoscopy as a minimally invasive tool to navigate to the central or peripheral lung. A mass in the lung is often like trying to find a specific leaf on a tree, and the operator has to find the specific branches that lead to the specific leaf to sample accurately.  
  • Video Mediastinoscopy: An incision is made by a surgeon at the top of the breastbone. A viewing instrument is used to examine inside the chest, and obtain lymph-node samples to accurately stage the patient’s cancer, if lung cancer is present.
  • Transthoracic Needle Aspiration: A needle is inserted through the chest to remove a sample of tissue from the tumor. The operator for this technique uses the CT scanner to guide the needle to the lung mass and obtain a tissue sample. This tissue is examined under the microscope for cancer cells. The physician may use a CT scan or other imaging technique to help guide the needle into the tumor.
  • Sputum cytology: This is an examination of the mucus, or sputum, that may be coughed up from the lungs.
  • Thoracentesis: The two linings around the lung are often compared to a double lining of plastic bags around your groceries. In certain cases fluid builds up between the two linings and pushes on the lung, creating a pocket of fluid. The specialist uses an ultrasound machine to find a safe place to sample the fluid. The skin is numbed with medication, and a small tube is inserted into the fluid which is drained and sent to be evaluated.
  • Thoracoscopy: A surgeon makes small incisions in the chest and back to examine the lungs with a viewing instrument. The surgeon can biopsy any abnormal areas, including masses and/or lymph nodes, as well as obtain pleural fluid if present for analysis.
  • Thoracotomy: The chest is opened by a surgeon with an incision. Lymph nodes and other tissue are examined and may be removed.

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