Lung Cancer Diagnosis

About Lung Cancer

Penn Medicine's Abramson Cancer Center and the Abramson Cancer Center at Pennsylvania Hospital offer hope to patients facing lung cancer. Early and accurate diagnosis and the full range of treatment options available at Penn give patients with lung cancer the best chance of being cured.

Penn's Lung Cancer Program features a comprehensive team of thoracic surgeons, pulmonologists, nurses, respiratory therapists, rehabilitation specialists, medical oncologists, radiation oncologists, and pathologists. Each provides comprehensive expertise in treating lung cancer. These specialists incorporate surgery, radiation, chemotherapy and immunotherapy to deliver integrated medicine for complex management of lung cancer.

In addition, Penn researchers are on the forefront of testing new surgical procedures, applying new drug therapies and developing the protocols for proton therapy and other radiation therapies that incorporate cutting edge technology and are changing the way lung cancer is treated.

Read more About Lung Cancer

Lung Cancer Diagnosis

Penn Medicine's Lung Cancer Program at the Abramson Cancer Center offers hope to patients facing lung cancer. The early and accurate diagnosis and full range of immediate options available at Penn give patients with lung cancer the best chance of being cured.

Early diagnosis of lung cancer can be difficult. The early stages of lung cancer do not usually produce any symptoms, so only a small number of lung cancers are found early. When lung cancer is found early, it is often because of tests that were being done for something else.


Lung Cancer Screening

Screening is the use of tests or exams to find a disease like cancer in people who don't have any symptoms. Because lung cancer often spreads beyond the lungs before it causes symptoms, a screening test that finds lung cancer early could save many lives.

In the past, no lung cancer screening test had been shown to lower the risk of dying from this disease. Studies involving spiral CT (or helical CT) have shown some promise in finding early lung cancers in heavy smokers and former smokers. So far, major medical groups have not recommended routine screening tests for all people or even for people at increased risk, such as smokers.

People who smoke, who smoked in the past, or who have been exposed to secondhand smoke, as well as those who have worked around materials that increase the risk for lung cancer need to be aware of their lung cancer risk. They should talk to their doctors about their chances of getting lung cancer and the pros and cons of lung cancer screening.

For those who decide in favor of testing, the physicians in Penn Medicine's Lung Cancer Program are experienced in lung scanning and the latest screening techniques for people at high risk.

Lung Cancer Diagnostic Tools

If patients have any signs or symptoms that suggest they might have a lung tumor, their physician takes a complete medical history, including family history, and checks for symptoms and possible risk factors.

A physical exam provides information about general health, possible signs of lung cancer and other health problems. During the physical exam the doctor pays close attention to the chest and lungs.

If symptoms and/or the results of the physical exam suggest a lung tumor might be present, imaging tests, lab tests and other procedures may be performed to confirm the diagnosis.

Imaging Tests

There are a number of different tests that take pictures of the chest and lungs. Some of these are used to find lung cancer, to see if it has spread, to find out whether treatment is working, or to spot a cancer that has come back after treatment.

  • Chest X-ray: Often the first test performed to look for any spots on the lungs is a traditional X-ray of the chest. If anything on the X-ray looks abnormal, the doctor may order more tests.
  • CT scan (computed tomography): A CT scan uses X-rays to produce detailed cross-sectional pictures of your body. The CT scanner takes many pictures as it moves around the body, and a computer combines these pictures into a detailed picture of a slice of the body. A CT scan can provide exact information about the size, shape and location of a tumor. It can also help find swollen lymph nodes that might contain cancer. CT scans are also used to find tumors in other organs that might be the spread of lung cancer. A CT scan can be used to:
    • Spot very small lung tumors and help determine the exact location and extent of the tumors.
    • Stage cancer (determining the extent of its spread). For example, CT scans of the abdomen can show if the cancer has spread to the liver or other organs. This can help to determine if surgery is a good treatment option.
    • Guide a biopsy needle precisely into a suspected tumor or metastasis.
  • Spiral CT: Studies involving spiral CT (or helical CT) have shown some promise in finding early lung cancers in heavy smokers and former smokers. Spiral CT gives rotates around the body as the patient passes through the scanner. It provides more detailed pictures than a chest X-ray and is better at finding small changes in the lungs. The National Lung Screening Trial (NLST) is a large study that compared spiral CT scans to chest X-rays in people at high risk of lung cancer to see if these scans could help lower the risk of dying from lung cancer. People in the study were current or former heavy smokers between the ages of 55 and 74, who were followed for several years. Early results from the study, announced in November 2010, found that people who received spiral CT had a 20 percent lower chance of dying from lung cancer than those who got chest X-rays.
  • MRI scan (magnetic resonance imaging): Like CT scans, MRI scans give detailed pictures of soft tissues in the body. MRI scans use radio waves and strong magnets instead of X-rays. MRI scans take longer than X-rays, but are useful in finding lung cancer that has spread to the brain or spinal cord.
  • PET scan (positron emission tomography) and PET/CT scan: For a PET scan, a form of radioactive sugar is injected into the blood. Cancer cells in the body take in large amounts of the sugar and a special camera takes images of the radioactivity. This test is useful for seeing if the cancer has spread to the lymph nodes or other parts of the body. It is also helpful in telling whether a spot on a chest X-ray is cancerous. Radiologists at Penn combine PET and CT scan to even better pinpoint tumors.

Blood and Tissue Tests

At Penn, pathologists look at cells under a microscope to determine if they are cancerous.

  • Sputum cytology: A sample of mucus, or phlegm, is looked at under a microscope to see if cancer cells are present.
  • Fine needle biopsy (FNA): A long, thin needle is put into the place in the lung that might be cancer to remove a sample of cells. The sample is looked at in the lab to see whether there are cancer cells. An FNA biopsy may also be done to take samples of lymph nodes around the trachea and the bronchial tubes. If the results are unclear, a larger needle may be used to remove a slightly bigger piece of lung tissue. This is known as a core needle biopsy.
  • Bronchoscopy: A lighted, flexible tube called a bronchoscope is passed through the mouth or nose and into the larger airways of the lungs. This scope can help physicians see tumors, or it can be used to take samples of tissue or fluids to determine if cancer cells are present.
  • Endobronchial ultrasound: A bronchoscope fitted with an ultrasound device at its tip is passed down into the windpipe to look at nearby lymph nodes and other structures in the chest. A hollow needle can be passed through the bronchoscope and guided by ultrasound to take biopsy samples.
  • Endoscopic esophageal ultrasound (EUS): This test is much like an endobronchial ultrasound, except an endoscope is passed down the throat and into the esophagus. Ultrasound images taken from inside the esophagus can help find large lymph nodes inside the chest that might contain lung cancer, and a hollow needle can be passed through the endoscope to get biopsy samples of them.
  • Mediastinoscopy and mediastinotomy: Both of these tests are performed in an operating room. They allow the doctor can look at and take samples of the structures in the area between the lungs, called the mediastinum.
  • Thoracentesis: A hollow needle is placed between the ribs to drain fluid from the chest to check for cancer cells.
  • Thoracoscopy: A thin, lighted tube connected to a video camera and screen is inserted into the chest to look at the space between the lungs and the chest wall. By doing this, the doctor can see any cancer deposits on the lung or the lining of the chest wall and take out small pieces of tissue to be looked at under the microscope. Thoracoscopy can also be used to sample lymph nodes and fluid and to tell whether a tumor is growing into nearby tissues or organs.
  • Bone marrow aspiration and biopsy: These two tests are usually done at the same time. A thin, hollow needle is inserted into the hip bone to remove a small amount of fluid from the marrow. A larger needle is then used to remove a small piece of the hip bone and some marrow. Both samples are checked for cancer cells. This is done mostly to help find if small cell lung cancer has spread to the bones.
  • Blood and urine tests: Blood and urine tests are not used to find lung cancer, but they are done to get a sense of a person's overall health. Because carcinoid tumors can secrete hormone-like chemicals into the blood, a tumor can sometimes be detected by simple blood or urine tests.

Pulmonary Function Test

Pulmonary function tests (PFTs) are often done after lung cancer has been found. These tests show how well the lungs are working. PFTs can give the surgeon an idea of how much lung can be removed or whether surgery is a good option at all.

Biopsy

Even if imaging tests such as a chest X-ray or CT scan find a mass, it is often hard for doctors to tell if the mass is a carcinoid tumor, another type of lung cancer, or an area of infection. In many cases, the only way to know for sure is to perform a biopsy, in which cells from the tumor are removed and examined under a microscope.

  • Bronchoscopic biopsy: A long, thin, flexible, fiber-optic tube is inserted through the windpipe, and into the lungs to look at the lining of the lung's main airways. A small sample of cells can be removed through the tube. No surgical incision or hospital stay is needed, and patients are ready to return home within hours.
  • Endobronchial ultrasonography (EBUS): If a CT scan shows enlarged lymph nodes on either side of the trachea or in the area just below where the trachea divides, this minimally invasive approach can be used. EBUS uses a special bronchoscope that has a small balloon on the end. This balloon gives off sound waves and collects information about the waves that bounce back. Under ultrasound guidance, a needle is inserted into the lymph nodes and cells removed to be examined under the microscope.
  • Needle biopsy: Tumors away from the large airways are often sampled by needle biopsy. A long, hollow needle is passed between the ribs and into the lung. CT scan images are used to guide the needle into the tumor so that a small sample can be removed and looked at under the microscope. This procedure is also done without a surgical incision or overnight hospital stay.
  • Surgical biopsy: In some cases, bronchoscopic biopsy or needle biopsy don't remove enough tissue to identify the type of tumor, so a surgical biopsy is performed. Different types of operations may be used, including:
    • Thoracotomy: An incision is made in the chest wall between the ribs to get to the lungs and to the space between the lungs and the chest wall. If doctors strongly suspect a carcinoid or some other type of lung cancer they may do a thoracotomy and remove the entire tumor without first doing a biopsy.
    • Thoracoscopy: This procedure is less invasive than a thoracotomy and is also used to look at the space between the lungs and the chest wall. In the operating room, doctors insert a thin, lighted scope with a small video camera on the end through a small cut made in the chest wall to look at the space between the lungs and the chest wall. Using the scope, the doctors can see potential areas of cancer and remove small pieces of tissue to look at under the microscope.
    • Mediastinoscopy: If imaging tests such as a CT scan suggest that the cancer may have spread to the lymph nodes between the lungs, a small cut is made in the front of the neck above the breastbone (sternum) and a thin, hollow, lighted tube is inserted behind the sternum. Special instruments can be passed through this tube to take tissue samples from the lymph nodes along the windpipe and the major bronchial tube areas.

Staging Lung Cancer

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the stage of mesothelioma, so staging may not be complete until all the tests are finished.

The stage of a cancer does not change over time, even if the cancer progresses. A cancer that comes back or spreads is still referred to by the stage it was given when it was first found and diagnosed, only information about the current extent of the cancer is added. A person keeps the same diagnosis stage, but more information is added to the diagnosis to explain the current disease status.

Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's chance of recovery.

The TNM Staging System

The system used to describe the growth and spread of non-small cell lung cancer is the American Joint Committee on Cancer (AJCC) TNM staging system. The TNM system is based on three key pieces of information:

  • T indicates the size of the main (primary) tumor and whether it has grown into nearby areas.
  • N describes the spread of cancer to nearby (regional) lymph nodes. Cancer often spreads to the lymph nodes before going to other parts of the body.
  • M indicates whether the cancer has spread or metastasized to other organs of the body. (The most common sites are the brain, bones, adrenal glands, liver, kidneys, and the other lung.)

Numbers or letters appear after T, N, and M to provide more details about each of these factors. The numbers zero through four indicate increasing severity, and X means the information is not available.

The TNM staging system is complex and can be difficult to understand. Patients and their families are encouraged to ask the care team for an explanation of their cancer staging.

Stage Grouping

Once the T, N, and M categories have been assigned, this information is combined to assign an overall stage grouping. The staging diagnosis depends on the type of cancer and the staging system the doctor is using, but in general there are four stages of lung cancer:

  • Stage I: The tumor is localized, meaning it is restricted to the area where it originated.
  • Stage II: The tumor has spread or metastasized to lymph nodes in the chest.
  • Stage III: The tumor has metastasized into the chest wall, mediastinum (area of the chest between the lungs), heart, diaphragm, or abdominal lining.
  • Stage IV: The tumor has metastasized to distant organs or tissues.

Some stages are subdivided into A and B. The stages identify cancers that have a similar prognosis and thus are treated in a similar way. Patients with lower stage numbers tend to have a better prognosis.

Limited and Extensive Stage for Small Cell Lung Cancer

For treatment purposes, some doctors prefer the two-stage system that divides small cell lung cancers into limited stage and extensive stage.

  • Limitedstage usually means that the cancer is only in one lung and perhaps lymph nodes on the same side of the chest. The cancer is typically confined to an area that is small enough to be treated with radiation therapy.
  • Extensive stage is used to describe cancers that have spread to the other lung, to lymph nodes on the other side of the chest, or to distant organs. Many doctors consider small cell lung cancer that has spread to the fluid around the lung to be extensive stage as well. About two out of three people with small cell lung cancer have extensive disease when their cancer is first found.

Small cell lung cancer is often staged in this way because it helps separate patients who may be able to get local treatments such as surgery and/or radiation therapy to try to cure the cancer (limited stage) from those for whom these treatments aren't likely to be helpful (extensive stage).

Treating Lung Cancer at Penn

The lung cancer specialists at Penn Medicine develop personalized treatment plans designed to give every patient the best possible outcome. Like all of programs at Penn's Abramson Cancer Center, the lung cancer program is focused on patient-centered care and meeting the unique needs of every patient and family.

Treatment options for lung cancer include surgery, radiation therapy and systemic treatment including both chemotherapy and targeted agents, as well as combined approaches utilizing a combination of some or all of these therapies have shown promise in extending survival of some patients with early disease.

Penn's treatment options for lung cancer include:

Each of these treatment options is explained in detail below.

Read more Treating Lung Cancer at Penn

Lung Cancer Survivorship

There are more than 12 million cancer survivors living today as a result of advances in cancer treatment. However, cancer treatments can result in physical, emotional and financial complications long after the therapy is complete. Survivorship programs at Penn’s Abramson Cancer Center and the Abramson Cancer Center at Pennsylvania Hospital are a distinct phase of lung cancer care and are designed to help patients' transition from their cancer treatment routine to a post-cancer care lifestyle.

Read more Lung Cancer Survivorship


Andrew Vartanian

Immediately after being told by his primary care physician that the Abramson Cancer Center is one of the best cancer institutions in the country, Andrew Vartanian made his first appointment.

Abramson Cancer Center VideoWatch Focus on Lung Cancer Conference - Get information on the latest advances in lung cancer risk, prevention, diagnosis, treatment, symptom management and psychosocial issues.

Abramson Cancer Center VideoMedia Hub for Lung Cancer, Mesothelioma and Related Disorders - Watch Videos!

Abramson Cancer Center Video

Watch Focus on Mesothelioma Conference - Get information on the latest advances in mesothelioma risk, prevention, diagnosis, treatment, symptom management and psychosocial issues.
 


Clinical Trials

Lung Cancer Trials

A Phase 1 Study of the Safety, Tolerability, Pharmacokinetics and Immunoregulatory Activity of... more


myPennMedicine