Tests and diagnosis - Lung cancer

If a GP refers you to hospital or a rapid access lung clinic because they think you could have lung cancer, you'll have tests to check for cancer.

Tests for lung cancer

Tests to help diagnose lung cancer include:

• chest x-ray
• CT scan
• PET-CT scan
• bronchoscopy

Chest x-ray

Doctors use a chest x-ray to see if there is a mass (abnormal area) in your lungs.

A mass in your lungs does not always mean you have cancer. It can be caused by other conditions, such as an abscess.

If they see anything abnormal, they will refer you for more tests to find the cause.

CT scan

A CT scan is usually the next test you'll have after a chest x-ray.

For example, if:

• a chest x-ray shows you have a mass in your lungs
• you have unexplained symptoms such as coughing up blood

A CT scan uses x-rays and a computer to create detailed images of the inside of your body.

Before having a CT scan, you'll be given an injection containing a special dye called a contrast medium. This helps to improve the quality of the images.

The scan is painless and takes 10 to 30 minutes.

PET-CT scan

If the CT scan shows you have cancer, you may have a PET-CT.

PET-CT stands for positron emission tomography-computerised tomography.

The PET-CT scan can show:

• where there are active cancer cells
• if the cancer has spread to other parts of your body

This can help your doctors with diagnosis and choosing the best treatment.

Before having a PET-CT scan:

1. Your doctor will inject you with a slightly radioactive material.
2. They will ask you to lie down on a table.
3. The table slides into the PET scanner.

The scan is painless and takes 30 to 45 minutes.

Bronchoscopy

If a CT scan shows there might be cancer in the central part of your chest, you may be offered bronchoscopy.

A bronchoscopy is a type of endoscopy.

Your doctor can use a bronchoscopy to:

• see the inside of your airways
• remove a small sample of cells that they send to a lab to test for cancer

What to expect

Your doctor will:

1. Pass a thin tube called a bronchoscope through your nose or mouth into your airways.
2. Use small tools at the end of the bronchoscope to take images and remove samples of tissue (biopsy) or fluid (cytology).
3. Send the samples to the lab where they will be checked for cancer cells.

The procedure may be uncomfortable.

You'll be offered:

• a sedative before it starts to help you relax
• a local anaesthetic to make your throat numb - you will be awake but will not feel any pain

The procedure takes 30 to 40 minutes.

Endobronchial ultrasound scan (EBUS)

An endobronchial ultrasound scan (EBUS) uses both a bronchoscopy and an ultrasound scan.

Your doctor can use an EBUS to:

• see the inside of your airways
• remove a small sample of cells they send to a lab to test for cancer

What to expect

They will:

1. Pass a thin tube called a bronchoscope through your nose or mouth into your airways.
2. Use the ultrasound probe on the end of the bronchoscope to find the lymph nodes in the centre of your chest.
3. Take a sample of fluid from them.
4. Send the sample to a lab where they check it for cancer cells.

Lymph nodes are part of a network of vessels and glands that spread throughout the body. They work as part of your immune system.

A sample from a lymph node can show if cancerous cells are growing there and what type they are.

The procedure takes 30 to 45 minutes.

Other biopsy

You may be offered a different type of biopsy.

This may be a type of surgical biopsy, such as:

• thoracoscopy
• mediastinoscopy
• biopsy done using a needle inserted through your skin (percutaneous)

Thoracoscopy

Doctors use a thoracoscopy to check how the lining of your lungs look and take samples.

You will need a general anaesthetic before having a thoracoscopy. This means you will not feel, see or hear anything - it is like being asleep.

Your doctor will:

1. Make two or three small cuts in your chest.
2. Pass a small, flexible tube with a camera on it into your lung.
3. Use this to look inside your chest and take tissue samples.
4. Send the samples to a laboratory for testing to to check them for cancer cells.

After a thoracoscopy, you may need to stay in hospital overnight.

Mediastinoscopy

A mediastinoscopy is a test to:

• examine the area between your lungs at the centre of your chest (mediastinum)
• take samples of cells from your lymph nodes that they send to a lab for testing

Doctors do not do this test often. This test may be done instead of an EBUS.

For this test, you'll need to have a general anaesthetic. This means will not feel, see or hear anything - it is like being asleep. You will need to stay in hospital for a couple of days afterwards.

Percutaneous needle biopsy

A percutaneous needle biopsy is a way to take a sample from your lungs using a needle.

Your doctor will:

1. Use a local anaesthetic to numb your skin - you will be awake but will not feel any pain.
2. Use a CT scanner or ultrasound scanner to guide a needle through your skin into your lung to the site of a suspected tumour.
3. Use the needle to remove a small amount of tissue from a suspected tumour.
4. Send the samples to a lab for testing to to check them for cancer cells.

Risks of lung biopsies

A lung biopsy has a small risk of complications, such as a pneumothorax. This is when air leaks out of a lung and into the space between your lungs and the chest wall.

This can put pressure on your lung, causing it to collapse.

Your treatment team will explain all the risks in detail before you agree to have a biopsy. Afterwards they will check for symptoms of a pneumothorax, such as sudden shortness of breath.

If a pneumothorax does happen, it can be treated. Doctors use a needle or tube to remove the excess air, allowing your lung to expand again.

Lung cancer stages

You test results will show the stage of your cancer. This will help your doctors decide on the best treatment for you.

Non-small-cell lung cancer stages

Doctors use a staging system for lung cancer called TNM. This stands for tumour, node and metastasis. They may use TNM staging to give your cancer a number stage, usually between 1 and 4.

• T describes the size of the tumour (cancerous tissue)
• N describes the spread of the cancer into lymph nodes
• M describes whether the cancer has spread to another area of the body such as the liver (metastasis)

Your team will explain what the stage of your cancer is, and what this means.

Stage 1

Stage 1 lung cancer is also known as early lung cancer or localised lung cancer.

It is when the cancer:

• is less than 4cm in size
• has not spread outside your lung or to lymph nodes

Stages 2 and 3 lung cancer

Stages 2 and 3 lung cancer are both known as locally advanced lung cancer.

If you have stage 2 lung cancer, the cancer:

• can be different sizes
• may have spread to nearby lymph nodes
• may have spread to other parts of the lung, or areas just outside your lung

If you have stage 3 lung cancer, the cancer:

• can be any size
• has usually spread to lymph nodes
• may also have spread to areas further outside your lung but not to other parts of your body

Stage 4 lung cancer

Stage 4 lung cancer is known as metastatic or secondary lung cancer.

If you have stage 4 lung cancer, the cancer can be any size.

It may have spread to lymph nodes, and 1 or more of these:

• your other lung
• the lining of your lung (pleura)
• another part of your body, for example, your liver, bones or brain
  

Small-cell lung cancer stages

Small-cell lung cancer is less common than non-small-cell lung cancer.

Small-cell lung cancer has 2 possible stages:

• limited stage - where cancer cells can be seen in 1 lung and nearby lymph nodes
• extensive stage - where the cancer has spread to the other lung, to lymph nodes that are further away, or to other parts of your body