Most patients are referred to Dana-Farber Brigham Cancer Center by their general practitioner or another doctor because of symptoms or an abnormal chest X-ray. Some patients have already undergone diagnostic testing prior to coming to Dana-Farber Brigham Cancer Center, while others come for a second opinion, or to seek more treatment options than may be available elsewhere.
A surgeon or medical oncologist will coordinate with a multidisciplinary team to determine which tests are necessary to diagnose and analyze your condition. The process of diagnosis may include a number of different procedures, including imaging and biopsy.
All diagnostic scans are performed using a low-dose technique to minimize radiation exposure.
Typically, patients have already had a chest X-ray before coming to Dana-Farber Brigham Cancer Center. That test may be repeated, or existing films may be viewed. In addition to an X-ray, your physician may recommend additional imaging. We use state-of-the-art imaging techniques, including:
- Multidetector CT (Computerized Tomography) scan: A CT scan is often used as a follow-up to an X-ray, to provide more detailed images of your lungs and surrounding organs.
- MRI (Magnetic Resonance Imaging): The MRI allows physicians to look for any invasion of a tumor into your chest wall, diaphragm, or other areas.
- PET CT (Positron Emission Tomography): The PET CT visualizes metabolic activity throughout the body from neck to thighs, and provides a clearer picture of what type of cells might be growing.
Biopsy involves sampling a piece of tissue from a node or tumor for examination. In the case of non-small cell lung cancer, pathologists specializing in thoracic conditions conduct multiple tests on your tissue sample to determine not only the type and stage of the cancer, but also the genetic signature of the tumor. Sometimes, a biopsy is conducted without surgery; at other times, surgery is the best way to obtain a useful tissue specimen. A biopsy may be conducted using one of the following procedures:
- Fine and core needle biopsies of the lung: A sample of tissue or fluid from the lung is obtained using a fine needle. CT or ultrasound imaging is used for exact guidance. A sample is taken with the needle and evaluated by a pathologist while the patient is in the CT suite to ensure there is adequate diagnostic tissue. The entire sample is then sent to cytology for definitive evaluation to identify the presence and type of cancer cells; if present, the cells will undergo further analysis for genetic abnormalities.
- Bronchoscopy: A procedure to look inside the trachea and large airways in the lung for abnormal areas. A bronchoscope is inserted through the nose or mouth into the trachea and lungs. A bronchoscope is a thin, tube-like instrument with a light and a lens for viewing. It also has a tool to remove tissue samples, which are visualized under microscope for presence of cancer. Learn more about bronchoscopy.
- EBUS: Endobronchial ultrasound is a new technique that combines bronchoscopy with an ultrasound. This enables clinicians to visualize lymph nodes with high sensitivity, and allows a biopsy without an incision.
- Navigational bronchoscopy: This new procedure creates a GPS-type guidance system combined with a bronchoscope to biopsy deeper and smaller spots in the lung.
- Surgery: Depending on the location of your node or tumor, it may be necessary to surgically remove a small piece of tumor through a more complicated surgery. In some cases, it is possible to remove a sample, analyze it, and continue with appropriate surgery, all within minutes.
Diagnosis and Staging
Diagnosis begins with determining whether a node or lump is cancer. Your clinicians will work with the thoracic pathologist to establish the type of cancer, its stage, and its genetic signature.
At Dana-Farber Brigham Cancer Center, expert pathologists who specialize in analysis of lung tissues work with medical oncologists to determine whether individual patients can benefit from new and targeted therapies based on the genetic mutations in the tumor.
What type of cancer?
The most common types of non-small cell lung cancer are:
- Adenocarcinoma: Cancer that begins in the cells that line the alveoli.
- Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that look like fish scales.
- Large cell carcinoma: Cancer that may begin in several types of large cells other than adenocarcinoma or squamous cell carcinoma.
Other less common types of lung cancer are: small cell lung cancer, pleomorphic carcinoma, neuroendocrine carcinomas, salivary gland carcinoma, and unclassified carcinoma.
Staging Lung Cancer
When a clinician "stages" cancer, he or she is determining its size, its extent, and to what degree it has spread (metastasized) outside its initial location. Cancer stages range from stage 1 (very early and often curable with a single type of treatment) to stage 4 (advanced, metastasized, and more complex to treat).
In stage 1, cancer has formed, but is confined to the lung.
In stage 2, cancer has spread to lymph nodes or airways at the root of the lung, or to linings surrounding the lung.
In stage 3, cancer has spread to lymph nodes in the middle of the chest or above the collarbones and/or invaded adjacent organs and structures.
In stage 4, cancer has spread beyond the lung and surrounding structures to the other lung, and/or to one or more other parts of the body.