LUNG CANCER
( By JASCAP )

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Symptoms and Diagnosis of Lung Cancer

Symptoms of Lung Cancer

The symptoms of lung cancer may include any of the following:

  • a continuing cough, or change in a long-standing cough
  • a chest infection that doesn't get better
  • increasing breathlessness
  • coughing up blood-stained phlegm (sputum)
  • a hoarse voice
  • a dull ache, or a sharp pain, when you cough or take a deep breath
  • loss of appetite and loss of weight
  • difficulty swallowing
  • excessive tiredness (fatigue) and lethargy.

If you have any of the above symptoms, it„s important to have them checked by your doctor. All of these symptoms may also be caused by illnesses other than cancer.

Diagnosis of Lung Cancer

Most people begin by seeing their Family doctor when they develop symptoms. Your Family doctor will examine you and arrange for you to have tests or x-rays. Your Family doctor may need to refer you to the hospital for these tests, and for specialist advice and treatment.

At the hospital, the specialist will ask you about your general health and any previous medical problems before examining you. A chest x-ray will be taken to check for any abnormalities in your lungs. You may also be asked to give samples of phlegm (sputum), so that they can be examined under a microscope for cancer cells – this is known as sputum cytology.

The following tests may be used to diagnose cancer of the lung. Your doctor may arrange for you to have one or more of them.

  • CT scan
  • Spiral CT scan
  • Bronchoscopey

CT scan

A CT (computerised tomography) scan takes a series of x-rays which build up a three- dimensional picture of the inside of the body. The scan is painless but takes 10 to 30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.

You will probably be able to go home as soon as the scan is over.

Figure: Having a CT scan

Spiral CT scan

Some hospitals use low-dose spiral CT scans (helical CT scans). A CT scanning machine rotates rapidly around the body, taking more than one hundred pictures in sequence. The scan can detect smaller lung tumours than a conventional CT scan and takes only a few minutes. Spiral CT scans are quite new and you may have to travel to a specialist hospital to have one. They are not always necessary, but you can discuss with your doctor whether one would be useful in your case.

Bronchoscopy

A doctor, or a specially trained nurse, examines the inside of the lung airways and takes samples (biopsies) of the cells. Normally a thin, flexible tube called a bronchoscope is used and the test is carried out under local anaesthetic. Sometimes a rigid bronchoscope is used instead. In this case, a general anaesthetic is given and you may have to stay in hospital overnight. A CT scan will tell the doctors whether a bronchoscopy will be helpful. It will also guide the doctor or nurse to the abnormal area in the lung.

Before your bronchoscopy, you will be asked not to eat or drink anything for a few hours. Just before the test you may be given a mild sedative, to help you relax and to relieve any discomfort. You will be given another medicine which reduces the production of natural fluids in the mouth and throat. This medicine can make your mouth feel dry.

Once you are comfortable, a local anaesthetic will be sprayed onto the back of your throat, making it numb. The bronchoscope is then gently passed into your nose or mouth and down into the lung airways. The doctor or nurse can look through the bronchoscope to check for any abnormalities. Photographs and biopsies can be taken at the same time.

The test may be slightly uncomfortable, but it only takes a few minutes. You shouldn't eat or drink for at least an hour afterwards, because your throat will be numb and you won't know if food and drink is going down the wrong way. As soon as the sedation has worn off you will be able to go home. You shouldn't drive for 24 hours after the test as you may feel sleepy, so you'll need to arrange for someone to collect you from hospital. You may have a sore throat for a couple of days after your test, but this will soon disappear.

Further tests for diagnosis of Lung Cancer

If the first tests suggest that you may have lung cancer, your specialist may want to do some of the further tests described below, to confirm the diagnosis and to see if the cancer has spread to any other part of the body. The results will help your doctor to decide the best type of treatment for you.

  • MRI scan
  • Mediastinoscopy
  • Lung biopsy
  • PET scan
  • Ultrasound scan
  • Isotope bone scan
  • Lung function tests

MRI scan

An MRI (magnetic resonance imaging) scan is similar to a CT scan, but uses magnetic fields instead of x-rays to build up a series of cross-sectional pictures of the body. During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless. The machine is very noisy, but you will be given earplugs or headphones to wear.

The cylinder is a very powerful magnet, so before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or in the metal industry, or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips, or bone pins). You may not be able to have an MRI because of the magnetic fields.

Some people are given an injection of dye into a vein in the arm, but this usually doesn't cause any discomfort. If you feel claustrophobic inside the cylinder, you may be able to take someone into the room to keep you company. It may also help to mention to the staff beforehand if you don't like enclosed spaces. They can then offer extra support during your test.

An MRI scan can often distinguish between different types of body tissue more precisely than a CT scan, so in some situations it will give extra information.

Mediastinoscopy

In this test, the doctor examines the area at the centre of your chest (mediastinum), and the lymph nodes closest to the lungs. These are often the first places that lung cancer spreads to, and so are usually checked for signs of cancer. The test is done under a general anaesthetic and will mean a short stay in hospital.

A small cut is made in the skin at the base of your neck, and a tube is passed into the chest. The tube has a light and camera at the end, and can magnify the areas it looks at. The doctor can see any abnormal areas, and may also take samples of the cells and lymph nodes to examine under a microscope.

A similar test, known as a thoracoscopy, involves making a small cut in the skin and inserting a similar tube into another part of your chest, to look directly at the cancer and take samples from it.

Lung biopsy

This test is usually done in the x-ray department, most commonly during a CT scan. A local anaesthetic is used to numb the area. You will then be asked to hold your breath while a thin needle is passed through the skin and into the lung. An x-ray is used to make sure that the needle is in the right place. The doctors will then take a sample of cells to be examined under a microscope. The biopsy is sometimes slightly uncomfortable, but it only takes a few minutes.

After a lung biopsy, a small number of people may develop air between the layers that cover the lungs. This is known as a pneumothorax. Symptoms of a pneumothorax include sharp chest pain, breathlessness and a tight chest. You may be asked to remain in hospital for a few hours after your biopsy, to make sure that you have not got a pneumothorax. Let your doctor or nurse know if you develop any symptoms.

PET scan

A PET (positron emission tomography) scan uses low-dose radioactive glucose (a type of sugar) to measure the activity of cells in different parts of the body. A very small amount of this mildly radioactive substance is injected into a vein, usually in your arm. A scan is then taken a couple of hours later. Areas of cancer usually absorb more of the sugar than surrounding tissue and so show up on the scan.

PET scans may be used before surgery as they can give accurate information about the size of the cancer in the lung and whether a cancer has spread beyond the lungs. They can also be used to examine any lumps that remain after treatment to see whether they are scar tissue or whether cancer cells are still present. PET scans are a new type of scan and you may have to travel to a specialist centre to have one. They are not always necessary but you can discuss with your doctor whether one would be useful in your case.

Ultrasound scan

Ultrasound uses sound waves to look at the liver and the other organs in the upper part of the abdomen. It is the same sort of scan that pregnant women have.

Once you are lying comfortably on your back, a gel is spread on to the area to be scanned.

A small device that produces sound waves is passed over the area and the sound waves are converted into a picture by computer. The test only takes a few minutes.

Isotope bone scan

This is more sensitive than an x-ray, and shows up any abnormal areas of bone more clearly. However, it is not always clear whether an abnormality is caused by cancer or other conditions such as arthritis.

A small amount of a mildly radioactive substance is injected into a vein, usually in your arm. Abnormal bone absorbs more radioactivity than normal bone, so these areas are highlighted and picked up by the scanner as „hot spots'. There is generally a wait of 2–3 hours between having the injection and the scan taking place, so you may like to take a magazine or book to pass the time. The level of radioactivity used in the scan is very small and doesn't cause any harm.

Lung function tests

If your doctor wants to remove the lung cancer using surgery, or is planning for you to have a course of radiotherapy, they may first ask you to have breathing tests to see how well your lungs are working.

It will probably take several days for the results of your tests to be ready, and this waiting period will obviously be an anxious time for you. It may help to talk things over with a close friend or relative.

Staging of lung cancer

The stage of a cancer is a term used to describe its size, position and whether it has spread beyond where it started in the body. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment.

Generally cancer is divided into four stages:

Stage 1 small and localised

Stages 2 or 3 has spread into surrounding structures

Stage 4 has spread to other parts of the body.

If the cancer has spread to distant parts of the body, this is known as secondary or metastatic cancer.

The staging is different for small cell and for non-small cell lung cancers.

Staging for Small cell lung cancer

Small cell lung cancers are divided into just two stages. This is because small cell lung cancer often spreads outside the lung quite early on. Even if the doctor can't see any spread of the cancer on your scans, it's likely that some cancer cells will have broken away and travelled through the bloodstream or lymph system.

To be safe, small cell lung cancers are usually treated as though they have spread, whether any secondary cancer can be seen or not.

The two stages of small cell lung cancers are:

Limited disease – the cancer cells can be seen only in one lung, in nearby lymph nodes, or in fluid around the lung (known as a pleural effusion).

Extensive disease – it is clear that the cancer has spread outside the lung, within the chest area or to other parts of the body.

Staging for Non-small cell lung cancer

Non-small cell lung cancer is usually divided into four stages.

Stage 1 cancer is localised and has not spread to the lymph nodes. This stage is further divided in two:

Stage 1A The cancer is no bigger than 3cm in size.
Stage 1B The cancer is larger than 3cm, or growing into the main airway of the lung (bronchus). The cancer may also have spread to the membrane covering the lung (pleura), or made the lung partially collapse.

Stage 2 for non-small cell lung cancer is also divided in two:

Stage 2A The cancer is small and measures 3cm or less in size and affects nearby lymph nodes.

Stage 2B Either the cancer is larger than 3cm and in the nearby lymph nodes, or there is no cancer in the lymph nodes, but the tumour has made the whole lung collapse; or it has grown into the chest wall, the membrane covering the lung (pleura), the muscle layer below the lungs (diaphragm), or the covering of the heart (pericardium).

Stage 3 for non-small cell lung cancer is also divided in two:

Stage 3A The cancer is of any size and has spread into the lymph nodes in the middle of the chest (mediastinum), but not to the other side of the chest. or, the cancer has spread into tissue around the lung near to where the cancer started. This can be into:

the chest wall
the covering of the lung (pleura)
the middle of the chest (mediastinum) or other lymph nodes close to the affected lung.

Stage 3B The cancer has spread

to lymph nodes on either side of the chest or above either collar bone
to another major structure such as the gullet (oesophagus), the heart, windpipe (trachea) or to a main blood vessel.

or there may be

two or more tumours in the same lung
a collection of fluid containing cancer cells around the lung (pleural effusion).

Stage 4 lung cancer has spread to a distant part of the body, such as the liver, bones or the brain.

Revised Lung Cancer Staging System

Introduction to the revised system

There are different systems for staging lung cancer. This page is about an updated version of the most widely used system (introduced in 2009). This new system will help doctors to plan the best treatment for people with lung cancer. It can also help to give an idea of the likely outcome of treatment. It can be used for both of the main types of primary lung cancer: small cell and non-small cell.

If you've already been told the stage of your lung cancer it might help to check with your doctors whether they've used the new system or the previous one.

The TNM system

The TNM staging system is used worldwide. It can be used for different types of cancer.

  • T refers to the size of the primary tumour – where the cancer first starts in the body
  • N refers to which lymph nodes are affected, if any
  • M refers to metastatic disease – the cancer has spread to other parts of the body.

Different sorts of cancer behave differently, so the TNM staging system varies slightly from one type of cancer to another. Numbers and letters may be added after the T, N and M to describe in more detail the exact size and extent of the cancer. For example, T (tumour) is usually numbered from one to four.

The new TNM system for lung cancer is quite complicated. Don't worry if it doesn't make sense straight away or if you have to re-read it a few times. Your doctors can help you to understand what it might mean for you.

The TNM system for lung cancer has been revised so that the size of tumour of lung cancer in different TNM staging system is:

      • T1a: The cancer measures 2cm or less across.
      • T1b: The cancer measures between 2 and 3cm across.

      • T2a: The cancer measures between 3 and 5cm across.
      • T2b: The cancer measures between 5 and 7cm across.

      Note: Any T2 tumour may also affect the main airway (bronchus), or the membrane covering the lung (pleura), or the lung may be partially collapsed.

      • T3: The tumour measures over 7cm
        or the tumour has spread to: the chest wall, or the muscle separating the chest and the abdomen (diaphragm), or the covering membrane in the middle of the chest (mediastinal pleura), or the phrenic nerve, or the outer covering of the heart (pericardium), or the main airway (bronchus)
        or the lung has completely collapsed
        or there are two or more tumours in the same lobe of the lung.

      • T4: The tumour is any size that has spread to the central area of the chest (mediastinum), the heart, a major blood vessel, the windpipe (trachea), the nerve which controls the voice box, the gullet (oesophagus), a spinal bone, or the main bronchus where it divides.

Lymph nodes (See Figure above: "The lungs and surrounding structure”)

  • N0: There is no cancer in the lymph nodes.
  • N1: There are cancer cells in the nearby lymph nodes in the same side of the chest as the cancer.
  • N2: There are cancer cells in lymph nodes in the centre of the chest (still on the same side) or in the nodes under where the windpipe (trachea) divides into the left and right bronchus.
  • N3: There are cancer cells in lymph nodes on the opposite side of the chest or the nodes at the top of the lungs or by the collar bone.

Metastases

  • M0: The cancer hasn't spread to anywhere else in the body.
  • M1: The cancer has spread to the opposite lung; the person has fluid around the lungs (malignant pleural effusion) or heart (malignant pericardial effusion). which contains cancer cells (M1a) or the cancer has spread to other parts of the body (M1b).

The number system

The T, N and M stages are often grouped together to make a number stage. So a cancer may also be given a stage from Stage 1 to Stage 4. These stages may also have letters to describe the stage more accurately. Different combinations of T, N and M make up the different stages and the same stage may have more than one description.

The new lung cancer stages, in the Revised Lung Cancer Staging System are:

StageTumourLymph nodesMetastases
Stage 1AT1a or T1bN0M0
Stage 1BT2aN0M0
Stage 2AT1a or T1b or T2aN1M0
T2bN0M0
Stage 2BT2bN1M0
T3N0M0
Stage 3AAny T between T1a and T3N2M0
T3N1M0
T4N0 or N1M0
Stage 3BT4N2M0
Any T between T1a and T4N3M0
Stage 4Any TAny NM1a or M1b

We hope this information has helped you to understand the new lung cancer staging system. Remember, your doctor or any of your healthcare team will be able to answer any questions you may have about your particular situation. You can also talk to one of our cancer support specialists|.

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