Lung Cancer Diagnosis
Early stage lung cancer often does not have symptoms. In addition, when symptoms appear they can easily be mistaken for common respiratory illnesses like bronchitis or pneumonia. Because of this, many cases are diagnosed at an advanced stage.
Patients at high risk for lung cancer, especially those with a history of smoking, should undergo regular screenings in order to catch the disease at its early stages, when there is a better chance of cure.
If you have symptoms that signal lung cancer, your doctor will ask you questions about your medical, smoking and family history and whether you have been around certain chemicals or substances.
You will then undergo an imaging exam, typically a chest X-ray. Images cannot diagnose lung cancer, but they can show areas of concern. If the image shows such an area, the doctor may order other scans, including a CT scan or PET scan, for additional details regarding the area of concern.
If the findings on the imaging scans indicate cancer, the doctor will request that tissue or fluid be removed from the lung for examination. The act of obtaining a tissue or fluid sample is called a biopsy. There are several ways doctors can perform biopsies of lung tumors:
- Needle biopsy: A CT-guided biopsy where a needle is inserted through the skin under local anesthesia to acquire a tumor sample. One type of needle biopsy is fine needle aspiration (FNA), which uses a very small needle and suction to remove a small amount of tissue.
- Thoracentesis: Fluid from around the lungs is drawn out with a needle and tested for cancer cells.
- Bronchoscopy: A thin, flexible tube with a tiny camera is inserted through the nose or mouth and down into the lungs to obtain a small tissue sample (biopsy). This is usually performed under mild sedation. Bronchoscopies are rarely done alone. Bronchoscopy is usually performed with an endobronchial ultrasound.
- Endobronchial ultrasound (EBUS): A bronchoscope with an attached ultrasound device is used to check for lung cancer inside nearby chest lymph nodes. EBUS is often performed at the same time as a bronchoscopy and requires general anesthesia.
- Video-assisted thoracoscopic surgery (VATS): This minimally invasive surgical procedure uses a small camera to help retrieve tumor samples that are otherwise difficult to access. VATS requires a general anesthetic and is performed in the operating room by a thoracic surgeon.
- Thorascopy/pleuroscopy: A thin, flexible tube with a tiny camera is inserted through a small incision in the back (for a thorascopy) or between the ribs (for a pleuroscopy). Doctors use this device to look for and retrieve suspected cancer tissue.
To complete assessment of how advanced the cancer is, which is called staging, the patient will undergo a PET-CT scan and an MRI or CT scan to check for signs of cancer spread to other organs, including the brain. This will guide the treatment decisions for each patient’s lung cancer.
In some cases, lung cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Visit our family history site to learn more about genetic counseling and testing.
Lung cancer staging
If you are diagnosed with lung cancer, your doctor will determine the stage (or extent) of the disease. The various stages classify cancer by how far and to which parts of the body it has spread. Staging helps the doctor plan the best treatment for you.
When you’re diagnosed with lung cancer, one of the most important things you’ll learn is your cancer’s stage. Staging is a way of describing the location of a tumor or cancer cells in your body, the tumor’s size and whether the cancer is in one spot or has spread.
That knowledge is crucial, says medical oncologist Natalie Vokes, M.D.
“To identify the best treatment plan for you, your doctor first needs to know your cancer’s stage,” Vokes says. “Staging is so critical, in fact, that you should never begin treatment without it.”
But lung cancer is complex, and different forms of the disease are staged in different ways. We spoke with Vokes to learn more.
How is a lung cancer’s stage determined?
You’ll undergo various tests and procedures to learn your cancer’s stage. These usually include MRIs, CT scans and/or PET scans, and lymph node biopsies. You may also have a lung function test to see how healthy your lungs are.
Your doctor will combine the results of these procedures to stage your cancer, using the TNM classification system. These letters stand for:
- T (tumor) – Describes a tumor’s size and where it’s located
- N (node) – Reveals if the cancer has spread to the lymph nodes
- M (metastasis) – Tells whether the cancer has spread to other organs in the body
Why are lung cancers staged?
Besides helping doctors arrive at your recommended treatment plan, lung cancer staging provides an educated estimate for your prognosis. Although each patient is different, cancers with the same stage tend to have comparable results.
Cancer staging is also used to identify clinical trials that patients may be eligible to join. Clinical trials test new, experimental cancer drugs and treatments for specific stages of cancer. If you’re diagnosed with stage IV lung cancer, for example, you may be eligible for a clinical trial of a drug designed to treat stage IV lung cancer.
What are the primary types of lung cancer?
There are two main kinds of lung cancer: non-small cell lung cancer and small cell lung cancer. They’re named based on the way their cells appear when viewed under a microscope. Non-small cell lung cancer cells appear large and round, whereas small cell lung cancer cells are smaller and oval shaped.
Non-small cell lung cancer is the most common type. It accounts for 85% of cases. This type of cancer develops in the cells that line the lung’s surface. It typically grows at a slower rate than small-cell lung cancer and causes few or no symptoms until it has advanced.
Small cell lung cancer accounts for the remaining 15% of all lung cancers. It typically develops in the bronchi, the two large tubes that carry air from the windpipe to the lungs. It’s usually diagnosed in people with a history of smoking. This type of cancer tends to grow and spread faster than non-small cell lung cancer.
Because non-small cell and small cell lung cancers develop from different types of cells and behave differently, they are staged differently.
What are the stages for non-small cell lung cancer?
The general stages for non-small cell lung cancer range from the occult (earliest) stage to stage IV, the most advanced stage:
- occult stage: Cancer cells are found in the mucus you cough up. This stage is also called hidden cancer, because no tumor is seen on imaging scans or a biopsy.
- stage 0: Cancer cells are found only in the top lining of the lung or bronchus. They haven’t spread deeper into your lung tissues. This stage is also called carcinoma in situ, Latin for “in its place.”
- stage I: A small amount of cancer is in your lung tissues but has not spread to your lymph nodes or other parts of your body.
- stage II: The amount of cancer in your lungs has increased, but it still has not spread to your lymph nodes or distant organs.
- stage III: Cancer has spread to your lymph nodes in the middle of your chest.
- stage IV: Cancer has spread widely around your body. It may have spread to your brain, bones or liver.
Each of these stages are further divided into substages based on tumor size and location.
Small cell lung cancer stages
The staging system for small cell lung cancer is simpler. Doctors classify the cancer into two main categories: limited or extensive.
- Limited stage: Cancer is only in one lung and may have spread to nearby lymph nodes. It can be treated with radiation therapy.
- Extensive stage: The tumor has spread beyond the originally affected lung, either to the opposite lung or to other organs, like the brain. It is typically too widespread to be safely treated with radiation therapy.
Can a person have both types of lung cancer?
Around 5% to 10% of lung cancers are mixed. This means a person has non-small cell and small cell cancers.
Do lung cancer stages change?
Your lung cancer stage typically stays the same as when you’re first diagnosed, no matter what happens with the disease. For example, if you’re diagnosed with stage II lung cancer, that’s what it will be called, whether it spreads or is successfully treated. Occasionally, cancer may be restaged with a new round of tests if it goes away, then comes back. Also, patients who seek a second opinion from MD Anderson after being diagnosed elsewhere may be restaged based on their MD Anderson test results.
Lung cancer is a complex disease
Though lung cancer may at first sound like a simple diagnosis, it’s actually a very complex disease. Knowing the stage of your cancer and the details of your treatment can help reduce your anxiety. Whatever your diagnosis, remember that staging isn’t a crystal ball. Many people who are diagnosed with later stage cancer do well with the right treatment.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Non-small cell lung cancer stages
Source: National Cancer Institute
Occult (hidden) stage
In the occult (hidden) stage, cancer cannot be seen by imaging or bronchoscopy. Cancer cells are found in sputum or bronchial washings (a sample of cells taken from inside the airways that lead to the lungs). Cancer may have spread to other parts of the body.
Stage 0
In stage 0, abnormal cells are found in the lining of the airways. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 may be adenocarcinoma in situ (AIS) or squamous cell carcinoma in situ (SCIS).
Stage I
In stage I, cancer has formed. Stage I is divided into stages IA and IB.
- Stage IA: Stage IA lung cancer. The tumor is in the lung only and is 3 centimeters or smaller. Cancer has not spread to the lymph nodes.
The tumor is in the lung only and is 3 centimeters or smaller. Cancer has not spread to the lymph nodes. - Stage IB: Stage IB lung cancer. The tumor is larger than 3 centimeters but not larger than 4 centimeters. Cancer has not spread to the lymph nodes; OR the tumor is 4 centimeters or smaller. Cancer has not spread to the lymph nodes and one or more of the following is found: (a) cancer has spread to the main bronchus, but has not spread to the carina; and/or (b) cancer has spread to the inner membrane that covers the lung; and/or (c) part of the lung or the whole lung has collapsed or has pneumonitis (inflammation of the lung).
The tumor is larger than 3 centimeters but not larger than 4 centimeters. Cancer has not spread to the lymph nodes.
or
The tumor is 4 centimeters or smaller and one or more of the following is found:
- Cancer has spread to the main bronchus, but has not spread to the carina.
- Cancer has spread to the innermost layer of the membrane that covers the lung.
- Part of the lung or the whole lung has collapsed or has developed pneumonitis.
Cancer has not spread to the lymph nodes.
Stage II
Stage II is divided into stages IIA and IIB.
Stage IIA: The tumor is larger than 4 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes and one or more of the following may be found: (a) cancer has spread to the main bronchus, but has not spread to the carina; and/or (b) cancer has spread to the inner membrane that covers the lung; and/or (c) part of the lung or the whole lung has collapsed or has pneumonitis (inflammation of the lung).
The tumor is larger than 4 centimeters but not larger than 5 centimeters. Cancer has not spread to the lymph nodes and one or more of the following may be found:
- Cancer has spread to the main bronchus, but has not spread to the carina.
- Cancer has spread to the innermost layer of the membrane that covers the lung.
- Part of the lung or the whole lung has collapsed or has developed pneumonitis.
Stage IIB: Stage IIB lung cancer. The primary tumor is 5 centimeters or smaller and cancer has spread to the lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus.
The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following may be found:
- Cancer has spread to the main bronchus, but has not spread to the carina.
- Cancer has spread to the innermost layer of the membrane that covers the lung.
- Part of the lung or the whole lung has collapsed or has developed pneumonitis.
or
Stage IIB lung cancer: Cancer has not spread to lymph nodes and one or more of the following is found: (a) the primary tumor is larger than 5 centimeters but not larger than 7 centimeters; and/or (b) there are one or more separate tumors in the same lobe of the lung as the primary tumor; and/or cancer has spread to any of the following: (c) the chest wall and/or the membrane that lines the inside of the chest wall, (d) the nerve that controls the diaphragm, and/or (e) the outer layer of tissue of the sac around the heart.
Cancer has not spread to the lymph nodes and one or more of the following is found:
- The tumor is larger than 5 centimeters but not larger than 7 centimeters.
- There are one or more separate tumors in the same lobe of the lung as the primary tumor.
- Cancer has spread to any of the following: the membrane that lines the inside of the chest wall; the chest wall, the nerve that controls the diaphragm, outer layer of tissues of teh sac around the heart.
Stage III
Stage III is divided into stages IIIA, IIIB, and IIIC.
Stage IIIA: Stage IIIA lung cancer. The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the trachea or aorta (not shown), or where the trachea divides into the bronchi. Also, one or more of the following may be found: (a) cancer has spread to the main bronchus, but has not spread to the carina; and/or (b) cancer has spread to the inner membrane that covers the lung; and/or (c) part of the lung or the whole lung has collapsed or has pneumonitis (inflammation of the lung).
The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the trachea or aorta, or where the trachea divides into the bronchi. Also, one or more of the following may be found:
- Cancer has spread to the main bronchus, but has not spread to the carina.
- Cancer has spread to the innermost layer of the membrane that covers the lung.
- Part of the lung or the whole lung has collapsed or has developed pneumonitis.
or
Stage IIIA: Cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found: (a) the tumor is larger than 5 centimeters but not larger than 7 centimeters; and/or (b) there are one or more separate tumors in the same lobe of the lung as the primary tumor; and/or cancer has spread to any of the following: (c) the chest wall and/or the membrane that lines the inside of the chest wall, (d) the nerve that controls the diaphragm, and/or (e) the outer layer of tissue of the sac around the heart.
Cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found:
- The tumor is larger than 5 centimeters but not larger than 7 centimeters.
- There are one or more separate tumors in the same lobe of the lung as the primary tumor.
- Cancer has spread to any of the following:
- The membrane that lines the inside of the chest wall.
- Chest wall.
- The nerve that controls the diaphragm.
- Outer layer of tissue of the sac around the heart.
or
Stage IIIA: Cancer may have spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found: (a) the primary tumor is larger than 7 centimeters; and/or (b) there are one or more separate tumors in a different lobe of the lung with the primary tumor; and/or the tumor is any size and cancer has spread to any of the following: (c) trachea, (d) carina, (e) esophagus, (f) breastbone or backbone, (g) diaphragm, (h) heart, (i) major blood vessels that lead to or from the heart (aorta or vena cava), or the nerve that controls the larynx (not shown).
Cancer may have spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are in the lung or near the bronchus. Also, one or more of the following is found:
- The tumor is larger than 7 centimeters.
- There are one or more separate tumors in a different lobe of the lung with the primary tumor.
- The tumor is any size and cancer has spread to any of the following:
- Trachea.
- Carina.
- Esophagus.
- Breastbone or backbone.
- Diaphragm.
- Heart.
- Major blood vessels that lead to or from the heart (aorta or vena cava).
- Nerve that controls the larynx (voice box).
Stage IIIB: Stage IIIB lung cancer. The primary tumor is 5 centimeters or smaller and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following may be found: (a) cancer has spread to the main bronchus, but has not spread to the carina; and/or (b) cancer has spread to the inner membrane that covers the lung; and/or (c) part of the lung or the whole lung has collapsed or has pneumonitis (inflammation of the lung).
The tumor is 5 centimeters or smaller and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following may be found:
- Cancer has spread to the main bronchus, but has not spread to the carina.
- Cancer has spread to the innermost layer of the membrane that covers the lung.
- Part of the lung or the whole lung has collapsed or has developed pneumonitis.
or
The tumor may be any size and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the trachea or aorta (not shown), or where the trachea divides into the bronchi. Also, one or more of the following is found: (a) there are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor; and/or (b) cancer has spread to any of the following: the chest wall or the membrane that lines the inside of the chest wall, the nerve that controls the voice box, the trachea, the carina, the esophagus, the breastbone or backbone (not shown), the diaphragm, the nerve that controls the diaphragm, the heart, the major blood vessels that lead to or from the heart (aorta or vena cava), or the outer layer of tissue of the sac around the heart.
The tumor may be any size and cancer has spread to lymph nodes on the same side of the chest as the primary tumor. The lymph nodes with cancer are around the trachea or aorta, or where the trachea divides into the bronchi. Also, one or more of the following is found:
- There are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor.
- Cancer has spread to any of the following:
- The membrane that lines the inside of the chest wall.
- Chest wall.
- The nerve that controls the diaphragm.
- Outer layer of tissue of the sac around the heart.
- Trachea.
- Carina.
- Esophagus.
- Breastbone or backbone.
- Diaphragm.
- Heart.
- Major blood vessels that lead to or from the heart (aorta or vena cava).
- Nerve that controls the larynx (voice box).
Stage IIIC lung cancer. The tumor may be any size and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following is found: (a) there are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor; and/or (b) cancer has spread to any of the following: the chest wall or the membrane that lines the inside of the chest wall, the nerve that controls the voice box, the trachea, the carina, the esophagus, the breastbone or backbone (not shown), the diaphragm, the nerve that controls the diaphragm, the heart, the major blood vessels that lead to or from the heart (aorta or vena cava), or the outer layer of tissue of the sac around the heart.
The tumor may be any size and cancer has spread to lymph nodes above the collarbone on the same side of the chest as the primary tumor or to any lymph nodes on the opposite side of the chest as the primary tumor. Also, one or more of the following is found:
- There are one or more separate tumors in the same lobe or a different lobe of the lung with the primary tumor.
- Cancer has spread to any of the following:
- The membrane that lines the inside of the chest wall.
- Chest wall.
- The nerve that controls the diaphragm.
- Outer layer of tissue of the sac around the heart.
- Trachea.
- Carina.
- Esophagus.
- Breastbone or backbone.
- Diaphragm.
- Heart.
- Major blood vessels that lead to or from the heart (aorta or vena cava).
- Nerve that controls the larynx (voice box).
Stage IV
Stage IV is divided into stages IVA and IVB.
Stage IVA: The tumor may be any size and cancer may have spread to the lymph nodes. One or more of the following is found: (a) there are one or more tumors in the lung that does not have the primary tumor; and/or (b) cancer is found in fluid around the lungs or heart or there are cancer nodules in the lining around the lungs or the sac around the heart; and/or (c) cancer has spread to one place in an organ or tissue not near the lung, such as the brain, adrenal gland, kidney, liver, or bone, or to a lymph node that is not near the lung.
The tumor may be any size and cancer may have spread to the lymph nodes. One or more of the following is found:
- There are one or more tumors in the lung that does not have the primary tumor.
- Cancer is found in the lining around the lungs or the sac around the heart.
- Cancer is found in fluid around the lungs or the heart.
- Cancer has spread to one place in an organ not near the lung, such as the brain, liver, adrenal gland, kidney, bone, or to a lymph node that is not near the lung.
Stage IVB: The cancer has spread to multiple places in one or more organs that are not near the lung, such as the brain, adrenal gland, kidney, liver, distant lymph nodes, or bone.
Small cell lung cancer stages
Source: National Cancer Institute
Limited-stage small cell lung cancer
In limited-stage, cancer is in the lung where it started and may have spread to the area between the lungs or to the lymph nodes above the collarbone.
Extensive-stage small cell lung cancer
In extensive-stage, cancer has spread beyond the lung or the area between the lungs or the lymph nodes above the collarbone to other places in the body.