There are lots of different diagnostic tests for cancer. I encountered some that were almost the same as last time, and some that were different. None of them so far have been especially painful or scary. In fact, waiting for results is definitely the most difficult part of diagnostic testing.
Many cancers have a visual sign–spot on the skin, enlarged lymph node. Lung cancer is different. There usually aren’t physical symptoms until it’s pretty far along, which was the case with me. Early lung cancer is commonly caught by accident, on an x-ray for a broken collarbone, for example. Later lung cancer is detected because of metastasis symptoms, like pain in the bones or seizure symptoms (from metastasis to the brain). 40% of all lung cancer is initially diagnosed at Stage IV (the most advanced) because there were few or no symptoms.
In my case, I had pneumonia. The first chest x-ray didn’t show a mass and in fact showed so little pneumonia that my doctor didn’t catch it (a radiologist noted it on a report a few days later). The second chest x-ray showed clear pneumonia over the bottom third of my right lung. We changed antibiotics a couple times, which would help for about 5-7 days before I would start going downhill again. My doctor ordered a chest CT, and that’s where the mass and enlarged nodes were first detected. Many people have had a CT scan, so I won’t describe it here.
I knew a biopsy and PET scan would be coming next, but I forgot about the necessity for a brain MRI. It may have been a bit of subconscious choice in forgetting the brain MRI, since my mom’s lung cancer first presented with stroke symptoms caused by significant metastasis in her brain. I’ll describe the tests in the order they were performed.
Last time I had cancer, I had two biopsies: a traditional needle biopsy (which is just what it sounds like, sticking a special syringe into the skin and then sucking up cells) that returned a false negative, and then a punch biopsy (which is also what it sounds like, a painful process that resembles using a hole punch to get samples of tissue). The punch biopsy caused a lot of pain that lingered for a while since the primary samples were taken from my tonsil and the roof of my mouth.
This time, I had a CT guided needle biopsy. I laid on my stomach on a CT scan table, and after giving me a sedative and local anesthetic, the resident began gradually inserting a special sampling needle into my back. She moved the needle forward a tiny bit, verified by CT scan, then moved it a bit more until she could verify on the CT that it was in the mass in my lung. I heard a “snap, snap, snap” as they took 6-7 samples.
They actually took two separate sets of samples and sent one to pathology (for cancer) and the other to microbiology because the doctor said he saw a lot of infection in the cells. The whole process was much less painful than my last biopsy even though I had a lung punctured… twice. Within a day or so, there was no pain and the only dressing was a single bandaid on my back.
Biopsy results come in stages. Your oncologist can often call and get preliminary results within a day or two which includes the type of cancer. The full report usually takes several days to a week, and any secondary tests (such as for HPV) take extra time. Biopsies for lung cancer have an extra step that takes even more time, where they check the cancer for genetic and immune weaknesses to see if you’re a candidate for targeted therapy.
The PET scan is usually a full body CT scan with an added intravenous agent: radioactive glucose. You fast before the test, then are injected with the agent. You sit in the dark and do nothing for an hour, so your muscles don’t absorb the glucose, leaving cancer cells (and infection) as the cells that absorb the glucose most quickly. They then perform an extended CT scan, which shows via brightness and color where you have cancer cells in your body. You’ll hear cancer patients talk about where a PET scan “lit up” when they discuss their results.
Since lung cancer tends to be discovered relatively late, it’s not uncommon to have metastasis in the brain. The brain naturally absorbs a lot of glucose, so PET scans aren’t always helpful. A brain MRI gives a clear view so radiologists can spot any lesions or masses.
The chest has a lot of lymph nodes in it, and some are difficult to see or distinguish on a PET scan. The PET scan can also have areas “light up” and not be clear about the exact cause. In that case, a surgeon performs a procedure to directly view and sample each lymph node in the chest. Some nodes can be sampled via a camera and tools down the throat (bronchoscopy) while others may require a small incision to insert a camera and tools into the chest. The samples taken are sent to pathology for analysis.
The bronchoscopy turned out to have enough clarity for the biopsy, so I didn’t have a mediastinoscopy. The brochoscopy showed cancer where we weren’t expecting it from the PET scan–a few lesions starting in my airways and an area in the center of my chest that may or may not be affected. The surgeon sent samples to the radiologist and oncologist. We need to expedite treatments, so I’m very glad he requested this specific test (which had not been planned until the lung cancer board reviewed my case).
What’s in so far:
- The PET scan showed cancer in the expected locations (based on the CT scan): a mass in the right lung, and a few “lit up” lymph nodes beside the lung and at the collarbone. That’s great news–there’s no cancer spreading in my bone, liver, etc.
- The brain MRI was also clear so there’s no cancer spreading there yet, either.
- The biopsy of the mass came back as squamous cell carcinoma, a non-small cell lung cancer (NSCLC) and the second most common type of NSCLC.
- The bronchoscopy showed the expected cancer and a few new areas still local to the lung, most likely moving me into treatments more quickly (which is fine with me).
What’s not in yet:
- The specific pathology reports on the first set of biopsy samples will take a bit more time for HPV staining and then for genetic and immune testing for targeted therapies.
What Does All This Mean?
These are the steps in staging a cancer: classifying it according to the severity and amount of spread. The staging (along with your specific cancer location, general health, circumstances, etc.) help determine which treatments give the highest chance of success. My preliminary stage is IIIa, although that might change as more detailed results come in.
Apologies for the big data dump in this post. These are terms that will come up in other posts, and lots of people usually ask questions about tests so hopefully this is useful as well!