Tests for Lung Cancer When your doctor suspects that you might have lung cancer, she will order one or more tests in an effort to arrive at a firm diagnosis. Some of the tests performed are necessary to determine if surgery would be useful, if you are suffering from a benign condition not requiring surgery, or if lung cancer is so widespread surgery would not effect a cure. Other tests are used during and after treatment to determine that you are responding to treatment, that you are healing from surgery, that disease has not returned, or that side effects and late effects have not arisen. Only the tests that are most commonly used for lung cancer patients are described here. Blood tests, however, are not included. Your doctor might order additional tests not described below. An excellent resource for finding information about other tests is Everything You Need to Know About Medical Tests, published by Springhouse. Several issues arise with almost all tests and should be considered beforehand: Pain control. It's not unusual to feel nervous about tests. You have the right to ask for and receive pain medication before any potentially painful test is administered. You might already have some idea regarding your sense of pain, but if you have any doubts, ask in advance about options for controlling pain. Various pain-controlling medications can be requested in advance, such as the injected sedative Demerol; the sedative and brief amnesiac Versed, also injected; the topical cream EMLA, which contains the drug Xylocaine familiar to us from dental care, throat sprays and gargles; or the short-acting anti-anxiety tablet Ativan. Make comfort a priority. Many of the tests done today require that you lie on a table for extended periods while cameras and x-ray machines do imaging. Get comfortable for this opportunity to nap by asking for extra blankets and finding a position that you can maintain pain-free for long periods. Ask for pillows to support your back and knees if you suffer from back pain. Unnecessary testing. Become aware of alternatives to testing. For tests about which you feel unsure or uneasy, ask the following: Why is this procedure or test necessary? Will it change my treatment plan? Is there a safer or more comfortable alternative? What are the risks and side effects? How will pain be controlled? Please explain this procedure to me, or provide me with literature that describes it thoroughly. How experienced is the technician or doctor performing this procedure? Inform and be informed. Never assume that the hospital staff are fully aware of your circumstances. Always tell the technicians doing tests that you are a lung cancer survivor. Tell them of any other health problems or allergies you have, such as previous allergic reactions to the iodine in shrimp, any prescribed or over-the-counter medications you are taking, and your previous surgeries, particularly if most or all of your large intestine has been removed. Timely results. To spare yourself agonized waiting, you should discuss in advance with your treatment team how test results will be relayed to you. Some patients mistakenly assume that their doctors will take the initiative and contact them when in fact it may be the doctor's policy that the patient should take the initiative and call for results. If you know that your best method of coping includes acquiring as much information as possible as quickly as possible, tell your surgeon or oncologist that you appreciate timely communication and offer to expedite communication by making yourself available at the appropriate time. Be aware that some physicians are reluctant to leave test results on an answering machine without assurance from you that this is not a violation of your privacy. In addition, many ancillary doctors involved in your testing may choose for ethical reasons to communicate only with your primary oncologist or surgeon unless instructed otherwise. Discussing these issues in advance with your doctors is wise. Descriptions of tests The information below provides the specific details of experiencing various tests. This information will help you to relax and will prepare you to ask questions or request pain medicine if necessary. Bone marrow aspiration/biopsy By examining the liquid marrow or the solid core of marrow/bone structure under a microscope, a pathologist can determine if lung cancer has spread into the marrow. Bone marrow aspiration involves drawing a small amount of liquid bone marrow into a narrow needle; bone marrow biopsy involves drawing a piece of bone and its attached marrow into a larger needle called a trephine. Although in most people all bones are capable of producing marrow, for these tests the large bone of the hip is usually used. Bone marrow aspiration and biopsy is usually, but not always, an outpatient procedure. Preparation. A sedative and/or an amnesiac may be given to you in advance. Bring a heating pad with you and ask the staff if you can place it over the hip area for ten minutes or so beforehand, as some patients report this reduces pain afterward. If you have had biopsies in the past and prefer the technique of a particular staff member, try to obtain an appointment that matches his or her schedule. Be sure your sedative or local anesthetic has become fully effective before allowing the staff to proceed. Method. A local anesthetic is injected over the back of the hipbone, and a very small incision is made. Into this incision the needle or trephine, or each in turn if both aspiration and biopsy are being done, is inserted to penetrate the bone. For a marrow aspiration, the liquid marrow is drawn into the needle and the needle is removed. For a biopsy, the trephine is pushed through the bone to collect a core of bone and its attached marrow and is removed. If not enough marrow can be obtained, a second insertion through the same incision but into a different area of bone will be tried. Pressure is applied over the insertion point for a few minutes to stop bleeding. A small bandage is applied. Pain. Many patients report moderate to severe pain during this procedure. Be sure to ask for a sedative or an amnesiac such as Versed if you know from past experience that you prefer being very much unaware of Pain. You may feel unpleasant pressure as the needle is pushed through the bone, especially if your bones are very dense. You may feel a unique unpleasant sensation as the marrow is drawn into the needle. You may feel pain if the needle slips across the bone surface as it is being inserted. Recovery. Afterward, your hip may feel sore for a few days. This can usually be relieved with Tylenol-type medications. Risks. There is a slight risk of infection at the incision site. Bone scan (scintigraphy) This outpatient test exploits the fact that some bone irregularities will absorb more of a substance than will healthy bone. Preparation. A mildly radioactive agent, usually technetium-99, will be injected and you will be asked to return later, perhaps in three hours, for scanning. You will be encouraged to drink copious amounts of water to spread the agent from soft tissue into bone. Get comfortable after lying down on the table for the scan, because you must hold this position for up to an hour. Method. Scanning is done by having the fully clothed patient lie on a table that has, above and below it, a camera that is sensitive to the energy emitted by the agent injected. It is important to hold still for the duration of the film exposure. The table is fully open, not enclosed like an MRI machine, and you'll see the arm of the camera passing over your body starting with your head and going toward your feet. The arm is about six inches wide and about as long as the table is wide. It moves slowly: a whole-body scan can take thirty or forty minutes. Pain. A slight sting may be felt when the scintigraphic agent is injected. Recovery. There are no recovery issues associated with this test. Risks. As with other imaging techniques, there are risks of false-positive and false-negative readings. Bronchoscopy Bronchoscopy is a form of endoscopy, an outpatient procedure that uses a microscope and light source on a narrow flexible tube to examine, sample, or unblock tissue in the airways that otherwise would require an open surgery to access. Bronchoscopy is sometimes not used on those who have: Difficulty breathing or who are on a ventilator, as the risk of further compromising air intake with a bronchoscope and sedatives is too high. Increased cranial pressure, as bronchoscopy can further increase cranial pressure. Cardiac arrythmia, as bronchoscopy can worsen this condition. Preparation. You might be asked to restrict your diet for a number of hours, or to forego certain medications such as aspirin for a day or more. You will be asked to bring someone with you to drive you home. Remove dentures, contact lenses, and jewelry, but retain hearing aids. To reduce any pain or gagging the scope might cause, a numbing spray and an anesthetic liquid gargle will be given to you just before the procedure. Some medical centers might use a facial gas mask to deliver the numbing agent instead of a gargle or spray. A sedative will be injected into a vein of your forearm to relax you. It may be administered with a syringe, or by an IV that will remain in place until you are ready to go home. A self-inflating blood pressure cuff may be used on your upper arm, and a rubber thimble for monitoring oxygen levels may be placed on your finger. Method. You will be lying on your back, raised on pillows, or you'll be seated in a reclining chair. Your lung function will be supplemented with inhaled oxygen. Lights will be dimmed so that the doctor can see the images on the monitor. Once the sedative has taken effect, the bronchoscope will be inserted into your mouth or nose. The medical staff might ask you to swallow, make sounds, or cough to assist them in placing the tube or to visualize certain tissues. Do not try to talk. While the scope is being used, most likely you will be only vaguely aware that the procedure is underway. You are likely to gag and cough, but the sedative will make you feel as if it is happening to someone else. Your lungs and bronchial tubes will be examined, and very small pieces of tissue and sputum might be collected and sent to the pathology lab for testing. A needle might be passed through the lung into deeper nearby tissue, such as lymph nodes, a procedure called transbronchial lung biopsy. Instruments for clearing blockage might be used. A saline wash called lavage might be done to rinse cells out of the lungs for examination. A fluoroscope, a large x-ray machine with a viewing screen, might be used above your chest to show the bronchoscope's placement inside your airways. Recovery. It will take a half-hour or more to awaken. The nursing staff will check your vital signs and your gag reflex for one to three hours to be sure all medications have worn off before you attempt to eat or drink. If your breathing has been compromised by lung disease, you will be watched especially carefully to be sure your pulmonary function is sound before you are allowed to leave. You will be instructed to spit out your saliva instead of swallowing it, to avoid smoking for at least 24 hours, and to avoid clearing your throat or coughing for several hours. No matter how alert you feel, you should not drive for at least 8 hours after having had a sedative. For a few days after having a bronchoscopy, fatigue, achiness, swelling and pain in your throat, difficulty swallowing, hoarseness, and dry mouth are common. Pain. Some people report a panicked feeling of being unable to breathe during bronchoscopy, a strong urge to cough, or a sore throat afterward. Risks. There are low to moderate risks of the following associated with bronchoscopy: puncture of a bronchial tube or lung, infection at the sedative injection site, infection from an improperly disinfected bronchoscope, slight or copious bleeding from the lungs, pneumonia arising from accidental introduction of foreign material, and spasms of the airway that reduce pulmonary function. If a biopsy or brushing is done, a slight chance of collapsed lung or of pneumothorax--air escaping through a small opening in the lung into surrounding tissue--exist. If after bronchoscopy you have pain, fever, difficulty breathing, blood in sputum, cardiac symptoms such as chest tightness, or lumps under the skin near the chest, call your doctor immediately. CT scan (computed tomography, "CAT" scan) An outpatient procedure, computed tomography is a series of many very narrow X-rays taken at many varying depths of tissue and from different angles around your body. These X-ray images are then analyzed and reassembled by a computer into an image of your internal organs. CT scans differ from traditional X-ray imaging in that X-ray imaging can't readily distinguish organs that are lying behind other organs. Imagine looking at several veils hanging one behind the other, each painted with a different design. Imagine how difficult it might be to discern the design on the farthest veil. CT scans, on the other hand, are able to delineate even those organs that are obscured by other tissue. Preparation. You may be asked to fast overnight, to use a laxative, or to purchase and drink a contrast agent if a CT scan of your abdomen and/or pelvis is planned. Your studies may require an iodine-based contrast agent. Be sure to tell your doctor and the staff doing the test if you have thyroid disease or are allergic to iodine in seafood or other sources. A non-ionizing version of the contrast agent can be substituted. Because the iodine contrast agent used may cause a sensation of heat, skin flushing, or rapid heartbeat, be sure to tell the technician if you have heart disease, high blood pressure, or any other health concerns in addition to being a lung cancer survivor. If you have internal staples from a previous surgery or pieces of metal embedded in your body from a previous injury, tell the technician. They represent no danger to you during the scan, but may appear on the film as unexplained phenomena. CT scanners are open, doughnut-shaped machines that generally do not cause patients to feel claustrophobic. Method. CT scans are performed while you are lying in a carefully chosen position that has been aligned with the machine. It is important to maintain the position that was chosen until the technician says you can relax. Most CT scan sessions include a fast, initial pass with no contrast agent followed by a second, slower scan with a contrast agent. The first scan images the entire body to use as a frame of reference for the rest of the scanning. During the first scan, you'll feel the table you're lying on move smoothly through the doughnut-hole of the machine without stopping and starting. While the second, slower scan is underway, you may be asked to hold your breath briefly over and over. Some scanning machines take ten to twenty minutes to scan, depending how much of the body is being scanned. During this time, the contrast agent is slowly dripped into your vein. The part of you being scanned is positioned inside the doughnut hole, which is about twelve inches thick. You'll feel the table you're lying on move slowly through the machine a few centimeters at a time, stopping and starting. Some people prefer taking a nap at this point. Newer scanners can do the entire scan very quickly, in about twenty seconds. For these machines, you may have to hold your breath for the entire twenty seconds, and if a contrast agent is injected, it will be pushed rapidly into your vein instead of slowly dripped. This quick administration of the contrast agent may cause stronger feelings of heat and faster heartbeat, sensations that are not considered an allergic reaction. You will feel the table you're lying on move smoothly through the doughnut-hole of the machine without stopping and starting. For some studies of the stomach or bowels, you may be required to drink a contrast agent just before the scan is taken, or as it is being done. Pain. CT scans are painless; however, when a contrast agent is used, it is injected into a vein, perhaps causing minor discomfort. As mentioned above, the iodine contrast agent used may cause a sensation of heat, skin flushing, or rapid heartbeat. Recovery. If you have had a study that required drinking a contrast agent, you may experience gas, diarrhea, or constipation for one to three days afterward. Drinking large amounts of water will hasten the removal of the contrast agent from the digestive tract. If you have had a contrast agent injected, you may have a harmless and temporary discoloration of the urine or skin for several days afterward. If you are sensitive to iodine or have a thyroid condition, you may feel fatigue for several days after receiving an iodine-based contrast agent. Risks. A CT scan, if repeated over and over for many years, may deliver enough radiation to body tissue to cause health problems later in life, such as lung, thyroid, or breast cancers. However, as CT scanning technology has improved, the amount of radiation delivered has lowered. Lung diffusion testing (diffusing capacity) This test measures the amount of carbon monoxide taken up by the lungs. As carbon monoxide (CO) is more readily absorbed by blood from the lungs than is oxygen, certain critical pulmonary functions regarding gas exchange can be measured with this test. Preparation. Avoid heavy meals and smoking for four to six hours before the test. You might be asked either to use or avoid certain medications, such as bronchodilators, beforehand. Method. You'll be asked to inhale a gas that contains a known amount of carbon monoxide, hold your breath for ten seconds, then rapidly exhale. The amount of CO remaining in the exhaled gas reveals how much was absorbed by your pulmonary bloodstream. The mouthpiece will fit snugly against your mouth, and noseclips will be used to prevent the escape of air through the nose. Pain. No pain is experienced during this test. The sensation of breathing through a mouthpiece might be uncomfortable. Recovery. No recovery events are anticipated following this test. Risks. No risks are associated with this test. MRI (magnetic resonance imaging) This outpatient test uses large magnets and radio waves to cause the different atoms that make up our cells to vibrate at different speeds. The different speeds are then mapped by a computer into an image of the body part being examined. MRI is better than a CT scan for imaging soft tissue, such as cartilage or the brain. Preparation. You will be asked to lie on a table that moves in and out of the tunnel-shaped MRI machine. The body part being scanned may be positioned within a basket-like brace to help keep the position chosen by the technician. MRI machines make hammering noises because the magnets are being repositioned constantly while the images are being generated. The technician will supply you with disposable earplugs. A contrast agent may be injected for imaging certain organs. Imaging the brain, for example, is sometimes facilitated by injecting a very safe contrast agent called gadolinium. Ask the technician about the risk associated with the agent being used, and tell her if you have any allergies or problems with blood clotting. Some people find enclosed MRI machines claustrophobic. Other MRI models have an open gazebo-like design to reduce claustrophobia, with the magnets overhead supported on pillars. Yet others are made of clear plastic. While images from open models may be distinct enough for diagnosing knee problems, for example, they might not be detailed enough for mapping the brain. If you're claustrophobic, there are several things that will help, such as knowing that there is a speaker inside the machine so that the technician can hear you if you ask for help and that you, in turn, can hear her. There is also a hand-held beeping summons that you can press if you feel tense. Most facilities have a sound system and will let you choose the music. You might also notice that relaxing photographs have been taped to the inside of the machine. Fans circulate fresh air into the tunnel at all times. It's also possible that, unless your head is being imaged, only part of your body will be within the machine and your head may not. Most relaxing of all may be the thought that this is seventeen million dollars of technology, and for one hour, it's all yours. Some people, on the other hand, report that the MRI experience is comforting, like a return to the womb. In fact, a friend reports that he likes to have an MRI because it's the only place where nobody can interrupt his thinking. If you still feel that claustrophobia will be a serious problem, ask your doctor whether a sedative would interfere with the imaging process. Method. An initial scan to set benchmarks is done rapidly using no contrast agent. A second scan for finer detail is then repeated at slower speed. If a contrast agent is to be used, it is injected into a vein in the arm before the second scan. Although sound is muted by earplugs, you will hear hammering noises that vary in speed and pitch. While being scanned, one must remain as still as possible, but breathing is not restricted as it sometimes is during a CT scan. A scan of the knee or brain, for example, takes about forty minutes. After scanning is complete, there is a five-to-ten-minute wait while the computer analyzes and maps the signals generated by the magnets. The technician will check the resulting images to be sure they are readable. Pain. The imaging process is painless, although you may feel a slight sting or warmth during injection if a contrast agent is used. Recovery. If a contrast agent is used, temporary changes in the color of skin, urine or feces is possible. Risks. There may be risks of an allergic reaction associated with specific contrast agents: ask your doctor or the technician. As always, there is a very slight risk of infection at the injection site, and a risk of minor, painless bruising at the injection site. Needle biopsy (fine-needle aspiration, CT-guided needle biopsy, percutaneous needle biopsy) Needle biopsy might be used as a means of diagnosing lung cancer that has spread to other organs such as the liver. Organs commonly examined using needle biopsy are the thyroid, kidney, liver, lymph nodes, breast, uterine cervix, pancreas, salivary gland, spinal fluid, and bone marrow. Lung biopsy performed during bronchoscopy is discussed under "Bronchoscopy;" bone marrow biopsies are discussed separately above. Preparation. You may be asked to fast for twelve hours before the procedure if a sedative or general anesthetic will be used, or if the tissue being biopsied is part of the digestive system. Blood or urine samples may be collected prior to the biopsy. Bring comfortable clothing to wear afterward, and plan on not being able to walk or drive alone after a sedative or general anesthetic is used. Method. You will be lying flat on a table for most such biopsies. The skin will be cleaned. A local anesthetic will be injected, or a sedative or general anesthetic may be given by injection or by inhalation, or, if a fine-needle biopsy through the skin is planned, no anesthetic might be used. Directly before the biopsy, the area of interest may be imaged by CT scan, ultrasound, or X-ray, and the skin above may be targeted with ink or dye. Depending on the organ being examined, you may be asked to regulate your breathing or to hold quite still during the biopsy. A tiny incision is made, and the biopsy needle is inserted through the incision. For kidney biopsies, a guide needle may be used first. A small amount of tissue is drawn (aspirated) into the syringe. The needle is withdrawn, pressure is applied to halt bleeding, a bandage is applied--no stitches are required--and the tissue is sent to the pathology lab for analysis. Pain. A slight sting from injected anesthetic or fine-needle biopsy is common. Depending on which organ is being biopsied, you may feel pressure; a brief, sharp pain; a dull, deep ache; or cramping. For liver or other digestive tract biopsies, you may feel pain in the shoulder. Tenderness or bruising may exist at the site of the biopsy and within any intervening muscle tissue for three to seven days. Some physicians prescribe Tylenol or Tylenol/Codeine combinations for the aftereffects. Recovery. Following kidney biopsies you may be asked to lie on your back for twelve to twenty-four hours, and you may note red blood in your urine for twenty-four hours. Risks. Risks of organ failure while under general anesthesia; of infection; of bleeding, internal or external, at the site of the puncture; or of injury to adjacent organs exist. For kidney biopsies, blood in the urine may persist beyond twenty-four hours and should be reported to your doctor. Pulmonary ventilation/perfusion scan (V/Q scan) This is a two-part test performed to determine pulmonary capacity. Both injection and inhalation of one or more mildly radioactive agents is done to visualize circulation of air and blood in the lungs with a special camera. Preparation. Remove dentures; wear clothing with no metal zippers or fasteners. A chest x-ray usually is performed either directly before or after these two tests. Method. Perfusion: A natural body protein, albumin, that has been joined to a mildly radioactive element, technetium-99, is injected into an arm vein. Directly afterward, you're placed on a table beneath a scanner that contains a movable gamma camera. The detection of technetium-99 particles by the camera as they decay shows how well your blood is circulated by and within your lungs. Ventilation: You will lie upon a table and wear a mask that allows you to inhale a mixture of air and a mildly radioactive agent, perhaps technetium-99 or xenon-133, that can be detected with a gamma camera as you inhale and exhale. For both of these studies, you must lie still while being scanned. Pain. The mask worn for the perfusion study might cause feelings of claustrophobia or an inability to breathe in some people. Minor pain might be associated with the injection of technetium-99 into an arm vein. Recovery. No special recovery events are expected to occur with these tests. Risks. Very low risks include low radiation exposure associated with the radioactive agents, a small risk of infection at the site of injection, and a small chance of an allergic reaction to the injected compound. Radioimmunoscintigraphy This outpatient test exploits the fact that some tumors will attract and retain more of a substance than will healthy tissue. This homing agent is first coupled to a radioactive substance that gives off energy that can be detected by specialized equipment. Your doctor will choose a radioimmunoscintigraphic agent that works best for the type of tumor you have. Agents often used today for detecting microscopic lung cancer are radioactive isotopes coupled with monoclonal antibodies--proteins secreted by white blood cells and made en masse in the laboratory. Preparation. An enema or laxative may be necessary the day before the test. After lying down on the camera table, get comfortable because you must hold this position for about one hour. Method. An injection of the radioactive agent is made into a vein in the forearm and the needle is withdrawn. Depending on the agent used, the patient may be scanned repeatedly in two, four, twenty-four, forty-eight or seventy-two hours, or a combination of these times. For tests intended to be repeated, the patient must return to the hospital. No second injection is required before the second scan. Scanning usually is done by having the fully clothed patient lie above or below a camera table that is sensitive to the energy emitted by the agent injected. It is important to hold still for the duration of the film exposure. Some patients are embarrassed to note that, although they are fully clothed, the computer-assembled image on the screen is of the naked body. Depending on the scintigraphic agent used, this procedure may be performed using a camera that is sensitive to the emission of a single positron (a positron is a piece of an atom). This is called a SPECT (single photon emission computed tomography) scan, and works on a similar principle, that is, the radioactive agent makes your tissue more visible to the camera. If the substance emits gamma rays, a gamma camera might be used, similar to a shield that moves back and forth in half circles starting at the top of the body and working down. It moves close to the body, but does not touch it. Pain. A slight sting may be felt when the scintigraphic agent is injected. Recovery. There are no recovery issues associated with this test. Risks. As with other imaging techniques, there are risks of false-positive and false-negative readings with scintigraphic agents. A very low amount of radiation exposure is associated with the radioactive agents used. You won't have to stay away from others later to avoid exposing them to radioactivity, as is necessary after receiving injections of some other isotopes. Because many of these agents are manufactured using white blood cell antibodies from mice, they may cause an allergic reaction in humans, although allergic reactions are rare. Sonogram (ultrasound, sonography) An outpatient procedure, sonography creates a map of how your body structures appear when sound waves echo from them. The sonography equipment includes a wand that generates sound waves and a microphone for sensing the echoes the sound waves generate. The wave signal is passed to a computer that reformats the signals into a picture of body organs on a screen. Bone interferes with sonography, so scanning the brain with this equipment is not successful using the equipment readily available today. Color Doppler ultrasound is specialized sonography that can detect the speed and direction of blood flow within the body, called the Doppler shift. The differences are mapped by the computer as different colors. This is useful because some tumors commandeer a large blood supply, and this excessive blood supply may be visible and meaningful using color Doppler ultrasound. Ultrasound might be used in conjunction with bronchoscopy, which is described above. Preparation. For a pelvic sonogram, you may be asked to drink large quantities of water, because the urinary bladder acts as a window for sound waves when the bladder is very full. If prostate tissue will be biopsied during transrectal sonogram, an antibiotic may be required for several days prior, and an enema about four hours beforehand is necessary. Method. You will be lying on a table while the technician gently presses a wand called a transducer over your body. Depending on what body part is being imaged, you may be asked to remove certain items of clothing and to wear a sheet in their place. The technician will first apply warmed gel to your skin to make the wand move smoothly. She may ask you to tilt your body and to maintain the tilt with your muscles, or she may place pillows under you. For transrectal ultrasound, you may be asked to lay on your side with your knees pulled up to your chest. For transvaginal or transrectal ultrasound, the technician will apply warm gel to a specially shaped wand and ask you to insert it comfortably into your vagina or rectum. Once in place, she will guide it from side to side to visualize the uterus, ovaries, prostate, or rectum. This specialized wand is quite long, which means that the technician's hands are not very close to your private body parts, and, being covered by a sheet, you probably won't feel that your body is overly exposed to a stranger. If prostate tissue is to be sampled via transrectal sonography, a needle rapidly enters and exits the prostate gland through the wall of the rectum to collect tissue for analysis. If you are having pelvic sonography along with a second sonographic scan, ask the technician to do the pelvic scan first so that you can empty your bladder. Many sonography facilities have an overhead screen so that you can see the same image the technician is seeing. Pain. Most sonography procedures are not painful, but having to maintain a very full bladder for a pelvic sonogram is uncomfortable. If prostate tissue is sampled during a transrectal sonogram, slight pain or pressure may be felt as the needle rapidly enters and exits the prostate gland through the wall of the rectum. Recovery. There are no recovery issues following sonography if biopsy was not performed. If prostate tissue was sampled, blood in the stool or semen may persist for a few days after the procedure. Risks. There are no known risks associated with most sonography procedures, except for biopsy of prostate tissue during ultrasound, which entails a slight risk of continued bleeding. Spinal tap (lumbar puncture) This outpatient test collects a sample of cerebrospinal fluid (CSF) that surrounds the spine and brain. For lung cancer, CSF usually is examined for the presence of cancer cells, but it also may be collected for many other reasons, such as identifying opportunistic organisms that may gain a foothold during chemotherapy. Preparation. No physical preparation is necessary. Method. You will be asked to lie on your side with your knees pulled up to your chest and your chin down on your collarbone during the drawing of the fluid, which takes only a few minutes. The area around your lower spine will be cleaned and a local anesthetic will be injected. After the anesthetic has taken effect, a needle will be inserted between two bones of your backbone (lumbar vertebrae) to tap the fluid that lies under the membrane that surrounds your spinal column. Once the needle is inserted, you must hold very still in the curved position to avoid spinal damage. The spinal fluid is drawn into the syringe, the needle is removed, brief pressure is applied to stop bleeding, and a small bandage is applied. Pain. Some people report a brief, sharp pain as the needle enters the membrane. Others report pronounced pressure until the needle is properly positioned. Some people report severe headache after the procedure, especially if they were not able to lie flat for the six or eight hours recommended. Recovery. You must lie flat for six to eight hours after this procedure to allow your body to replace and redistribute spinal fluid surrounding the spine and the brain. This posture prevents headache. Risks. A serious risk of spinal damage or paralysis exists if movement during the procedure displaces the needle. Slight risks of infection at the injection sites or of bleeding into the spinal column exist. Risk of headache exists, especially if the patient does not lie flat for several hours after the procedure. Spirometry and other lung volume tests These tests measure the amount of air taken in, held, and expelled by the lungs in one breath. Usually they are repeated several times over a few minutes, using both normal and forceful breathing. Preparation. Avoid heavy meals and smoking for four to six hours before the test. You might be asked either to use or avoid certain medications, such as bronchodilators, beforehand. Wear loose clothing and sit straight or stand during these tests. Method. Spirometry, FVC, FEV: You'll be asked to exhale into the spirometer, which offers no resistance to breathing, but measures the speed and volume of air that passes through it, known as forced vital capacity (FVC) and forced expiratory volume in one second (FEV). A mouthpiece might be used, which will fit snugly against your mouth, and noseclips might be used to prevent the escape of air through the nose. Match Test: Using a deep breath, a forceful exhalation, and an open (not pursed) mouth, try to blow out a lighted match held six inches from your mouth. Forced expiratory time (FET): Exhale your deepest breath as fast and completely as possible with your mouth wide open. Count the number of seconds it takes for you to exhale the air. Repeat three times; note the fastest time. Peak expiratory flow rate (PEFR): Breathe in as deeply as possible. Blow into the peak expiratory flow monitor's mouthpiece as hard and fast as possible. Do this three times, and record the highest flow rate. Maximum ventilatory volume (MVV): Using rapid in-and-out breaths, blow as hard and as fast as possible into the mouthpiece of a spirometer for fifteen seconds. Count the number of breaths as you go. Multiply this number by four to determine the number of breaths for one minute. Pain. No pain is experienced during these tests, but dizziness or shortness of breath might result from rapid, forceful breathing. Recovery. No recovery events are anticipated following these tests. Risks. No risks are associated with these tests. Sputum cytology This test examines phlegm that is suctioned or deliberately expelled from your lungs. It can in some cases detect cancerous cells being shed by a tumor, but this test is not accurate enough to be used alone as a screening or diagnostic tool. Preparation. You'll be asked to have this outpatient test, or to collect sputum at home, in the early morning. You might be instructed to drink lots of fluids up to 12 hours beforehand, or to avoid food or drink for 12 hours before, to brush your teeth and gargle with a mouthwash. If you collect sputum at home, you'll be given a sterile container to collect sputum and instructions for handling it. Method. A saline aerosol mist is administered as a spray or inhalant for five to fifteen minutes. If you're collecting sputum at home, this saline aerosol will loosen phlegm to enable you to cough samples out of the lung. Be sure the material you collect is thick mucus, not thin saliva. If this test is being done in the clinic, saline aerosol is administered, and you will be asked to breathe oxygen through a mask. A tube called a catheter will be inserted into your nose or mouth to suction material for evaluation. After a few seconds of suction, the tube is removed. Pain. Some pain or discomfort might be associated with insertion of the suction tube into the nose and throat. Recovery. No recovery is associated with this test, although you might have a sore throat afterward if a suction tube was used. Risks. No physical risks are associated with this test. There is a possibility that precancerous or cancerous cells will be detected in sputum originating in a lung tumor that cannot be found. This might be either a false positive result or a very early tumor the location of which is undetectable using the technology available today. X-rays (radiographic studies) X-ray imaging may be used early in the diagnostic process to detect unusual masses and determine the extent of disease, although X-ray studies in the absence of a biopsy cannot positively diagnose lung cancer. During treatment, X-rays can be used to track tumor shrinkage, and to detect other secondary conditions caused by tumor growth, such as blockage of the ureters, the tubes descending from the kidney to the bladder. After treatment, radiographic studies of the chest may be done to monitor the lungs for possible spread of disease. X-ray imaging is diagnostic, and is different from X-radiation therapy in that it delivers much lower doses of radiation to tissue. X-ray studies are an outpatient procedure. Preparation. You may be asked to fast overnight, to use a laxative, to purchase and drink a contrast agent, or to drink copious amounts of water if X-ray imaging studies of your kidneys are planned. If your studies will require an iodine-based contrast agent, as is used for certain X-ray studies of the kidneys, be sure to tell your doctor and the staff doing the test if you have thyroid disease or are allergic to iodine in seafood or other sources. A non-ionizing version of the contrast agent can be substituted. If you have internal staples from a previous surgery or pieces of metal embedded in your body from a previous injury, tell the technician. They represent no danger to you during the X-ray session, but may appear on the film as unexplained phenomena. Method. X-rays are taken while you are sitting, standing, or lying in a carefully chosen position that has been aligned with the X-ray machine. It is important to maintain the position that was chosen, and to remain very still, until the technician says you can relax. For some studies of the stomach or bowels, you may be required to drink an additional amount of contrast agent while the X-rays are being taken. For some bowel studies, an enema may be administered to fill the lower bowel with a contrast agent such as barium or barium and air. Pain. X-ray studies are painless; however, if a contrast agent such as dye is needed, it may be injected into a vein causing minor discomfort. Some studies require positioning of the body that may be temporarily uncomfortable, if, for example, you suffer from back pain. If you are having a barium enema, ask the technician to let you remove the nozzle of the enema yourself when the test is complete to reduce the chance of rectal discomfort. Recovery. If you have had a study that required barium in the stomach, small intestine or large intestine, you may experience gas, diarrhea or constipation for one to three days afterward. Drinking large amounts of water will hasten the removal of the contrast agent from the digestive tract and will reduce the chance of barium forming an obstruction. If you have had a contrast agent injected, you may have a harmless and temporary discoloration of the urine or skin for several days afterward. If you are sensitive to iodine or have a thyroid condition, you may feel fatigue for several days after receiving an iodine-based contrast agent. Risks. X-ray studies, if repeated over and over, may deliver enough radiation to body tissue to cause health problems later in life, such as lung, thyroid, or breast cancers. Barium used as a contrast agent in the gastrointestinal tract can cause an impaction if not cleared by drinking copious amounts of water after the test. This fact sheet was adapted from Lung Cancer (forthcoming) by Lorraine Johnston, © 2001 by Patient-Centered Guides. This material has been reviewed by an MD and will receive further technical review prior to publication. For more information, call (800) 998-9938 or see www.patientcenters.com.