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Date-15/6/2015

Pulmonary MetastasesDr. Manmohan Bir ShresthaMD Resident, Phase-ADepartment of Radiology & Imaging

MetastasisMetastasis are the tumor implants discontinuous with primary tumor.It is the hallmark of malignancy.All cancers can metastasize with few exceptions. The major exceptions are gliomas and basal cell carcinoma.

Pulmonary MetastasesIn about 75 % cases, presents as multiple pulmonary nodules.

Also present as solitary pulmonary nodule/ cavitation/ calcification.

Approximately 3 % of asymptomatic pulmonary nodules are metastases.

Site

Usually bilateral, affecting both lungs equally with a basal predominance.

They are often peripheral and may be subpleural.

Route of spreadMost commonly - haematogenous.

Lymphatic spread - less common.

Endobronchial spread - rare

Lungs Filter like OrganSupplied by pulmonary artery containing deoxygenated blood from right ventricle.This blood contains lymphatic fluid from the body tissues which flows into the lungs.

Primary siteMay originate at any site.

Approximately 80 % of pulmonary metastases arise from primary tumours of-BreastSkeletonUrogenital system.

Clinical featuresCoughDyspnea or shortness of breathChest painHaemoptysisHoarseness of voiceFeatures of secondary pulmonary infection.

Radiological findingsCommonOther patternsNodules.CavitationCalcificationPneumonia-like consolidationA halo of ground glass opacity.EndobronchialCannon-ball metastasesMiliary metastasesLymphangitis carcinomatosa.

NodulesMay be solitary or multiple.Rounded nodules of variable sizes ranging from few millimeters to few centimeters with well-defined margin.75 % - multiple pulmonary nodules.Commonest tumours producing solitary pulm. nodules are carcinomas of ColonKidneyBreastTesticular tumoursBone sarcomasMalignant melanoma.

CavitationMay occur from any site.

More common from-Squamous carcinomas from head & neckSarcomas.May be seen after chemotherapy

Subpleural cavitation is a recognized cause of spontaneous pneumothorax.

Absent fluid levels.

CalcificationIs seen in some cases.

Most often in Osteogenic sarcomaChondrosarcomaMucinous adenocarcinoma.

Pneumonia-like consolidation

Adenocarcinoma metastases may destroy adjacent lung parenchyma, resulting in pneumonia-like consolidation.

A halo of ground-glass opacity

Ground-glass opacity surrounding a mass or a nodule which represents haemorrhage.

Seen in choriocarcinoma & angiosarcoma.

Endobronchial metastasesRareThey may occlude the airway and cause segmental or lobar collapse.Primary sites being Kidney BreastLarge bowel.

Cannon-ball metastasesCommonest primary sites beingRCCChoriocarcinoma.

Miliary metastases

Commonest primary sites are-Thyroid carcinomaMalignant melanomaRCCOsteosarcomaPancreatic neoplasms.

Lymphangitis CarcinomatosaResults from haematogenous metastases invading and occluding peripheral pulmonary lymphatics.Commonest primary sites areLung BreastStomachPancreasCervixprostate

ContUsually bilateral, but lung and breast cancer may cause unilateral lymphangitis.

Chest X-rayCoarse, linear, reticular and nodular basal shadowing often with pleural effusions and hilar lymphadenopathy.

Cont

HRCTNodular thickening of the interlobular septa and thickening of the centrilobular bronchovascular bundles.

D/D of a solitary pulmonary noduleMalignantBenignGranulomaInfectionPulmonary infarctPulmonary haematoma

7.Collagen diseases8.Congenital9.Impacted mucus10.Amyloidosis11.Intrapulmonary lymph nodePleuralNon-pulmonary

D/D of a multiple pulmonary noduleMalignantBenignInfectionInflammatoryVascularMiscellaneous.

D/D of a cavitating pulmonary lesionInfectionsMalignantAbscessPulmonary infarctPulmonary haematomaPneumoconiosis7. Developmental8. Sarcoidosis9. Bulles, blebs10. Traumatic lung cysts11. Pneumatocele.

Approaching to the pulm. metastasesPulmonary metastases initial finding

Unknown Primary.

Clinical presentation and clinical evaluation.

ContChest X-ray

CT Scan

PET Scan

Cont.Cytological examination of sputumCytological examination of pleural fluidFNAC or excision biopsy of an enlarged lymph nodeBronchoscopy- biopsy bronchoscopic alveolar lavage cytology.

ContUSG guided FNAC of lesionCT guided FNAC of lesionSurgical lung biopsy or open lung biopsyHRCT.

ComplicationsPneumothorax

Pleural effusion

Lung collapse.

Treatment modalitiesChemotherapyRadiotherapyPlacements of stents in the airwaySurgicalPalliative care.

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