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Atypical pulmonary metastasis: the radiologic findings

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Atypical pulmonary metastasis: imaging findings

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Atypical pulmonary metastasis: the radiologic findings

  1. 1. Atypical pulmonary metastasis Chest Conference THORSANG CHAYOVAN 26.08.2014
  2. 2. Principle of pulmonary metastasis • Lung is a filter-like organ – The venous return contains lymphatic fluid from the body tissues flows into the lung • Pulmonary metastasis is extremely common • Incidence of metastases to lung parenchyma – 20% to 54% of patients who died of malignancy • The common primary organs are: – Breast, colon, kidney, uterus, H&N – Choriocarcinoma, osteosarcoma, testis, melanoma, Ewing’s sarcoma, thyroid carcinoma
  3. 3. Pathogenesis of pulmonary metastasis • 5 mechanisms 1. Pulmonary or bronchial artery 2. Lymphatics 3. pleural space 4. Airway 5. Direct neoplastic invasion • Hematogenous spread--most common – Most reach the arterioles and capillary beds – Some survive and grow into the interstitium
  4. 4. Typical pulmonary metastasis • Hematogenous -> Random distribution -> Multiple -> Round-shaped -> Variable-sized • Diffuse thickening of the interstitium (lymphangitic carcinomatosis)
  5. 5. Atypical pulmonary metastasis • Unusual radiologic features of metastases – Poorly-defined/irregulary-marginate nodules – Cavitation – Calcification – Hemorrhage around the metastatic nodules – Pneumothorax – Air-space pattern – Tumor embolism – Endobronchial metastasis – Solitary mass – Dilated vessels within a mass – Sterilized metastasis
  6. 6. Nodule • The most common presentation of metastasis • Spherical nodules of varying size • Random or peripheral • Basal portion of the lung
  7. 7. • Tumor cells hematogenously transferred to the lung proliferate into the perivascular interstitium – > interstitial lesions: clear, smooth margins • Tumors grow out of vessels into the interstitium and alveolar air space – > lung parenchymal lesions Nodule
  8. 8. • At autopsy, – 38% well-defined, smooth margins – 16% well-defined, irregular margins – 16% poorly-defined, smooth margins – 30% poorly defined, irregular margins
  9. 9. Comparison of HRCT to histopathological characteristics • Well-defined, smooth margins – Expanding type – Alveolar space-filling type • Poorly-defined margins – Alveolar cell type • Irregular margins – Interstitial proliferating type
  10. 10. Correlation between the histological type of the primary tumor and the CT appearance • Well-defined smooth margin – Expanding type – Observed in most metastatic HCC • Metastatic adenocarcinomas – Poorly defined, either irregular or smooth margins – alveolar cell type and interstitial proliferation type • Irregular margins – Metastatic squamous cell carcinomas • Irregular margins – Metastases after chemotherapy
  11. 11. Well-defined, smooth margin HCC Expanding type
  12. 12. Adenocarcinoma Poorly-defined, irregular margin Alveolar cell type
  13. 13. Cavitation • Incidence – 4% in metastases – 9% in primary lung cancer • 70% are metastatic squamous cell carcinomas • The most common primary organ – Head and neck in males – Genitalia in females • Metastatic adenocarcinoma – no statistically significant difference in the frequency of cavitation between the two histologic types. • Metastatic sarcoma – Pneumothorax is a frequent complication • Chemotherapy is known to induce cavitation • Indeterminate mechanism
  14. 14. Aquamous cell CA
  15. 15. Adenocarcinoma of rectum
  16. 16. Angiosarcoma of scalp with pneumothorax and hemorrhage
  17. 17. Squamous cell CA S/P chemotherapy
  18. 18. Calcification • Benign nodules – Granuloma – Hamartoma: less common • Calcification in metastasis
  19. 19. Calcification in metastasis • Morphology-specific 1. Dense eccentric—osteosarcoma 2. Multifocal—osteosarcoma, chondrosarcoma 3. Dystrophic—after treatment • Morphology-nonspecific – Synovial sarcoma, giant cell tumor, colon, ovary, breast, thyroid, choriocarcinoma
  20. 20. Osteosarcoma
  21. 21. Hemorrhage around metastatic nodules • CT halo sign – nodular attenuation surrounded by a halo of ground- glass opacity • Ill-defined fuzzy margins NON-SPECIFIC!! • Invasive aspergillosis • Candidiasis • Wegener granulomatosis • Tuberculoma • Bronchioloalveolar carcinoma • Lymphoma
  22. 22. Hemorrhagic metastatic nodules • Examples – Angiosarcoma – Choriocarcinoma
  23. 23. Choriocarcinoma with hemorrhagic metastasis Multiple nodular attenuation with surrounding GGO
  24. 24. Pneumothorax • A result of tumor necrosis • In aggressive and necrotic tumors – Osteosarcoma: most frequent—5-7% of cases – Other sarcomas • Necrosis of subpleural metastases produces a bronchopleural fistula -> Pneumothorax • 10 of 1,143 cases with a spontaneous pneumothorax have been attributed to a malignancy • A spontaneous pneumothorax in a patient with a sarcoma should raise the possibility of occult pulmonary
  25. 25. Osteosarcoma with pneumothorax
  26. 26. Air-space pattern • Metastases from an adenocarcinoma, breast and ovary origin – May spread into the lung along the intact alveolar walls (lepidic growth) – Also in BAC • The radiologic features mimic pneumonia – Air-space nodules – Consolidation containing an air bronchogram – Focal or extensive ground-glass opacities – CT halo signs
  27. 27. Adenocarcinoma of stomach
  28. 28. Tumor embolism • In small or medium arteries • Diagnosis is difficult radiologically – Multifocal dilatation and beading of the peripheral subsegmental arteries – Infarction: peripheral wedge-shaped areas of attenuation – Large tumor emboli in the main, lobar, or segmental pulmonary arteries • Tumors frequently associated with pulmonary tumor emboli – Hepatomas, breast and renal cell carcinomas, gastric and prostatic cancers, and choriocarcinomas
  29. 29. HCC with massive tumor emboli
  30. 30. Endobronchial metastasis • Rare • Major airway in only 2% of cases • Two possible routes 1. Directly on the bronchial wall – Aspiration of tumor cells – Lymphatic spread – Hematogenous metastasis to the bronchial wall -> polypoid lesion inside the bronchial lumen 2. Tumor cells in the lymph nodes or lung parenchyma that surround the bronchus grow along the bronchial tree -> intraluminal lesion
  31. 31. • Kidney, breast, and colorectal cancers • The most common radiologic appearance – Lobar atelectasis RCC Endobronchial metastasis
  32. 32. RCC with endobronchial metastasis
  33. 33. • Solitary metastasis without a history of malignancy – CT: 0.4%–9.0% – Chest radiograph: 25% • Solitary pulmonary nodules detected in patients with extrapulmonary malignancies – 46% proved to be a metastasis Solitary metastasis
  34. 34. • The likelihood that a solitary nodule represents a pulmonary metastasis – varies according to the histologic type of the primary tumor and the patient’s age • The most frequent malignancies – melanoma; sarcoma; and cancer of the colon, breast, kidney, bladder, and testis Solitary metastasis
  35. 35. Dilated vessels within mass • Engorged tumor vessels – Suggest hypervascularity – Sarcoma • Alveolar soft-part sarcoma • Leiomyosarcoma
  36. 36. Dilated vessels in alveolar soft-part sarcoma metastasis
  37. 37. Sterilized metastasis • After adequate chemotherapy • Necrotic nodules with or without fibrosis and without viable tumor cells • Histologic confirmation is necessary • Common: choriocarcinoma and testis • Germ cell tumors can convert to a benign mature teratoma after chemotherapy and result in persistence of the masses
  38. 38. Benign Metastasizing Tumor • Rare • Generally originate from – Leiomyoma of the uterus – Hydatidiform mole of the uterus – Giant cell tumor – Chondroblastoma – Pleomorphic adenoma of the salivary gland – Meningioma • Despite their metastatic spread, these tumors are histologically benign. • Indistinguishable from malignant tumors, however, benign ones show very slow growth
  39. 39. Benign metastasis from a uterine leiomyoma
  40. 40. Conslusion • Radiological diagnoses--based on typical findings • Awareness of the spectrum of radiologic manifestations in atypical pulmonary metastases • Presence of atypical radiologic features and metastasis is suspected – > tissue diagnosis is recommended
  41. 41. Typical pulmonary metastasis • Random distribution • Lower distribution • Multiple • Round shape • Variable size
  42. 42. Atypical pulmonary metastasis • Poorly-defined/irregulary-marginate nodules • Cavitation • Calcification • Hemorrhage
  43. 43. Atypical pulmonary metastasis • Pneumothorax • Air-space pattern • Tumor embolism • Endobronchial metastasis • Solitary mass • Dilated vessels within a mass • Sterilized metastasis
  44. 44. THANK YOU • "Atypical Pulmonary Metastases: Spectrum of Radiologic Findings."RadioGraphics:. N.p., n.d. Web. 24 Aug. 2014. • "Atypical Pulmonary Metastases: Spectrum of Radiologic Findings."RadioGraphics:. N.p., n.d. Web. 24 Aug. 2014 References

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