lung mets - presentation, investigation and management

1. Lung metastasis
DR SUHAS K R

2. BACKGROUND
2nd most common organ for
secondaries after liver
• Before effective chemotherapy
up to 80% of patients treated by
radical resection of the primary
tumor of osteosarcoma died
from lung metastasis
• More than 80% of sarcomas
metastasize initially to the lung
• Upto 10-15% of colorectal ca
develop lung mets post curative
resection(rectum>>colon)

3. Number games
Highest predilection MC metastasis
• Choriocarcinoma – 60%
• Osteosarcoma – 15%
• Testicular tumors – 12 %
• Melanoma – 5%
• Head and neck - 5%
• Breast
• Colon
• Kidney
• Uterus
• Prostate
• oropharynx

4. Likelihood
• SLN in a patient with known extra thoracic primary – 24%
• With no primary – 3% metastatic
Type of primary SLN on x ray
Sarcoma ,melanoma Mostly metastatic
Ca breast , squamous cell ca Mostly primary ca lung
Adeno ca Equal chances

5. CHARACTERISTICS
CANNON BALLS:
• Neoplasms with rich vascular supply draining directly into the
systemic venous system.
• Colorectal cancer and sarcoma
MILIARY PATTERN:
• Thyroid carcinoma
• Renal cell carcinoma
• Sarcoma of the bone
• Trophoblastic disease

6. Cavitating Lesions:
• Cavitation - in 4% of
metastatic deposits is more
likely in squamous cell lesions.
• Colon, anus, cervix, breast and
larynx account for 69% of
such occurrences.
• Avascular necrosis of the
lesion secondary to vascular
occlusion, is the presumed
mechanism for cavitation.

7. Calcification:
o Calcification of metastasis from ovarian, thyroid, breast and
mucin producing gastrointestinal neoplasms.
o Lung metastasis may also calcify following therapy.
o Almost all calcified or ossified lung metastasis occurring prior to
therapy are due to osteosarcoma or chondrosarcoma.
o Isolated cases - with synovial sarcoma and giant cell tumor of
the bone.

8. Endobronchial Lesion
• Endobronchial metastases - rare in comparison with parenchymal deposits
and account for 2% of patients who died from solid neoplasms.
• Diagnostic challenge:
o Simulate primary bronchogenic carcinoma in clinical presentation
o X ray - bronchial obstruction and obstructive atelectasis or
pneumonia.
o The endobronchial lesion - characteristic pigment on bronchoscopy in
metastatic melanoma.

9. Endobronchial Lesion
• Persistent cough, hemoptysis, wheezing - may have normal chest x-rays.
• Kidney, colon, breast sarcoma and melanoma account for 67% of the
cases.
• The metastases is located subepithelially and is due to hematogenous
metastases through the bronchial arteries.
• Palliative radiation or resection becomes necessary
if the patient has hemoptysis or refractory obstructive
pneumonitis.

10. Lymphadenopathy
• Autopsy incidence related to various primaries range from 20-60%.
• Head and neck and genitourinary tract neoplasms most often cause
visible intrathoracic enlargement followed by malignant melanoma
and breast carcinoma.
• Considered positive on CT scans by size criteria; namely, if the short
axis is 1cm or greater.
• Nineteen percent of nodes from 0.5-1cm have been reported positive
for micrometastases

11. Diagnostic challenge
o Lymphadenopathy may be hilar, mediastinal or both.
o Sarcoidosis - rarely causes mediastinal nodular enlargement
without hilar enlargement.
o Lymph node metastasis is not always associated with lung
metastasis.
o D/D - sarcoid, non-infectious granulomatous disease, lymphoma,
leukemia or a primary mediastinal tumor.
o Metastatic disease may cause bilateral hilar enlargement.
However, these patients are usually symptomatic.

12. Pleural Effusion
• The effusions - tend to be
massive, recurrent and associated
with shortness of breath.
• Associated with extensive
underlying lung and systemic
metastases.
• Malignant effusions >50% of
exudative pleural effusions.
• Lung, breast, stomach and ovary
- 81% of cases.

13. PLEURAL MASSES
•Significant pleural masses can exist without recognition (as in the adjoining
CXR), even in the absence of pleural effusion.
•CT scan – investigation of choice
•Thymoma, multiple myeloma and cystadenocarcinoma lung are reported to
give such a metastatic pattern.
SPONTANEOUS PNEUMOTHORAX
•Pneumothorax occurring secondary to pulmonary metastasis is rare.
•This mode of presentation occurs secondary to necrosis of subpleurally
located metastases with the resultant bronchopleural fistula.
•Cavitating sarcoma is reported to present in this manner.

14. Alveolar Pattern
• Alveolar form of metastases - relatively rare and unrecognized form
• Histologically - indistinguishable from primary alveolar cell lung
carcinoma.
• Pancreatic carcinoma is the most common primary
• Metastatic liposarcoma and laryngeal carcinoma - occasionally
• The metastatic lesions from choriocarcinoma also have features of alveolar
pattern.
o However, this is secondary to bleeding into the lesions rather then due
to tumor, per se.

15. Interstitial Pattern
• Less than 10% of lung metastases
have a lymphangitic pattern.
• Pathogenesis:tumor spread along
the perivascular lymphatics after
initial deposition of tumor
embolus in a pulmonary capillary
by hematogenous route.
• The stomach, lung and breast
account for 80% of cases.

16. • A doubling time of between 20 and 400 days is consistent with a malignant
lesion. Doubling of the volume means that a nodule 0.5cm in diameter
increases by 0.12cm in diameter, a nodule of 1cm increases by 0.26cm in
diameter, a nodule of 2cm increases by 0.52cm in diameter, a mass of 3cm
in diameter increases by 0.78cm in diameter, and so forth.
• Patterns of calcification strongly suggestive of a benign nature of a nodule
are diffuse homogenous calcification, central calcification, laminated
concentric calcification, and popcorn calcification.

17. Prognostic factors
ROLE NO ROLE
• Complete resectability
• Tumor doubling time
• Disease free interval
• Number of nodules
• Histology
• Nodal status
• Age
• Gender
• U/L vs B/L disease
• Wedge resection vs formal
lobectomy

18. Investigations
• Cancer-specific tumor markers
• Chest Radiography
o potential to overlook lesions located in the lung apices or posterior sulci
or against the heart or mediastinum
o 25% of the total lung volume is not readily accessible for visual
examination using plain posteroanterior chest radiography.

19. CT SCAN
• CT is the most effective method of imaging lung metastasis
• 80 - 95% sensitivity of helical CT in detecting pulmonary nodules of 6 mm
or greater but only 69% with nodules less than 6 mm
• Surveillance - every 3 to 6 months for at least the first 2 years, then every 6
months for another 3 years.
• After 5 years, chest radiographs are performed at regular intervals between
6 and 12 months

20. Role of PET
• For small nodules (i.e. 10 mm)
the sensitivity 20- 30 %;
• Nodules larger than 10 mm the
sensitivity 80 - 90%.

21. Transthoracic needle aspiration biopsy (TNAB) - the initial procedure
for the diagnosis of pulmonary nodules.
• Sensitivity for malignant lesions - 86.1% (range, 83.8-88.4%), with
a pooled specificity - 98.8% (range, 98.4-99.2%)
Bronchoscopy with transbronchial needle aspiration (TBNA)
• Diagnostic yield for lesions less than 2cm in diameter is 54%,
compared with 80% for those more than 3cm in diameter.
• For lesions located in the lower lobe basilar segments or in the
apical segments of the upper lobes, yield is 58%, compared with
83% for other locations, and
• For lesions with sharp borders, the yield is 54%, compared with
83% for lesions with fuzzy borders.

22. Surgery
• In 1882, Weinlechener performed the first operation to remove two
pulmonary metastases (en bloc chest wall resection) in a patient with
sarcoma who subsequently died 1 day later.
• Kronlein successfully resected a chest wall sarcoma and its
pulmonary metastasis in 1883.
• After 7 years, the patient
died with recurrent disease.

23. Surgical indications
• No other known extrapulmonary metastases - If additional
metastases are present, they should be considered amenable to
surgical or some other form of therapy
• Good surgical candidates from the standpoint of cardiopulmonary
and other comorbid conditions
• The location of the metastatic lesion is such that it can be
completely resected with reasonable (depending on baseline
pulmonary status) preservation of the remaining normal lung
• The primary tumor site has been controlled or resected

25. Surgery
• Goal - complete resection of the lesion with maximal preservation
of normal parenchyma
•
Bilateral
disease
Staged
thoracotomy
Clamshell
hemiclamshell

26. • Formal node dissection not indicated
• Wedge resection is enough
histology Without surgery With surgery
all 25- 40%
STS 20-40%
osteosarcoma 0-17% 20-40%
Breast ca 11% 35-50%
melanoma 3-4% 21-36%
colorectal <5% 40-45%
Renal cell ca 13-54%

27. VATS
Advantages of minimally invasive procedure
INDICATIONS
1. U/L disease
2. Fewer lesions (3-4)
3. < 3cm in size
4. Peripherally located

29. Prognostic factors
Study Tumor
Subgroup(s) with Improved
Survival DFI (Y) Resectability (Yes/No) Resected Nodules (n)
Pastorino et al.22 All Germ cell 3 Yes 1 vs. >1
Billingsley et al.23 STS Gynecologic sarcoma 1 Yes No
Pfannschmidt et
al.61
Renal cell Node negative 2 Yes 7 vs. >7
Saito et al.94 Colon CEA <10 ng/mL, node negative NS NS 1 vs. >1
Saeter et al.45 Osteosarcoma Response to chemotherapy NS Yes 1 vs. >1
Seki et al.64 Uterine cervix Tumor <3 cm NS Yes NS
Liu et al.62 Head and neck Glandular tumors 2 Yes NS
Friedel et al.59 Breast 3 Yes NS
CEA, carcinoembryonic antigen; DFI, disease-free interval; NS, not stated; STS, soft tissue sarcoma.

30. Individual malignancies

31. Sarcomas
• 80-90% metastasis is to lungs
• 25% will develop mets majority within 2 years
• 40-60 % in case of high grade tumors
• Half of the patients relapse after R0 resection
• Highest predisposition with LMS,MFH,synovial sarcoma
• 5 yr survival – 35-40%
• Poor Prognostic indicators
o Three or more lesions
o Largest lesion with diameter >2 cm
o High grade primary tumor

32. Colon
metastatic
• Typically involves regional lymph nodes, liver, and lung
• 8.7% develops lung metastasis, and only around 1% are candidates
for metastasectomy
• Lung metastasis - significantly higher (11.5%) after resection of
rectal carcinoma than after resection of right (3.8%) or left (3.4%)
colon carcinoma
• Only complete resection and low preoperative carcinoembryonic
antigen level - statistically significant indicators of a good prognosis
in multivariate analysis

33. • Synchronous liver and lung metastasis even if resectable - worse prognosis
• Patient who undergoes curative resection of liver metastasis, only to
develop lung lesions later – 5 yr survival 20 – 30%

34. Breast
• Occur through lymphatic channels via internal mammary or
mediastinal lymph nodes, or both
• Solitary lesions - fewer than 1% of all patients with metastatic
breast cancer
• Solitary lung metastasis - survival rate of 44% at 5 years and 23% at
10 and 15 years
• The 5-year survival was 37% after the first procedure and remained
as high as 40% at 5 years after repeated thoracotomies.

35. Head and Neck
• Except for cancers of the lip, tonsil, and adenoid, metastasize
initially to the lung
• Difficulty is to differentiate between a metastatic lesion and a
primary lung carcinoma
• Five year survival 30-60%

36. Melanoma
• The resection of pulmonary metastasis , in general, disappointing
• The 5-year survival in those with complete resection - 21%
• Four risk factors that adversely affect survival:
o nodular histology,
o two or more metastases,
o a disease-free interval of 5 years or less, and
o the presence of extrathoracic metastases

37. Germ Cell Tumors
INDICATIONS FOR RESECTION
• an absence of response to chemotherapy,
• a partial response followed by recurrence while on chemotherapy,
• recurrence after standard and second-line chemotherapy,
• to determine the presence of residual viable tumor, and
• to resect enlarging benign teratomatous elements of the tumor
*necrosis in 54% of patients, mature teratoma in 33%, and residual
cancer in 13%

38. Ewing's Sarcoma Family of Tumors - Surgical resection of
pulmonary metastasis does not appear to improve survival and should
be limited to patients with pulmonary relapse only
• use - whole lung radiation, dose-intensified chemotherapy
Gynecologic Cancers - Isolated lung metastasis from uterine or
cervical carcinoma is relatively rare
Chemotherapy is the primary treatment for metastatic choriocarcinoma
Resistant choriocarcinoma, surgical resection - 5-year survival rate of
50%

39. Intervention
• Nd:YAG laser resection of the endoluminal tumor
• Electrocauterization
• Argon plasma coagulation
• Cryotherapy
• Brachytherapy
• Mechanical removal of the obstruction with rigid bronchoscopy
• Endoluminal stent placement

40. Radiofrequency Ablation
• Maximum size – 3 cm
• No of lesions – 4
Mostly air filled pulmonary parenchyma acts as a thermal insulator
Complications – pneumothorax (25% require ICD)
Pleurisy, hemorrhage, infection
SBRT
High doses can be delivered – upto 20 Gy
Hilar and central mediastinal tumors – relative CI
Major toxicity around 10%

41. 1. Surgical resection of pulmonary metastases is safe and effective
2. VATS is an acceptable alternative that is both safe and efficacious in
properly selected cases
3. 25% of cases more metastases found at the time of surgery than detected by
pre op scans

42. Thank you