PULMONARY METASTASES
Lung metastasis occurs in one-third to one-half of all patients with a non-lung primary malignancy at the time of death based on autopsy data. Primary malignancies with the greatest tendency to metastasize to the lung are breast, lung, melanoma, osteosarcoma, choriocarcinoma, and germ cell tumors. Most pulmonary metastases are caused by common malignancies that include breast, colorectal, prostate, and renal cell carcinomas. Recent studies have demonstrated a high number of circulatory tumor cells in many different primary cancers. These are believed to lodge in the small pulmonary vessels, proliferate, and ultimately form nodules. Multiple pulmonary nodules are the most common manifestations of pulmonary metastasis. They are frequently spherical and variable in size. Multiple nodules larger than 1 cm in diameter are more likely to be malignant than benign. Larger lesions or “cannonballs” are a classic manifestation. Approximately 90% of individuals with pulmonary metastasis have or had a known primary malignancy. Solitary pulmonary metastasis may occur and in general should be treated as a possible new primary lung cancer if no other metastatic sites are identified and benign disease cannot be confirmed. Surgical resection is the treatment of choice in medically fit individuals.
Cavitation of metastatic nodules occurs in 5% or fewer
of cases and is most commonly associated with squamous cell carcinoma of the
head and neck, esophagus, and cervix. Sarcomas, especially osteosarcoma, are
well known to cavitate. Cavitation has also been observed with adenocarcinoma
of colorectal origin and transitional cell carcinoma of the bladder. Pneumothorax
occurs with cavitary pulmonary metastasis in the subpleural location because of
rupture into the pleural space. Osteosarcoma is the most common metastatic
malignancy to cause a spontaneous pneumothorax. A spontaneous pneumothorax in a
patient with a history of a sarcoma should raise the question of occult
pulmonary metastasis. Calcification of nodules, although generally a sign of
benignity, has been observed in metastatic chondrosarcoma and osteosarcoma and
very rarely from other primary sites.
Airspace consolidation is most often seen with
metastatic adenocarcinoma for gastrointestinal sources. The adenocarcinoma may
spread along intact alveolar structures (lepidic growth) and form consolidation
with air bronchograms or extensive ground-glass opacities. Sometimes this
pattern is confused with primary bronchioloalveolar cell lung cancer.
Lymphangitic pulmonary metastasis is most commonly
associated with adenocarcinoma. It is believed to be caused by hematogenous
spread of tumor to the periphery of the lung and subsequent lymphangitic spread
centrally toward the hilum. By this mechanism, it is most commonly bilateral.
Some cases may develop because of hilar tumor involvement with centrifugal
spread and account for cases of unilateral lymphangitic spread. The primary
malignancies that account for most lymphangitic metastases are the lung,
breast, and gastrointestinal tract, especially the stomach. The chest radiograph may reveal increased interstitial markings
or demonstrate a sunburst pattern radiating from the hilar area.
High-resolution computed tomography is more sensitive at detecting lymphangitic
disease than chest radiography. Characteristic findings are a thickened
interlobular septum with beading with or without polygonal formations. A thickened
subpleural interstitium is also a frequent occurrence.
Patients will usually present with dyspnea with or
without cough. The chest radiograph may be normal. Bronchoscopy with
bronchoalveolar lavage and transbronchoscopic biopsy will result in a high diagnostic
yield. The prognosis of lymphangitic carcinoma is generally poor unless the
patient has a chemoresponsive tumor such as breast cancer, lymphoma, or choriocarcinoma.
