Multiple Lesions

Multiple discrete lung lesions occur due to widely disseminated hematogenous

metastasis.
The pattern can vary from:
o diffuse micronodular shadows resembling miliary disease, or
o to multiple large well defined masses cannon balls.
Occasionally, cavitation or calcification can be noted.
Symptoms:
o Due to the interstitial location, these lesions are often asymptomatic.
o Cough and hemoptysis are the usual symptoms.
eedle aspiration or transbronchial biopsy would be the procedure of choice for confirmation
of the nature of the lesion.
Treatment:
o Chemotherapy is the choice when the tumor is responsive.
o Occasional surgical resection of multiple lesions were attempted with some reported
success.
o !n refractory hemoptysis, selective occlusion of bronchial arteries by Teflon is a
consideration.
Cannon Balls:
eoplasms with rich vascular supply draining directly into the systemic venous system often
present in this fashion.
Miliary Pattern: This presentation is seen in patients with the following:
Thyroid carcinoma
"enal cell carcinoma
Sarcoma of the bone
Trophoblastic disease
Cavitating Lesions:
Cavitation is identified in #$ of metastatic deposits and, as with primary bronchial carcinoma,
is more li%ely in s&uamous cell lesions.
Colon, anus, cervix, breast and larynx account for 6! of such occurrences.
'enerally, small thin "alled metastases usually indicate a primary site in the head or nec%,
where as most large, thic# "alled secondaries arise from the gastrointestinal tract.
(vascular necrosis of the lesion secondary to vascular occlusion, is the presumed
mechanism for cavitation.
Calcification:
Calcification or ossification is rarely visible in metastasis to the thora).
o Calcification of metastasis from ovarian, thyroid, breast and mucin producing
gastrointestinal neoplasms.
o Calcification in lymphomatous nodes has most often occurred following therapy.
o *ung metastasis may also calcify follo"ing therapy.
o (lmost all calcified or ossified lung metastasis occurring prior to therapy are due
to osteosarcoma or chondrosarcoma.
o !solated cases of such metastasis have also been reported with synovial sarcoma
and giant cell tumor of the bone.
$olitary Pulmonary %odule
+ulmonary metastases clinically present as a solitary pulmonary nodule.
Similar to other solitary pulmonary nodular lesions, these are detected by routine chest ),
rays.
Of the solitary pulmonary nodular lesions, solitary metastases accounts for less than -$ of
cases.
Colon, chest, sarcoma, melanoma and genitourinary malignancies account for ./$ of
such instances.
Solitary metastatic lesion can precede, follow or appear concomitantly with the malignancy.
&iagnostic $trategy:
0hen it appears concomitantly or following definitive therapy of the primary, thin needle
aspiration of the lesion is probably the best procedure to establish the nature of the lesion.
C' scans are superior to whole lung tomograms in evaluating the presence of other occult
metastatic lesions.
0hen the solitary pulmonary metastasis precedes clinical recognition of the primary, standard
management of the solitary pulmonary nodular lesion should follow.
o This clinical presentation accounts for less than 1$ and routine search for primary
is not recommended.
'reatment:
Surgical resection of single metastasis should be considered:
o when the primary tumor is resectable
o no other organ metastasis is evident
o and no effective alternate therapy is available
Surgical resection of solitary lung lesions occurring a few years following curative resection of
primary have a better prognosis than the lesions that manifest concomitantly with the primary
tumor.
(ndobronchial Lesion
2ndobronchial metastases are rare in comparison with parenchymal deposits and account for
3$ of patients who died from solid neoplasms.
Diagnostic challenge:
o They simulate primary bronchogenic carcinoma in clinical presentation and are often
difficult to distinguish, even pathologically.
o Simultaneous occurrence of two primaries is a difficult differential to settle on many
occasions.
o The usual roentgen findings are bronchial obstruction and obstructive atelectasis or
pneumonia.
o The endobronchial lesion may have characteristic pigment on bronchoscopy in
metastatic melanoma.
+atients may complain of persistent cough, hemoptysis, whee4ing and may have normal
chest ),rays.
)idney, colon, breast sarcoma and melanoma account for 6*! of the cases.
The metastases is located subepithelially and is due to hematogenous metastases through
the bronchial arteries.
!t is unli%ely to be secondary to endobronchial drop metastasis as tumor cells often re&uire
fibrin thrombin to impact. The cough and mucociliary refle) may efficiently clear aspirated
cells.
Palliative radiation or resection becomes necessary if the patient has hemoptysis or
refractory obstructive pneumonitis.
'racheal Metastasis
0hen the lesion is located in the trachea, patients will present with severe whee4ing and have normal
chest ),ray findings.
Lymphadenopathy
The incidence of lymph node metastasis is high with e)trathoracic primaries, as well as
bronchogenic carcinoma.
(utopsy incidence related to various primaries range from 35,65$.
7owever, the reported incidence and radiographically visible lymphadenopathy vary greatly.
"adiographically visible enlargement is probably found in less than 8$ of all patients with
e)trathoracic primary neoplasms.
+ead and nec# and genitourinary tract neoplasms most often cause visible intrathoracic
enlargement followed by malignant melanoma and breast carcinoma.
&iagnostic challenge
o *ymphadenopathy may be hilar, mediastinal or both.
o This opposed to sarcoidosis, which rarely causes mediastinal nodular enlargement
without hilar enlargement.
o *ymph node metastasis is not always associated with lung metastasis.
o The radiographic appearance may, therefore, be indistinguishable from sarcoid, non,
infectious granulomatous disease, lymphoma, leu%emia or a primary mediastinal
tumor.
o Diagnostic problems arise in the minority of patients who do not have %nown primary
neoplasms.
o (symptomatic patients with symmetric hilar enlargement usually have sarcoidosis.
o Metastatic disease may cause bilateral hilar enlargement. 7owever, these patients
are usually symptomatic.
o (nterior mediastinal node masses are common in lymphoma but rare in sarcoid, as
seen on chest radiographs.

Pleural (ffusion
+leural effusion is one of the common metastatic patterns.
The effusions often tend to be massive, recurrent and associated with shortness of breath.
This pattern is associated with e)tensive underlying lung and systemic metastases.
Most patients e)pire within three months.
Malignant effusions account for more than ,-! of exudative pleural effusions.
Lung, breast, stomach and ovary account for 91$ of cases.
+leural biopsy and fluid cytology establish the malignant nature of the process.
+leural sclerosis with tetracycline instillation is the palliative procedure of choice in problem
effusions.
Pleural Masses
Significant pleural masses can e)ist "ithout recognition :as in the ad;oining C<"=, even in
the absence of pleural effusion.
!atrogenic pneumothora) facilitates visuali4ation of pleural masses.
CT scan can reveal pleural masses that are not seen on routine ),rays.
'hymoma, multiple myeloma and cystadenocarcinoma lung are reported to give such a
metastatic pattern.
Spontaneous pneumothora)
+neumothora) 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.
!n some instances, the subpleural
metastases are not sufficiently large enough
to be recogni4ed in ),rays and pneumothora)
is the presenting manifestation.
Chest .all Lesion
Metastatic lesions to ribs are common.
Occasionally, these lesions e)pand and encroach on the lung, mas&uerading as a lung lesion.
The characteristic extrapleural signs, namely the peripheral location, indistinct outer margin
with a sharp inner margin and biconcave edges help point towards the true location of the
lesion.
"ecognition of such lesions focuses ones attention to the ribs and facilitates easy biopsy by
percutaneous techni&ues.
/lveolar Pattern
(lveolar form of metastases is relatively rare and is often an unrecogni4ed form of metastatic
pattern.
7istologically, they are indistinguishable from primary alveolar cell lung carcinoma.
Pancreatic carcinoma is the most common primary to present in such a fashion.
Metastatic liposarcoma and laryngeal carcinoma have occasionally been reported to give
a similar pattern.
The metastatic lesions from choriocarcinoma also have features of alveolar pattern.
o 7owever, this is secondary to bleeding into the lesions rather then due to tumor, per
se.
0nterstitial Pattern
*ess than 15$ of lung metastases have a lymphangitic pattern.
+athogenesis:
o *ymphangitic metastatic disease in the lung is generally believed to be the result of
tumor spread along the perivascular lymphatic after initial deposition of tumor
embolus in a pulmonary capillary by hematogenous route.
o There is evidence that gastric carcinoma is an e)ception to this with direct lymphatic
e)tension occurring from the abdomen to chest, across the diaphragm.
The stomach, lung and breast account for 95$ of cases.
The large ma;ority of patients with unilateral diseases have bronchogenic carcinoma.
Most patients have dyspnea with or without cough. !nitially, symptoms can be mild.
Diagnostic challenge:
o There is evidence of lung tissue disease on chest radiographs: small linear and
nodular densities, reticular nodular pattern, septal lines.
o The appearance is similar to interstitial changes seen in pulmonary edema,
pneumoconiosis, usual interstitial pneumonitis or sarcoid.
o There is fre&uent pleural effusion on hilar lymphadenopathy.
o Some symptomatic patients have normal radiographs.
Transbronchial lung biopsy or needle aspiration can provide tissue for diagnosis.
!n the absence of suitable chemotherapy, only symptomatic therapy can be provided.
Most patients become severely dyspneic and e)pire within a few months.
$ubacute Cor Pulmonale
This form of presentation occurs when small
subliminal tumor deposits obstruct a sufficient
cross section of the pulmonary vascular bed.
The spectrum of pulmonary symptoms is
identically to thromboembolism.
+atients are in prolonged respiratory distress
with normal chest ),ray, and with or without
signs of pulmonary hypertension.
Choriocarcinoma, hepatoma, breast and
stomach tumors account for most of the
primaries with such presentation.
This entity should be considered in a female
with severe respiratory distress with a history
of recent abortion or delivery chorionic
gonadotropin levels are high.
0hen recogni4ed, chemotherapy offers a
favorable prognosis in patients with
choriocarcinoma.
+rognosis is poor with other primary
malignancies.