Cancer metastases

Question 1

What is metastasis?

Answer 1

• Primary cancer can spread to other areas of the body.
• Secondary involvement = metastases
• Cells in metastasis resemble those in primary tumour.

Question 2

Main routes of metastatic spread

Answer 2

1. Lymphatic system
   - spreads to lymph nodes elsewhere.
2. Haematogenous spread
   - via blood
3. Transcoelomic
   - through body walls into abdominal/chest cavities

Question 3

Lymphatic spread

Answer 3

• Follows lymphatic system
• Spread and growth of cancer cells/reactive hyperplasia
• Lymphadenopathy

Question 4

Lymphadenopathy

Answer 4

Swelling of lymph nodes

Question 5

What is haematagenous spread?

Answer 5

• Spread of metastases via circulatory system
• Veins more readily invaded than arteries
• Can get:
  
  • Portal system invasion
  • Inferior vena cava invasion
  • BBB invasion

Question 6

Portal system invasion

Answer 6

Liver metastases

Question 7

Inferior vena cava invasion

Answer 7

Lung metastases

Question 8

BBB invasion

Answer 8

• Cross BBB
• Brain metastases

Question 9

What is transcoelomic spread?

Answer 9

• Across peritoneal cavity
• Affects surfaces/organs of the abdominal and pelvic cavities covered by the peritoneum
• Often associated with fluid build up – inflammatory response to presence of cancer cells in cavity

Question 10

Name two types of cancer metastases that have arisen from transcoelomic spread?

Answer 10

1. Ovarian cancer - across peritoneum
2. Lung cancer - across pleural cavity

Question 11

Primary cancer - Bladder

Answer 11

Metastases to:
- Bone
- Liver
- Lung

Question 12

Primary cancer - Breast

Answer 12

Metastases to:
- Bone
- Brain
- Liver
- Lung

Question 13

Primary cancer - Colon

Answer 13

Metastases to:
- Liver
- Lung
- Peritoneum

Question 14

Primary cancer - Kidney

Answer 14

Metastases to:
- Adrenal gland
- Bone
- Brain
- Liver
- Lung

Question 15

Primary cancer - Lung

Answer 15

Metastases to:
- Adrenal gland
- Bone
- Brain
- Liver
- Other lung

Question 16

Primary cancer - Melanoma (skin)

Answer 16

Metastases to:
- Bone
- Brain
- Liver
- Lung
- Skin
- Muscle

Question 17

Primary cancer - Ovary

Answer 17

• Liver
• Lung
• Peritoneum

Question 18

Primary cancer - Prostate

Answer 18

Metastases to:
- Adrenal gland
- Bone
- Liver
- Lung

Question 19

Diagnosis of metastases

Answer 19

• CT Scans
• X-ray
• Tumour markers
• Biopsy
• Cytology

Question 20

Bone metastases

Answer 20

• Osteolytic activity leads to hypercalcaemia.
• Bisphosphonates - to reduce calcium
• May lead to fractures
• Linked to spinal cord compression

Question 21

Osteolysis

Answer 21

• Osteoclasts (cells in the bone) increase their activity.
• Break down the surrounding minerals.
• Associated with renal, breast and prostate cancers.

Question 22

Spinal cord compression - treatment

Answer 22

• Dexamethasone, 8 mg BD with PPI.
• Radiotherapy to bone (rarely chemo - takes too long to work)
• Pain relief
• Laxatives

Question 23

General treatment of brain metastases

Answer 23

• Dexamethasone PO 2-8mg OD (long term), with PPI.
• Anti-epileptics, as it often causes seizures.
• Anti-emetics, as it triggers chemoreceptor trigger zone.
• Anxiolytics
• Headaches and dizziness.

Question 24

General treatment of lung metastases

Answer 24

• Dexamethasone 2-8mg OD, with PPI.
  Minimise inflammation
• Salbutamol
  Open airways
• Tranexamic acid
  Haemoptysis = coughing up blood
  Reduces bleeding.

Question 25

What can lung metastases cause?

Answer 25

• Superior vena cava obstruction (SVCO)
• Small cell lung cancer

Question 26

SVCO

Answer 26

Narrowing or blockage of the superior vena cava

Question 27

General treatment - SVCO

Answer 27

• Dexamethasone 8mg BD with PPI cover
• Usually chemotherapy (especially if SCLC as very chemo-responsive)
• Radiotherapy if not chemo-sensitive
• Stent
• Pain relief
• Anticoagulants if clot suspected

Question 28

Pain - Liver

Answer 28

• Dexamethasone 2-4 mg OD

Question 29

Ascites - Liver

Answer 29

Drainage

Question 30

Jaundice and pruritis - Liver

Answer 30

• Anti-itch creams
• Caution with anti-histamines due to sedation.