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Metastasis

Metastasis is a clinical process by which cancer spreads from a primary site where it arose to distant locations of the body. Cells that metastasize to distant sites will have the same cell characteristic as the tumor of origin. The word metastasis originates from ancient Greek language meaning “the removal from one place to another”.


Presentation

Patients with brain metastasis will present with neurologic symptoms like seizures, headache, cranial nerve deficiency, and positional vertigo. Thoracic metastasis may presentwith hemoptysis, dry cough, and dyspnea. Jaundice, hepatomegaly and nausea are usually observed in hepatic metastasis. Bone metastasis will present with the most excruciating metastasis especially those with spinal cord involvement. Regional lymph node adenopathy are typically seen in regional metastasis [8].

Cervical Lymphadenopathy
  • A practical treatise on diseases of the skin, for the use of students and practitioners (1897) (14784221795).jpg 1 820 1 444; 530 KB Cancer Metastasis in Vertebra.jpg 1 303 746; 41 KB Cannon ball mets in ca breast.jpg 1 277 633; 96 KB Cervical lymphadenopathy[commons.wikimedia.org]
  • A practical treatise on diseases of the skin, for the use of students and practitioners (1897) (14784221795).jpg 1.820 1.444; 530 KB Cancer Metastasis in Vertebra.jpg 1.303 746; 41 KB Cannon ball mets in ca breast.jpg 1.277 633; 96 KB Cervical lymphadenopathy[commons.wikimedia.org]
Weight Loss
  • In case 2, a 61-year-old man with worsening dysmetria in the setting of unintentional weight loss presented with multiple masses in the pelvis, abdomen, lung, and brain.[ncbi.nlm.nih.gov]
  • Liver metastases may cause jaundice (a yellow discoloration of the skin,) bloating, abdominal pain, and weight loss. Metastases to the adrenal gland are often asymptomatic but important with regard to treatment.[verywell.com]
  • Liver metastasis can cause pain, weight loss, nausea, loss of appetite, abdominal fluid (ascites) or jaundice (yellowing of the skin and the whites of eyes, dark urine, light colored stools). Diagnosis There is no one test to check for metastasis.[my.clevelandclinic.org]
  • They can include: Blockage of the flow of bile Decreased appetite Fever Liver failure (usually only in the late stages of disease) Pain Weight loss[surgery.ucsf.edu]
  • loss Metastatic Kidney Cancer Cancer spread to the kidneys may cause: Pain in the side or back Lumps on the side or back Blood in urine High blood pressure Anemia Metastatic Brain Cancer Cancer spread to the brain can cause a variety of neurological[asbestos.com]
Fatigue
  • However, the treatment was discontinued because of gastrointestinal side effects and fatigue.[ncbi.nlm.nih.gov]
  • Symptoms of Metastases Symptoms of metastatic cancer can include those related to the presence of tumor in a particular area of the body to which a cancer has spread, as well as non-specific symptoms such as unintentional weight loss and fatigue.[verywell.com]
  • Common side effects are fatigue, fever, nausea, vomiting, diarrhea, anemia, weakness, arthralgia, myalgia, and bone/joint pain.[physio-pedia.com]
  • […] liver Abdominal pain, appetite loss, nausea, and vomiting Metastasis to the lungs may cause: Chronic cough or inability to get a full breath Abnormal chest X-ray Chest pain Other nonspecific systemic symptoms of metastatic breast cancer can include fatigue[nationalbreastcancer.org]
  • A genetic test can identify which women can safely be treated with only surgery and hormone therapy, sparing them severe side effects such as nausea, fatigue and permanent nerve pain.[newscientist.com]
Fever
  • They can include: Blockage of the flow of bile Decreased appetite Fever Liver failure (usually only in the late stages of disease) Pain Weight loss[surgery.ucsf.edu]
  • Malignant Peritoneal Mesothelioma Presenting with Persistent High Fever. Retrieved from: Chen, Y. (2014, March 23). Metastatic Brain Tumor. Retrieved from: American Cancer Society. (2015, March 3). Signs and Symptoms of Kidney Cancer.[asbestos.com]
  • Weight loss, loss of appetite, fever, and gastrointestinal disorders may indicate liver metastases. Liver blood tests may first detect cancer in the liver.[imaginis.com]
  • Common side effects are fatigue, fever, nausea, vomiting, diarrhea, anemia, weakness, arthralgia, myalgia, and bone/joint pain.[physio-pedia.com]
  • If a liver metastasis does cause symptoms, they can include pain or discomfort in the mid-section, fatigue and weakness, weight loss or poor appetite, fever, and others. Learn more.[breastcancer.org]
Respiratory Distress
  • However, he died of acute respiratory distress syndrome. CONCLUSIONS: Awareness of the possibility of abdominal metastasis by salivary carcinosarcoma may help in managing patients with a history of abdominal surgery.[ncbi.nlm.nih.gov]
  • After primary tumor removal, mice were sacrificed at the first signs of respiratory distress (typically 8–10 weeks after surgery) to collect metastases.[doi.org]
Abdominal Pain
  • Six months after parotidectomy, he presented abdominal pain as a symptom of abdominal metastasis by the sarcomatous component. At that time, the possibility of abdominal metastasis was overlooked because of the history of abdominal surgery.[ncbi.nlm.nih.gov]
  • We reported on a 52-year-old man who diagnosed as extensive stage SCLC with abdominal pain for 2 months, aggravated for 2 days.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 50-year-old woman complained of abdominal pain beneath the xiphoid process for 1 day. Physical checkup revealed tenderness at the right upper abdomen. A fecal occult blood test was positive.[ncbi.nlm.nih.gov]
  • A 74-year-old man was admitted to the emergency room with abdominal pain and vomiting, and abdominal computed tomography (CT) indicated obstruction of the ascending colon due to a huge mass.[ncbi.nlm.nih.gov]
  • […] weakness Abdominal pain or discomfort Weight loss Metastatic Kidney Cancer Cancer spread to the kidneys may cause: Pain in the side or back Lumps on the side or back Blood in urine High blood pressure Anemia Metastatic Brain Cancer Cancer spread to the[asbestos.com]
Loss of Appetite
  • Liver metastasis can cause pain, weight loss, nausea, loss of appetite, abdominal fluid (ascites) or jaundice (yellowing of the skin and the whites of eyes, dark urine, light colored stools). Diagnosis There is no one test to check for metastasis.[my.clevelandclinic.org]
  • The side effects vary but may include fever, chills, nausea, loss of appetite, rashes, and fatigue. Radiopharmaceuticals: Drugs that have radioactive elements are injected into the body through a vein.[physio-pedia.com]
  • This can cause problems such as constipation, nausea, loss of appetite, and extreme thirst. The high calcium also causes you to make more urine, leading to dehydration. It can make you feel very tired and weak, too.[cancer.org]
  • Weight loss, loss of appetite, fever, and gastrointestinal disorders may indicate liver metastases. Liver blood tests may first detect cancer in the liver.[imaginis.com]
  • In a community sample of patients with locally advanced lung cancer referred for consideration of radiation, the great majority experienced fatigue (80%), dyspnea (73%), loss of appetite (65%), and chest pain at distressing levels.[doi.org]
Jaundice
  • Jaundice, hepatomegaly and nausea are usually observed in hepatic metastasis. Bone metastasis will present with the most excruciating metastasis especially those with spinal cord involvement.[symptoma.com]
  • Abdominal swelling or jaundice can indicate that cancer has spread to the liver. Sometimes a person’s primary cancer is discovered only after the metastatic tumor causes symptoms.[cisncancer.org]
  • Liver metastasis can cause pain, weight loss, nausea, loss of appetite, abdominal fluid (ascites) or jaundice (yellowing of the skin and the whites of eyes, dark urine, light colored stools). Diagnosis There is no one test to check for metastasis.[my.clevelandclinic.org]
  • Liver metastases may cause jaundice (a yellow discoloration of the skin,) bloating, abdominal pain, and weight loss. Metastases to the adrenal gland are often asymptomatic but important with regard to treatment.[verywell.com]
  • Some common signs of metastatic cancer include: Pain and fractures, when cancer has spread to the bone Headache, seizures, or dizziness, when cancer has spread to the brain Shortness of breath, when cancer has spread to the lung Jaundice or swelling in[cancer.gov]
Blurred Vision
  • The patient was hospitalized for a cough with blood-tinged sputum, dysphagia, and blurred vision in the left eye at the age of 57.[ncbi.nlm.nih.gov]
Back Pain
  • Univariate analysis showed that back pain (P   .028), preoperative CA19-9 level (P[ncbi.nlm.nih.gov]
  • A 63-year-old woman with known metastatic cervical squamous cell carcinoma presented with a pathologic fracture of the L2 vertebra, unrelenting back pain, bilateral lower extremity weakness, and inability to ambulate.[ncbi.nlm.nih.gov]
  • For example, a man whose prostate cancer has spread to the bones in his pelvis may have lower back pain (caused by the cancer in his bones) before he experiences any symptoms from the primary tumor in his prostate.[cisncancer.org]
  • *Severe back pain accompanied by leg numbness or difficulty with bowel or bladder control, must be evaluated by a doctor immediately.[my.clevelandclinic.org]
  • When to See a Doctor Anyone with a cancer or a history of cancer should call the physician if back pain occurs suddenly and/or if existing back pain suddenly becomes much worse.[spine-health.com]
Hip Pain
  • The main complaint was hip pain with limited activity for about 3 months. Expansive bone destruction and periprosthetic osteolysis at the right femoral trochanter were identified through X-ray and Tc bone scan.[ncbi.nlm.nih.gov]
Numb Chin Syndrome
  • The diagnosis was numb chin syndrome secondary to mandibular metastasis. Apart from supportive treatment, she was started on palliative chemotherapy and radiotherapy.[ncbi.nlm.nih.gov]
Neglect
  • The rarity of endometrial metastatic melanoma may incline clinicians to neglect the importance of malignant melanoma in a patient's history when they present with abnormal uterine bleeding.[ncbi.nlm.nih.gov]

Workup

The following tests and work up modalities are implored in the diagnosis of metastasis:

  • Tissue biopsy: Tissues taken from metastatic lesions are examined under the microscope to determine the point of origin of the tumor [9].
  • Cranial CT scan: This imaging technique will demonstrate the presence and the extent of the cranial metastatic tumor.
  • Chest X-ray: This imaging modality can be used to screen patients with possible chest or intrathoracic metastasis.
  • Magnetic resonance imaging (MRI): This imaging scan will elucidate and define tumors intraabdominally and in the thoracic cavity.

Treatment

The management of metastasis greatly depends on the patient’s age, general health, and history of previous treatments. The treatment options for metastasis include radiosurgery, radiation therapy, debulking surgery, chemotherapy, and hormone therapy [10]. A combination therapy from among these may be implored to treat some cancer metastasis. A great majority of the cancers are hard to treat but testicular and thyroid metastasis are usually treatable.

Prognosis

The prognosis of metastastatic cancers depend on the time the disease condition is diagnosed and how aggressive the management is. The site of the metastasis also affects the relative morbidity and mortality of the patient. Brain metastasis and thoracic metastasis carries the most morbid prognosis among the other possible sites. Pain symptoms are more pronounced and debilitating in bone metastasis compared to thoracic metastasis that may sometimes remain asymptomatic. Metastasis where the tumor of origin is not identified may be difficult to treat and control which occurs in 3% of all the cases [7].

Etiology

Almost all types of cancer can metastasize including cancers of the blood and the lymphatic system. Primary tumor may metastasize to distant organs by way of the lymphatic system or the blood stream. The formation of the metastatic tumor in the recipient organ will form a clinically detectable cancer which may invade the vascular or lymphatic structures of the new site and metastasize to another site. Primary cancers can spread contiguously to another coelom or compartment which is also known as transcoelomic metastasis. Cancers can also spread to regional lymph nodes and show signs of cancer spread within a solitary or group of lymph nodes. The lymphatic spread of the cancer cells to a nearby lymph node is called transplantation and implantation metastasis [1].

Epidemiology

The actual incidence and prevalence of metastasis a disease is a reflection of the aggressiveness of a given primary cancer. Metastatic tumors to the brain are the most common type of brain tumor in adults [2]. In the case of hepatocellular carcinoma (HCC), intrathoracic metastasis is the most common site of metastasis, followed by abdominal spread, and bone metastasis accordingly [3]. As in the case of pulmonary metastasis, the incidence of its metastasis increased with increasing age. An approximate total of 6 to 10% of invasive breast cancers are initially diagnosed as metastatic or stage IV in classification.

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of metastasis starts with the breaking away of the cancer cells from the primary tumor that attaches to it, or degrades to the extracellular matrix (ECM) which separates the tumor from the normal apposing tissues. Recent researches on cancer have postulated that one of the most critical event involved in the development of metastasis is the development of the new blood vessel network or tumor angiogenesis [4].

In the same way, angiogenesis inhibitors has been successfully determined to prevent the progression of some metastatic processes. The endothelial progenitor cells are critical for the development of metastasis and its angiogenesis [5]. Epigenetic regulations like H3K4 methylation and H3K9 methylation in the histones allows for the proliferation of the disseminated tumor cells in distant organs [6].

Prevention

Metastasis can actively be prevented by the early diagnosis and treatment of the primary tumors. A routine annual bone scan, chest X-ray and ultrasound of the pelvic organs can prevent the progression of some primary tumors to disseminate to distant organs. Regular Pap smear and self-examination of the breast can effectively detect cancers in its very early stages. Slight neurological disturbances merit an early cranial CT scan to detect brain metastasis.

Summary

Metastasis is a medical condition where a cancer cell from a tumor of origin disseminates to another organ not directly related to it. The tumor that is formed by a metastatic cancer cell is known as a metastatic tumor or secondary tumor. The majority of metastatic tumors could not be healed by standard treatment modalities. The primary goal in the treatment of metastatic cancer is to control the neoplasm growth and control the symptoms brought about by its occurrence.

Patient Information

Definition

Metastasis is a clinical process by which cancer spreads from a primary site where it arose to distant locations of the body.

Cause

Metastasis can spread by contiguous spread, lymphatic circulation, lymph node transplantation, and hematogenous spread.

Symptoms

Symptoms largely depend on the site where metastasis has thrived. Lung metastasis presents with hemoptysis and dyspnea, brain metastasis with neurologic signs, bone metastasis with bone pain, and regional lymph node swelling.

Diagnosis

Imaging techniques for the diagnosis of metastasis include X-ray, CT scan, and MRI. Tissue biopsy of the metastasis can determine the origin and the mode of treatment.

Treatment and follow-up

Metastasis are treated with a combination of radiation therapy, chemotherapy, hormone therapy, radiosurgery and debulking surgery.

References

Article

  1. Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Robbins, Stanley L; Cotran, Ramzi S (2005). Robbins and Cotran pathologic basis of disease (7th Ed.). Philadelphia: Elsevier Saunders. 
  2. Fox BD, Cheung VJ, Patel AJ, Suki D. Epidemiology of metastatic brain tumors. Neurosurg Clin N Am. 2011 Jan; 22(1):1-6, v. 
  3. Si MS, Amersi F, Golish SR, Ortiz JA, Zaky J, Finklestein D. Prevalence of metastases in hepatocellular carcinoma: risk factors and impact on survival. Am Surg. 2003 Oct; 69(10):879-85.
  4. Weidner N, Semple JP, Welch WR, Folkman J. Tumor angiogenesis and metastasis—correlation in invasive breast carcinoma. N Engl J Med. 1991 324 (1): 1–8. Doi: 10.1056.
  5. Gao D, Nolan DJ, Mellick AS, Bambino K, McDonnell K, Mittal V. Endothelial Progenitor Cells Control the Angiogenic Switch in Mouse Lung Metastasis. Science 2008 319 (5860): 195–198.
  6. Lujambio A, Esteller M. How epigenetics can explain human metastasis: a new role for microRNAs. Cell cycle 2009 (Georgetown, Tex.) 8 (3): 377–82.
  7. Briasoulis E, Pavlidis N. Cancer of Unknown Primary Origin. Oncologist 1997 2 (3): 142–152.
  8. Coghlin C, Murray GI. Current and emerging concepts in tumour metastasis. Journal of Pathology 2010; 222(1):1–15.
  9. Ramaswamy S, Ross KN, Lander ES, Golub TR. A molecular signature of metastasis in primary solid tumors. Nature Genetics 2003 33 (1): 49–54.
  10. Nguyen DX, Bos PD, Massagué J. Metastasis: from dissemination to organ-specific colonization.Nature Reviews Cancer 2009; 9(4):274–284.

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Last updated: 2019-07-11 22:34