I- Overview :
It is a common condition, donning radio-clinical tables of great disparity, a very poor prognosis with limited therapeutic options.
All cancers can metastasize to the lungs in order of decreasing frequency of the sphere ENT cancers, to be, you pure, colon and rectum…
II- Epidemiology :
The main tumors associated with lung metastases are as follows :
Board 1 – Origin of pleuropulmonary metastasis
III- Physiology :
The 03 propagation paths secondary cancers are :
1- Spread by contiguity : the esophageal cancer can reach the trachea and the left main bronchus. Breast cancers and sub-diaphragmatic cancers can reach the pleura and lung by contiguity.
2- Spread through blood : many tumors drain into the pulmonary capillary filter and metastasize readily in the lung.
Other drain into the capillary filter of another member for example the door system for gastrointestinal tumors or ovarian. In that case, neoplastic cells preferably embolize in the first site is the liver and the lung secondarily.
3- Spread via the lymphatic : It is sometimes the only way followed in digestive tumors and of course bronchial tumors themselves.
The route is mostly : lymphatic, thoracic duct, then intravenously.
Diffuse invasion gives the particular aspect of lymphangitis carcinomatosis.
IV- positive diagnosis :
– In 25% cases of these cancers are systematic radiological discovery.
– The secondary cancer can be discovered on the occasion of an abundant and recurrent pleurisy or pulmonary disease persistent and recurrent.
Clinical signs :
– respiratory functional signs : exertional dyspnea, hoarse cough persistent, chest pain and testifying to the parietal pleural invasion, rarely hemoptysis.
– Extra pulmonary symptoms may be related to a primary cancer : costal or vertebral bone pain, device ADP.
– Clinical examination : can be normal, sometimes found a condensation syndrome parenchymal pleural effusion, or exceptionally pneumothorax .
complete physical examination is essential with a general review : lymph nodes, thyroid. His, prostate, testicle, foie, rate…
radio-clinical forms :
1- nodular form : may be single or multiple.
Especially primary lung cancer.
– Nodules multiples : classic appearance balloon release, the evolution of this form is quick to end-asphyxiation.
2- reticulonodular form : 2 forms :
A- Lymphangite carcinomateuse : Lung lymph are packed with neoplastic cells, it plays a reticular form pure.
Clinique :dyspnea + cyanose + hippocratisme digital.
Diagnosis is made by bronchial biopsy and histology.
B- Miliaire carcinomateuse : nodules 1-3 mm, extending fact databases to vertices, it exists 3 clinical stages of this form :
1- stage clinical latency : symptomatic.
2- stage of symptomatic dyspnea.
3- stage of asphyxia.
From the 2th stade, dyspnea is usually increased by the existence of an abundant pleural effusion.
3- Forme infiltrative : opacity sparse track on vague limits and extension hilifuge.
4- atelectatic form :
5- pleural form : abundant pleurisy, painful recurrent ; the pleural liquid is sérohématique or sérofibrineux, neoplastic cells can be detected in this fluid, pleural biopsy performed sometimes in pleuroscopy allows the diagnosis.
6- mediastinal form : bulky ADP médistinal seat can cause bronchial irritation with dry coughs, recurrent laryngeal compression or superior vena cava syndrome.
DIAGNOSTIC APPROACH :
1- Bronchoscopy : it is important to multiply biopsies to obtain the maximum sampling to increase the chances of getting a diagnosis. We can therefore :
- biopsied budding mucosa which is uncommon.
- biopsied mucosa healthy especially if there is an aspect of "big folds" suggestive of lymphangitis.
- making biopsies and / or transbronchial guided by fluoroscopy.
- finally , cytological studies can be very helpful and should address the bronchial aspirate or better on the product of alveolar washing done in the suspect area.
2- The transmural puncture : percutaneous puncture guided by the scanner is particularly advantageous when the mass and the peripheral.
3- Aspiration and biopsy : in case of pleurisy are also informative exams.
4- thoracotomy : it may be indicated if all previous tests are negative and can set a time in the diagnosis and treatment by excision for some types of cancer.
DIAGNOSTIC STRATEGY :
1- For lymphangitis carcinomatosis :
– biopsies, or transbronchial.
– value LBA with cytology.
2- For nodules :
– Biopsies fiberoptic first line..
– transthoracic needle biopsy if negative biopsies at endoscopy.
V- Differential diagnosis :
it is essentially X-ray :
1- before bronchial forms : discuss : a primary lung cancer.
2- front unique shapes : discuss the diagnosis of intra single parenchymal opacities round (hydatid cysts, tuberculome,benign tumor).
3- to multiple forms : multiple hydatid cysts, ataphylome, tuberculome multiple.
4- front forms miliary : pneumoconiosis (especially silicosis), miliary tuberculosis,sarcoïdose, miliaire cardique…
5- front forms pleural : discuss all pleurisy or sero-hematic sérofibrineuses.
6- front forms mediastinal : ADP mediastinal hematological malignancies, tuberculosis,sarcoïdose.
WE- Treatment :
Symptomatic treatment : depending on the clinical form of metastasis.
1- Pleurisy :
Liquid : evacuation, corticosteroids, symphyse (pleuroscopy or surgery).
pains : painkillers (the 3 pliers).
2- lymphangitis neoplastic – miliary – balloon release(f. bilateral) :
ineffective steroids, Oxygen temporary efficiency, anxiolytics and opiates.
3- The bronchial stenoses :
Surgery if possible, Local gesture sometimes (laser / cryothérapie / radiotherapy / prosthesis) palliative treatment (corticosteroids, antibiotics… ).
4- single opacity :
The recommended surgery when prolonged interval between primary and metastasis, tumor in shoulder, slow running (sarcoma, rein, colon…) Surgery can even when multiple lesions. Surgeries often iterative. The surgery of metastases will be thrifty (wedge resection).
Etiological treatment depending on the hormone sensitivity or alleged chemosensitivity of primary tumor
– His : tamoxifen or other hormonal trt, chemotherapy
– Prostate : anti-androgen agonist LHRH
– thyroid : iodine 131
– Digestive tract : 30 % responders to chemotherapy
Metastases do not always have the same sensitivity as the primary tumor ; prior chemotherapy suggests a less good activity during the relapse or metastasis.
Treatment surgical :
Note especially rare in some cases metastases in single and mass device without locoregional invasion and when the primary tumor is surgically treated effectively.
VII- Prognosis :
– Overall some forms have a lightning evolution and others have very limited changes (metastasis of colon cancer)
– The average survival after finding untreated pulmonary metastases is 9 at 11 month. The prognosis is better in some cases and can be improved by chemotherapy, hormone therapy or surgery.
Course of Dr Kherbi – Faculty of Constantine