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Multiple Lesions
Multiple discrete lung lesions occur due to widely disseminated
hematogenous metastasis.
The pattern can vary from:
diffuse micronodular shadows resembling miliary disease, or
to multiple large well defined masses cannon balls.
Occasionally, cavitation or calcification can be noted.
Symptoms:
Due to the interstitial location, these lesions are often asymptomatic.
Cough and hemoptysis are the usual symptoms.
Needle aspiration or transbronchial biopsy would be the procedure of
choice for confirmation of the nature of the lesion.
Treatment:
Chemotherapy is the choice when the tumor is responsive.
Occasional surgical resection of multiple lesions were attempted with
some reported success.
In refractory hemoptysis, selective occlusion of bronchial arteries by
Teflon is a consideration.
Cannon Balls:
Neoplasms 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
Renal cell carcinoma
Sarcoma of the bone
Trophoblastic disease
Cavitating Lesions:
Pleural Effusion
Pleural 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 extensive underlying lung and systemic
metastases.
Most patients expire within three months.
Malignant effusions account for more than 50% of exudative pleural
effusions.
Lung, breast, stomach and ovary account for 81% of cases.
Pleural biopsy and fluid cytology establish the malignant nature of the
process.
Pleural sclerosis with tetracycline instillation is the palliative procedure
of choice in problem effusions.
Pleural Masses
Significant pleural masses can exist without recognition (as in the
adjoining CXR), even in the absence of pleural effusion.
Iatrogenic pneumothorax facilitates visualization of pleural masses.
CT scan can reveal pleural masses that are not seen on routine x-rays.
Thymoma, multiple myeloma and cystadenocarcinoma lung are
reported to give such a metastatic pattern.
Spontaneous pneumothorax
Pneumothorax occurring secondary to pulmonary metastasis is rare.
This mode of presentation occurs secondary to necrosis of subpleurally located metastas
Cavitating sarcoma is reported to present in this manner.
In some instances, the subpleural metastases are not sufficiently large enough to be reco
Conclusion
Lung metastases occur in approximately 30% of malignant disease
cases.
Frequently, it is the presenting manifestation and search for the primary
is lengthy and cumbersome.
The roentgen patterns of thoracic metastases vary. Awareness of the
common primaries presenting with a metastatic pattern facilitates the
search for the source.
The venous and lymphatic drainage of the organ and the cell type are
some variables that seem to determine the metastatic pattern.
Each metastatic pattern has a unique clinical presentation because of
its locale and extent.
Each pattern raises a distinct differential diagnosis, differs in the best
diagnostic procedure and the choice of therapeutic modality.