Hematogenous metastasizes:

On the other hand, sarcomas do not like to go to lymph nodes. They go right through BV’s  and are characterized by hematogenous spread, and that’s why lungs and bones are common sites of sarcomas.  They don’t like to go to lymph nodes.  Therefore, they are a  little worse b/c they immediately go hematogenous, and do not give a clue that they are spreading. Example: have angiosarcoma of the breast; would you do a radical dissection of the axilla? No, b/c angiosarcoma does not go to the lymph nodes, therefore, do a simple mastectomy. If it is breast carcinoma, take breast and lumpectomy and local axillary lymph nodes and complete the dissection.

Exceptions: Follicular carcinoma of the thyroid (thinks it’s a sarcoma) – skips lymph nodes and goes straight to BV’s, and takes the hematogenous route.

37. Vascular invasion-follicle carcinoma of the thyroid

Renal adenocarcinoma – goes to renal veins (also determines prognosis) Hepatocellular carcinoma – always like to attack the vessels

In general, carcinomas 1^st like to go to lymph nodes, and the have the potential to become hematogenous. Sarcomas go hematogenous, making them dangerous.

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C. Seeding: Classical Example: cancers that are in cavities and have a potential of seeding, like little malignant implants. Most ovarian cancers are surface derived cancers, therefore derived from lining around the ovary, and they seed like little implants. Therefore, easy to throw out these implants and for it to metastasize to the omentum, and into the pouch of Douglas. The pouch of Douglas is posterior to the uterus and anterior to the rectum and is felt by digital rectal exam. The pouch of Douglas is to a woman, as the prostate gland is to the man. If you do a rectal on a man, and push forward, you will feel the prostate. If you do a rectal on a woman and push forward, this is the pouch of Douglas. This is an imp area b/c it’s the most dependent area of a woman’s pelvis and many things go here – clotted blood in a rupture ectopic pregnancy, where endometrial implants go in endometriosis, and where seeding goes in ovarian cancers (pouch of Douglas). So, seeding of ovarian cancer to the omentum and can actually invade. Can also seed in the pleural cavity, for example:

peripherally located lung cancer that can seed into the pleural cavity. GBM (MC primary malignancy of the brain in adults) can seed into the spinal fluid and implant into the entire spinal cord, as can a medulloblastoma in a child.

36. Omental seeding

So, the 3 mechanisms for metastasis are lymphatic, hematogenous, and seeding.

VII. Most Common (MC) cancers

The first question is to ask: “Is the metastasis more common than primary cancer?” 

In most cases, metastasis is the MC cancer in an organ (not a primary cancer). Exception:

renal adenocarcinoma (which is more common than metastasis to it).

Lung: MC cancer is metastasis from the breast cancer. Therefore, MC cancer in the lung is breast cancer. Therefore, women are more likely to get lung cancer.

Bone: MC cancer in bone is metastasis (not multiple myeloma or osteogenic sarcoma). MC cancer that metastasis to bone is breast cancer b/c the batsom system; it is a venous complex going from base of the skull down to the sacrum, and has no valves in it. The little tributaries communicate with the vena cava and also go right into the vertebral bodies. Then they collect around the spinal cord and go up. For example: a lady has a little plug of tumor in the

intercostal vein, and bends down to pick up something off the ground, which causes the cancer to be dislodged from the vein to the vena cava to the batson plexus in the vertebral bodies, and 3 months later she is complaining of lower back pain. All of a sudden, she is stage four cancer.

MC bone metastasis TO the vertebral column. 2^nd MC is the head of the femur (in a woman, this is due to breast cancer – ie breast cancer in head of femur, when they thought it was degenerative arthritis).

MC organ metastasis to = lymph nodes (carcinomas are more common than sarcomas, and carcinomas like to go to lymph nodes, meaning it is the MC metastasis to)

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Liver: MC cancer of liver = metastasis from lung into liver (not colon – colon is 2^nd b/c portal vein drainage).

Testicular Cancer: Where would testicular cancer metastasize first? Paraortic lymph nodes;

NOT the inguinal lymph nodes b/c it derived from the abdomen, and then descended.

Example: seminoma (malignant) will metastasize to paraortic nodes b/c that is where it came from

Left supraclavicular node, aka Virchow’s node. The MC primary metastasize to Virchow’s  nodes = stomach cancer! There is a mass in the left supraclavicular nodes along with wt loss and epigastric distress.

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Bone: Best test looking for bone mets? Radionucleide scan. Example: everywhere that is black in a woman is mets from breast cancer. MC bone metastasis to = vertebral column!

Mets that are lytic (break bone down) and mets that are blastic (mets go into bone and induce osteoblastic response).

A. Lytic Metastasis:

For lytic mets, they can lead to pathologic fractures and hypercalcemia.

Multiple myeloma with punched out lesions b/c all malignant plasma cells have IL-1 in them (aka osteoclast activating factor)

39. Osteolytic metastasis B. Blastic metastasis:

For blastic mets, alkaline phosphatase will be elevated. Example: this is a male with prostate cancer (prostate cancer is blastic!); it is making bone and will release alkaline phosphatase

38. Osteoblastic metastasis

MC location for mets = lumbar vertebrae

Example: 80 y/o man with lower lumbar pain with pt tenderness; what is first step in management? Digital rectal exam would be the first thing to do b/c this would be stage four dz, and the prostate is palpable; so, this is the easiest and cheapest test (not PSA, or radionucleide bone scan to make sure its not mets).

Lytic mets – have lucency (absence of bone) – ie vertebrae collapse Blastic mets – have entity on x ray

If you see any specimen with multiple lesions in it, it is METS (primary cancers are confined to one area of the organ).

MC cancer brain = mets

MC cancer killer in men and women = lung cancer MC primary site for cancer in brain = lung

MC cancer in lung = mets from breast

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MC mets to adrenal = lung – therefore they always do a CT of the hilar lymph nodes, and adrenal glands in the staging of all lung cancers.

Bone = blastic, therefore the most likely cause is prostate cancer.

VIII. Stains and EM used to help dx dz:

Stains: desmin – good stain for muscle – ie used for rhabdomyosarcoma Stain for keratin (most carcinomas have keratin in it, therefore stain for that) Stains help ID diff types of tumors

Vimentin- mesenchymal cells EM: Used when nothing else helps

Auput tumor – see neurosecretory granules.

Histiocyte tumor (ie histiocytosis X) – see birbeck granules, with CD 1 Muscle – see actin and myosin filaments

Vascular malignancy – Wibble palad bodies (have vWF in them); they are of endothelial origin Know gap junc (which communicate, which don’t)

IX. Oncogenesis:

In document Goljan Lectures Notes Part 1 (Page 69-73)