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Key Features

Essentials of Diagnosis

  • Identification of a primary cancer

  • Radiographic findings consistent with pulmonary spread from the cancer (eg, nodules)

  • Exclusion of other diseases in the differential diagnosis of multiple pulmonary nodules

General Considerations

  • Represent metastases from extrapulmonary malignancies

  • Almost any cancer can spread to the lung, usually hematogenously via the pulmonary artery

  • Lung metastases are found in 20–55% of patients with various metastatic malignancies

Clinical Findings

Symptoms and Signs

  • Symptoms are uncommon, but include cough, hemoptysis, and dyspnea in advanced cases

  • Symptoms are most commonly referable to the primary tumor

Differential Diagnosis

  • Bronchogenic carcinoma

  • Lymphoproliferative cancer

  • Tuberculosis

  • Lung abscess

  • Granulomas (eg, tuberculous, fungal)

  • Coccidioidomycosis

  • Histoplasmosis

  • Sarcoidosis

  • Silicosis

  • Coal worker's pneumoconiosis

  • Mycobacterium avium complex

  • Arteriovenous malformations

  • Rheumatoid nodules

  • Hamartomas

  • Granulomatosis with polyangiitis

  • Methotrexate-induced

Diagnosis

Laboratory Tests

  • Appropriate studies should be ordered in a search for the primary tumor

  • Occasionally, cytologic studies of pleural fluid or pleural biopsy are diagnostic

Imaging Studies

  • Chest radiograph usually shows multiple spherical densities with sharp margins

  • Lesions are usually bilateral, pleural, or subpleural and are more common in lower lung zones

  • CT imaging of the chest, abdomen, and pelvis may reveal the site of a primary tumor and will help determine feasibility of surgical resection of the metastatic lung tumors

  • PET-CT scan is helpful in identifying the site of a primary cancer or identifying other areas of extrathoracic metastasis

  • Mammography should be performed in a search for the primary tumor

Diagnostic Procedures

  • If a primary tumor cannot be found, tissue from lung lesions may be obtained by bronchoscopy, percutaneous biopsy, or thoracotomy

Treatment

Surgery

  • Resection of a solitary pulmonary nodule is often prudent in a patient with known current or prior extrapulmonary cancer

  • Local resection of one or more pulmonary metastases is feasible in a few carefully selected patients with various sarcomas and carcinomas (such as testis, colorectal, and kidney)

  • Only about 15–25% of patients with metastatic solid tumor have metastases limited to the lungs and are therefore surgical candidates

  • Surgical resection should be considered only if

    • The primary tumor is under control

    • The patient has adequate cardiopulmonary reserve to tolerate resection

    • All metastatic tumor can be resected

    • Effective nonsurgical approaches are not available

    • There is no evidence of extrathoracic metastases that are not controlled or controllable

  • Patients who are not surgical candidates but have solitary or limited metastatic disease to the lungs may be candidates for stereotactic radiosurgery, radioablation or cryotherapy

  • Repeat surgery for pulmonary metastases can be performed as long as the criteria for pulmonary metastatectomy are still met

Therapeutic Procedures

  • Management consists ...

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