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Colorectal cancer: metastatic patterns and prognosis.

From 1979 to 1982, 163 patients with colorectal cancer were found to have distant metastases. Of these, 112 (69%) had metastatic disease at the time of initial diagnosis (synchronous metastases [SM]); in the remaining 51 (31%) metastases developed during the course of the disease (metachronous metastases [MM]). The liver was the most common site of metastasis in both groups (72% and 65%, respectively); with the exception of brain metastasis, liver metastasis had the worst prognosis (median survival time [MST], 9 months). The MST for other sites of metastasis were: lung, 10.5 months; bone, 10 months; multiple sites, 10 months; and brain, 5.5 months. Of the 81 patients with SM in the liver, 38% were treated with single modality therapy and 62% with combined modality therapy. Thirty-three patients had MM in the liver. The median time for development of liver metastases (metastasis-free interval [MFI]) was 17.5 months; only lung metastases developed faster (12 months). MFIs for other sites were 20, 20.5, and 33 months for bone, multiple sites, and brain, respectively.

Adult↗

Metastatic patterns of prostate cancer: an autopsy study of 1,589 patients.

The prognosis of prostate cancer is mainly determined by the presence or absence of metastases. Nevertheless, the metastatic pathways in prostate cancer are not entirely understood. Among 19,316 routine autopsies performed from 1967 to 1995 on men older than 40 years of age, the reports from those 1,589 (8.2%) with prostate cancer were analyzed. Hematogeneous metastases were present in 35% of 1,589 patients with prostate cancer, with most frequent involvement being bone (90%), lung (46%), liver (25%), pleura (21%), and adrenals (13%). Several lines of evidence suggested the existence of a backward metastatic pathway through veins from the prostate to the spine in addition to classical hematogeneous tumor spread via the vena cava. First, there was an inverse relationship between spine and lung metastases, suggesting that metastasis to the spine is independent of lung metastasis. Second, the maximum frequency of spine involvement occurred in smaller tumors (4 to 6 cm) as compared with the maximum spread to lung (6 to 8 cm) and liver (>8 cm), suggesting that spine metastases precede lung and liver metastases in many prostate cancers. Third, there was a gradual decrease in spine involvement from the lumbar to the cervical level (97% v 38%), which is consistent with a subsequent upward metastatic spread along spinal veins after initial lumbar metastasis. The results of this study show that bone, lung, and liver are the most frequent sites of distant prostate cancer metastases. Besides the cava-type of metastasis through lung passage, there are strong arguments for the existence and clinical significance of a backward venous spread to the spine, which is likely to occur early in the metastatic process.

Adult↗

Cervical lymph node metastatic patterns of squamous carcinomas in the upper aerodigestive tract.

The radical neck dissection specimens of 384 ethnically Chinese patients with different primary squamous carcinomas in the head and neck region were studied. Over 50 per cent of the specimens showed metastatic disease at one level in the neck. For oral cavity carcinoma, the levels of metastasis frequently involved were I, II and III while for carcinoma of the oropharynx, hypopharynx and larynx the levels were II, III and IV. Extracapsular spread was present in 112/384 of patients (29 per cent) and this increased with advancing N-stages. Based on these findings, different selective neck dissections could be used for patients harbouring different primary head and neck carcinomas with limited neck disease.

Carcinoma, Squamous Cell↗

[The metastatic pattern of malignant tumors].

Four hundred autopsy cases of malignant tumors were analysed. Of these 321 cases (80.3%) had carcinoma and 79 (19.7%) sarcoma. In the 79 cases, 65 had malignant lymphoma, and 14 (3.5%) soft tissue and bone tumor. The tumor cells metastatic to the lung and liver were common in the autopsy cases. There were 163 cases of metastatic tumors in the lung and liver respectively (40.5%). The metastatic tumor in the liver was mainly from the breast, large intestinal, ovary, stomach and NHL, and in the lung mainly from the breast, liver, NHL, stomach and ovary. The lymph node metastasis was mainly located in the neck, mediastina, aorta. The extensive metastatic tumors were lung cancer, gastric cancer, breast cancer and NHL, However, carcinoma in uterus cervix, urinary bladder, pharynex and testis was mainly infiltrated in the original region. The tumor metastasis was related to the region, histologic type and differentiation and so on.

Adenocarcinoma↗

[A comparative study of the biological behavior of gastric cancer from the view of the amount of connective tissue in the cancerous tissue--a correlation between the amount of connective tissue and the metastatic pattern].

Differences between advanced gastric cancer of the medullary type (med.: 138 cases) and the scirrhous type (sci: 164 cases) with regard to the amount of connective tissue that was cancerous have been studied clinicopathologically. A correlation was found between med and liver metastasis, and sci and peritoneal dissemination in metastatic types, whereas no correlation was observed in other factors except between med and a localized type, sci and infiltrating type in gross type. The study of tumorigenicity in nude mice showed remarkable difference between med (86.7%) and sci. (0%). These results indicate that there is definite relationship between the amount of connective tissue and the biological behavior of a gastric cancer.

Adenocarcinoma, Scirrhous↗

[Study of vertebral metastasis by MR imaging: significance of T2*weighted image (gradient field echo) and metastatic pattern].

Fifty-one patients with vertebral metastasis were studied by MR imaging. T1 and T2*-gradient field echo (FE) sequences (0.5 Tesla) were performed in all patients. Primary sites were the lung (10 cases), breast (9 cases), colorectal area (9 cases), prostate (7 cases), liver (4 cases) and others. Of the 618 vertebrae evaluated, 315 had metastatic abnormalities, 241 (76.5%) of which showed low intensity on T1-weighted images. High intensity lesions on T2* weighted images were seen in 301 vertebrae (95.5%). Concerning the distribution of metastatic lesions, lumbosacral vertebrae were the most common sites, with the thoracic spine second in frequency. No significant difference was noticed between these primary sites. A total of 244 metastatic lesions occupied most of the vertebral body, 49 of which were accompanied with epidural tumors. Seventy-one small lesions were considered early metastasis, two-thirds of which were located in the metaphysis of vertebrae. No epidural tumors were seen in this group. These findings suggest that the main route for metastatic cancer cells to the vertebrae is the systemic circulation rather than the vertebral venous system.

Adult↗

Invasive carcinomas of the male breast: a morphologic study of the distribution of histologic subtypes and metastatic patterns in 778 cases.

The current investigation was conducted to evaluate the proportional distribution of the various histologic subtypes (including newly recognized variants) of male breast carcinomas, to determine whether any histologic subtypes occur with a frequency that is markedly discordant with the expected frequencies from published data on parallel female breast tumors. We also aimed to document the distribution of malignancies metastatic to the breast. Seven hundred fifty-nine archived cases of primary invasive carcinoma involving the male breast were retrieved and sub-categorized into histologic subtypes according to contemporary criteria. Six hundred forty-three (84.7%) tumors were pure infiltrating ductal carcinoma (IDC) not otherwise specified. The most common of the remainder included papillary carcinoma with invasion in the form of IDC (n = 34), mixed IDC and mucinous carcinoma (n = 26), and pure mucinous carcinoma (n = 21). In 19 cases, metastases from other sites involved the breast, most commonly (58%) cutaneous melanoma. Invasive carcinoma of the male breast appears to display a morphologic spectrum and distribution of histologic subtypes that is comparable to those of the female breast, with some expected variation. Compared with published experience on their female counterparts, there is a two-fold increase in the frequency of invasive papillary carcinoma in the male breast. Finally, the most common tumor metastatic to the male breast in this series was cutaneous melanoma.

Adolescent↗

Metastatic pattern and response to endocrine therapy in human breast cancer.

The effect of endocrine therapy in 465 postmenopausal patients with advanced breast cancer who entered four consecutive, randomized trials has been related to the site of the metastases. Patients received either tamoxifen (T) alone or T in combination with medroxyprogesterone acetate, diethylstilbestrol, halotestin, or aminoglutethimide. The overall response rate was 40%. Responses were most frequently seen in patients with metastases in soft tissue, and the duration of response to endocrine therapy in these patients was longer than for those with metastases in bone or viscera (p less than 0.00001). In addition, the response rate was inversely correlated with the number of main metastatic sites in patients with soft tissue metastases, whereas the response rate was not associated with the number of metastatic sites in patients with metastases in bone and viscera. Survival after first recurrence was significantly longer in responding patients with soft tissue lesions compared to those with recurrence in bone or viscera. In contrast, survival after first recurrence was identical in patients with nonresponding disease, irrespective of dominant site of metastases. The outcome of endocrine therapy depends partially upon the dominant site of metastases. This may reflect a difference in biological characteristics of human breast cancer tumor cells that metastasize to different sites.

Aminoglutethimide↗

Early metastatic patterns and survival in malignant melanoma.

Two hundred fifty patients with distant metastasis from malignant melanoma were analyzed at the first appearance of systemic metastasis. Commonly involved sites were lung, subcutaneous tissue, brain, and liver. Frequency of liver metastasis was higher with eye and mucous membrane primary sites (P less than 0.01). Liver involvement had the worse survival compared to lung and brain. Patients with mucosal or unknown primary sites had decreased survival compared to other sites (P less than 0.01). Patients with primary melanomas thicker than 4 mm had significantly shorter survival (P less than 0.02). Single-organ involvement correlated with longer survival compared to multiple-organ involvement (P less than 0.04). Survival of metastatic disease was more favorable in patients with involvement of subcutaneous tissue only and in those with a disease-free interval of 2 years or longer. Five-year survival from first appearance of metastasis was 7% and median survival was 8 months.

Humans↗

Role of immune mechanisms in metastatic patterns of hemopoietic tumors in rats.

Two hemopoietic tumors induced in rats by Gross leukemia virus and dimethylbenz(a)anthracene, respectively, display distinctive and consistent patterns of metastases, the former in the thymus and lymph nodes, the latter in the liver and spleen. To investigate the role of circulatory anatomy in the localization of metastases, 51Cr-labeled cells were injected i.v., and their distribution was followed at various intervals. To explore the influence of immune mechanisms, Gross leukemia virus- and dimethylbenza(a)anthracene-induced leukemic cells as well as a line of antigenically modulated cells were administered to newborn, X-irradiated, and immunologically unresponsive recipients. The circulation of tumor cells through various organs was indiscriminate. The immune response of the host was operative in limiting the local and metastatic tumor growth but not in determining the site of secondary tumors. The conclusion of these experiments was that the selective organ distribution of tumor metastases was solely dependent on intrinsic cellular properties.

9,10-Dimethyl-1,2-benzanthracene↗

Bone metastases in vulvar cancer: a rare metastatic pattern.

Bone metastases from a vulvar carcinoma are exceptionally rare with only five reported cases in the literature. We report on a patient who was initially treated with radical vulvectomy and bilateral inguinal lymphadenectomy for a vulvar cancer (pT2, pN2 (6/37), M0; G2). Due to a positive nodal status, adjuvant radiation of the vulva and the pelvis was performed additionally. The patient presented 4 months after initial therapy with severe pain in the right humeral shaft due to a pathologic fracture based on an osteoclastic metastasis. During osteosynthetic stabilization histologic and immunohistochemical stain gave evidence of a metastasis of the known vulvar carcinoma. Bone scan showed enhancements in both humeral heads as well as the right distal femur, whereas plain radiographs confirmed further metastases in all suspected areas. In conclusion, bone metastases should be considered in the differential diagnoses of unclear osseous pain in women with a history of vulvar cancer. Immunohistochemical examinations might be important to depict the epithelial character of the tissue and allude to the metastatic nature of such rare lesions. The atypical location should alert the physician to suspect distant metastasis, rather than locoregional disease.

Aged↗

Metastatic patterns of lung cancer visualized live and in process by green fluorescence protein expression.

We demonstrate here the visualization of human lung cancer metastasis live and in process in nude mice by green fluorescent protein (GFP) expression. The human lung adenocarcinoma cell line Anip 973 stably transfected with the humanized GFP-S65T cDNA was selected for very bright green fluorescence. GFP-transfected lung cancer cells were initially inoculated subcutaneously in nude mice. Five weeks after transplantation, the resulting tumor had reached over 1 cm in diameter and had very bright GFP fluorescence. Fragments of subcutaneous tumor were implanted onto the visceral pleura of the left lung of nude mice by surgical orthotopic implantation (SOI) of histologically-intact tissue via transverse thoracotomy. The ipsilateral resulting tumor was highly fluorescent due to GFP expression. GFP expression allowed the visualization of the advancing margin of the ipsilateral tumor into the fresh normal lung tissue. Lymphogenous and direct-seeding metastases in the pulmonary hilum, cervical lymph nodes, the mediastinum and contralateral pleural cavity and contralateral lung in the SOI-treated mice were brightly visualized by GFP expression in fresh tissue. GFP-transfected and untransfected tumor had similar metastatic characteristics suggesting that GFP expression had no effect on metastasis itself. The results with the GFP-transfected tumor cells, combined with the use of SOI, demonstrate a fundamental advance in the visualization and study of lung cancer metastasis in process.

Adenocarcinoma↗

Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved.

Prostatic cancer in 1885 autopsy cases was classified according to the number of organs involved in metastasis, and a comparison was made concerning the frequency of metastasis to the various organs. The frequencies of metastasis to the lungs and para-aortic lymph nodes were low in cases with single-organ involvement (4.6% and 2.3%, respectively), but increased rectilinearly in accordance with the number of organs involved and became high in cases with metastasis to three or more organs (49.1% and 21.8% in total, respectively). On the other hand, the frequencies of local extension to the bladder and invasion of the pelvic lymph nodes were high even in cases with single-organ involvement (34.5% and 9.2%, respectively) and were not significantly changed regardless of the number of organs involved. No significant correlation was seen between pelvic and para-aortic lymph node involvement. In cases with single-organ involvement, metastasis to the lumbar spine occurred frequently, but those to the ribs, sternum, and ilium occurred less frequently. There may be multiple metastases in cases with metastases to the para-aortic lymph nodes, sternum, and ilium. The number of metastatically involved organs is useful in analyzing the mode of metastasis.

Aged↗

Endothelial expression of vascular cell adhesion molecule-1 correlates with metastatic pattern in spontaneous melanoma.

OBJECTIVE: Adhesive interactions between tumor cell surface receptors and endothelial cell adhesion molecules are thought to contribute to tumor cell arrest and extravasation during hematogenous metastasis. Recent reports suggest that melanoma cell integrin alpha4beta1 (very late antigen-4, VLA-4) interaction with the inducible cell adhesion molecule, vascular cell adhesion molecule-1 (VCAM-1), is critical for tumor cell arrest. However, no information is available regarding microvascular VCAM-1 expression during spontaneous melanoma metastasis. The objectives of this study were to evaluate VCAM-1 expression in pulmonary and extrapulmonary vascular beds during melanoma progression, and to determine whether there is an organ-specific profile for VCAM-1 expression which corresponds with the clinical pattern of melanoma metastasis. METHODS: The dual-radiolabeled monoclonal antibody (mAb) technique for quantification of VCAM-1 in different vascular beds was applied to a physiological model of melanoma (B16-BL6) metastasis. Measurements of VCAM-1 were obtained when primary tumors reached 5 mm in size, and every 7 days following removal of the primary lesion. Histological examinations were performed, and mice were placed into 2 groups, based on the presence (+colonies) or absence (-colonies) of pulmonary metastases. VCAM-1 measurements obtained from several organ systems were then compared between these 2 groups of mice. Localization of VCAM-1 was achieved through immunohistochemical staining of tissues. Plasma collected from each experimental animal, as well as melanoma-conditioned media, was assayed to determine levels of the cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin-1alpha (IL-1alpha). RESULTS: Data collected from the dual-radiolabeled mAb technique indicate that 3 weeks following removal of the primary lesion, there is a tendency for VCAM-1 expression to increase in cardiac, hepatic, and cerebral vascular beds. Four weeks following primary resection, when pulmonary metastatic burden was maximal, VCAM-1 was significantly upregulated in each of these vascular beds. Results obtained from the lung indicate that VCAM-1 remains unchanged in pulmonary vessels at all time points examined. Immunohistochemical staining of heart and brain support the radiolabeled mAb measurements, and reveals that these organs exhibit an inflammatory phenotype in mice with heavy pulmonary tumor burden. Furthermore, 25% of these mice had histological evidence of melanoma metastases in heart and brain. Transplantation of liver fragments from mice with advanced pulmonary metastases into subcutaneous tissue of donor mice resulted in the formation of melanotic outgrowths. Plasma levels of the cytokines TNF-alpha and IL-1alpha were negligible in both groups of mice. CONCLUSIONS: Our results indicate that upregulation of VCAM-1 is not a prerequisite for the formation of pulmonary metastases during spontaneous melanoma metastases. However, once lung metastases become well established, organ-specific increases in VCAM-1 expression become apparent. Furthermore, these organ-specific increments in VCAM-1 expression correspond with documented clinical patterns of melanoma metastasis. The enhanced expression of VCAM-1 is independent of systemic levels of TNF-alpha and IL-1alpha, but may be the result of melanoma-induced alterations at the local level, as we found evidence of melanoma cell occupation in heart, brain, and liver in pulmonary metastases-bearing mice.

Animals↗

Influence of S-phase fraction on metastatic pattern and post-recurrence survival in a randomized mammography screening trial.

Using static cytofluorometry, S-phase was determined on the primary tumors of 421 patients with breast carcinomas in stages I-III diagnosed 1981-85 during the second and third screening rounds of a randomized trial evaluating the effect of mammographic screening. Through December 1988, 82 patients had developed local and/or distant recurrence, 51 of whom had died of cancer during the same period. The distribution among sites of recurrence differed between patients with tumors detected by mammography screening and cancers diagnosed due to clinical symptoms. The mean S-phase fraction was highest in patients with liver or brain metastases and lowest in patients with metastases in subcutaneous and cutaneous tissue and lymph nodes only. In univariate analysis, survival after first recurrence was significantly associated with the site of primary recurrence, the disease-free interval, and node status and tumor size at diagnosis, as well as the S-phase level. The median survival period was 31.3. months for patients with a S-phase fraction below 6%, and 10.7 months in cases with S-phase exceeding 10%. Neither ploidy nor the estrogen receptor content had significant influence on post-recurrence survival. In Cox's multiple regression analysis, only metastatic site, disease-free interval, and S-phase fraction showed significantly independent prognostic value.

Breast Neoplasms↗

The metastatic patterns of osteosarcoma.

The paper presents a detailed comparison of the anatomical distribution and frequency of clinically evident metastases in 152 cases of osteosarcoma, and autopsy findings in 43 cases. The behaviour of long bone tumours is contrasted with those arising elsewhere, which tend to metastasize less widely because of early death from effects of the primary tumour. In both clinical and autopsy series long bone tumours produced lung metastases (LM) in over 90% of patients dying with metastases, but the terminal frequency of extra-pulmonary metastases (EPM) rises from a clinical level of 33% to 83% at autopsy. There was little difference between tumours of the major long bones in the frequency of either LM or EPM, but EPM from the humerus tended to be fewer and sited above the diaphragm and from the femur below it. EPM most often involved other bones, notably vertebrae and pelvis. Not more than 10% of tumours invaded regional lymph nodes but terminally a quarter of the long bone tumours had metastasized to heart and abdomen. The infrequency of metastases in muscle was confirmed. The median time for LM was 5-6 months after starting treatment, for EPM 9-10. months. First metastases after 24 months were infrequent, especially in children. With delay in the appearance of metastases, whether LM or EPM, post-metastatic survival lengthened. Neither age, sex nor mode of treatment of the primary notably affected metastatic frequency, although recurrences were much more numerous when radiotherapy, even with high dosage, was the definitive treatment. Local recurrence usually appeared within 6-8 months and was shown to lead to increased frequency of osseous metastases. It is suggested that terminal dissemination may often be tertiary but not always from a pulmonary secondary.

Adolescent↗

Metastatic patterns in soft-tissue sarcomas.

In 242 patients with recurrent soft-tissue sarcomas, the most common sites of initial recurrence were the primary site in 47.5% of patients and the lungs in 38% of patients. Further recurrences in the course of the disease concerned the lungs, bones, liver, and brain. Total survival and survival after recurrence were influenced by the histologic type, which also affected the site of recurrence. In the management of local recurrence, a five-year disease-free survival rate of 38% was achieved with surgical treatment, while radiation or chemotherapy alone was ineffective. Local recurrences resulted in significantly higher survival rates than those involving other organs. The disease-free interval was a significant prognostic indicator of subsequent survival in the whole group of patients and among those with local recurrence.

Adolescent↗

Metastases to the retroperitoneum in patients with extremity soft tissue sarcoma: an unusual metastatic pattern.

BACKGROUND: Extremity soft tissue sarcoma (STS) metastasizes preferentially to the lungs via the hematogenous route. Metastases in extrapulmonary sites such as bone, brain, and subcutaneous tissues are observed less frequently. To the authors' knowledge, limb STS primarily metastasizing to the retroperitoneum has not been described to date. The current study reviews the clinical course, management, and patient prognosis in such a pattern of metastasis. METHODS: Records of patients with retroperitoneal metastases originating from an extremity STS between 1994-1998 were reviewed. Patient demographics, primary tumor site, other tumor sites, local recurrence, distant metastasis, treatment, and survival were analyzed. RESULTS: Ten patients were included in the study. All had primary STS of different histologic types and high histologic grade confined to a lower limb. The retroperitoneal metastases were diagnosed between 6-120 months (mean, 45 months) after diagnosis of the primary sarcoma. At that time, one patient had evidence of local recurrence of the primary tumor site, two patients had lung metastases, and one patient had diffuse bone metastases. Eight patients were eligible for surgery. In six of these patients the metastases were excised completely. The median follow up was 12 months. Of the six patients who underwent complete resection, 3 were alive at last follow-up with no evidence of disease after 12 months, 14 months, and 24 months, respectively. Two patients with recurrent retroperitoneal disease and one patient with retroperitoneal and lung metastases died despite systemic chemotherapy. CONCLUSIONS: Extremity STS can metastasize hematogenously to the retroperitoneum, a fact that mandates a high index of suspicion and abdominal imaging studies during the follow-up of such patients. Retroperitoneal metastases necessitate aggressive surgical resection to enable prolongation of survival.

Adult↗