Patterns of tumour spread

Patterns of tumour spread

INITIAL COMMON PATTERNS OF TUMOUR SPREAD

Local spread	• Mediastinal invasion chest wall invasion brachial plexus invasion (Pancoast’s tumour)
Lymph node spread	• Hilar and mediastinal nodes are often present at diagnosis • Spread is usually sequential: ipsilateral peribronchial (± ipsilateral) hilar and intrapulmonary nodes (N1) > ipsilateral mediastinal (± subcarinal) nodes (N2) ipsilateral mediastinal (± subcarinal) nodes (N3)
Haematogenous spread	• Liver > adrenal > brain > bone > kidney Adrenal mass < 2cm: likely adenoma Adrenal mass > 2cm: likely metastasis
PEARL	• Squamous cell tumours are the least likely type to metastasize SCLCs have usually metastasized at presentation

Local spread	• Local spread into adjacent structures (e.g. pancreas, colon, spleen)
Lymph node spread	• Perigastric: pericardial lesser curvature greater curvature suprapyloric • Extraperigastric: left gastric common hepatic coeliac splenic hilum and artery hepatic pedicle retropancreatic mesenteric root middle colic para-aortic • NB: retropancreatic, para-aortic and mesenteric nodes are classified as M1 metastatic disease
Haematogenous spread	• Via the portal vein to the liver (25% at presentation) a similar number will have peritoneal metastases
PEARL	• Transcoelomic spread can occur through the peritoneum (e.g. Kruckenberg tumours)

Local spread	• Early local invasion of adjacent structures due to lack of a serosal barrier – therefore usually at an advanced stage at diagnosis
Lymph node spread	• Involved nodes are usually at the same level as the tumour • Oesophageal lymphatics tend to course longitudinally, however ‘skip’ nodal involvement can occur Cervical oesophagus: cervical and supraclavicular nodes Upper and middle third: mediastinal nodes Lower third: lower medistinal, left gastric, coeliac, and para-aortic nodes
Haematogenous spread	• Common (tumour has easy access to lymphatics and blood vessels) • Liver > lungs > bone > kidney > brain

Local spread	• Invasion through the bowel wall into the perirectal fat – an important predictor of local recurrence and survival • Extramural venous invasion is an adverse prognostic factor
Lymph node spread	• From the level of the tumour cranially within the mesorectum – proximal blockage (e.g. extensive adenopathy) may cause retrograde spread with lower rectal tumours rarely spreading to the inguinal nodes • Pelvic side wall spread is unusual
Haematogenous spread	• Liver (via the portal vein)
PEARLS	• Involvement of the circumferential resection margin (CRM) is an adverse prognostic feature (including disruption during surgery) • Perforation of the peritoneal membrane can result in transcoelomic spread as well as an increased risk of recurrence • Transcoelomic spread favours the lower right small bowel mesentery and the pouch of Douglas

Hepatocellular carcinoma (HCC)

Local spread	• Vascular invasion of the portal or hepatic veins
Lymph node spread	• Spread to lymph nodes along the hepatoduodenal ligament
Haematogenous spread	• Lung = bone > adrenals > peritoneum
PEARL	• Abdominal lymph nodes are often enlarged with cirrhosis

Local spread	• 70% of tumours arise within the pancreatic head • Tumour spreads by direct perivascular and perineural invasion • Head/uncinate process tumours: these usually extend along the SMA and mesenteric root • Body/tail tumours: these usually infiltrate the coeliac, hepatic or splenic arteries • Local invasion can involve the stomach, duodenum and retroperitoneum
Lymph node spread	• Early micrometastases at presentation are common • Primary drainage: superior, inferior, anterior, posterior and splenic lymph nodes • Secondary drainage: porta hepatis, common hepatic, coeliac, mesenteric root lymph nodes • Tertiary drainage: peri-aortic and distal superior mesenteric lymph nodes
Haematogenous spread	• Early micrometastases at presentation are common • These usually involve the liver and peritoneal surfaces
PEARL	• Usually only tumours of the head and uncinate process are surgically resectable (tumours of the body and tail usually have perivascular or perineural metastases at presentation)

Cholangiocarcinoma

Local spread	• Vascular invasion of the portal or hepatic veins
Lymph node spread	• Spread to lymph nodes along the hepatoduodenal ligament – with a propensity to spread to the portocaval lymph node chain as well as the anterior and posterior pancreaticoduodenal chain
Haematogenous spread	• Less common than with HCC – remote metastases are usually to the lung (less commonly to bone, the adrenals and peritoneum)

Renal cell carcinoma

Local spread	• Perinephric fat ipsilateral adrenal adjacent viscera (including muscles) • Renal vein invasion (± IVC)
Lymph node spread	• Via lymphatics following the renal vessels to the ipsilateral para-aortic nodes direct connections with the thoracic duct and mediastinum also exist
Haematogenous spread	• Common sites: lungs > bones, CNS, adrenals
PEARL	• IVC tumour thrombus extending above the hepatic veins requires a transthoracic surgical approach – right atrial involvement requires cardiopulmonary bypass

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Tags: Grainger & Allisons Diagnostic Radiology Essentials Expert Consu

Feb 27, 2016 | Posted by admin in GENERAL RADIOLOGY | Comments Off

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Local spread	• Initially perivesical fat infiltration subsequent invasion of adjacent pelvic organs and the pelvic side wall by direct invasion
Lymph node spread