Makindo Medical Notes

🗺️ Overview

Metastatic disease refers to the spread of cancer from the primary site to distant organs. Understanding the common primary cancers that metastasize, as well as their typical sites of metastasis, is crucial for diagnosis and management.

🧭 Key Steps in the Metastatic Process

1. 1️⃣ Local Invasion: Cancer cells breach the basement membrane using enzymes (e.g., MMPs) to cut through the extracellular matrix.
2. 2️⃣ Intravasation: Cells enter blood or lymph by traversing the endothelium and perivascular spaces.
3. 3️⃣ Circulation: 🛡️ Cells survive shear stress and immunity, often cloaking with platelets to form microemboli.
4. 4️⃣ Extravasation: 📍 Adhesion to distant endothelium → exit vessels → invade new tissue.
5. 5️⃣ Colonization & Growth: 🌱 Cells adapt to the “soil” and proliferate to establish secondary tumours.

🧠 Mechanisms of Metastasis

• 🩸 Angiogenesis: Tumour-derived VEGF drives new vessel growth to sustain tumour oxygen and nutrient needs.
• 🌀 Epithelial–Mesenchymal Transition (EMT): Loss of polarity/adhesion → motility and invasiveness akin to mesenchymal cells.
• 🛡️ Immune Evasion: Downregulated MHC, immunosuppressive cytokines, and checkpoint expression (e.g., PD-L1) help tumours hide.
• 🧭 Organotropism: “Seed and soil” concept—certain primaries prefer specific organs (e.g., breast → 🦴 bone; colorectal → 🧫 liver).

🗺️ Common Sites of Metastasis

• 🧬 Lymph nodes: Often the earliest basin for spread from solid tumours.
• 🧫 Liver: Classic in GI primaries (e.g., colorectal) and also breast/lung.
• 🫁 Lungs: Frequent for sarcomas, renal cell carcinoma, and many epithelial cancers.
• 🦴 Bone: Breast, prostate, and lung—pain, fractures, metabolic complications.
• 🧠 Brain: Lung, breast, melanoma, renal cell carcinoma commonly seed here.

⚙️ Factors Influencing Metastasis

• 🌿 Tumour Microenvironment: Hypoxia, stromal/immune cells, and metabolites shape metastatic potential.
• 🧬 Genetic Mutations: Alterations in p53, BRCA1/2, KRAS and others promote invasion and survival.
• 🛡️ Immune System: Surveillance can suppress spread, but tumours evolve escape pathways.
• 🧱 Extracellular Matrix (ECM): Composition and stiffness guide migration and invasion routes.

🔎 Diagnostic Tools for Detecting Metastasis

• 🖼️ Imaging: CT, MRI, PET, and bone scans to stage lungs, liver, bone, and brain.
• 🧪 Biopsy: Histology ± molecular profiling of metastatic deposits to confirm and target therapy.
• 🩸 Tumour Markers: CEA, CA-125, PSA, etc., support monitoring and response assessment.

🧾 Causes of Metastatic Disease

Primary Cancer	Common Sites of Metastasis	Clinical Features	Diagnostic Approach
Breast Cancer 🎀	🦴 Bone 🧫 Liver 🫁 Lungs 🧠 Brain	🦴 Bone pain (osteolytic lesions) 🟡 Jaundice, hepatomegaly 😮‍💨 Dyspnoea, cough 🤕 Headache, seizures	🖼️ Mammography/US for primary 🦴 Bone scan; LFTs; chest imaging; 🧠 MRI 🧪 Biopsy if unclear
Lung Cancer 🫁	🧫 Liver 🧠 Brain 🦴 Bone 🟠 Adrenals	🤧 Cough, haemoptysis, chest pain 🧠 Seizures, headache 🦴 Pain, fractures 🟡 Liver dysfunction	🖼️ CXR/CT for primary 🧠 MRI; 🦴 bone scan; 🧫 liver tests 🔍 PET-CT for staging
Colorectal Cancer 🧻	🧫 Liver 🫁 Lungs 🫙 Peritoneum	🩸 PR bleeding, abdominal pain 🟡 Jaundice/hepatomegaly 😮‍💨 Dyspnoea, pleural effusion 🌊 Ascites, distension	🪞 Colonoscopy for primary 🖼️ CT A/P for staging 🫁 Chest CT; LFTs
Prostate Cancer 🧔	🦴 Bone 🫁 Lungs 🧫 Liver	🦴 Bone pain, fractures 😮‍💨 Dyspnoea/cough 🟡 Hepatomegaly/jaundice	🧪 PSA; ✋ DRE 🦴 Bone scan; chest imaging; LFTs 🧲 MRI for detail
Renal Cell Carcinoma 🫘	🫁 Lungs 🦴 Bone 🧫 Liver 🧠 Brain	🩸 Haematuria, flank pain 😮‍💨 Dyspnoea/pleural effusion 🦴 Pathological fractures 🧠 Neurological deficits	🖼️ CT abdomen (primary) 🫁 Chest CT; 🦴 bone scan 🧠 MRI if neuro symptoms
Melanoma 🧴	🫁 Lungs 🧫 Liver 🧠 Brain 🦴 Bone	🧍 Skin lesion change 😮‍💨 Chest pain/dyspnoea 🟡 Jaundice 🤕 Seizures, headaches	🔬 Excisional skin biopsy 🖼️ Chest imaging/CT 🧠 MRI; LFTs

🧰 Management of Metastatic Disease

The management of metastatic disease is complex and often multimodal:

• 🔪 Surgery: Primary resection or oligometastatic debulking when feasible.
• 💊 Chemotherapy: Systemic cytotoxic regimens targeting disseminated cells.
• ☢️ Radiation Therapy: Local control and symptom relief (e.g., bone/brain mets).
• 🎯 Targeted Therapy: Agents against specific pathways (e.g., TKIs).
• 🛡️ Immunotherapy: Checkpoint inhibitors (e.g., PD-1/PD-L1, CTLA-4) for selected tumours.
• 🌿 Palliative Care: Early integration for symptom control and quality of life.

✅ Conclusion

Metastatic disease drives most cancer mortality. Earlier detection, precision diagnostics, and modern systemic therapies are improving outcomes—pair oncological intent with proactive symptom control to optimise survival and quality of life.