00:01
Okay, welcome back.
00:04
We're going to look at metastatic disease.
00:07
We're going to look at a particular
case that is illustrative.
00:10
But tumors in general, do their darndest
to get loose into the bloodstream
and to go to other places within the body.
00:21
And it's frequently the metastases
rather than the primary tumor
that is the ultimate cause of
significant morbidity and mortality.
00:30
There are exceptions, of course
but metastases are often kind of a very
important step in the progression of malignancy
and usually indicates the
patient is not going to do well.
00:47
So here's where we are in terms
of paraneoplastic syndromes,
local growth and invasion and
metastases, and without any further ado,
let's look at our case.
00:56
This was a 60-year old man who had a prostate cancer.
01:01
What's being shown on the
left hand side is the bladder.
01:04
It's been opened
up so we can see inside the bladder.
01:07
And at higher magnification, what we can see
is that there is a kind of a bulging tumor mass
in the middle of the slide on the right
hand side, that represents prostate cancer
that is growing into the bladder wall.
01:23
If we cut that in a different plane,
we can see this nodule of tumor
this is up is into the bladder wall, down
is towards the seminiferous tubules,
which are shown as well as the prostate
and there was just this local extension of the tumor.
01:39
This was a surgical specimen that was
resected in hopes of curing the patient.
01:46
Unfortunately, at the time of the surgical resection,
we did not know that there
was any metastatic disease.
01:52
The patient subsequently died, not as a
consequence of that primary tumor in that site
but because of the metastatic spread.
02:01
Where did it go?
Well, we're just going to look at examples.
02:06
This is the lung and both lungs were affected.
02:09
And in the upper lobes, we can
see tumor that has infiltrated
and arrived via the circulation.
02:17
We also have tumor that is
extending into the lymphatics.
02:20
So the panel on the left hand side
is showing the surface of the lung
and you see this lacy
reticulate-likepattern of white tan material
that's actually tumor that's within the lymphatics.
02:33
So it had gone to the lung and then
the lung lymphatics had picked it up.
02:37
We're seeing that grossly on the left hand side.
02:39
On the right hand side, we're seeing
lymphatic vessels stuffed with a tumor.
02:44
Each ball there is a bunch of
tumor cells in the lymphatic
and that will also have gone to the lymph node.
02:52
So that we have expression of the
tumor, so called lymphangitic spread.
02:59
This is an autopsy.
03:01
Obviously in this patient
we have opened the rib cage.
03:05
The red circle indicates the normal
appearance of a cross section of rib
with the marrow that should be kind of red tan.
03:14
The white circle on the other
hand is demonstrating an area
where the tumor had completely
replaced the bone in the rib
and that all that white tan
material is metastatic tumor.
03:27
Interestingly, as we discussed previously,
prostate does like to go to bone
for reasons that are not
entirely completely understood.
03:36
But prostate cancer not only was it in
the ribs, it was in the vertebral bodies
and what is circled on the lower
inset now is an area of tumor invasion
causing an osteoblastic, as opposed to an osteolytic
but an osteoblastic sclerosing area of metastasis
and multiple bones in the vertebral
bodies were affected by the tumor.
04:02
This is the adrenal and the normal adrenal kind
of thickness and appearance is on the right hand side.
04:09
All those big lumps of kind of
red, brown hemorrhagic material
represent tumor metastasis to the adrenal.
04:18
It is possible to have adrenal
insufficiency due to tumor metastasis.
04:22
And in this particular case, there was sufficient
adrenal function on the contralateral side
that the patient didn't suffer any
adrenal insufficiency manifestations
Tumor can go and in this case did go to the
liver, so we have multiple nodules of tumor.
04:41
They are centrally hemorrhagic and necrotic
because the tumor has grown too quickly.
04:46
Compared to its vascularization, it's
angiogenesis, so we have central zones of necrosis.
04:52
And there are multiple different size tumors,
so there are large tumors, large metastases
that had probably been there for
weeks, maybe months as they've grown.
05:03
There are smaller ones.
05:04
They represent tumor cells that are in
the circulation and arrived more recently,
so they tend to be smaller, small, round nodules.
05:12
Important kind of take home, just as
a pathologist and let you in on this.
05:17
The liver is so redundant, it's over
engineered, we have such an excess capacity
that this amount of involvement by cancer in
the liver would not have caused any significant
hepatic dysfunction.
05:30
You have to replace greater than 70% of
the liver in order to have hepatic failure.
05:35
So this patient may not have had any
symptoms and didn't have any symptoms related
to the hepatic metastasis.
05:42
The tumor went to a variety of interesting places.
05:44
What is shown on the left hand
side is the dura that was taken off
the brain at the time of autopsy.
05:52
And on the right hand side, you can
see the bright, pink-red material.
05:58
On the left hand side that
linear material, that's the dura.
06:02
But in the dura, attached to the dura
is a metastasis of the same tumor.
06:07
So this tumor went into multiple locations.
06:11
And it also into the heart.
06:13
This patient had a history of hypertension, so
there is left ventricular wall thickness increase.
06:21
There's hypertrophy.
06:22
There is a remote scar as indicated there,
that white, collagenous, scar-like material
in the posterior wall.
06:31
But that, there wasn't any gross
manifestation of the malignancy.
06:36
However, when we looked microscopically,
we could find tumor within the lymphatics
in the small vessels within the heart.
06:43
Again, the metastasis here were not sufficient
to cause any significant cardiac dysfunction,
but we're definitely there.
06:54
And with that, just an example of metastatic
spread, you can think of any of a variety of tumors
and how things spread either via
lymphatics or through the blood vessels.