Metastasis and Bone Metastasis – Neoplasia

by Carlo Raj, MD

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    00:00 Lymphatic, first site usually for carcinoma; however, big time exception.

    00:08 Two of them, I just talked to you about one.

    00:11 [0:00:11,2] are cancers, what kind of cancer? Is it a carcinoma? Or is it a sarcoma? It’s a carcinoma.

    00:18 And what structure did I just give you there from metastasis? Did I give you lymphatics? Or did I give you portal vein? I give you portal vein.

    00:29 Read this statement.

    00:31 Carcinoma, rule of thumb pathology, sure.

    00:35 Prefers lymphatics, but there’s some major exceptions: colorectal cancer – third leading cause of death in a man, third leading cause of death from cancer in a female.

    00:49 What about renal cell carcinoma? Especially left side.

    00:53 you invade, invade, invade and as you do so, you will then enter the renal vein.

    00:59 What’s renal cancer? It’s a carcinoma.

    01:01 So from henceforth, you start thinking of carcinomas as such.

    01:06 You start thinking about carcinoma as being it’s spread that it would choose as far as the most convenient method of spreading.

    01:13 Sometimes it might be lymphatic, sometimes it could be hematogenous.

    01:18 Hematogenous tends to be more sarcomas.

    01:23 Carcinomas, if they get through the lymph node, into efferent, then it will then become hematogenous in general, keep that in mind.

    01:30 You take a look at this liver.

    01:31 This is not cirrhosis.

    01:34 How many nodules do you find? Many, many, many, many? As far as you’re concerned, multiple nodules on an organ.

    01:41 And if you know for a fact that it’s cancer, it means metastasis.

    01:45 So where most likely did the metastasis to the liver take place in this picture? Most likely colorectal cancer.

    01:54 So probably one through the lymphatics, went into the portal vein and then invaded hematogenously to the liver.

    02:03 What does seeding mean to you? Seeding means a cancer on the surface of an organ.

    02:09 Let me give you a couple of surfaces that you want to pay attention to: Ovaries, Pleura, Cerebrospinal fluid.

    02:19 How does this work? For example, as a family, And we’ll take a look at later; ovarian tumors, the most common set of family or the family of ovarian cancers that’s most common is not germ cell tumor, it’s surface-derived ovarian tumor.

    02:37 You’ve heard of serous cystadenocarcinoma, that is the most common malignant ovarian tumor.

    02:42 Guess what family belongs to: surface.

    02:46 So, what type of spread would surface-derived cancers then take or choose? Seeding, what does seeding mean? Literally, the cancer on the surface. I’m going to give you another one.

    02:58 What is the only cause of mesothelioma in the United States? What if your patient was a roofer? Asbestos, right? The only cause of mesothelioma in the United States is asbestos exposure.

    03:15 Pleural cancer, isn’t the pleura on surface? Yes.

    03:21 What do you think is the most common cause of brain cancer especially adults? It’s astrocytoma, a glioma known as Glioblastoma multiforme.

    03:32 I gave you three major cancers just now.

    03:34 Ovarian tumors, serous cystadenocarcinoma, mesothelioma, and glioblastoma multiforme.

    03:41 the spread of these cancers because they’re more likely on the surface of that organ would then seed into the adjacent structures.

    03:51 If it’s the ovary, it might then seed into the peritoneum.

    03:55 Pleura, we talk about seeding there, and particularly glioblastoma multiforme, it might then seed, Or the glioma may then seed into the cerebrospinal fluid.

    04:05 Three major different types of metastasis: lymphatic, hematogenous and seeding.

    04:10 And I have given you specific behavioral characteristics.

    04:15 Our topic is bone metastasis.

    04:17 How important is this? Really common.

    04:20 The vertebrae would be the most common site and the way that it would spread to the bone would be a particular type of plexus known as your Batson paravertebral plexus.

    04:31 I’ll give you an example.

    04:33 Here’s your patient.

    04:34 72 years of age, and comes in for a physical examination, upon digital rectal examination, you feel a gritty, gritty prostate.

    04:47 What does gritty feel like? Chin.

    04:50 You find that there is increase in PSA.

    04:52 And in addition, you find increase in Alk Phos, alkaline phosphatase.

    04:59 Tell me about prognosis of your patient. What’s going on? The gritty type of palpation that you felt on the prostate and increase in PSA would then mean prostate cancer as far as you are concerned.

    05:12 I gave you no symptoms otherwise, did I? I didn’t give you increased frequency, I didn’t give you inadequate voiding, I gave you prostate cancer.

    05:21 Usually on the peripheral portion of the prostate.

    05:25 Next, I gave you alk phos.

    05:27 What does that mean? The prostate cancer now spread and metastasize through the Batson paravertebral plexus to the vertebrae giving alk phos.

    05:40 Osteoblastic, what does that mean to you? Good. Bone growth.

    05:45 Right? So there was deposition of bone.

    05:48 If there’s deposition of bone taking place with the metastasis, this type of spread would be more opaque or would there be destruction of the bone resulting in lucency.

    06:03 Osteoblastic, B – blastic, will build bone, more bone that you find, take a look at the x-ray, its called “hot bone”.

    06:13 A hot bone to you means that there is increase opacity of that bone due to increased osteoblastic activity.

    06:20 Increase in alk phos.

    06:23 Are we clear about how you should be using alk phos in a setting of metastasis to the bone which is your topic.

    06:32 On the other side, we have osteolytic.

    06:35 Whenever you think about osteolytic, take a look at the skull here.

    06:39 It looks like bullets have actually gone through the skull.

    06:42 And What I mean by that is punched out lesions, lytic punched out lesions.

    06:48 One, there is such damage taking place to the skull then you’ll find there to be hypercalcemia and this will be a different topic in which we will go through and [0:06:56,4], known as multiple myeloma.

    06:59 This does not necessarily bone metastasis. Right? So this will be multiple myeloma.

    07:04 Where the metastasis comes in to play would be on the left, where you find the patient with prostate cancer and then osteoblastic activity of the vertebrae.

    07:15 The vertebrae would be the most common site as for as bone metastasis.

    07:19 If it’s osteoblastic, increased alk phos.

    07:22 If it’s osteolytic, then you would expect there to be destruction of bone would only mean the calcium starts depositing or being released into circulation guaranteed your patient has hypercalcemia and with the lytic bone lesion, you expect there to be pathologic fractures.

    About the Lecture

    The lecture Metastasis and Bone Metastasis – Neoplasia by Carlo Raj, MD is from the course Cellular Pathology: Basic Principles with Carlo Raj.

    Included Quiz Questions

    1. Pleura
    2. Liver parynchema
    3. Colon
    4. Kidney
    5. Skin
    1. Sarcoma- hematogenous
    2. Carcinoma - hematogenous
    3. Seeding - lymphatic
    4. Sarcoma - lymphatic
    5. Carcinoma - surface derived
    1. Increased alkaline phosphatase
    2. Increased calcium
    3. Decreased calcium
    4. Decreased alkaline phosphatase
    5. Increase in both alkaline phosphatase and calcium
    1. Osteoblastic bone metastasis
    2. Sarcoma
    3. Osteolytic bone metastasis
    4. Lymphoma
    5. Teratoma

    Author of lecture Metastasis and Bone Metastasis – Neoplasia

     Carlo Raj, MD

    Carlo Raj, MD

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