RespiratoryTier 2Disease (DEADMAN)

Pulmonary and pleural metastases

Description

The lung is a common site of metastatic spread (haematogenous, given it receives the entire cardiac output) from a wide range of primary cancers; the pleura can be involved separately (malignant pleural effusion) or alongside parenchymal metastases

Pulmonary metastases are more common than primary lung cancer in patients with a known extrathoracic malignancy; common primaries: breast, colorectal, renal cell, sarcoma, melanoma, germ cell tumours

Haematogenous spread -> typically multiple, bilateral, well-circumscribed peripheral nodules ("cannonball" pattern classic for renal cell/choriocarcinoma)
Lymphangitic spread produces a distinct pattern - diffuse septal thickening, more symptomatic (progressive breathlessness) than nodular metastases
Malignant pleural effusion arises from direct pleural seeding (lung, breast primaries most common)

CT chest is the primary imaging test
Pleural fluid cytology confirms malignant effusion in most cases (sensitivity increases with repeat sampling)
Biopsy (CT-guided or via thoracoscopy) for tissue diagnosis when cytology is negative but suspicion remains high, or when molecular/receptor testing is needed to guide primary cancer treatment

Isolated pulmonary metastases from certain primaries (colorectal, renal, sarcoma) may be amenable to surgical resection with survival benefit in carefully selected patients (oligometastatic disease)
Malignant pleural effusion - drainage for symptom relief; recurrent effusion -> indwelling pleural catheter or talc pleurodesis depending on prognosis, lung re-expansion, and patient preference
Systemic therapy directed at the primary cancer for widespread metastatic disease

Breast cancer, colorectal cancer, renal cell carcinoma, sarcoma, malignant pleural effusion

Development of malignant pleural effusion or diffuse lymphangitic spread generally indicates a poor prognosis and a shift toward palliative-focused management

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