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METASTASIS PULMONAL ATIPIKAL:

Oleh:
Yusuf S. Nawawi

SPEKTRUM TEMUAN RADIOLOGI Pembimbing:


Dr. dr. Widiastuti, Sp.Rad(K)TR
PENDAHULUAN
Paru-paru organ yang menyerupai filter
 Venous return mengandung cairan limfatik dari jaringan tubuh mengalir ke
paru
Metastasis paru sangat sering
 20%–54% pasien dengan keganasan meninggal
 Payudara, colon, ginjal, uterus dan KL
 Choriocarcinoma, osteosarcoma, testis, melanoma, Ewing’s sarcoma,
karsinoma tiroid
PATOGENESIS METASTASIS PARU
Mekanisme
 Arteri pulmonal/bronchial
 Limfatik
 Cavum pleura
 Jalan nafas
 Invasi langsung
Penyebaran hematogen—paling sering
 Sebagian besar hingga mencapai capillary bed dan arteriol
 Beberapa bertahan dan tumbuh dalam interstisial
METASTASIS PARU
Tipikal metastasis Atipikal metastasis

Hematogen Massa dengan kavitasi


 Nodul ukuran bervariasi, random, multiple
Massa dengan kalsifikasi
Penebalan difus interstisial (limfangitik
Pneumotoraks spontan
karsinomatosis)
Atenuasi ground-glass sekitar massa (CT halo
sign)
Konsolidasi dengan atau tanpa ground-glass
opacity
Massa dalam arteri pulmonal
Atelektasis, massa endobronchial
KAVITASI
Insiden: 4% metastasis; 9% primer
 70% berasal dari squamous cell ca; laporan lain menyebut tidak terdapat perbedaan
signifikan dengan adenoca
 Sarkoma metastasis dapat membentuk kavitas, disertai pneumotoraks
 Kemoterapi menginduksi kavitasi

Organ primer yang paling sering


 Kepala dan leher pada pria
 Genital pada wanita

Mekanisme:
 Nekrosis jaringan tumor
 Check-valve mechanism pada infiltrasi tumor pada struktur bronkhial
Figure 1. Cavitating
metastasis in a 72-year-old
man with a squamous cell
carcinoma in the left main
bronchus. Transverse CT scan
obtained with lung window
settings shows multiple
metastatic nodules in both
lungs. There are several
cavitating nodules (arrows) in
both lower lobes. Note the
irregular thickening of the
cavity walls.
Figure 2. Cavitating metastasis in a 51-year-old man who had undergone total laryngectomy due to a laryngeal
squamous cell carcinoma 2 years previously. (a) Frontal chest radiograph obtained before chemotherapy shows multiple
masses (arrows) in both lungs. Note the small eccentric cavitation (arrowhead) of the mass in the left upper lung. (b)
Frontal chest radiograph obtained after two cycles of chemotherapy shows extensive cavitation of nodules with air-fluid
levels (arrows). Note the irregular thickening of the cavity walls. Sputum cytologic examination revealed squamous cell
carcinoma.
Figure 3. Cavitating metastasis in a 28-
year-old man who had undergone
resection of the rectum due to an
adenocarcinoma 2 years previously.
Transverse CT scan of the left lung,
obtained with lung window settings, shows
multiple areas of nodular attenuation
with central cavitations (arrows). The walls
of the nodules are relatively thin.
Cavitation of the nodules was not seen on
the chest radiograph (not shown).
Figure 4. Cavitating metastasis associated
with a pneumothorax and hemorrhage from
an angiosarcoma of the scalp in an 86-year-
old man who experienced abrupt onset of
dyspnea and hemoptysis. (a) Frontal chest
radiograph shows bilateral pneumothoraces
(arrows) and diffuse reticular attenuation of
both lungs. A drainage catheter is seen in the
left hemithorax. (b) Transverse thin-section
(1.0-mm) CT scan shows multiple variable-
sized thin-walled cavities and bilateral
pneumothoraces. Although most of the
cavities appear round, some of them have
bizarre shapes, mimicking the cysts of
Langerhans cell histiocytosis. A subpleural
cavity is ruptured into the pleural space
(arrow). Multifocal areas of ground-glass
opacity are seen in both lungs. (c)
Photograph of the resected specimen shows
hemorrhagic nodules (arrows) with central
cavitary change. (d) Photomicrograph
(original magnification, 400; hematoxylin-
eosin stain) reveals the wall of the cavity () is
composed of large plump tumor cells. Note
the freely anastomosing vascular channels
(arrows) within the tumor.
KALSIFIKASI
Nodul jinak Mekanisme:
 Granuloma  Bone formation: osteosarcoma atau
 Hamartoma: jarang terjadi chondrosarcoma
 Kalsifikasi distrofik: ca papillary
Kalsifikasi di metastasis carcinoma of the thyroid, GCT,
synovial sarcoma, tumor metastasis
dengan terapi
 Kalsifikasi mucoid: mucinous
adenocarcinoma GI dan payudara
Figure 5. Calcified metastasis in a 44-year-old woman who had undergone wide excision of a left
thigh mass, which proved to be an osteosarcoma, 7 years previously. (a) Frontal chest radiograph
shows multiple areas of nodular attenuation in both lungs. A focal calcification (arrow) is suspected in
the nodule in the left upper lobe. (b) Transverse contrast-enhanced CT scan obtained at the level of
the aortic arch clearly shows calcification (arrow) within the nodule. Histopathologic examination of the
resected mass revealed a metastatic osteosarcoma with the foci of ossification.
PERDARAHAN SEKITAR NODUL METASTASIS
CT halo sign TIDAK SPESIFIK Mekanisme:
 Atenuasi nodular dikelilingi ground  Rapuhnya jaringan neovascular
glass opacity halo yang memicu rupture pembuluh
 Batas tidak tegas darah

Hemorrhagic metastasis nodul: Kondisi patologis lain:


 Angiosarcomas  Invasive aspergillosis, candidiasis,
Wegener granulomatosis,
 Choriocarcinomas
tuberculoma associated with
hemoptysis, bronchioloalveolar
carcinoma, dan limfoma
Figure 7. Hemorrhagic metastasis in a 42-year-old woman with a choriocarcinoma who presented with hemoptysis.
Her blood –human chorionic gonadotropin level was more than 140,000 U/mL. (a) Frontal chest radiograph shows
ill-defined nodular and patchy attenuation in both lungs. (b) Transverse CT scan obtained with modified lung window
settings shows multiple areas of nodular attenuation with surrounding areas of ground-glass opacity (arrows). The
areas of ground-glass opacity are due to hemorrhage around the metastatic nodules. A small cavitation
(arrowhead) is seen within the mass in the right lung.
PNEUMOTORAKS
Akibat nekrosis tumor
Paling sering--osteosarkoma: 5-7%
kasus
Mekanisme: nekrosis subpleural
metastasis menimbulkan fistula
bronchopleural

Figure 8. Pneumothorax in a 19-year-old man with a known osteosarcoma of


the lower extremity who suddenly developed dyspnea. Frontal chest radiograph
shows a pneumothorax (arrows). Note the multiple small metastatic pulmonary
nodules (arrowheads).
Figure 9. Air-space pattern of metastasis from an
adenocarcinoma of the stomach in a 38-year-old man who had
undergone radical gastrectomy 4 years previously. (a) Frontal
AIR-SPACE PATTERN chest radiograph shows air-space consolidation with an air
bronchogram in the right upper lobe. A chest radiograph
obtained 1 year previously (not shown) revealed small patchy
Metastasis adenocarcinoma, poorly marginated lesions in the right upper lobe that were
payudara dan ovarii consistent with tuberculosis and failed to respond to
antituberculous therapy. (b) Transverse CT scan shows
Penyebaran melalui dinding consolidation in the right upper lobe with surrounding ground-
alveolus yang intak (lepidic glass opacity and an air bronchogram (arrow). Wedge biopsy of
growth) ~ this lesion revealed an adenocarcinoma, which was also the
bronchioloalveolar histopathologic finding in the stomach lesion.
carcinoma
TUMOR EMBOLISM
• Pada arteri kecil-medium
• Diagnostik radiologis sulit
• Dilatasi dan beading multifocal arteri subsegmental perifer
• Infark: atenuasi area wedge-shaped perifer
• Emboli tumor yang besar pada arteri pulmonal utama, lobar atau
segmental
• Tumor sering terkait dengan emboli pulmonal
• Hepatoma, payudara, RCC, gastrik dan prostat dan choriocarcinoma
Figure 10. Massive tumor emboli in a 48-year-old man who had
undergone hepatic segmentectomy because of a hepatocellular
carcinoma 2 years previously and who suddenly developed
dyspnea. (a) Transverse contrast-enhanced CT scan obtained at
the subcarinal level shows large thrombi (arrows) in the right
main and left descending interlobar artery. The thrombi are
thought to have originated from the tumor in the inferior vena
cava. (b) Transverse CT scan obtained with lung window settings
through the lung bases shows multifocal areas of peripheral
wedge-shaped consolidation and ground-glass opacity that are
thought to be pulmonary infarction. Subsegmental arteries
(arrows) have a dilated and beaded appearance. Because they
were not seen on CT scans obtained with lung window settings
through the same level 5 days earlier (not shown), associated
areas of nodular attenuation (arrowheads) within the areas of
ground-glass opacity are thought to be dilated small arteries or
arterioles filled with tumor emboli rather than hematogenous
metastatic nodules. (c) Transverse contrast-enhanced abdominal
CT scans obtained 5 days before a and b show a diffuse
hepatoma (arrow) in the right hepatic lobe and a surgical
defect in segment 8. Tumor thrombi (arrowheads) are also seen
in the right hepatic vein and the inferior vena cava. (d)
Transverse contrast-enhanced CT scans of the abdomen,
obtained with a and b, show that the extent of the hepatic
lesion has not changed, but the tumor thrombi in the inferior
vena cava (arrowheads) are not seen. The patient died of
respiratory failure 20 days later, despite intensive thrombolytic
and supportive therapy.
ENDOBRONCHIAL METASTASIS
• Jarang
• Terjadi pada jalan nafas mayor pada 2% kasus
• Rute utama yang mungkin
• Langsung pada dinding bronchus
• Aspirasi sel tumor
• Penyebaran limfatik
• Metastasis hematogen pada dinding bronchial
• Sel tumor pada limfonodi atau parenkim paru yang berada di sekitar
bronchus tumbuh sepanjang bronchial tree  lesi intraluminal
Figure 11. Solitary endobronchial metastasis in a 47-year-old man
Ginjal, payudara, dan who had undergone right nephrectomy because of a renal cell
carcinoma 3 years previously. (a) Transverse CT scan shows a solitary
kolorektal pulmonary nodule (arrow) adjacent to the posterior segmental
bronchus of the right upper lobe. Mild dilatation of the peripheral
Tampilan radiologis yang bronchi (arrowheads) is also seen. (b) Bronchoscopic image shows an
paling sering endobronchial mass (arrow) in the posterior segmental bronchus of the
right upper lobe. (c) Photomicrograph (original magnification, x10;
-- atelectasis lobaris hematoxylin-eosin stain) reveals a metastatic tumor () of a renal cell
carcinoma invading through the bronchial wall and shows the
endobronchial extension (arrow).
Figure 12. Endobronchial metastasis in a 59-year-old man with renal cell carcinoma who presented
with dyspnea. (a) Frontal chest radiograph shows collapse of the left upper lobe with a suggested
mass shadow (arrow) in the left hilum. (b) Transverse contrast-enhanced CT scan at the carinal level
shows an endobronchial mass (arrowhead) in the orifice of the left upper lobar bronchus with
collapse of the left upper lobe (arrow). Biopsy of the endobronchial mass and the right renal mass
revealed a renal cell carcinoma. (Case courtesy of Jin Hwan Kim, MD, Department of Radiology,
Chungnam National University, Taejeon, Korea.)
SOLITARY METASTASIS
• Metastasis soliter tanpa riwayat keganasan
• CT: 0.4-9%
• Foto Toraks: 25%
• Nodul pulmonal soliter dideteksi pada pasien dengan
keganasan ekstrapulmonal
• 46% terbukti metastasis
• Kecenderungannya bervariasi berdasarkan tipe histologis tumor
primer dan usia pasien
• Keganasan yang sering:
• Melanoma, sarcoma, colon ca, payudara, ginjal, bladder, dan testis
DILATED VESSELS WITHIN A MASS
• Dilatasi pembuluh darah
• Hipervaskularitas
• Sarkoma
• Sarkoma alveolar soft-part
• leiomyosarkoma
Figure 13. Dilated vessels within a
metastatic mass in a 32-year-old woman
who had undergone excision of an
alveolar soft-part sarcoma of the left
foot 5 years previously. (a) Transverse
contrast-enhanced CT scan shows a well-
defined enhancing nodule in the left
lower lobe. Enhancing tubular structures
(arrowheads) in the lesion suggest
dilated vessels. (b) Photograph of a
resected specimen slide (original
magnification, X1; hematoxylin-eosin
stain) reveals a well-circumscribed
nodule containing a dilated vascular
structure (arrow), which corresponds to
the enhancing tubular structure seen in a.
The black line at the top indicates 1 cm.
(Reprinted, with permission, from
reference 46.)
STERILIZED METASTASIS
• Setelah kemoterapi adekuat
• Nodul nekrotik dengan atau tanpa
fibrosis dan tanpa tumor sel viable
• PET scan dan konfirmasi histologis • Sering: choriocarcinoma
penting, untuk membedakannya dengan dan testis
jaringan tumor viable
• GCT dapat berubah
menjadi teratoma matur
jinak setelah kemoterapi
dan menjadi massa
persisten
BENIGN METASTASIZING TUMOR
• Jarang
• Biasanya berasal dari tumor yang secara histologi jinak:
• Leiomioma uterus
• Mola hidatidosa
• GCT
• Chondroblastoma
• Adenoma pleomorfik glandula saliva
• Meningioma

• Tidak bisa dibedakan dengan tumor ganas; tumor jinak tumbuh sangat
lambat
Figure 15. Benign metastasis from a giant cell tumor in a 42-year-old man who had undergone
repeated curettage of the left third finger. (a) Transverse contrast enhanced CT scan shows a round
mass in the right lower lobe. Note the central nonenhancing area and the septum-like structure
(arrowhead). (b) Transverse CT scan obtained at a distal tracheal level shows another 1-cm-
diameter nodule in the left upper lobe (arrow). On a follow-up CT scan obtained 3 months later
(not shown), the nodule had grown to 2 cm in diameter. (c) Photograph of the resected specimen
demonstrates the cut surface of the mass that was removed from the right lower lobe with video-
assisted thoracic surgery. The mass is confined within the visceral pleura and shows areas of
hemorrhage (arrows) that correspond to the nonenhancing area in a. (d) Photomicrograph (original
magnification, X 400; hematoxylin-eosin stain) reveals stromal cells and multinucleated giant cells
that were similar to those found in the finger lesion.
TERIMA KASIH