Patterns Of Metastases

Disease dissemination can occur from the primary tumor either by local infiltration, lymphatic spread, or via the bloodstream. The most common site of spread of disease is to the liver, and approximately 80% of patients will have hepatic involvement at the time of death. The liver has a dual blood supply from the hepatic portal circulation, along which most metastases are thought to spread, as well as from the hepatic artery. Isolated lesions confined to anatomic segments can frequently be identified in the liver before further spread elsewhere. Aggressive surgical management at this stage can have a significant impact on the patient's prognosis. However cure is by no means assured and reported five-year survival rates (5YS) post hepatectomy are usually approximately 25% (1,2), while a very recent reviewer has quoted a figure of 40% (3).

The lungs are the next most common site of spread of metastatic disease. This is often asymptomatic and found on routine imaging, but patients can present with symptoms of local pain or cough, or with haemoptysis and dyspnoea due to localized lesions, or, less commonly, with dyspnoea resulting from lymphangitis. Spread to other distant sites occurs less commonly, but as patients live longer following chemotherapy, bone, and, less frequently, brain, adrenals, skin, and other sites may be involved.

In view of the pattern of metastatic spread of this cancer it is important that patients are monitored carefully and relapsed disease is identified at an early stage as there is some trial evidence to suggest that earlier intervention with chemotherapy on recurrence may be more beneficial.

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