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Metastatic Cancer
Alan P. Venook, MD, and Sabrina Selim, MD
University of California San Francisco Comprehensive Cancer Center

Everyones Guide to Cancer Therapy by Malin Dollinger, Ernest H. Rosenbaum, Margaret Tempero and Sean Mulvihill. Andrews McMeel. 4th edition, (July 2002).

Metastatic Site

Supportive Therapy

The Most Important Questions to Ask Your Doctor

When a cancer spreads (metastasizes) from its original site to another area of the body, it is termed metastatic cancer. Virtually all cancers have the potential to spread this way. Whether metastases develop depends on the complex interaction of many tumor cell factors, including the type of cancer, the degree of maturity (differentiation) of the tumor cells, the location and how long the cancer has been present, as well as other incompletely understood factors.

The treatment of metastatic cancer depends on where the cancer started. When breast cancer spreads to the lungs, for example, it remains a breast cancer and the treatment is determined by the tumor's origin within the breast, not by the fact that it is now in the lung. About 5 percent of the time, metastases are discovered but the primary tumor cannot be identified. The treatment of these metastases is dictated by their location rather than their origin

Although the presence of metastases generally implies a poor prognosis, some metastatic cancers can be cured with conventional therapy.

Virtually all cancers can develop metastases.

How It Spreads
Metastases spread in three ways - by local extension from the tumor to the surrounding tissues, through the bloodstream to distant sites or through the lymphatic system to neighboring or distant lymph nodes. Each kind of cancer may have a typical route of spread.

What Causes It
The characteristics of each tumor are different, and it is not known what factors make the metastasis develop in particular places.

Common Signs and Symptoms
Many patients have no or minimal symptoms related to the tumor and their metastases are found during a routine medical evaluation. If there are symptoms, they depend on the site involved.

Metastatic Site
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Signs and Symptoms Diagnostic Blood Tests Diagnostic Exams Common Treatments

A cancer which has spread from an initial (primary) site to another one. The tumor is called by the primary site (ex. breast cancer that has spread to the brain is called metastatic breast cancer to the brain).

Many cancers may not cause symptoms until late stage although these represent the most common ones.

There may be serum blood tests that are abnormal. Not all tumors have specific serum markers.

For most suspicious masses, a biopsy with either a regular or fine needle (FNA) is often necessary to determine whether it is benign. If malignant, the type of cancer cell and origin can be determined

Treatment of metastatic cancer primarily depends on the original site of the cancer In some clinical situations, however, metastases may be treated in specific ways.

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Signs and Symptoms Diagnostic Blood Tests Diagnostic Exams Common Treatments

Any cancer may spread to the brain, although the most common to do so are lung and breast cancer.



Blurred vision

Other symptoms related to the nervous-system


A CT scan is useful for determining the extent of a tumor within the head

MRI determines much the same information as a CT scan

The treatment of brain metastases depends on many factors, such as the tumor of origin, the number and location of lesions within the brain and the extent of cancer in places other than the brain.

Surgery: If there is only one tumor and the patient's overall condition is good, surgical removal of the metastasis may be attempted, although location, duration and metastases should be considered

Gamma knife: This is a type of radiation treatment delivered by a machine that focuses multiple radiation beams directly at the involved area.

Radiation therapy: In patients with more than one brain metastasis, surgery is not usually an option and radiation is delivered to the entire brain.


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Signs and Symptoms Diagnostic Blood Tests Diagnostic Exams Common Treatments
The most common to metastasize to the liver are colon or other gastrointestinal cancers.

Weight loss



Loss of appetite

Abdominal pain

Fluid in the abdomen (ascites)

Yellowing of skin (jaundice)

Swelling of legs (edema)

Liver function studies--blood tests looking at serum bilirubin and liver enzymes--may be abnormal. They can, however, be completely normal even in advanced stages of metastatic cancer.

Elevated CEA

Abdominal ultrasound is one way to evaluate the abdomen if a mass is suspected. It can reveal the presence of fluid in the abdomen and is particularly useful for distinguishing a solid mass from a non-cancerous accumulation of fluid within the pelvis or liver (benign cyst).

A CT scan is useful for determining the extent of a tumor within the abdomen and for evaluating the possible spread of tumor tissue into lymph nodes or other structures

Surgery: If metastases to the liver are localized in one part of the liver, surgery may be a cure.

Chemotherapy delivered by an implanted pump. This therapy takes advantage of the liver's ability to metabolize some drugs, meaning that the tumor may be exposed to high concentrations of chemotherapy while the rest of the body is spared the side effects.

Chemoembolization this involves administering a combination of chemotherapy and colloid particles directly into the liver tumor via its main (hepatic) artery. The procedure is performed by a radiologist and does not require surgery or prolonged bedrest. It is very effective for primary tumors, but it is much less effective for metastases.

Combination chemotherapy: Liver metastases from colon cancer may be treated with irinotecan, 5-fluorouracil + leucovorin


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Signs and Symptoms Diagnostic Blood Tests Diagnostic Exams Common Treatments

The most common cancers to spread to the bones are prostate, lung and breast cancer.


Bone breakage following minor or no injury

Elevated phosphatase

A bone scan will identify most tumor spread to the bones. It involves the injection of a special contrast agent into a vein, followed by whole body imaging by a special camera.

x-ray : Abnormal areas on a bone scan almost always have to be evaluated further with plain x-rays of the suspicious area.

Chemotherapy: Bone metastases that don't produce symptoms and involve bones that are not weight-bearing (weight-bearing bones include the hip, upper leg and shoulder) may be treated with the chemotherapy appropriate for the primary tumor.

Radiation Therapy: If the tumor is not likely to respond to chemotherapy or if the bone involved is a weight-bearing one, the best option is to give radiation focused only on the involved area. The symptomatic relief is usually rapid and complete. Healing causes improvement in bone strength and makes the chance of a fracture less likely.

Pamidronate: This medication can diminish the progress of bone metastases in some diseases.


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Signs and Symptoms Diagnostic Blood Tests Diagnostic Exams Common Treatments

Metastases to the lung are common for many types of cancer.

Non-productive cough

Cough producing bloody sputum

Chest pain

Shortness of breath


A CT scan is useful for determining the extent of a tumor within the chest and for evaluating the possible spread of tumor tissue into lymph nodes

chest x-ray : If metastases have been found on biopsy, a chest x-ray should be done because the lungs are a very common site of metastases.

Chemotherapy: directed against the primary tumor type.

Surgery: If the tumor is isolated, it may be surgically removed without causing significant loss of lung function.

Supportive Therapy
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- Pain relievers are sometimes called for in liberal doses. Narcotics may have excessive side effects, however, because they are metabolized by the liver, which may not be functioning properly.
- Non-steroidal anti-inflammatory drugs may be effective even against the severe pain associated with metastatic cancer.
- The loss of appetite that often accompanies metastatic cancer may be relieved with a medication called Megace.
- Water pills (diuretics) to alleviate fluid in the abdomen or legs may cause a significant imbalance in kidney function if their use is not carefully monitored.
- Nausea can be adequately treated with standard medications, including suppositories.
- Sleep disturbances are common, but sleeping pills (sedatives) should be used carefully, since most are metabolized by the liver.

The Most Important Questions to Ask Your Doctor
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- Should any other tests be done to determine whether my cancer has metastasized?
- Should I see another physician to review the treatment of my metastatic tumor or to offer another viewpoint?
- If metastases are present, what effect do they have on the treatment plan and the curability of my cancer?
- Could I benefit from an investigational therapy available at another institution?
- How sick will the proposed chemotherapy make me relative to its potential benefit?

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