328.4 📋 章末速記 Summary

328.4.1 🔑 一句話總結

Pulmonary metastases 是 lung 最常見 cancer presentation (多於 primary lung cancer)；routes：hematogenous (most) + lymphatic + bronchogenic + direct extension；patterns：multiple bilateral peripheral nodules (most)、miliary (thyroid papillary, renal, melanoma, sarcoma)、lymphangitic carcinomatosis (breast, GI, prostate — poor prognosis)、endobronchial (renal, colon)、pleural (Ch311)、cavitating (squamous, sarcoma)；common primary tumors：breast (50-60%), colorectal (30-40%), melanoma (50-70%), sarcoma, kidney, testicular, head/neck；treatment：systemic therapy (depends on primary type — breast subtypes, FOLFOX colorectal, BEP germ cell, sarcoma chemo, melanoma IO + BRAF/MEK) + surgical metastasectomy for selected (controlled primary + no extrapulmonary mets + all resectable + adequate reserve) — outcomes vary by primary (colorectal 30-50% 5-yr, sarcoma 25-40%, germ cell high cure)；PulMiCC 2020 questioned routine metastasectomy in colorectal；SABR-COMET 2019 confirmed oligometastatic disease + aggressive local therapy ↑ OS；lymphangitic carcinomatosis = rapid progressive dyspnea + HRCT linear/reticular + poor prognosis；paraneoplastic pulmonary syndromes：HPOA (clubbing + periostitis, adenocarcinoma), Trousseau (hypercoagulability), tumor embolism (choriocarcinoma classic), drug-induced pulmonary toxicity from chemotherapy + TKIs + IO。

328.4.2 💊 治療精要

• systemic therapy by primary：breast (HER2 → trastuzumab/T-DXd; HR+ → endocrine + CDK4/6i; TNBC → chemo + IO); colorectal (FOLFOX/FOLFIRI + anti-EGFR/VEGF; IO for MSI-H); renal cell (TKI + IO); melanoma (IO + BRAF/MEK); testicular (BEP highly chemo-sensitive); sarcoma (doxorubicin + ifosfamide)
• metastasectomy criteria (Class IIa-IIb)：primary controlled + no extrapulmonary mets + all resectable + adequate pulmonary reserve + disease-free interval > 1 year often
• metastasectomy approach：VATS preferred；wedge resections (multiple if needed)；lobectomy if necessary；repeat possible
• SABR (stereotactic ablative RT)：oligometastatic (SABR-COMET 2019), non-surgical candidates；ablation for small lesions
• RFA / microwave / cryoablation：alternative local therapy
• endobronchial metastasis：bronchoscopic resection (laser, cryo, electrocautery) + stenting + radiation
• lymphangitic carcinomatosis：treat primary + supportive (steroids debated)
• Trousseau syndrome：LMWH (preferred for cancer-VTE, especially GI; Caravaggio supports DOAC option for many)

328.4.3 🎯 盧醫師的考前提醒

1. lung = #1 metastasis site for many cancers (vs being primary)；breast, colon, kidney, testicular, head/neck, melanoma, sarcoma 為主要 primary
2. metastasis patterns：multiple bilateral peripheral nodules (hematogenous, most common)、miliary (thyroid papillary + renal + melanoma + sarcoma)、lymphangitic (breast + GI + prostate — poor prognosis)、endobronchial (renal + colon)、cavitating (squamous + sarcoma)
3. metastasectomy 評估 4 大原則：primary controlled + no extrapulmonary mets + all resectable + adequate pulmonary reserve；多種 cancers benefit (colorectal 30-50% 5-yr, sarcoma 25-40%, germ cell high)
4. SABR-COMET (2019) 改寫 oligometastatic disease management：1-5 mets + aggressive local therapy → ↑ OS 28% vs 18% (5-year)
5. PulMiCC (2020) colorectal lung metastasectomy benefit questioned — controversial；some still recommend in select cases
6. lymphangitic carcinomatosis 特徵：rapid progressive dyspnea + HRCT linear/reticular + interlobular septal thickening + peribronchovascular thickening；poor prognosis (median 3-6 months)；breast/GI/prostate primaries
7. HPOA (hypertrophic pulmonary osteoarthropathy)：clubbing + periostitis + joint pain；adenocarcinoma classical；resolves with cancer treatment；bisphosphonates may help
8. Trousseau syndrome = migratory superficial thrombophlebitis：cancer-associated hypercoagulability；GI + pancreatic + lung adenocarcinoma classic；LMWH or DOAC (Caravaggio) for treatment
9. endobronchial metastases：renal cell, colon, breast；airway obstruction symptoms (cough, dyspnea, post-obstructive pneumonia, hemoptysis)；bronchoscopic intervention + radiation
10. pulmonary tumor embolism：choriocarcinoma classic + other germ cell；rapid dyspnea + RV failure；β-hCG elevated；treatment chemo (MTX, EMA-CO highly effective)