STEPTRACKERCROSS-SYSTEM | ONCOLOGY + ANATOMY | RAPID-FIRE REVIEW

Metastasis Patterns

Where tumors spread and how they get there — destination by destination, with the anatomic route that explains each pattern.

FOCUS ON
Metastases outnumber primaries in brain, lung, liver, bone and adrenal. Carcinomas spread by lymph first, sarcomas by blood — with classic exceptions (RCC, HCC, follicular thyroid, choriocarcinoma go by blood). Venous drainage predicts the first stop: portal → liver, systemic veins → lung, Batson plexus → spine.
DESTINATION
COMMON SOURCES
PATTERN
CLUE · PAGE
Brain
Lung > breast > melanoma > kidney > colon
Multiple round lesions at the gray–white junction with edema
Hemorrhagic: melanoma, RCC, choriocarcinoma, thyroid · 16.11
Liver
Colon > stomach, pancreas (portal) > breast, lung
Multiple nodules, often umbilicated
More common than HCC · 11.10
Bone
Prostate, breast > lung, kidney, thyroid; myeloma
Vertebrae, pelvis, ribs, proximal femur (red marrow)
Blastic vs lytic · 17.05
Lung
Breast, colon, kidney, testis, sarcomas, head and neck
Multiple "cannonball" nodules; lymphangitic spread (breast, stomach)
Systemic veins drain to lungs · 9.10
Adrenal
Lung, breast, melanoma, kidney
Often bilateral
Rarely causes Addison
Ovary
Stomach (signet ring), breast (lobular), colon, appendix
Bilateral solid masses (Krukenberg)
13.07
Peritoneum
Ovary, stomach, pancreas, colon, appendix
Malignant ascites, omental caking; pseudomyxoma (appendix)
Transcoelomic seeding
Named lymph nodes
Abdominal and pelvic cancers
Virchow (left supraclavicular — gastric), Sister Mary Joseph (umbilical), left axillary (Irish)
Thoracic duct drainage · 10.05
Spine via Batson plexus
Prostate, breast, kidney
Valveless vertebral veins → vertebral bodies → cord compression
14.06
Pleura & pericardium
Lung, breast, lymphoma, melanoma
Malignant effusions, tamponade
Cytology of fluid
CSF seeding
Medulloblastoma, ependymoma, germinoma; leptomeningeal carcinomatosis (breast, lung, melanoma)
"Drop metastases" to cord and cauda equina
16.12
Bone marrow
Neuroblastoma, small cell lung, breast, prostate
Leukoerythroblastic smear, cytopenias
Teardrop cells
Testis
Lymphoma, leukemia (ALL), prostate
Older men; often bilateral
14.04

Mechanism — routes of spread

LymphaticCarcinomas → regional nodes
HematogenousSarcomas; RCC (renal vein), HCC (hepatic vein), follicular thyroid, choriocarcinoma
TranscoelomicOvary, stomach, mesothelioma → body cavities
CSFMedulloblastoma → spine
GI tract
→
Portal vein
→
Liver first
Most other organs
→
Systemic veins → right heart
→
Lung first

Lytic vs blastic bone metastases

TYPE
SOURCES
CLUE
Lytic
Lung (non-small cell), kidney, thyroid, melanoma, myeloma
Holes, fractures, hypercalcemia
Blastic
Prostate, small cell lung, carcinoid
Dense sclerosis, ↑ ALP
Mixed
Breast, GI
Both patterns
Bone scan negative
Multiple myeloma
No osteoblast activity

How it's tested

COMMON CONFUSION"Most common site of metastasis from X" (e.g., colon → liver) vs "most common source of metastases to Y" (brain → lung). Read which direction is asked.
THE TRAPCarcinomas that spread by blood early (RCC, HCC, follicular thyroid, choriocarcinoma) are favorite exceptions — RCC can present with lung or bone metastases before any local symptom.
YOUR APPROACHPrimary organ → its venous and lymphatic drainage → first organ filter → common distant sites → pattern (lytic, hemorrhagic, multiple).

If you see… think…

Several brain masses in a smoker → lung cancer metastases
Liver nodules in a patient with rectal bleeding → colon cancer metastases
Sclerotic lumbar vertebrae in an older man → prostate cancer
Lytic bone lesion + hematuria + polycythemia → renal cell carcinoma
Bilateral ovarian masses with signet ring cells → Krukenberg (gastric)
Hard left supraclavicular node + weight loss → Virchow node (abdominal cancer)
Periumbilical nodule with abdominal cancer → Sister Mary Joseph nodule
Hemorrhagic brain metastases → melanoma, RCC, choriocarcinoma, thyroid
Child with a cerebellar tumor and spinal nodules → medulloblastoma drop metastases
Teardrop cells and nucleated RBCs in a cancer patient → marrow infiltration