Lymphangitic Carcinomatosis

1. LymphangiticCarcinomatosis A Reinders Department of Radiology UFS

2. Case Presentation • 52 year old female patient • Retroviral disease negative • Previously known with right sided breast carcinoma • Had right mastectomy and axillary clearance • Now clinically showed progression • CXR shows scattered infiltrates • Pleural effusion • Pleural changes on the right

3. Case presentation • Medical/social history • No significant • Special investigations • Nuclear medicine • Bone Scintigram • “Degenerative lesions in thoracic spine – unable to exclude metastases” • Radiology • CXR • CT Chest/abdomen and pelvis

4. CXR

5. CXR

6. Computed Tomography

7. LymphangiticCarcinomatosis • 6 – 8% of all pulmonary metastases • Tumor cell accumulation within connective tissue1 • Tumor cell embolizationof blood vessels • Subsequent lymphatic obstruction • Interstitial oedema • Collagen deposition • Associated cancers • Cervic/colon • Stomach • Breast • Pancreas • Thyroid • Larynx “Certain cancers spread by plugging the lymphatics”1

8. Imaging • CXR1 • Reticular/reticulonodularopacities • Coarsenendbronchovascularmarkings • Kerley A and B lines • Small lung volumes • Hilar/mediastinallymphadenopathy • Pleural effusions

9. CXR

10. HRCT • Normal lung architecture1 • Focal/diffuse/unilateral/bilateral distribution • Thickenendinterlobular septa • Thickenendcentrilobularbronchovascularbundle • “Dot in box” appearance • Pleural effusions (30 – 50%) • Lymphadenopathy (30 – 50%)

11. CT Chest, abdomen and pelvis

12. HRCT Pulmonary lymphangiticcarcinomatosis. Available from URL:http://www.radiopedia.org2

13. Differential diagnoses1 • Pulmonary Tuberculosis • Hypersensitivity pneumoniae • Sarcoidosis • Cardiogenic Pulmonary Edema Thinking cap.....

14. Pulmonary Tuberculosis • Primary TB3,4 • Consolidation • Lymphadenopathy • Pleural effusion • Regresses • Secondary TB • “Reactivation” • Consolidation apical segments/superior segment lower lobes • Cavitation • Miliary TB • 2 – 3 mm nodules in random distribution throughout lung

15. Pulmonary Tuberculosis • Clinial history • Immunocompromised • “Tree -in-bud appearance” • Endobronchial spread • Simultaneous occurance with LCM • Rare • May also present with septal thickening • Almost impossible to distinguish radiologically • Incidental findings in immunocompromised patients • Secondary reactivation of Tuberculosis5 Tuon FF, Miyaji KT, DE Vidal PM et al. Simultaneous occurence of pulmonary tuberculosis and carcinomatouslymphangitis. Rev. Oc Bras Med Trop. 2007 Jan-Feb; 40(1) :76-7

16. Pulmonary Tuberculosis Left: Active pulmonary Tuberculosis with cavitation in the apical segment of right lower lobe Right: Tree in bud appearance indicating endobronchial spread

17. Hypersensitivity Pneumonia • Extrinsic Allergic Alveolitis • “Farm worker’s lung” • “Bird fancier’s lung” • Stages3 • Acute • Subacute • Ill defined centrilobular nodules • Mosaic pattern • Bronchiolitis with air trapping (lucencies) + patchy areas of infiltration (ground glass) • Chronic • Mosaic pattern • Fibrosis and parenchymal distortion in midzone distribution • Fibrosis typically through whole lung • From periphery to centrum

18. Hypersensitivity Pneumonia Morissa AM, Nishimurab S, Huanga L. Subacute hypersensitivity pneumonitis in an HIV infected patient receiving antiretroviral therapy. Thorax 2000;55:625-627 doi:10.1136/thorax.55.7.6256

19. Sarcoidosis • Systemic disorder of unknown origin3,4 • Non caseatinggranulomas in multiple organs • 90% of patients have lung involvement • Lobar predominance • Upper and midzone predominance • Small nodules in perilymphatic distribution • 1-2-3 Sign + calcifications • Silzbach classification • Stage 0 = normal lungs • Stage 1 = Lymphadenopathy only • Stage 2 = Lung involvement and lymphadenopathy • Stage 3 = Lung involvement only • Stage 4 = Fibrosis

20. Sarcoidosis Pulmonary sarcoidosis. Available from URL: http://www.radiopedia.org2

21. Cardiogenic Pulmonary Edema • HRCT3 • Bilateral smooth septal thickening • Ground glass opacity • Perihilar and gravitational distribution of fluid • Cardiomegaly • Pleural effusion

22. Cardiogenic Pulmonary Edema Smithuis R, Van Delden O, Schaefer-Prokop C. HRCT part II: Key findings in Interstitial Lung Diseases.3 Available from URL: http://www.radiologyassistant.nl/en/

23. Bibliography • 1. Chest Disorder. In: Dahnert W. Editor. Radiology Review Manual. 6th Edition. Lippincot Williams & Wilkins. 2007; p509 • 2. Images available from URL: http://www.radiopedia.org • 3. Smithuis R, Van Delden O, Schaefer-Prokop C. HRCT part II: Key findings in Interstitial Lung Diseases. Available from URL: http://www.radiologyassistant.nl/en/ • 4. Chest Imaging. In: Weissleder R, Wittenberg J, Harisinghani MG, Chen JW. Editors. Primer of Diagnostic Imaging. 4th Edition. Mosby Elsevier 2007; p34 - 35 • 5. Tuon FF, Miyaji KT, de Vidal PM et al. Simultaneous occurence of pulmonary tuberculosis and carcinomatouslymphangitis. Rev. Oc Bras Med Trop. 2007 Jan-Feb; 40(1) :76-7 • 6. Morissa AM, Nishimurab S, Huanga L. Subacute hypersensitivity pneumonitis in an HIV infected patient receiving antiretroviral therapy. Thorax 2000;55:625-627 doi:10.1136/thorax.55.7.625