A ReindersDepartment of Radiology

UFS

Lymphangitic Carcinomatosis

52 year old female patientRetroviral disease negative

Previously known with right sided breast carcinomaHad right mastectomy and axillary clearance

Now clinically showed progressionCXR shows scattered infiltratesPleural effusionPleural changes on the right

Case Presentation

Medical/social historyNo significant

Special investigationsNuclear medicine

Bone Scintigram“Degenerative lesions in thoracic spine – unable to exclude

metastases”Radiology

CXRCT Chest/abdomen and pelvis

Case presentation

CXR

CXR

Computed Tomography

6 – 8% of all pulmonary metastasesTumor cell accumulation within connective tissue1

Tumor cell embolization of blood vessels Subsequent lymphatic obstruction Interstitial oedema Collagen deposition

Associated cancers Cervic/colon Stomach Breast Pancreas Thyroid Larynx

Lymphangitic Carcinomatosis

“Certain cancers spread by plugging the lymphatics”1

CXR1

Reticular/reticulonodular opacitiesCoarsenend bronchovascular markingsKerley A and B linesSmall lung volumesHilar/mediastinal lymphadenopathyPleural effusions

Imaging

CXR

Normal lung architecture1

Focal/diffuse/unilateral/bilateral distributionThickenend interlobular septaThickenend centrilobular bronchovascular bundle

“Dot in box” appearancePleural effusions (30 – 50%)Lymphadenopathy (30 – 50%)

HRCT

CT Chest, abdomen and pelvis

HRCT

Pulmonary lymphangitic carcinomatosis. Available from URL:http://www.radiopedia.org2

Pulmonary TuberculosisHypersensitivity pneumoniaeSarcoidosisCardiogenic Pulmonary Edema

Differential diagnoses1

Thinking cap.....

Primary TB3,4

ConsolidationLymphadenopathyPleural effusionRegresses

Secondary TB“Reactivation”Consolidation apical segments/superior segment lower lobesCavitation

Miliary TB2 – 3 mm nodules in random distribution throughout lung

Pulmonary Tuberculosis

Clinial historyImmunocompromised

“Tree -in-bud appearance”Endobronchial spread

Simultaneous occurance with LCMRareMay also present with septal thickening

Almost impossible to distinguish radiologicallyIncidental findings in immunocompromised patientsSecondary reactivation of Tuberculosis5

Pulmonary Tuberculosis

Tuon FF, Miyaji KT, DE Vidal PM et al. Simultaneous occurence of pulmonary tuberculosis and carcinomatous lymphangitis. Rev. Oc Bras Med Trop. 2007 Jan-Feb; 40(1) :76-7

Pulmonary Tuberculosis

Right: Tree in bud appearance indicating endobronchial spread

Left: Active pulmonary Tuberculosis with cavitation in the apical segment of right lower lobe

Extrinsic Allergic Alveolitis “Farm worker’s lung” “Bird fancier’s lung”

Stages3

AcuteSubacute

Ill defined centrilobular nodulesMosaic pattern

Bronchiolitis with air trapping (lucencies) + patchy areas of infiltration (ground glass)Chronic

Mosaic patternFibrosis and parenchymal distortion in midzone distribution

Fibrosis typically through whole lung From periphery to centrum

Hypersensitivity Pneumonia

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

Systemic disorder of unknown origin3,4

Non caseating granulomas in multiple organs90% of patients have lung involvement

Lobar predominanceUpper and midzone predominanceSmall nodules in perilymphatic distribution1-2-3 Sign + calcifications

Silzbach classificationStage 0 = normal lungsStage 1 = Lymphadenopathy onlyStage 2 = Lung involvement and lymphadenopathyStage 3 = Lung involvement onlyStage 4 = Fibrosis

Sarcoidosis

Sarcoidosis

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

HRCT3

Bilateral smooth septal thickeningGround glass opacityPerihilar and gravitational distribution of fluidCardiomegalyPleural effusion

Cardiogenic Pulmonary Edema

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/

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 carcinomatous lymphangitis. 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

Bibliography