History: 47-yr-old male patient with weight loss and severe back pain.

Case of the Month 6December 2015

Case of the Month 6

Case of the Month 6

What is your diagnosis ?

History: 47-yr-old male patient with weight loss and severe back pain.

Question: What does the CXR show?

Case of the Month 6December 2015

Author: Sujal R Desai London

Reticulo-nodular patternBilateral; mid/lower zones

Bulky left hilum Smooth thickening of horizontal fissure

Normal heart size No pleural effusions

Case of the Month 6

Case of the Month 6

Question: What is shown on the CT images & what is your differential diagnosis

Case of the Month 6

Thickened interlobular septa Thickened right oblique fissure Bronchial wall thcikening Focal sclerotic lesions

Case of the Month 6

What is your diagnosis ?

Case of the Month 6Diagnosis

Lymphangitis Carcinomatosa*Differential Diagnosis • Interstitial Oedema• Pulmonary Veno-Occlusive Disease• Congenital lymphatic disorders (e.g. lymphangiectasia)• Erdheim-Chester Disease

* subsequent abdominal MRI and biopsy confirmed diagnosis of a pancreatic tumour

Case of the Month 6Discussion

Dissemination of malignant cells into the pulmonary lymphatics is most commonly associated with cancers of the breast, gastro-intestinal organs (incl. pancreas & stomach) and lung

Spread into pulmonary lymphatics may be ‘retrograde’ from hilar nodes into lung lymphatics

Case of the Month 6Discussion

CHEST RADIOGRAPHY Bilateral thickened interlobular septa / Kerley B lines Thickening of fissures (caused by sub-pleural oedema) Pleural effusion(s)

HIGH-RESOLUTION CT Thickened, nodular interlobular septa Thickening of bronchovascular bundles Hilar/mediastinal lymph node enlargement Pleural effusion(s)

Case of the Month 6Further Reading

LYMPHANGITIS CARCINOMATOSA1) Bruce DM et al. Lymphangitis carcinomatosa: a literature review JR Coll Surg Edinb 1996;41:7-132) Kelly DM et al. Pulmonary lymphangitis carcinomatosa and acute pancreatitis: a rare presentation of choledochal cyst HPB Surg 1999;11:163-1683) Yahng SA et al. Erdheim-Chester disease with lung involvement mimicking pulmonary lymphangitic carcinomatosis Am J Med Sci 2009;337:302-3044) Honda O et al. Comparison of high resolution CT findings of sarcoidosis, lymphoma, and lymphangitic carcinoma: is there any difference of involved intersitium? J Comput Assist Tomogr 1999;23:374-379