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Pulmonary lymphangitic carcinomatosis is one rare pattern of pulmonary metastases in advanced cancers. Gastric cancer is one of the most common forms of cancer that causes pulmonary lymphangitic carcinomatosis. However, recurrent gastric cancer presenting as pulmonary lymphangitic carcinomatosis after surgery is extremely rare. Furthermore, recurrence is usually observed within 5 years. We present the first case of pulmonary lymphangitic carcinomatosis in a patient with recurrent gastric cancer, 19 years after resection. In patients with a history of gastric cancer and the presence of interstitial shadow, pulmonary lymphangitic carcinomatosis should be considered in the differential diagnosis even if several years have passed since surgery.

Lymphangitic carcinomatosis, the presence of tumor within the pulmonary lymphatics, occurs in the setting of malignant tumors and is associated with a poor prognosis. Here we describe a case of lymphangitic carcinomatosis in the setting of renal cell carcinoma and review the radiological manifestations of this disease.

The diagnosis of lymphangitic carcinomatosis is challenging due to the manifestation of nonspecific symptoms and radiographic abnormalities that bear similarity to those of interstitial lung disease. Herein, we report the case of a 53-year-old woman diagnosed with lymphangitic carcinomatosis from metastatic gastric adenocarcinoma, 3 months after her initial presentation.

Pulmonary metastases typically present as well-circumscribed solid nodules, often with a basilar and peripheral distribution due to hematogenous spread. When an atypical pattern of metastasis occurs, a lack of recognition may result in understaging or a delay in diagnosis. The purpose of this article is to review the imaging findings of atypical pulmonary metastatic disease in children. Atypical pulmonary metastatic patterns that can be seen in children include cavitary lesions, calcified pulmonary nodules, nodules with peritumoral halos, tree-in-bud or strial pattern secondary to tumor in peripheral pulmonary arterial branches, lymphangitic carcinomatosis, and miliary disease. An awareness of the spectrum of imaging findings of atypical pulmonary metastases along with an understanding of histopathological underpinnings will allow the radiologist to make an accurate diagnosis.

Highlights • Papillary thyroid carcinoma (PTC) is the most common carcinoma encountered in the paediatric setting. • PTC often presents with advanced locoregional disease in children and pulmonary metastasis are seen in up to 46% of cases. • Miliary nodules on chest roentgenogram may be caused by miliary tuberculosis but other causes including metastatic carcinoma should be considered., Introduction Papillary thyroid carcinoma (PTC) is the most common carcinoma to occur in childhood with a peak incidence between 11–17 years, and typically presents with advanced locoregional disease. Pulmonary metastases are seen in up to 46% of cases and should enter the differential diagnosis of miliary nodules seen on chest roentgenogram, even in regions where tuberculosis is endemic. Presentation of case An 11-year-old male presented with a short history of cough, shortness of breath and constitutional symptoms. Examination revealed cervical lymphadenopathy and diffuse bilateral nodular infiltrates on the chest roentgenogram. Investigation for Mycobacterium tuberculosis was negative and this initiated biopsy of a cervical lymph node. Histopathological examination revealed metastatic PTC. Ultrasonography and magnetic resonance imaging (MRI) were performed for preoperative staging. The patient subsequently underwent total thyroidectomy with selective neck dissection. Discussion There are several potential causes when dealing with miliary nodules on chest roentgenogram. Thorough interrogation of the clinical, radiological, pathological and microbiological data is required to arrive at the correct diagnosis. Postoperative adjuvant therapy with radioactive iodine is recommended in children with metastatic disease, but this should be restricted preferably to a single dose to avoid the complication of pulmonary fibrosis. Conclusion This case highlights the differential diagnostic considerations of a patient presenting with constitutional symptoms and a miliary pattern on chest roentgenogram. Carcinomas are uncommon in children but should not be forgotten.

BACKGROUND: The eighth edition of the TNM classification for lung cancer does not provide a definite guideline for pulmonary lymphangitic carcinomatosis. The purpose of this retrospective case-control study is to evaluate the prognosis of pulmonary lymphangitic carcinomatosis in patients with non-small cell lung cancer compared with those with intrapulmonary metastases. METHODS: Non-small cell lung cancer (NSCLC) patients with pulmonary lymphangitic carcinomatosis detected on chest computed tomography scan during staging evaluation between 2000 and 2016 were included. The extent of pulmonary lymphangitic carcinomatosis was classified as being around the primary tumor (cLy1), at a distance from the tumor but confined to the same lobe (cLy2), in other ipsilateral lobes (cLy3), or affecting the contralateral lung (cLy4). Overall survival rates of the subjects were compared with those with intrapulmonary metastases. RESULTS: A total of 103 subjects with pulmonary lymphangitic carcinomatosis were analysed. The 5-year overall survival rates of the subjects with pulmonary lymphangitic carcinomatosis (n=103) and intrapulmonary metastases (n=111) were 33% and 21%, respectively. The 5-year overall survival rates of cLy1 (n=28), cLy2 (n=40), cLy3 (n=26) and cLy4 (n=9) were 54%, 35%, 12% and 11%, respectively. On multivariable analyses after adjusting for possible confounders, the subjects with cLy1 and cLy2 had better overall survival (adjusted hazard ratio for death, 0.34 and 0.49; 95% confidence interval, 0.24–0.73 and 0.30–0.80; P

BackgroundPulmonary lymphangitic carcinomatosis (PLC) is a malignant lung disease characterized by metastatic tumor lesions in the lung lymphatic vessels with a poor prognosis. Early diagnosis is the key to improve the outcome. However, when PLC is the first manifestation of patients without a known malignancy, it often leads to delayed diagnosis and treatment, and even fatal consequences due to non-specific symptoms. Here, we describe a young male presenting PLC as the first and only manifestation followed by diagnosis of gastric adenocarcinoma and systemically summarized previously reported clinical properties of PLC cases in the literature.Case presentationA 32 years old male presented nonproductive cough for 20 days and progressive exertional dyspnea in a week. He was diagnosed with pneumonia and received antibiotics for almost 3 weeks without any improvement. Chest computed tomography showed multiple nodules and thickened interlobular septa in bilateral lung. PET/CT revealed a primary gastric tumor with PLC and the biopsy of the cervical lymph node confirmed a poorly metastatic differentiated gastric adenocarcinoma. The patient’s general condition deteriorated rapidly and he developed respiratory failure, requiring non-invasive mechanical ventilation on day 9 after admission. Chemotherapy was given to the patient on the tenth day. However, few hours after receiving the first dose, the patient died of respiratory failure. It was only one month from the onset of symptoms to death of our case.ConclusionsPatients presenting PLC as the first manifestation of an unknown malignancy carry a bleak prognosis. PLC be considered for differential diagnosis in patients who present with dyspnea, dry cough with or without loss of weight. Particular attentions need to be given to patients, especially young ones without histories of malignancy, whose chest imaging exhibits thickened interlobular septa. While the stomach, lung and prostate are the most likely origins of the primary tumors, patients with PLC derived from prostate cancer may have a better prognosis after anti-cancer treatment.

A 55-year-old man with cough, bone pain, and cervical lymphadenopathy underwent both 18F-FDG and 18F-PSMA-1007 PET/CT scans with clinical suspicion of malignant disease. Compared with 18F-FDG PET/CT, 18F-PSMA PET/CT showed intense tracer uptake in the prostate gland, lungs, osteogenic lesions, and multiple lymph nodes. Interestingly, we also found the high tracer concentration of pulmonary lymphangitic carcinomatosis, a very rare form of prostate cancer metastasis to the lung, on 18F-PSMA-1007 PET/CT images.

Background Pulmonary lymphangitic carcinomatosis (PLC) is a metastatic lung disease of malignant tumors that spread through pulmonary lymphatic vessels. Although prompt diagnosis and specific treatment of PLC are required due to the poor prognosis associated with this disease, it is often challenging to determine the primary cancer site. Case presentation A 67-year-old Japanese woman presented to our hospital with a 10-day history of cough and dyspnea on exertion. Chest radiography and computed tomography (CT) revealed diffuse nodular opacities with interlobular septal thickening. Both bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) revealed carcinoma cells with unknown origin. Contrast-enhanced CT depicted a mass in the right ureter with hydronephrosis, and retrograde urography showed a narrowing of the right ureter. Urine cytology from her right ureter via ureteral catheter also revealed atypical cells, highly suggestive of malignancy. Immunohistochemical examination of lung specimens via TBLB showed results consistent with lung metastasis of ureteral cancer. Therefore, we arrived at a diagnosis of PLC secondary to ureteral cancer. Conclusions This case encouraged multidisciplinary discussion and a whole-body examination, including TBLB with immunohistochemistry, to determine the origin of PLC.

The most common modalities to image thoracic metastases are chest radiography, chest computed tomography (CT), and 18F-fluorodeoxyglucose positron emission tomography (18FDG PET). In certain patient populations considered low risk for thoracic metastases, some management guidelines recommend chest radiography to screen for thoracic metastasis (1,2). However, chest CT remains the most sensitive imaging modality to detect and delineate the patterns of thoracic metastases. If volumetric 1–2 mm axial reconstructions are not routinely performed, high-resolution chest CT (HRCT) provides better resolution of the interstitial architecture, which is particularly useful in cases of lymphangitic carcinomatosis. 18FDG PET imaging is well established for the diagnosis and staging of metastases in lung, colon, head and neck tumours, melanoma, breast, and lymphoma (3,4).

With the advent of high-resolution computed tomography (HRCT), micronodular lung disease is a routinely encountered pathology in thoracic imaging. This article will review how to differentiate the three main micronodular patterns and review the differential diagnosis for each. Differential diagnosis of micronodular lung disease may be extensive, but by identifying the pattern and using additional clues, such as distribution, additional imaging findings, and clinical history, a radiologist can make an accurate diagnosis. First, three micronodular patterns - centrilobular, peri-lymphatic, and random - can be identified by using a simple algorithm based on the location of nodules. This algorithm requires understanding of the anatomy and function of the secondary pulmonary lobule. Each micronodular pattern offers a unique differential diagnosis. Centrilobular nodules can be seen with inflammatory, infectious, or vascular aetiologies; peri-lymphatic nodules with sarcoidosis and lymphangitic carcinomatosis; and random nodules with haematogenous metastases or infections.

Rearranged during transfection proto-oncogene (RET) fusions represent a potentially targetable oncogenic driver in non-small cell lung cancer (NSCLC). Imaging features and metastatic patterns of advanced RET fusion-positive (RET+) NSCLC are not well established. Our goal was to compare the imaging features and patterns of metastases in RET+, ALK+ and ROS1+ NSCLC. Patients with RET+, ALK+, or ROS1+ NSCLC seen at our institution between January 2014 and December 2018 with available pre-treatment imaging were identified. The clinicopathologic features, imaging characteristics, and the distribution of metastases were reviewed and compared. We identified 215 patients with NSCLC harboring RET, ALK, or ROS1 gene fusion (RET = 32, ALK = 116, ROS1 = 67). Patients with RET+ NSCLC were older at presentation compared to ALK+ and ROS1+ patients (median age: RET = 64 years, ALK = 51 years, p &lt, 0.001, ROS = 54 years, p = 0.042) and had a higher frequency of neuroendocrine histology (RET = 12%, ALK = 2%, p = 0.025, ROS1 = 0%, p = 0.010). Primary tumors in RET+ patients were more likely to be peripheral (RET = 69%, ALK = 47%, p = 0.029, ROS1 = 36%, p = 0.003), whereas lobar location, size, and density were comparable across the three groups. RET+ NSCLC was associated with a higher frequency of brain metastases at diagnosis compared to ROS1+ NSCLC (RET = 32%, ROS1 = 10%, p = 0.039. Metastatic patterns were otherwise similar across the three molecular subgroups, with high incidences of lymphangitic carcinomatosis, pleural metastases, and sclerotic bone metastases. RET+ NSCLC shares several distinct radiologic features and metastatic spread with ALK+ and ROS1+ NSCLC. These features may suggest the presence of RET fusions and help identify patients who may benefit from further molecular genotyping.

Diagnosis in cases with pulmonary lymphangitic carcinomatosis as a primary manifestation is difficult due to unawareness of the cancer. An 81‐year‐old man was admitted due to a one‐week history of dyspnoea and haemoptysis. Chest computed tomography showed diffuse bilateral ground‐grass opacity and partial consolidation. We suspected diffuse alveolar haemorrhage. High‐dose methylprednisolone and cyclophosphamide did not improve his condition and he died from respiratory failure. Autopsy revealed pulmonary lymphangitic carcinomatosis of whole lungs and primary gallbladder cancer. We should consider pulmonary lymphangitic carcinomatosis in the differential diagnosis of patients with haemoptysis and diffuse lung opacity of unknown origin., An 81‐year‐old man was admitted due to dyspnoea and haemoptysis. We suspected diffuse alveolar haemorrhage based on computed tomography (CT) findings of diffuse bilateral ground‐grass opacity and partial consolidation. Autopsy revealed pulmonary lymphangitic carcinomatosis of whole lungs and primary gallbladder cancer.

The diverse imaging manifestations of thoracic metastatic disease often challenge accurate interpretation. Malignant cells usually arrive via the bloodstream but find fertile substrates within the pulmonary circulation, lymphatic networks, branching airways, and pleural envelope. Unusual metastatic nodules cavitate, calcify, or hemorrhage. Widespread intravascular tumor may induce pulmonary hypertension. In lymphangitic carcinomatosis the deep and superficial lymphatic networks expand with tumorlets, with consequent parenchymal congestion. Nodal lymphomas can spread retrograde via lymphatic pathways, forming multilobar consolidations that mimic pneumonia. Sarcoid-like reactions occasionally develop in thoracic nodes and lung in settings of malignancy or immunotherapy, and are often confused with tumor recurrence.

Although pulmonary tumor embolism (PTE) is a well-recognized end-stage form of pulmonary metastases at postmortem examination, the entity is rarely the first clinical sign of prostate cancer. Diagnosis of this condition in patients who have no previous history of malignancy is a challenge. Herein, we reported a 79-year-old man presented with progressive, unexplained dyspnea on exertion. Microscopic PTE coinciding with pulmonary lymphangitic carcinomatosis were readily recognized based on the presence of multifocal dilatation and beading of the peripheral pulmonary arteries with thickening of the bronchial walls and interlobular septa on the initial thin-section chest CT images. Pathologic examination of the transbronchial lung biopsy specimen revealed tumor emboli occluding both the small muscular pulmonary arteries and lymphatic vessels. These tumor cells were positive for prostatic specific antigen on immunohistochemical staining. The final diagnosis of prostatic adenocarcinoma was confirmed. Remarkable clinical and radiographic improvement was achieved following bilateral orchiectomies and anti-androgen treatment., Highlights • Pulmonary tumor embolism (PTE) can be the first clinical sign of advanced prostatic adenocarcinoma. • CT findings of dilated, beaded peripheral pulmonary arteries should raise a concern of microscopic PTE. • Dilated, beaded pulmonary arteries should not be mistaken for tree-in-bud opacities caused by bronchiolar disease on CT. • Prostate cancer should always be considered in the differential diagnosis of adenocarcinoma of unknown origin in men.

Skin metastases are a rare event in patients with cervical cancer. One form of such metastasis is carcinomatous lymphangitis, which is a rare presentation of skin metastases. Here we report a woman with cervical cancer diagnosed cutaneous lymphangitic carcinomatosis., Highlights • Cervical cancer is the most common gynecologic malignancy in developing countries • Skin metastasis of cervical cancer is a rare entity, more often seen with adenocarcinoma • The management of skin metastases in patients with cervical cancer depends on the mode of presentation

Osimertinib is an oral, irreversible epidermal growth factor receptor inhibitor that is associated with various pulmonary manifestations including transient asymptomatic pulmonary opacities (TAPOs) and pneumonitis. We present a case of a 61-year-old female with Stage IV lung adenocarcinoma, who developed bilateral ground glass opacities on her chest-computed tomography (CT) three months after initiating osimertinib. Her imaging findings were thought to represent lymphangitic carcinomatosis responding to chemotherapy rather than drug induced toxicity, and she was continued on osimertinib. Conversely, we present a second case of a 57-year-old female with Stage IV lung adenocarcinoma who developed osimertinib-induced pneumonitis and was successfully rechallenged with osimertinib and glucocorticoids. These cases, described herein, illustrate examples of the range of pulmonary manifestations of osimertinib, as well as the safety of rechallenging patients with osimertinib and glucocorticoids following the development of pneumonitis.

Interstitial lung diseases (ILD) are a heterogeneous group of diseases and one of the differential diagnosis which have to be excluded during diagnostic procedures are malignancies. We will present four patients who were referred to our Department because of suspicion of interstitial lung diseases according to radiology finding. In one case only, one of the radiologist’s differential diagnosis was pulmonary lymphangitic carcinomatosis. All four patients had exertional dyspnea and dry cough which are nonspecific and can be first manifestation of ILD or obstructive lung diseases. After diagnostic evaluation in three cases, diagnosis was pulmonary lymphangitic carcinomatosis due to metastatic lung adenocarcinoma and in one due to metastatic adenocarcinoma of unknown primary origin. Patients with lymphangitic carcinomatosis have poor prognosis without treatment and usually die because of respiratory failure. With these four cases we want to highlight importance of thinking about malignancies when we have patients with suspicion of interstitial lung disease especially when reticular pattern is present on chest X ray. We also wanted to show how important is radiology finding and multidisciplinary approach, and how radiologist’s differential diagnosis can be very helpful in making decisions in further investigations and way of clinicians thinking.

Breast cancer typically spreads primarily to regional lymph nodes and subsequently to distant sites via hematogenous routes. Occasionally metastasis can occur through lymphangitic spread, usually to the lungs, resulting in lymphangitic carcinomatosis. Lymphangitic spread of several malignancies have been reported at other sites in the body with varying degrees of clinical significance. In this case report, we describe a rare case of lymphangitic spread of invasive lobular carcinoma to the contralateral breast identified on imaging as significant background enhancement without a discrete suspicious mass.

Hirokazu Toshima, Toshikazu Ikusue, Atsushi Hisamatsu, Kouji Kobayashi, Ken Shimada Medical Oncology, Showa University Koto Toyosu Hospital, Tokyo, Japan Abstract: Clinicians often encounter cases of pulmonary lymphangitic carcinomatosis when treating patients with cancer. When such a condition develops before the diagnosis of cancer, its diagnosis is often challenging. Herein, we report about two patients with colorectal carcinoma diagnosed after the identification of lymphangitic carcinomatosis, which achieved complete remission with combination anti-epidermal growth factor receptor (anti-EGFR) antibody therapy. In case 1, a 74-year-old woman presented with cough and dyspnea that had persisted for 1month. She had unresectable advanced carcinoma of the sigmoid colon with lymphangitic carcinomatosis. Her respiratory status gradually deteriorated due to the disease. Thus, FOLFIRI plus cetuximab therapy was initiated. Her dyspnea rapidly resolved with the treatment, and complete remission of lymphangitic carcinomatosis was achieved. In case 2, a 46-year-old man presented with fever and dyspnea that had persisted for 1month. He had unresectable advanced carcinoma of the transverse colon with lymphangitic carcinomatosis. FOLFOXIRI therapy was then initiated. However, his respiratory status did not improve. Therefore, his treatment was immediately switched to FOLFIRI plus panitumumab. His dyspnea rapidly resolved with the treatment, and complete remission of lymphangitic carcinomatosis was achieved. In oncologic emergencies, such as lymphangitic carcinomatosis, requiring an early response to treatment, the administration of anti-EGFR antibodies may be a highly effective treatment option. Keywords: anti-epidermal growth factor receptor antibody, early tumor shrinkage, depth of response, chemotherapy, Pan-Asian adapted ESMO consensus guidelines, tumor location

Unilateral absence of the pulmonary artery (UAPA) represents a rare condition that is often associated with cardiac congenital abnormalities but can also be relatively asymptomatic and indolent. There is a lack of consensus regarding the management of UAPA. However, in the setting of associated complications and ongoing infection, pulmonary resection is advocated. Although rare, the association between UAPA and bronchogenic carcinoma has been previously reported in seven published cases. In the majority of these, anatomic lung resection (most commonly with pneumonectomy) was curative. We present the first reported case of ipsilateral metastatic non-small-cell lung cancer- (NSCLC-) associated UAPA in a 47-year-old patient with ventilator-dependent hypoxic respiratory failure and bronchorrhea, who had been lost to follow-up for 8 years. Initial investigations did not yield evidence of malignancy, and confirmation of metastatic disease was made intraoperatively at the time of thoracotomy. The findings demonstrated evidence of diffuse metastatic pleural disease with lymphangitic carcinomatosis and superimposed infection. The patient was palliated and passed away shortly thereafter. In the setting of UAPA, clinicians should have a high index of suspicion for the possibility of malignancy, and if proven, they should consider early resection following appropriate staging.

e21064 Background: Pulmonary lymphangitic carcinomatosis (PLC) occurs in 6%-8% of intrathoracic metastases among malignant tumor. The median survival was only 2.0 months from time of pulmonary symptoms to death in cases during 2000-2018, which is a poor prognosis. Effective interventions were needed besides standard chemotherapy and symptomatic support. Anlotinib showed a critical effect on lymphangiogenesis, and lymphatic metastasis in mouse models of lung adenocarcinoma, it might be a therapeutic option for tumor lymphatic metastasis. In this study, we retrospectively analyzed the efficacy and safety of anlotinib for PLC in patients with Non-small Cell Lung Cancer (NSCLC). Methods: We retrospectively investigated NSCLC patients with PLC at our hospital between May 2018 and November 2020, who received anlotinib monotherapy or combined therapy for PLC. Data were analyzed for progression-free survival (PFS), overall survival (OS), objective response rate(ORR), disease control rate(DCR) and adverse events (AE). The impact of clinical and genomic factors on PFS and OS were also assessed. Results: A total of 14 patients were enrolled with a median age of 64 years. 10(71.4%) were male, 4(28.6%) has smoking history, 10(71.4%) of patients had a performance status of 2-3. 9, 3, 2 patients had TP53 mutation, EGFR mutation, ALK fusion respectively. 9(64.3%) patients received anlotinib monotherapy. Of 14 patients, 8 achieved partial response (PR), 5 presented stable disease (SD), 1 had progressed disease. The ORR and DCR were 57.1% and 92.9% respectively. The median PFS was 3.1 months (95% CI: 2.0-4.2), the median OS for 1, 2, ≥3 line were 13 months, 7.2 months, 5.2 months, respectively. Median PFS and OS (≥3 line) were significantly longer for patients with TP53-mutant tumors compared with those with TP53–wild-type tumors (median PFS: 7 vs. 1.1 months, median OS (≥3 line): 6.8 vs. 1.9 months). No difference of PFS and OS (≥3 line) was found between EGFR or ALK alteration and the corresponding wild type patients. The most frequently reported AEs were high blood pressure (11, 78.6%), hand foot syndrome (6, 42.9%), diarrhea (5, 35.7%), fatigue (4, 28.6%), hoarseness (3, 21.4%), proteinuria (2, 14.3%) and stomatitis (2, 14.3%). Conclusions: Anlotinib presented favorable efficacy in patients with pulmonary lymphangitic carcinomatosis and conferred considerable survival benefit compared with previous studies, especially in patients harboring TP53 mutations. The AEs were manageable. These indicated that anlotinib can be a promising therapeutic treatment of PLC. More clinical data is needed to validate this finding.

Introduction The lymphangitic carcinomatosis (LC) pattern of metastatic malignancy is associated with a poor prognosis but is currently not well defined in malignant pleural mesothelioma (MPM). Here, we report the incidence and prognostic significance of the radiographic development of LC in MPM following extended pleurectomy/decortication (EPD). Methods Consecutive patients with biopsy-proven MPM undergoing EPD with intraoperative photodynamic therapy (PDT) at our institution from 2008 to 2014 were included in this retrospective study. Patients without available post-surgical clinical or imaging data for direct review were excluded. CT images were reviewed by an experienced, board-certified thoracic radiologist and confirmed by consensus review. Overall survival (OS) and progression-free survival (PFS) were calculated by Kaplan Meier methodology. Hazard ratios were compared with a cox proportional hazard model. Results 44 patients underwent EPD with PDT during the study period and had available clinical and imaging data. During the follow-up period (median 34 months), 17 patients (39%) developed LC at a median of 10 months after surgery (IQR 5–21 months). 16 of the 17 patients who developed LC (94%) died during the follow-up period, compared to 17 of the 27 who did not develop LC (63%). OS for the LC versus non-LC group was 53% versus 93% at 1 year and 18% versus 67% at 3 years. LC was significantly associated with a lower OS (HR 4.07; 95% confidence interval 1.44–11.48; p = 0.008). PFS for the LC group versus non-LC group was 8 months (IQR 5–9 months) compared to 17 months (IQR 11–24 months) (p Conclusion LC is a common form of failure in MPM following EPD and is associated with a poor prognosis. Thus, further studies are warranted to determine if any evidence of preoperative LC should be an absolute contraindication to EPD and may warrant an EPP or no surgery at all.

Gingival metastasis of lung cancer is uncommon. We report the case of an 82-year-old male smoker admitted to the pulmonology department with right pleural effusion. A chest computed tomography (CT) scan showed an invasive right hilar tumour, adherent to the superior vena cava, pulmonary artery, main right bronchus, mediastinal pleura and pericardium with lymphangitic carcinomatosis of the right lung. Pleural biopsy revealed pleural metastasis of pulmonary adenocarcinoma, its primary lung origin being confirmed by immunohistochemistry. One month later, the patient developed an ulcerated polypoid gingival mass. Biopsy of this lesion showed a poorly differentiated carcinoma compatible with metastasis from the lung adenocarcinoma. The patient underwent irradiation of the gingival mass at a dose of 30 Gray, but his condition worsened rapidly and he was not fit for chemotherapy. He received palliative treatment and died 2 months after diagnosis of his metastatic lung cancer. LEARNING POINTS Lung cancers mostly metastasize to the bones, liver, lymph nodes, brain, lung and adrenal glands, with adenocarcinoma being the most common histological type. Distant metastasis to the oral region is very uncommon but can be the first manifestation of a primary tumour. Oral metastasis can be mistaken for a benign lesion, so a biopsy should be taken for further analysis.

A diagnosis of ‘chronic cough’ (CC) requires the exclusion of sinister pulmonary pathology, including infection and malignancy. We present a patient with a 3 month history of CC who had an extensive workup including a normal high resolution computed tomography of the chest (HRCT) 6 weeks prior to consultation at our center. He subsequently developed constitutional symptoms including weight loss and loss of appetite 5 weeks after initial consultation. A repeat HRCT chest and a subsequent whole body PET scan found that he had developed extensive pulmonary lymphangitic carcinomatosis (PLC) from a colon primary. Treatment of the colon cancer resulted in significant decrease in metastatic disease burden and cough resolution. PLC is a very rare cause of ‘chronic cough’ and incipient/occult PLC presenting with chronic cough and a normal initial HRCT chest has not been previously reported., Highlights • Asthma, GERD and postnasal drip are the 3 most common causes of chronic cough. • Constitutional symptoms (weight loss etc.) never occur in chronic cough. • Pulmonary lymphangitic carcinomatosis can rarely present with chronic cough.

Introduction:The thorax is a frequent site of metastasis from numerous non-pulmonary cancers. Intrathoracic metastatic disease may manifest in a variety of forms, including solitary or multiple pulmonary nodules, endobronchial tumor, lymphangitic carcinomatosis, or a pleural effusion.Material and Methods:This is muticentric, observational study conducted in Pulmonary Medicine, MIMSR medical college & Venkatesh chest hospital and critical care center, Latur during June 2012 to November 2016 to observe various thoracic manifestations of gynecological malignancies. Total 2300 cases of various gynecological malignancies were screened and finally 330 cases showing various thoracic manifestations were enrolled after subjecting those cases to inclusion and exclusion criteria. All study cases were subjected to chest radiological investigations and histopathological investigations whenever necessary to diagnose metastatic disease. Hospital’s ethical committee & IRB approval has been taken and written informed consent of patient was taken before enrollment.Results:Screened total 2000 cases of gynecological malignancies (ovary, endometrium, cervix & benign ovarian tumors) and selected 330 cases with various metastatic thoracic manifestations. Malignant gynecological tumors including endometrial, cervical & ovarian cancers predominantly observed in above 50 years of age while benign ovarian and uterine tumors in below 50 years of age (p

Renal medullary carcinoma is a rare renal malignancy of childhood. There are no large series describing the imaging appearance of renal medullary carcinoma in children. To characterize the clinical and imaging features of pediatric renal medullary carcinoma at initial presentation. We retrospectively analyzed images of 25 pediatric patients with renal medullary carcinoma enrolled in the Children’s Oncology Group renal tumors classification, biology and banking study (AREN03B2) from March 2006 to August 2016. Imaging findings of the primary mass, and patterns of locoregional and distant spread were evaluated in correlation with pathological and surgical findings. Median age at presentation was 13 years (range: 6-21 years), with a male predominance (3.2:1). The overall stage of disease at initial presentation was stage 1 in 1, stage 2 in 2 and stage 4 in 22. Maximum diameter of the primary renal mass ranged from 1.6 to 10.3 cm (mean: 6.6 cm) with a slight right side predilection (1.5:1). Enlarged (>1 cm short axis) retroperitoneal lymph nodes were identified at initial staging in 20/25 (80%) cases, 10 of which were histologically confirmed while the others did not undergo surgical sampling. Enlarged lymph nodes were also identified in the mediastinum (14/25; 56%) and supraclavicular regions (4/25; 16%). Metastatic disease was present in the lungs in 19/25 (76%) and liver in 6/25 (24%). The pattern of lung metastases was pulmonary lymphangitic carcinomatosis: 10 cases (9 bilateral, 1 unilateral), pulmonary nodules with indistinct margins: 6 cases, pulmonary nodules with distinct margins: 2 cases, while 1 case had pulmonary nodules with both indistinct and distinct margins. Pulmonary lymphangitic carcinomatosis was pathologically confirmed in 4/10 cases. All cases with pulmonary lymphangitic carcinomatosis had associated enlarged mediastinal lymph nodes. Renal medullary carcinoma in children and young adults presents at an advanced local and distant stage in the majority of patients. The diagnosis of renal medullary carcinoma should be considered when a child or young adult presents with a poorly defined/infiltrative, centrally located renal mass, especially in the setting of known sickle cell hemoglobinopathy. Distant metastases are common at initial presentation in the lungs, distant lymph nodes and liver and often involve multiple sites simultaneously. Pulmonary lymphangitic carcinomatosis, a distinctive and uncommon form of lung metastasis in children, is common in this patient population.

Collecting duct carcinoma is a rare neoplasm of the kidney, accounting for only 1–2% of renal tumors. These tumors arise from the principal cells of the renal collecting ducts of Bellini. The majority of patients have lymph node involvement and metastases to lungs, liver, bone, adrenal glands, and brain. We present a case of a 48 year old woman who came to the hospital with a clinical presentation suspicious for pneumonia. One week later her symptoms aggravated. A CT chest and abdominal imaging showed bilateral pulmonary infiltrates, retroperitoneal lymphadenopathy, and left hydroureteronephrosis. She expired after developing acute respiratory failure. An autopsy was performed which revealed chylopericadium of 150 cc; bilateral reticular pattern on the surfaces of the lungs; neck, mediastinal and retroperitoneal lymphadenopathy, and a 5.1 cm left kidney mass located in the mid portion medulla. The kidney tumor was a rhabdoid collecting duct carcinoma. The lungs showed diffuse subpleural lymphangitic spread of the carcinoma. We report a rare case of chylopericardium due to lymphangitic carcinomatosis from a 5.1 cm rhabdoid collecting duct carcinoma not suspected clinically or radiologically. This case highlights the importance of performing autopsies in an era when clinicians heavily rely on high-tech imaging diagnostic modalities.

Rationale:The infiltration of tumor cells to pulmonary lymphatic system, as known as pulmonary lymphangitis carcinomatosis (PLC), is a rare presentation of pulmonary metastases.Patient concerns:We reported a case of a 66-year-old man after surgery, chemotherapy, and radiation therapy for col

We herein report two cases of malignant pleural mesothelioma with marked lymphangiosis. The patients included a 68-year-old man and a 67-year-old man who both had a history of exposure to asbestos. Computed tomography (CT) on admission showed pleural effusion with pleural thickening. In both cases, a histopathological examination of the pleura confirmed the diagnosis of epithelioid malignant mesothelioma. They received chemotherapy, but the treatment was only palliative. The chest CT assessments during admission revealed marked pleural effusion and mediastinal lymphadenopathy. CT also showed a consolidative mass with bronchovascular bundle and septal thickening in the lungs suggesting pulmonary parenchymal involvement and the lymphangitic spread of the tumor. These CT findings mimicked lung cancer with pleuritis and lymphangitic carcinomatosis. Autopsy was performed in both cases. Macroscopically, the tumor cells infiltrated the lung with the marked lymphatic spread of the tumor. Microscopy also revealed that the tumor had invaded the pulmonary parenchyma with the marked lymphatic spread of the tumor. Although this growth pattern is unusual, malignant pleural mesothelioma should be considered as the differential diagnosis, especially in patients with pleural lesions.

Purpose Findings not associated with thromboembolic disease on routine perfusion lung scan may sometimes have particular clinical significance. We wanted to assess the clinical importance and overall survival after the recognition of a lymphangitic carcinomatosis pattern on perfusion lung scan. Case report We report a case of lymphangitic carcinomatosis pattern on perfusion lung scan performed in a previously healthy patient who had rapid progressive course and died the next day. Method A Medline search of case reports that describes either lymphangitic carcinomatosis or tumour microemboli on perfusion lung scan. Results There were a total of 32 patients identified in 21 articles from various countries, including our case. The studied perfusion pattern was reported more often in female patients (81%) was associated with a progressive history of dyspnea (69%) and normal or mild findings on chest radiograph (58%). Of the 29 patients with available outcome data, 79% (23/29) had a progressive course after the lung scan interpretation. In 18 of these 23 cases, the actual interval of survival was given: 67% of these patients (12/18) died within the first month. Discussion A lymphangitic carcinomatosis perfusion pattern on scintigraphic imaging is associated with a poor prognosis. Nuclear medicine physicians should be aware of this association and that raising the suspicion for a metastatic process may make a difference in the treatment plan of these patients.

Three-dimensional (3D) conformal radiation therapy (CRT) and stereotactic body radiation therapy (SBRT) are designed to deliver the maximum therapeutic radiation dose to the tumor, allowing improved local disease control, while minimizing irradiation of surrounding normal structures. The complex configuration of the multiple beams that deliver the radiation dose to the tumor in 3D CRT and SBRT produces patterns of lung injury that differ in location and extent from those seen after conventional radiation therapy. Radiation-induced changes in lung tissue after 3D CRT and SBRT occur within the radiation portals. The imaging appearance of irradiated tissues varies according to the time elapsed after the completion of therapy, with acute-phase changes of radiation pneumonitis represented by ground-glass opacities and consolidation and with late-phase changes of radiation fibrosis manifesting as volume loss, consolidation, and traction bronchiectasis. Knowledge of treatment timelines and radiation field locations, as well as familiarity with the full spectrum of possible radiation-induced lung injuries after 3D CRT and SBRT, is important to correctly interpret the abnormalities that may be seen at computed tomography (CT). Differential diagnoses in this context might include infections, lymphangitic carcinomatosis, local recurrence of malignancy, and radiation-induced tumors. The integration of morphologic information obtained at CT with metabolic information obtained at positron emission tomography is helpful in distinguishing radiation-induced parenchymal abnormalities from residual, recurrent, and new cancers. Thus, multimodality follow-up imaging may lead to substantial changes in disease management.

There is a broad differential diagnosis for interstitial shadows on chest computed tomography in rheumatoid arthritis patients, especially those previously treated with immunosuppressant drugs. We report an immunocompromised rheumatoid arthritis patient in respiratory failure with diffuse ground-glass opacities (GGOs), who was diagnosed with pulmonary lymphangitic carcinomatosis as the initial presentation of prostate cancer. He was successfully treated with chemohormonal androgen deprivation therapy, including bicalutamide, leuprorelin acetate, denosumab, and docetaxel. Metastatic pulmonary lymphangitis, rarely from the prostate, should always be considered in the differential diagnosis of GGOs, even when the patient has no known prior malignancies.

Lymphangitic carcinomatosis is an uncommon manifestation of metastasis to lung. Its presentation can mimic several disorders of the lungs. A case is presented here where patient presented with progressive dyspnoea, dry cough, weight loss and fever. The patient was amenorrheic for the last 2 years. Her physical findings were unremarkable initially other than the weight loss and evidence of pulmonary hypertension. Subsequently her dyspnoea rapidly worsened and the patient became bed bound. Investigations revealed neutrophilic leucocytosis, normal Hb with high ESR. ANA, anti Cetromere and anti Scl 70 was negative. Serum calcium was normal. Liver function test was normal other than raised alkaline phosphatase. Tuberculin test was negative. Chest X-ray revealed increased bilateral symmetrical streaks and reticulation with peripheral and lower distribution which is consistent with pulmonary lymphangitic carcinomatosis. HRCT of Lungs has shown diffuse infiltrations, reticulo-nodular and ground glass opacities, centrilobular emphysema with accentuation of broncho-vascular densities in both lung fields. There were enlarged mediastinal lymph nodes, bilateral pleural effusion. Doppler Echo revealed mild pulmonary hypertension with fair EF. Tumor markers were done. CA125, CA 19.9 and AFP were ten times higher than normal. Fibreoptic nasopharyngoesophagoscopy was normal. Diagnosis of PLC was made on clinical feature, radiological finding and elevated tumor markers. Symptomatic treatment was given during the period of evaluation. Ultimately the patient succumbed to death.DOI: http://dx.doi.org/10.3329/jssmc.v5i2.20769J Shaheed Suhrawardy Med Coll, 2013;5(2):114-116

Radiation-induced lung disease (RILD) due to radiation therapy is common. Radiologic manifestations are usually confined to the lung tissue within the radiation port and are dependent on the interval after completion of treatment. In the acute phase, RILD typically manifests as ground-glass opacity or attenuation or as consolidation; in the late phase, it typically manifests as traction bronchiectasis, volume loss, and scarring. However, the use of oblique beam angles and the development of newer irradiation techniques such as three-dimensional conformal radiation therapy can result in an unusual distribution of these findings. Awareness of the atypical manifestations of RILD can be useful in preventing confusion with infection, recurrent malignancy, lymphangitic carcinomatosis, and radiation-induced tumors. In addition, knowledge of radiologic findings that are outside the expected pattern for RILD can be useful in diagnosis of infection or recurrent malignancy. Such findings include the late appearance or enlargement of a pleural effusion; development of consolidation, a mass, or cavitation; and occlusion of bronchi within an area of radiation-induced fibrosis. A comprehensive understanding of the full spectrum of these manifestations is important to facilitate diagnosis and management in cancer patients treated with radiation therapy.

Lymphangitic carcinomatosis of the lungs secondary to cervical cancer is a rare condition. It still has an unknown pathophysiology and is related to high mortality rates. Diagnosis is often delayed due to the common symptoms of nonproductive cough and dyspnea. There are only 10 cases described in the literature. Most of the reported cases received only supportive care due to low performance status. Only three reported patients received palliative chemotherapy. We describe a case that has successfully received platinum-based chemotherapy.

To clarify the bronchoscopic findings in metastatic spread to the bronchi, we analyzed the records of 65 cases of metastatic pulmonary disease in which fiberoptic bronchoscopy had been done. Forty-five patients (69.2%) had abnormal bronchoscopic findings. These patients could be divided into three groups, according to bronchoscopic findings and route of metastatic spread to the bronchi: endobronchial metastasis (n=15), bronchial involvement (that is, direct extension to the bronchi from adjacent metastatic foci, n=15), and lymphangitis carcinomatosa (n=15). Breast cancer and colon cancer were common in cases of endobronchial metastasis, and the bronchial tumor often presented as a polypoid or nodular lesion covered with necrotic material. Submucosal swelling with an irregular margin and narrowing of the bronchial lumen were seen in cases of bronchial involvement. In conclusion, each type of primary extrapulmonary tumor is associated with characteristic endobronchial findings of pulmonary metastases such as endobronchial metastasis and bronchial involvement, which should be discriminated if possible, because of their different metastatic process.

A pneumonia lipóide é uma doença rara, resultante da microaspiração de formulações lipídicas. Para seu diagnóstico, o grau de suspeição clínica deve ser elevado. Relata-se o caso de uma mulher com passado de câncer de mama, apresentando dispnéia e tosse progressivas e infiltrado pulmonar bilateral na radiografia. A suspeita de linfangite carcinomatosa com indicação de quimioterapia foi questionada por achados não usuais na tomografia computadorizada de alta resolução e história de ingestão crônica de laxantes contendo óleo mineral. A biópsia pulmonar confirmou pneumonia lipóide, que deve ser considerada em pacientes com pneumopatia difusa e exposição a potenciais agentes causadores. Lipoid pneumonia is a rare disease resulting from the micro-aspiration of lipid formulations. Making a diagnosis of lipoid pneumonia requires a high degree of clinical suspicion. Herein, we report the case of a female patient with a history of breast cancer, presenting progressive dyspnea and cough, together with radiological findings of bilateral pulmonary infiltrate. The working diagnosis of lymphangitic carcinomatosis, for which chemotherapy would be indicated, was called into question based on the high-resolution computed tomography findings and on the fact that the patient had a history of chronic ingestion of laxatives containing mineral oil. A lung biopsy confirmed a diagnosis of lipoid pneumonia, which should always be considered in patients with diffuse lung disease having been exposed to potential causative agents.

Objective: Patients with lung cancer often greeted their terminal phase in the treatment at home, and many cases complicated with lymphangitic carcinomatosis took a sudden turn. The aim of the present study was to determine a scoring system available at home health care for prediction of short-term survival of lung cancer complicated with lymphangitic carcinomatosis. Methods: In 14 lung cancer patients with lymphangitic carcinomatosis in our medical care at home, we determined significant close correlated and independent factors for assuming death during 14 days by logisticregression analysis, and made out new scoring system. Moreover, we determined cut-off value on receiveroperating characteristics analysis. Results: In our scoring system calculated as the summation points awarded for the presence of 5 parameters (i.e., systolic blood pressure 100 beats/minute, 3 point; blood oxygen saturation 2 L/minute, 2 point; respiratory frequency>20 times/minute, 3 point), cut-off value was 8 (sensitivity 90%, specificity 68%). Conclusions: We made a new a scoring system available at home health care for prediction of 14 days survival of lung cancer complicated with lymphangitic carcinomatosis assumed systolic blood pressure, pulse rate, respiratory frequency, blood oxygen saturation, and oxygen dose.

Two cases of histologically proven lobar pulmonary lymphangitic carcinomatosis are reported in which well-defined sites of accumulation of Tl-201 and Tc-99m MIBI were observed. The combination of Tl-201 and Tc-99m MIBI SPECT can detect the extent of pulmonary lymphangitic carcinomatosis.

A 56-year-old woman status post bilateral mastectomies, chemotherapy, and radiation treatment of breast cancer presented with dyspnea and associated pleuritic chest pain, fatigue, and chest heaviness. Imaging studies including a chest radiograph, lower extremity color Doppler ultrasound, computed tomography pulmonary angiogram, and high-resolution chest CT (HRCT) were all negative. Lung scan revealed contour mapping of the bronchopulmonary segments, a pattern which can be seen in patients with tumor emboli syndrome or lymphangitic carcinomatosis. A pulmonary angiogram with microvascular cytologic sampling revealed no pulmonary embolus but confirmed the presence of malignant cells identical to the patient's breast cancer.

Tuberculosis is a disease with protean manifestations. We present a case which was initially suspected as bronchogenic carcinoma with lymphangitic carcinomatosis, based on radiological appearance but later diagnosed as pulmonary tuberculoma with military tuberculosis and silicosis after thoracotomy and open lung biopsy. The patient was treated successfully with Antituberculosis Therapy (ATT). Rarity of presentation in form of pulmonary tuberculoma co-existing with histological features of miliary tuberculosis and silicosis, led us to report this case.