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Weekly Chest CasesArchive of Old Cases

Case No : 47 Date 1998-09-21

  • Courtesy of Tae Sung Kim, M.D., Kyung Soo Lee, M.D. / Samsung Medical Center
  • Age/Sex 45 / M
  • Chief Complaintdyspnea PMHx: S/P subtotal gastrectomy due to advanced gastric cancer
  • Figure 1
  • Figure 2

Chest PA

Diagnosis With Brief Discussion

Diagnosis
Pulmonary Lymphangitic Carcinomatosis
Radiologic Findings
HRCT findings in Pulmonary Lymphangitic Carcinomatosis
1. smooth or nodular peribronchovascular interstitial thickening ("peribronchial cuffing")
2. Smooth or nodular interlobular septal thickening
3. Smooth or nodular thickening of fissures
4. Normal lung architecture
5. Prominence of centrilobular structures
6. Diffuse, patchy, or unilateral distribution
7. Lymph node enlargement
8. Pleural effusion

Although, peribronchovascular interstitial thickening and smooth septal thickening, as are often seen in patients with pulmonary lymphangitic carcinomatosis (PLC), can also be seen in association with pulmonary edema, the differentiation of these entities can usually be made on clinical grounds. Nodular or beaded interstitial thickening is characteristic of PLC, but not pulmonary edema. In the study by Ren et al, nodular septal thickening was not noted in any pathologic specimens of patients with pulmonary edema, fibrosis, or in normal lungs. However, it is clear that the presence of nodular septal thickening is a nonspecific finding that reflects a perilymphatic distribution of abnormalities, also commonly seen in patients with sarcoidosis and coal worker's pneumoconiosis or silicosis. In sarcoidosis and coal worker's pneumoconiosis, although nodules are commonly seen, the septal thickening is usually less extensive than that seen in a patients with lymphatic spread of tumor. Moreover, in sarcoidosis and coal worker's pneumoconiosis, distortion of lung architecture and secondary pulmonary lobular anatomy is common, particularly if septal thickening is present; this distortion is not seen in patients with PLC. On the other hand, the presence of pleural effusion would be more in keeping with PLC than sarcoidosis or silicosis. In pulmonary fibrosis, nodular septal thickening is uncommon and the margins of the thickened interlobular septa are irregular. Distortion of the lung architecture and lung destruction (honeycombing) are common in patients with fibrosis.
Brief Review
References
1. Webb WR, Muller NL, Naidich DP. Diseases characterized primarily by nodular or reticulonodular opacities. In: High-resolution CT of the lung. 2nd ed. Philadelphia: Lippincott-Raven; 1996:149-191.
2. Ren H, Hruban RH, Kuhlman JE, et al. Computed tomography of inflation-fixed lungs: the beaded septum sign of pulmonary metastases. J Comput Assist Tomogr 1989;13:411-416.
Keywords
Lung, Interstitium, Malignant tumor, metastasis, Pulmonary Lymphangitic Carcinomatosis

No. of Applicants : 38

▶ Correct Answer : 25/38,  65.8%
  • - Northwestern Memorial Hospital Chicago IL., USA Mitchell J. Kline
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▶ Semi-Correct Answer : 6/38,  15.8%
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