Case of the Month April 2014, page 3

CASE ANSWER: Lymphangitic carcinomatosis.


Diffuse reticulonodular infiltrate on the chest X-ray, confirmed as irregular, interlobular septal thickening on CT.  Together with features concerning for a primary renal malignancy as well as multiple soft-tissue density pulmonary nodules, this is most likely lymphangitic carcinomatosis.  Renal cell carcinoma, which rarely causes lymphangitic carcinomatosis, was confirmed at biopsy.


1. Interstitial edema
2. Sarcoidosis
3. Hypersensitivity pneumonitis
4. Kaposi’s Sarcoma
5. Lymphocytic interstitial pneumonitis
6. Coal-Miners pneumoconiosis
7. Silicosis
8. Lymphoma.


Lymphangitic carcinomatosis describes the condition in which hematogenously metastatic cancer has infiltrated the lymphatic system of the lungs.  Most commonly, this is an adenocarcinoma, typically breast, lung, colon, or gastric cancer.  Less commonly, other varieties of metastatic adenocarcinoma can lead to this, as well as primary bronchoalveolar carcinoma.  Patients typically present with symptoms such as shortness of breath, dry cough, or hemoptysis prior to the development of radiographic features.


Diagnosis often relies on CT, as conventional chest radiographs may only have a 25% sensitivity.   Most commonly, lymphangitic carcinomatosis is seen as a focal area of interlobular septal thickening, thickening of the perihilar bronchovascular units, or both.  In the setting of only septal thickening (typically reticular with mild nodularity), high-resolution CT will demonstrate a “polygonal arcade” pattern.  With both septal and bronchovascular bundle thickening, the more-specific “dot-in-box” pattern can be seen.  Kerley lines can be sometimes seen on radiographs.   Pleural effusions and mediastinal adenopathy are inconstant associated features.  Asymmetry and preservation of normal secondary lobular architecture help to differentiate LC from similar-appearing conditions, however these findings are non-specific without a history of malignancy.  


1. Goldsmith HS, Bailey HD, Callahan EL, Beattie EJ. Pulmonary lymphangitic metastases from breast carcinoma. Arch Surg. 1967;94(4):483-488.
2. Ikezoe J, Godwin JD, Hunt KJ, Marglin SI. Pulmonary lymphangitic carcinomatosis: chronicity of radiographic findings in long-term survivors. AJR Am J Roentgenol. 1995;165(1):49-52.
3. Johkoh T, Ikezoe J, Tomiyama N, et al. CT findings in lymphangitic carcinomatosis of the lung: correlation with histologic findings and pulmonary function tests. AJR Am J Roentgenol. 1992;158(6):1217-1222.
4. Munk PL, Müller NL, Miller RR, Ostrow DN. Pulmonary lymphangitic carcinomatosis: CT and pathologic findings. Radiology. 1988;166(3):705-709.
5.  Lymphangitic Carcinomatosis Imaging.,

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