Ultrasonographic features of intestinal lipogranulomatous lymphangitis in 10 dogs.

Intestinal lipogranulomatous lymphangitis (ILL) is a granulomatous inflammation of the lymphatic vessels of the intestinal wall and mesentery characterized by lipogranulomas. The purpose of this retrospective, multi-center, case series study is to report the ultrasonographic features of canine ILL. Ten dogs with a histologically confirmed ILL undergoing preoperative abdominal ultrasound were retrospectively included. Additional CT was available in two cases. Lesion distribution was focal in eight dogs and multifocal in two. All dogs presented with intestinal wall thickening and two had a concomitant mesenteric mass adjacent to the intestinal lesion. All lesions were in the small intestine. Ultrasonographic features were altered wall layering with predominantly muscular and to a lesser extent submucosal layer thickening. Other findings included hyperechoic nodular tissue within the muscular, serosa/subserosal, and mucosal layers, hyperechoic perilesional mesentery, enlarged submucosal blood/lymphatic vessels, mild peritoneal effusion, intestinal corrugation, and mild lymphadenomegaly. The two intestinal to mesenteric masses presented heterogeneous echostructure, predominantly hyperechoic with multiple hypo/anechoic cavitations filled with mixed fluid and fat attenuation content on CT. Histopathological findings included lymphangiectasia, granulomatous inflammation, and structured lipogranulomas affecting mainly submucosa, muscularis, and serosa. The intestinal to mesenteric cavitary masses revealed severe granulomatous peritonitis with steatonecrosis. In conclusion, ILL should be considered as a differential diagnosis for dogs with this combination of ultrasonographic features.

Computed tomographic features of focal lipogranulomatous lymphangitis for differentiating from malignant intestinal lesions in a dog.

An eight-year-old Maltese dog presented with diarrhea and anorexia. Ultrasonography revealed marked focal wall thickening with loss of layering in the distal ileum. Contrast-enhanced computed tomography (CT) revealed a preserved wall layer with hypoattenuating middle wall thickening. In some segments of the lesion, small nodules protruding toward the mesentery from the outer layer were observed. Histopathology revealed focal lipogranulomatous lymphangitis (FLL) with lymphangiectasia. This is the first report to describe the CT features of FLL in a dog. CT features of preserved wall layers with hypoattenuating middle wall thickening and small nodules can assist in diagnosing FLL in dogs.

Lymphangitis Carcinomatosa in Neck Soft Tissue: Computed Tomography Findings With Emphasis on Differentiation From Cellulitis.

OBJECTIVE: Lymphangitis carcinomatosa (LC) is a rare form of metastasis. The purposes of this study were to evaluate computed tomography (CT) findings associated with LC in neck soft tissue and to determine those that were useful in distinguishing LC from cellulitis. METHODS: Contrast-enhanced CT images of 26 patients with pathologically confirmed LC (n = 5) and clinically proven cellulitis (n = 21) were reviewed retrospectively. The following CT findings were evaluated and compared between the 2 groups: subcutaneous fat infiltration, enlargement of muscle, thick irregular enhancement of the superficial cervical fascia, grouping of micronodules, focal intramuscular enhancement, localized fluid collection, and nodular skin thickening. RESULTS: Thick irregular enhancement of the superficial cervical fascia (80.0% vs 0%, P < 0.0005), grouping of micronodules (60.0% vs 0%, P < 0.005), and focal intramuscular enhancement (60.0% vs 4.8%, P < 0.05) were significantly more frequent in LC than in cellulitis. Other findings did not show statistical significance between both groups. CONCLUSIONS: When soft tissue swelling is present in the neck with either thick irregular enhancement of the superficial cervical fascia, grouping of micronodules, or focal intramuscular enhancement, the possibility of LC should be considered especially in patients with underlying malignancy.

Pulmonary Lymphangitic Carcinomatosis: Diagnostic Performance of High-Resolution CT and 18F-FDG PET/CT in Correlation with Clinical Pathologic Outcome.

The rationale of this study was to investigate the performance of high-resolution CT (HRCT) versus 18F-FDG PET/CT for the diagnosis of pulmonary lymphangitic carcinomatosis (PLC). Methods: In this retrospective institution-approved study, 94 patients addressed for initial staging of lung cancer with suspicion of PLC were included. Using double-blind analysis, we assessed the presence of signs favoring PLC on HRCT (smooth or nodular septal lines, subpleural nodularity, peribronchovascular thickening, satellite nodules, lymph node enlargement, and pleural effusion). 18F-FDG PET/CT images were reviewed to qualitatively evaluate peritumoral uptake and to quantify tracer uptake in the tumoral and peritumoral areas. Histology performed on surgical specimens served as the gold standard for all patients. Results: Among 94 included patients, 73% (69/94) had histologically confirmed PLC. Peribronchovascular thickening, lymph node involvement, and increased peritumoral uptake were more often present in patients with PLC (P < 0.009). Metabolic variables, including tumor SUVmax, SUVmean, metabolic tumor volume, and total lesion glycolysis, as well as peritumoral SUVmax, SUVmean, and their respective ratios to background, were significantly higher in the PLC group than in the non-PLC group (P ≤ 0.0039). Sensitivity, specificity, and area under the receiver-operating-characteristic curve for peribronchovascular thickening (69%, 83%, and 0.76, respectively; 95% confidence interval [95%CI], 0.67-0.85) and increased peritumoral uptake (94%, 84%, and 0.89, respectively; 95%CI, 0.81-0.97) were similar (P = 0.054). For detecting PLC, sensitivity, specificity, and area under the receiver-operating-characteristic curve were significantly higher, at 97%, 92%, and 0.98, respectively (95%CI, 0.96-1.00), for peritumoral SUVmax and 94%, 88%, and 0.96, respectively (95%CI, 0.92-1.00), for peritumoral SUVmean (all P ≤ 0.025). Conclusion: Qualitative evaluation of 18F-FDG PET/CT and HRCT perform similarly for the diagnosis of PLC, with both being outperformed by 18F-FDG PET/CT quantitative parameters.

Pulmonary lymphangitic carcinomatosis without concurrent liver metastasis from colon cancer detected using 18F-FDG PET/CT: A case report.

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 colon cancer. Two months after these therapies, the patient complained of nonproductive cough for 1 week. DIAGNOSES: 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scanning revealed increased FDG uptake along the thickened bronchovascular bundles, in bilaterally scattered ground-glass opacities and in mediastinal lymphadenopathy. The transbronchial biopsy and pathological study confirmed the diagnosis of PLC. INTERVENTIONS: Antineoplastic treatment (cetuximab) were administered after the patient was diagnosed with PLC. OUTCOMES: The patient died of respiratory failure within 3 months after the onset of his symptom. LESSONS: 18F-FDG PET/CT play an important role in identifying PLC, in selecting possible biopsy sites, and in accessing the extent of metastatic disease.

Lymphangitic spread of invasive lobular carcinoma to the contralateral breast.

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.

The new 8th TNM staging system of lung cancer and its potential imaging interpretation pitfalls and limitations with CT image demonstrations.

The tumor, node, metastasis (TNM) staging system approved by International Association for the Study of Lung Cancer (IASLC) and the American Joint Committee on Cancer (AJCC) to stage lung cancer was recently revised. The latest revision is the 8th edition published in January, 2017. This new edition made some important changes to the previous edition, including modification of the T classification based on 1 cm increment, downstage of T descriptor including endobronchial tumor disregarding its distance from carina (T2), merging total and partial atelectasis/pneumonitis into the same T category (T2), upstage diaphragmatic invasion to T4, new classification concept of adenocarcinoma in situ and minimally invasive adenocarcinoma for pure and part-solid ground-glass nodules, and further division of extrathoracic metastasis into M1b and M1c based on the number and sites of extrathoracic metastases. Consensus is reached for debating situations not covered in the previous edition of staging system, such as the classification of pancoast tumor based on its invasion depth and staging tumors that extend directly across the fissure as T2a. Classification of multiple sites of pulmonary involvement, including multiple primary lung cancer, separate lung cancer nodules, multiple ground-glass or lepidic lesions, and consolidation, is also discussed. Even though the 8th edition of the TNM lung staging system provides us with more precise classification based on prognostic analysis of each TNM descriptors, there are still some potential limitations and clinical situations that have not yet been clarified in terms of clinical staging by imaging. It is important for radiologists to understand the major changes introduced in the 8th edition of TNM staging and to recognize the potential pitfalls and limitations of imaging interpretation to precisely classify the clinical stage of lung cancer.

Microscopic features of small bowel mucosa of patients with Crohn's disease.

BACKGROUND: Double-balloon enteroscopy enables performing numerous small bowel biopsies for pathologic analysis. However, most histopathological characteristics of Crohn's disease are non-specific characteristics. We aimed to explore the small bowel mucosal histopathologic characters of Crohn's disease and identify some disease-specific changes. METHODS: We included 253 patients without tumors and grouped them into Crohn's disease, suspected Crohn's disease, and non-Crohn's disease groups. These patients underwent double-balloon endoscopy examination and small bowel biopsy at Renji Hospital, Shanghai. All histopathological sections were reviewed, and > 20 histopathological parameters were assessed. Immunohistochemistry was conducted when necessary. RESULTS: There were different forms of granulomatous lymphangitis on the small bowel mucosa in Crohn's disease. They showed as various macrophages or epithelioid cells in the lumina of lymphatics or in the center of the villi with or without evident obstruction. These features were only observed in Crohn's disease patients. Furthermore, they were correlated with granuloma and lymphangiectasia. Additionally, 15 other features showed significant differences among the three groups, and Crohn's disease patients showed an average of almost seven histopathological characteristics. CONCLUSIONS: We described the detailed morphologies of granulomatous lymphangitis on the small bowel mucosa and recommend it as a useful histopathological feature for the diagnosis of Crohn's disease. In terms of specificity and sensitivity, it was superior to non-caseating epithelioid granuloma.

Bronchoalveolar carcinoma as an unsuspected cause for worsening shortness of breath in a patient with metastatic breast cancer.

A 70-year-old woman with lung metastases from a breast cancer presented with worsening cough and dyspnoea. She recently had a pleurodesis for a malignant pleural effusion. Chest CT scans demonstrated various radiological changes leading to diagnostic challenges. Differential diagnoses included empyema, pleural disease progression, pulmonary oedema, pneumonitis, lymphangitis and atypical infections. She deteriorated despite a multimodality treatment strategy. Postmortem examination confirmed that lung changes were consistent with a bronchoalveolar carcinoma unrelated to the known metastatic breast cancer. The eventual knowledge of this diagnosis was reassuring to the treating medical team and a comfort to the relatives who witnessed the lack of response to standard treatment.

Lymphangitic Carcinomatosis From Prostate Cancer Identified With Gallium-68 Prostate-specific Membrane Antigen Positron Emission Tomography Imaging.

Lymphangitic carcinomatosis refers to the rare process of diffuse malignant invasion of the pulmonary lymphatics. We describe the first reported case of lymphangitic carcinomatosis visualized with gallium-68 prostate-specific membrane antigen positron emission tomography and its clinical significance in a 53-year-old man with prostate carcinoma. This case highlights the ability of gallium-68 prostate-specific membrane antigen positron emission tomography for prostate carcinoma characterization and the importance of always considering atypical patterns of metastatic disease.

Blue Lymphangitis of the Breast after Breast Cancer: Case Report.

Carcinomatous lymphangitis accounts for 5% of all skin metastases, but blue lymphangitis of the breast has never been described. We report a case of blue lymphangitis of the breast in a patient 11 years after treatment for ipsilateral breast cancer that was in full remission. Breast examination and imaging showed no other abnormalities. Skin biopsy revealed a carcinomatous-pigmented infiltration corresponding to melanoma metastasis, which helped highlight a primitive right flank injury. This case report emphasizes that a full body exam should always be performed with unusual presentation of breast cancer and reiterates the indispensable place of histology before any diagnosis.

[CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids)].

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) has been recently identified as an inflammatory central nervous system (CNS) disorder. Punctate and curvilinear gadolinium enhancement (peppering) the pons is a characteristic magnetic resonance imaging (MRI) feature of CLIPPERS. Pathogenesis of this disorder remains unknown. A specific serum or cerebrospinal fluid biomarker for this disorder is currently unknown. Whether CLIPPERS is an actual new disease or just represents overlapping symptoms from multiple diseases is still debated. Many differential diagnoses exist even when using imaging as a tool. Pre-lymphoma states, such as grade I LYG (lymphomatoid granulomatosis) and sentinel lesions of primary CNS lymphoma are the most difficult to distinguish.

Dermal Structure in Lymphedema Patients with History of Acute Dermatolymphangioadenitis Evaluated by Histogram Analysis of Ultrasonography Findings: A Case-Control Study.

BACKGROUND: Acute dermatolymphangioadenitis (ADLA) is a risk factor for increasing of edema and worsening severity. Reducing ADLA frequency is an important objective of lymphedema management because ADLA episodes are strongly associated with poor quality of life. Lymphedema changes dermal and subcutaneous structure, favoring ADLA; ADLA recurrence may be caused by structural change of the dermis. However, the structure of the skin following ADLA episodes has not been studied in depth. The aim of this study was to examine changes in the skin after episodes of ADLA in breast cancer-related lymphedema (BCRL) using histogram analysis of ultrasonography findings. METHODS AND RESULTS: This was a case-control study with matching for the duration of lymphedema. We compared 10 limbs (5 BCRL patients, Cases) with a history of ADLA and 14 limbs (7 BCRL patients, Controls) without. Ultrasonography was performed using a 20-MHz probe, and measurements were made at a site 10 cm proximal to the ulnar styloid process. We compared "skewness" of the images in the dermis from the histogram analysis. This study was approved by the Ethics Committee of Kanazawa University. Skewness was significantly different between the affected and unaffected limbs (p = 0.02). Cases showed a positive value (median 0.74, range -0.18 to 1.26), whereas Controls showed a negative value (median -0.21, range -0.45 to 0.31). CONCLUSIONS: Episodes of ADLA changed the distribution of echogenicity on imaging, which indicates a change in the collagen fibers in the dermis. These findings might contribute to improving the management of lymphedema and prevention of recurrent ADLA.

Clinicopathological features and outcomes of gastric cancer patients with pulmonary lymphangitis carcinomatosa.

OBJECTIVE: Breast, gastric and lung cancers are the most common cancers that cause pulmonary lymphangitis carcinomatosa. However, little is known about the clinical features of pulmonary lymphangitis carcinomatosa in advanced gastric cancer. METHODS: We retrospectively reviewed the data throughout the clinical courses of 33 patients with gastric cancer who developed pulmonary lymphangitis carcinomatosa. Pulmonary lymphangitis carcinomatosa was confirmed by both a pulmonologist and a diagnostic radiologist on the basis of computed tomography findings of interstitial patterns such as thickening or irregularity of interlobular septa and bronchovascular bundles. RESULTS: The median age of the 33 patients was 55 years old (range, 25-73 years). The percentages of female patients, those with performance status 3 or 4, and those with respiratory symptoms at diagnosis were 70, 36 and 76%, respectively. The histologically diffuse type of gastric cancer accounted for 85% of cases. Mediastinal lymph node, peritoneal and bone metastases were found in 64, 61 and 39% of patients, respectively. Disseminated intravascular coagulation was noted in 21% of patients. The median survival time of the 18 chemotherapy-naïve patients treated with chemotherapy was 5.7 months (range, 0.4-37.0 months). Two patients obtained symptomatic relief, and one patient treated with S-1 + cisplatin + sunitinib survived >3 years. CONCLUSIONS: Pulmonary lymphangitis carcinomatosa caused by gastric cancer has some specific clinicopathological features. While the prognosis of gastric cancer patients with pulmonary lymphangitis carcinomatosa is extremely poor, some patients may have survival benefit from chemotherapy.

Focal intestinal lipogranulomatous lymphangitis in 6 dogs (2008-2011).

BACKGROUND: Lipogranulomatous lymphangitis is inflammation of the intestinal lymphatic vessels and surrounding tissues caused by chronic leakage of lipid-laden chyle. Grossly, lipogranulomas are typically disseminated small masses on the serosa and surrounding lymphatic vessels and consist of epithelioid macrophages, multinucleated giant cells, and cholesterol. Lipogranulomatous lymphangitis is occasionally seen in patients with lymphangiectasia and protein-losing enteropathy (PLE). OBJECTIVES: To characterize the historical features, clinical signs, treatment, histopathology, and outcome of dogs with focal lipogranulomatous lymphangitis. ANIMALS: Six dogs with ultrasonographic evidence of focal, regional small intestinal masses, often with involvement of the adjacent mesentery, and a diagnosis of focal lipogranulomatous lymphangitis based on histopathology of biopsied masses. RESULTS: The median age of dogs was 6.9 years (range 3-10 years). All dogs had total protein, globulin, and albumin concentrations within the reference range at initial presentation and had intestinal masses identified on abdominal ultrasound examination. Histopathologic evaluation of lesions identified severe mural and mesenteric lipogranulomatous lymphangitis. Lymphangiectasia was noted in 5 cases and only in sections within the mass-like lesion; tissue without lipogranulomas had minimal lymphangiectasia, suggesting a localized phenomenon. Postoperative outcomes ranged from remission of clinical signs with no subsequent treatment for 10-12 months in 2 dogs, postoperative management with medical and nutritional management in 3 dogs, and no outcome for 1 case. CONCLUSIONS AND CLINICAL IMPORTANCE: This case series describes a unique mass-like manifestation of intestinal lipogranulomatous lymphangitis and should be considered as a possible differential diagnosis in dogs with an intestinal mass.