Lymphangitis carcinomatosa

Corticosteroids for pulmonary lymphangitic carcinomatosis

Pulmonary lymphangitic carcinomatosis (PLC) is a type of lymphangitic spread of cancer cells, from a primary site to the pulmonary vasculature and lymphatics. Corticosteroids are recommended for PLC by clinical guidelines, although scientific evidence for this traditional practice is still lacking. We report a patient with lung cancer who developed clinically diagnosed PLC and was successfully treated with steroid treatment. The pulmonary shadows suggestive of PLC were remarkably improved, as well as her symptom. Corticosteroids are worth trying when PLC is clinically suspected.

Lymphangitic carcinomatosis as the initial manifestation of primary signet-ring cell adenocarcinoma of the lung: A case report

Signet-ring cell carcinomas are an aggressive, poorly differentiated, and highly invasive adenocarcinoma carrying a poor prognosis. Most of these tumors originate in gastrointestinal organs; however, primary lung signet-ring cell adenocarcinomas can rarely occur. Tumoral lymphatic infiltration is a complication of these tumors and can cause phenomena such as lymphangitic carcinomatosis, characterized by a nodular thickening of the pleura, pleural effusions, and mediastinal lymphadenopathies. We report a case of a 63-year-old ex-smoker with a 2-week clinical course of dyspnea and pleuritic chest pain in which a nodular thickening of the pleura and pleural effusion were documented and led to the diagnosis of a primary signet-ring cell adenocarcinoma of the lung with lymphangitic carcinomatosis. This complication has never been described in the context of a primary lung tumor of this subtype. Both entities carry a high mortality and have no therapeutical options. This report adds to the information available about them.

Prognosis of pulmonary lymphangitic carcinomatosis in patients with non-small cell lung cancer

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<0.001 and 0.004, respectively) and the subjects with cLy4 had worse overall survival (adjusted hazard ratio, 2.21; 95% confidence interval, 1.03-4.70; P=0.040) compared with those with intrapulmonary metastases.

Conclusions

The subjects with cLy1/2 had better overall survival than those with cLy3/4 or intrapulmonary metastases. cLy1/2 seems to be a T descriptor (T3/4) rather than an M1 descriptor.

Lymphangitis carcinomatosa from gallbladder cancer

A 61-year-old woman was admitted to our hospital with productive cough and fever. Computed tomography images revealed ground glass opacities in both lung fields, and a space-occupying lesion in the gallbladder. Transbronchial lung biopsy revealed a poorly differentiated adenocarcinoma with invasion of the lymph ducts; accordingly, a diagnosis of lymphangitis carcinomatosa was made. We could not administer chemotherapy due to poor performance status, and the patient died of respiratory failure 30 days after admission. Owing to pathological autopsy findings of poorly differentiated adenocarcinoma in the gallbladder, we diagnosed this as a rare case of gallbladder cancer presenting with lymphangitis carcinomatosa.

Prognostic value of morphological characteristics assessed by CT scan in patients with non-small cell lung cancer treated with nivolumab

Background

Nivolumab is known to demonstrate superior overall survival compared with docetaxel in pretreated non‐small cell lung cancer (NSCLC) patients. Programmed death‐ligand 1 (PD‐L1) expression is reported to predict the outcome of treatment by nivolumab in lung cancer patients. However, the significance of the morphological characteristics of chest computed tomography (CT) as predictors of nivolumab efficacy for advanced NSCLC patients remains unknown.

Methods

We performed a multicenter retrospective trial from April 2013 to March 2017, to assess the significance of CT morphological characteristics as predictors of nivolumab efficacy for advanced NSCLC patients. A total of 78 NSCLC patients pretreated with nivolumab were enrolled. A chest radiologist used chest CT to assess the following morphological characteristics of each patient's main tumor and intrathoracic status prior to nivolumab treatment; interstitial septal thickening, peritumoral ground‐glass opacity, spiculated margin, air bronchogram, cavity or necrosis, adjacent organ invasion, bulky lymph node, and accumulation of small lymph nodes. Logistic regression and Cox proportional hazards regression models were used to analyze outcomes.

Results

A total of 60 (77%) patients were male and 72 (92%) had a performance status (PS) of 0 or 1. The objective response rates of male patients and heavy smokers were significantly higher than those of female patients and light or never smokers, respectively. Multivariate analysis identified light or never smoking, poor PS, histological type of squamous cell carcinoma, and interstitial septal thickening as independent negative predictors of progression free survival (PFS).

Conclusions

Interstitial septal thickening was a significant and independent predictor of PFS in NSCLC patients treated with nivolumab.

Key points

Significant findings of the study

Interstitial septal thickening is an independent predictor of progression free survival in non‐small lung cancer patients treated with nivolumab.

What this study adds

The current study reveals the significance of morphological characteristics obtained via chest computed tomography as a predictor of nivolumab efficacy for advanced non‐small cell lung cancer patients.

Efficacy of regorafenib in acute pulmonary carcinomatous lymphangitis as a manifestation of rectal cancer: A case report

Recent therapeutic advancements have prolonged the survival duration of patients with metastatic or recurrent colorectal cancer even during salvage treatment. Although treatment with regorafenib and trifluridine/tipiracil combination has exhibited apparent survival benefits, clear and objective evidence of a response to these drugs is scarce. Herein, the present study reports the case of a patient with rectal cancer refractory to multiple surgical interventions and standard chemotherapy. Treatment with regorafenib resulted in immediate improvement of respiratory failure caused by pulmonary lymphangitic carcinomatosis. This improvement persisted for over 3 months and was confirmed by radiology. Our findings suggest that regorafenib can reduce peritumoral edema via its interaction with the vascular endothelial growth factor receptor. Thus, regorafenib functions as a multityrosine kinase inhibitor to alleviate symptoms of lymphangitic carcinomatosis despite the low potency of the drug.

A Case of Lung Adenocarcinoma with Marked Improvement of Pulmonary Lymphangitic Carcinomatosis by Adding Bevacizumab to Cisplatin and Pemetrexed

A 40-year-old man with a diagnosis of lung adenocarcinoma (cT4N3M1c, stage IVB) experienced worsening of lymphangitic carcinomatosis in the right lung and right pleural effusion after receiving 1 cycle of first-line chemotherapy consisting of cisplatin and pemetrexed. Bevacizumab was thus added from the second cycle of the cisplatin-pemetrexed regimen, leading to a marked improvement in pulmonary lymphangitic carcinomatosis and a decrease in pleural effusion. Subsequently, maintenance therapy consisting of pemetrexed and bevacizumab was continued, successfully leading to long-term progression-free survival. Generally, pulmonary lymphangitic carcinomatosis shows poor prognosis because of poor response to chemotherapy. However, recent studies have been elucidating the role of the vascular endothelial growth factor A (VEGF-A)/VEGF receptor-2 pathway in pulmonary lymphangitic carcinomatosis. Therefore, bevacizumab is expected to be beneficial in the treatment of this pathological condition.

Maintaining sharp focus on a grainy film: miliary pattern in an elderly woman with acute respiratory failure

An elderly woman with a history of pulmonary tuberculosis reportedly diagnosed and treated 30 years prior to presentation was found unresponsive at home. Chest imaging revealed innumerable pulmonary nodules worrisome for an infectious process, specifically tuberculosis. The patient deteriorated rapidly and in accordance with her wishes, aggressive interventions were withheld. She died within 48 h from respiratory failure. A limited chest autopsy was performed and revealed the cause of death as lymphangitic spread of cancer from a primary lung adenocarcinoma.