Pulmonary lymphangitis carcinomatosis: A peculiar presentation clustering in MET-amplified gastric cancer

BACKGROUND

The clinicopathological features of MET-amplified gastric cancer (GC) and real-world data on the efficacy of MET-targeted therapies remain unknown. Pulmonary lymphangitis carcinomatosis (PLC) is a peculiar manifestation of GC, whose management has not been thoroughly described.

METHODS

This study analyzed patients diagnosed with MET-amplified GC or GC with PLC at any time point of the disease course from 2011 to 2021 in two centers. Clinicopathological features and survival outcomes of MET-amplified GC were analyzed. The clinical and molecular implications of GC with PLC were discussed.

RESULTS

Fifty-eight patients with MET-amplified GC and 20 patients with GC accompanied by PLC were finally enrolled for analysis (including 13 overlapped patients). GC with PLC was more common in female patients (p = 0.010), diagnosed at a younger age (p = 0.002), presented with a higher baseline ECOG PS (p = 0.016), and was more likely to develop lung metastasis (p < 0.001), and serous effusion (p = 0.026) than GC without PLC. Patients with primary MET-amplified GC had a worse prognosis than those with secondary MET-amplified GC (p = 0.005). The application of anti-MET therapy was associated with numerically prolonged survival, but the association was not statistically significant (p = 0.07). MET amplification was concentrated in patients with PLC, in which anti-MET therapies elicited a high response rate.

CONCLUSIONS

MET-targeted therapies are efficacious in real-world populations with MET-amplified GC. Patients with PLC have distinct clinical and molecular features and might benefit from MET-targeted therapies.

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.

Obstructive Lymphangitis Precedes Colitis in Murine Norovirus-Infected Stat1-Deficient Mice

Murine norovirus (MNV) is an RNA virus that can prove lethal in mice with impaired innate immunity. We found that MNV-4 infection of Stat1-/- mice was not lethal, but produced a 100% penetrant, previously undescribed lymphatic phenotype characterized by chronic-active lymphangitis with hepatitis, splenitis, and chronic cecal and colonic inflammation. Lesion pathogenesis progressed from early ileal enteritis and regional dilated lymphatics to lymphangitis, granulomatous changes in the liver and spleen, and, ultimately, typhlocolitis. Lesion development was neither affected by antibiotics nor reproduced by infection with another enteric RNA virus, rotavirus. MNV-4 infection in Stat1-/- mice decreased expression of vascular endothelial growth factor (Vegf) receptor 3, Vegf-c, and Vegf-d and increased interferon (Ifn)-γ, tumor necrosis factor-α, and inducible nitric oxide synthase. However, anti-IFN-γ and anti-tumor necrosis factor-α antibody treatment did not attenuate the histologic lesions. Studies in Ifnαβγr-/- mice suggested that canonical signaling via interferon receptors did not cause MNV-4-induced disease. Infected Stat1-/- mice had increased STAT3 phosphorylation and expressed many STAT3-regulated genes, consistent with our findings of increased myeloid cell subsets and serum granulocyte colony-stimulating factor, which are also associated with increased STAT3 activity. In conclusion, in Stat1-/- mice, MNV-4 induces lymphatic lesions similar to those seen in Crohn disease as well as hepatitis, splenitis, and typhlocolitis. MNV-4-infected Stat1-/- mice may be a useful model to study mechanistic associations between viral infections, lymphatic dysfunction, and intestinal inflammation in a genetically susceptible host.

A TNF-p100 pathway subverts noncanonical NF-κB signaling in inflamed secondary lymphoid organs

Lymphotoxin-beta receptor (LTβR) present on stromal cells engages the noncanonical NF-κB pathway to mediate RelB-dependent expressions of homeostatic chemokines, which direct steady-state ingress of naïve lymphocytes to secondary lymphoid organs (SLOs). In this pathway, NIK promotes partial proteolysis of p100 into p52 that induces nuclear translocation of the RelB NF-κB heterodimers. Microbial infections often deplete homeostatic chemokines; it is thought that infection-inflicted destruction of stromal cells results in the downregulation of these chemokines. Whether inflammation per se also regulates these processes remains unclear. We show that TNF accumulated upon non-infectious immunization of mice similarly downregulates the expressions of these chemokines and consequently diminishes the ingress of naïve lymphocytes in inflamed SLOs. Mechanistically, TNF inactivated NIK in LTβR-stimulated cells and induced the synthesis of Nfkb2 mRNA encoding p100; these together potently accumulated unprocessed p100, which attenuated the RelB activity as inhibitory IκBδ. Finally, a lack of p100 alleviated these TNF-mediated inhibitions in inflamed SLOs of immunized Nfkb2-/- mice. In sum, we reveal that an inhibitory TNF-p100 pathway modulates the adaptive compartment during immune responses.

Metastatic Crohn's disease accompanying granulomatous vasculitis and lymphangitis in the vulva

Metastatic Crohn's disease (CD) is an extremely rare extragastrointestinal manifestation of CD, and is characterized histopathologically by the presence of non-caseating granulomatous inflammation. Granulomatous vasculitis and lymphangitis have rarely been documented in metastatic CD. Herein, we report the first documented case of metastatic CD accompanied by both granulomatous vasculitis and lymphangitis in the vulva. A 35-year-old Japanese female with CD presented with multiple small nodules in her vulva. Biopsy was performed under a clinical diagnosis of genital warts. A histopathological study revealed marked lymphangiectasia in the papillary dermis. Within the dilated lymphatics, lymphocytes and aggregates of macrophages were present, which are typical features of granulomatous lymphangitis. Tiny non-caseating granulomas and granulomatous vasculitis were also observed. Accordingly, a diagnosis of metastatic CD accompanied by both granulomatous vasculitis and lymphangitis was made. The occurrence of cutaneous lesions in patients with CD is well known. Albeit extremely rare, lymphangiectasia has been reported in the vulva of CD patients that clinically mimicked viral warts, as in the present case. The diagnosis of metastatic CD in the present case was not difficult because characteristic histopathological features were present, and a clinical history of CD was available. However, a few cases of genital swelling associated with granulomatous inflammation prior to a diagnosis of gastrointestinal CD have been documented. Therefore, granulomatous vasculitis and lymphangitis in the external genitals should be considered as potential indication of metastatic CD even in cases without a history of gastrointestinal CD.

[Pulmonary carcinomatous lymphangitis: presentation as acute pneumopathy. Report of two cases]

INTRODUCTION

Carcinomatous lymphangitis of the lung accounts for 6-8% of lung's metastases. There are evidence that it can be a treatable condition with an impact on progression of dyspnea and radiographic lesions, and survival improvement. Two cases are reported, with the aim of increase the clinical suspicion at compatible cases.

METHODS

Case 1: woman 32 years old. Progressive dyspnea and cough two weeks ago, without antibiotic response. Tachypnea, increase of respiratory work, basal crackles. Respiratory failure. Radiography: basal alveolointerstitial opacities. Treatment for severe community-acquired pneumonia is started. She evolves unfavorably, with need of MRA and fatal outcome. Case 2: woman 46 years old. Progressive dyspnea and cough from one week ago. Tachypnea, diffuse crackles. Respiratory failure. Radiography: diffuse nodular-interstitialradiopacity, with radiopacy lesion in right apex. HRCT: nodular thickening of interlobular septum and peribrochovascular interstitial. Treatment for tuberculosis of the lung is started. She evolves unfavorably, with need of MRA and fatal outcome. In both cases a lung biopsy was performed, diagnosing carcinomatous lymphangitis.

DISCUSSION

Two cases are reported, with acute afebrilepneumopathyin young patients, whose manifestations guided to treatment of respiratory infection, and evolved quickly to refractory hypoxemic respiratory failure with need of MRA and fatal outcome.

CONCLUSION

Carcinomatous lymphangitis of the lung should be included as a differential diagnosis of cases of acute lung pathology, especially when there was an unfavorable evolution under antibiotics or have excluded more common etiologies.

Burden of podoconiosis in poor rural communities in Gulliso woreda, West Ethiopia

Background

Podoconiosis is an environmental lymphoedema affecting people living and working barefoot on irritant red clay soil. Podoconiosis is relatively well described in southern Ethiopia, but remains neglected in other parts of the Ethiopian highlands. This study aimed to assess the burden of podoconiosis in rural communities in western Ethiopia.

Methodology/Principal Findings

A cross-sectional study was conducted in Gulliso woreda (district), west Ethiopia. A household survey in the 26 rural kebeles (villages) of this district was conducted to identify podoconiosis patients and to measure disease prevalence. A more detailed study was done in six randomly selected kebeles to describe clinical features of the disease, patients' experiences of foot hygiene, and shoe wearing practice. 1,935 cases of podoconiosis were registered, giving a prevalence of 2.8%. The prevalence was higher in those aged 15–64 years (5.2%) and in females than males (prevalence ratio 2.6∶1). 90.3% of patients were in the 15–64 year age group. In the detailed study, 335 cases were interviewed and their feet assessed. The majority of patients were farmers, uneducated, and poor. Two-third of patients developed the disease before the age of thirty. Almost all patients (97.0%) had experienced adenolymphangitis (ALA - red, hot legs, swollen and painful groin) at least once during the previous year. Patients experienced an average of 5.5 ALA episodes annually, each of average 4.4 days, thus 24 working days were lost annually. The incidence of ALA in podoconiosis patients was higher than that reported for filariasis in other countries. Shoe wearing was limited mainly due to financial problems.

Conclusions

We have documented high podoconiosis prevalence, frequent adenolymphangitis and high disease-related morbidity in west Ethiopia. Interventions must be developed to prevent, treat and control podoconiosis, one of the core neglected tropical diseases in Ethiopia.

Podoconiosis is a chronic non-infectious disease resulting in below-knee swelling of the legs in bare-footed people living in red clay soil areas. It is an important and yet neglected problem in tropical Africa, central and south America, and north India. Podoconiosis can be prevented by consistently wearing shoes and washing feet. We aimed to assess the burden of the disease, to characterize features of the disease, and to describe foot hygiene and shoe wearing practice of patients in west Ethiopia. First, we did a survey of the 26 rural villages. We identified 1,935 podoconiosis patients, giving a prevalence of 2.8%. Podoconiosis was twice as prevalent in females as males. Second, we did a more detailed study among 335 patients in six randomly selected villages. We found that the majority of patients were farmers, uneducated, and poor. The disease developed before the fourth decade of life and the majority of patients became bed-ridden because of frequent attacks of red, hot legs and swollen and painful groin. Shoe wearing was limited mainly due to lack of money. We conclude that podoconiosis imposes a huge burden in west Ethiopia, and recommend that interventions be developed to prevent, treat and control the disease.

Successful treatment of nodular lymphangitis due to Mycobacterium chelonae in two immunosuppressed patients

M. chelonae is a classical but uncommon etiology of nodular lymphangitis. We report 2 cases of nodular lymphangitis caused by M. chelonae occurring in immunocompromised hosts; both were cleared with antibiotic therapy.

[Intralymphatic accumulation of lymphocytes mimicking intravascular lymphomatosis]

OBJECTIVE

To study the significance and differential diagnosis of intralymphatic accumulation of lymphocytes.

METHODS

The clinical and pathologic features of 4 cases of intralymphatic accumulation of lymphocytes were reviewed retrospectively. Immunohistochemical study was carried out and follow-up data were analyzed.

RESULTS

The sites of involvement included tonsil (2 cases), pharynx (1 case) and appendix (1 case). The duration of disease ranged from 1 week to 3 months. Follow up of the patients (from 3 to 84 months) showed no evidence of disease recurrence. Gross examination of the tissues (except in the case of appendiceal involvement) showed polypoid changes. Histologically, the lymphatic channels were filled up with small lymphocytes and associated with fibrosis in the vicinity. Immunohistochemical study revealed a T-cell phenotype of the intralymphatic lymphoid cells.

CONCLUSIONS

The accumulation of lymphocytes in lymphatic channels is associated with a benign clinical course. This phenomenon may be due to retention of lymphocytes secondary to the perilymphatic chronic inflammation and fibrosis. Although the lesion simulates intravascular lymphomatosis morphologically and shows a uniform T-cell phenotype, the lymphoid cells lack obvious cellular pleomorphism and mitotic activity. The solitary nature of the lesion, when coupled with the indolent clinical behavior, is also helpful in the differential diagnosis.

Vascular endothelial growth factor-C induces lymphangitic carcinomatosis, an extremely aggressive form of lung metastases

The lymphatic system is an important pathway for tumor dissemination to the lymph nodes, but to which extent it contributes to the formation of distant metastases remains unknown. We report that induction of lymphangiogenesis by vascular endothelial growth factor-C (VEGF-C) at the secondary site, in the lung, facilitates expansion of already disseminated cancer cells throughout the lung tissue. By using orthotopic spontaneous metastasis models in nude mice, we show that VEGF-C expression by tumor cells altered the pattern of pulmonary metastases from nodular to diffuse and facilitated disease progression. Metastases expressing VEGF-C were tightly associated with the airways, in contrast to the control cells that were scattered in the lung parenchyma, throughout the alveolar region. VEGF-C induced lung lymphangiogenesis and promoted intralymphatic spread of metastases in the lung and formation of tumor emboli in the pulmonary arteries. This pattern of metastasis corresponds to lymphangitic carcinomatosis metastatic phenotype in human cancer patients, an extremely aggressive pattern of pulmonary metastases. In accordance, pulmonary breast cancer metastases from patients which were classified as lymphangitic carcinomatosis showed high levels of VEGF-C expression in cancer cells. These data show that VEGF-C promotes late steps of the metastatic process and identify the VEGF-C/VEGF receptor-3 pathway as the target not only for prevention of metastases, but also for treatment of established metastatic disease.

[A case of advanced gastric cancer with pulmonary carcinomatous lymphangitis responding remarkably to combination chemotherapy of docetaxel, CDDP and S-1]

A 31-year-old woman suffering from stomach pain was admitted to our hospital, and diagnosed with unresectable advanced gastric cancer. She was initially treated with combination therapy of S-1 and CDDP, and a partial response was achieved. After two courses of the chemotherapy, however, she complained of dyspnea, and pulmonary carcinomatous lymphangitis was confirmed by computed tomography. As second-line chemo-therapy, we attempted combination therapy with docetaxel, CDDP and S-1(DCS). After one course of the combination therapy, a remarkable response in the pulmonary carcinomatous lymphangitis was achieved. Treatment of patients with advanced gastric cancer associated with pulmonary carcinomatous lymphangitis is quite difficult and there is no scientific evidence to select anti-cancer drugs for these patients. We concluded that DCF could be a useful regimen for patients with gastric cancer associated with pulmonary carcinomatous lymphangitis.

[Diagnostic image (294). A man with a painful, red, swollen finger]

A 35-year-old man presented with a tendineal panaritium and lymphangitis of his arm caused by a group A beta-haemolytic streptococcal infection after an accidental splinter injury.

Duodenal lymphangitis carcinomatosa: endoscopic characteristics and clinical significance

BACKGROUND AND AIM

Duodenal lymphangitis carcinomatosa has been sporadically described, but so far little attention has been paid to duodenal lymphangitis carcinomatosa.

METHODS

Four cases with duodenal lymphangitis carcinomatosa were endoscopically and histologically examined.

RESULTS

The four cases exhibited multiple polypoid lesions along the Kerckring's folds and/or were covered by characteristically granular, non-ulcerated mucosa upon thickening. The granularity seems to been caused by dilated lymph vessels containing the carcinoma cells. The lesions were microscopically characterized by: (i) involvement of lymph vessels located in the upper portion of the lamina propria; (ii) no inflammatory changes; and (iii) no desmoplastic changes. Primary sites were thought to be the stomach in case 1, the pancreas in cases 2 and 4, and unknown in case 3. All patients died within 6 months after admission or endoscopic examination.

CONCLUSIONS

As duodenal lymphangitis carcinomatosis shows characteristic endoscopic appearance, endoscopic diagnosis is not difficult. We should realize that the lesion represents extremely poor prognosis, and it should be distinguished from ordinary metastatic duodenal carcinoma.

Preliminary trial on the reproducibility of epizootic lymphangitis through experimental infection of two horses

Epizootic lymphangitis (EL) was experimentally reproduced in four horses that had been purchased from an EL-free district. Two horses were injected with either 0.2 mL of the yeast form of Histoplasma capsulatum var. farciminosum (HCF) in pus (Horse 1), or 0.2 mL (ca. 20 mg) of a suspension in saline of the mycelial form (Horse 2), both into the pre-scapular and pre-femoral lymph nodes, with scarification of the skin of the left hind limb, conjunctiva of the right eye and the nasal membrane of the right nostril. The two other horses served as controls. Nodular lesions of EL appeared during the fourth week of infection at all sites in the horse infected with the yeast form. Lesions only appeared in the lymph nodes and skin scratches of the horse infected with the mycelial suspension after three months. The control horses showed no clinical signs. The yeast form was recovered from the lesions of both infected horses. Similarly, the mycelial form was isolated from both horses on Sabouraud's Dextrose Agar. This experiment showed the reproducibility of clinical EL through experimental infection, and has laid the groundwork for the evaluation of the potency of a vaccine against EL using a vaccination and challenge experiment.

The Importance of Histology in the Evaluation of Pulmonary Transplantation: Carcinomatous Lymphangitis

Pulmonary carcinomatous lymphangitis is a form of neoplastic metastatic spread to the lungs, which represents a poor prognosis for the patient. The physician may be confronted by a differential diagnosis with diffuse pulmonary interstitial affections requiring specific treatment, including lung transplantation. We present the case of a patient, diagnosed with pulmonary interstitial disease with rapidly progressive worsening of lung function, who was considered for lung transplantation. Videothoracoscopic lung biopsy demonstrated the existence of carcinomatous lymphangitis, which completely changed the therapeutic direction.

Asymptomatic lymphangitis carcinomatosis due to squamous cell lung carcinoma

Lymphangitis carcinomatosa most commonly due to primary malignancy originating in the breast, stomach, pleura and prostate but may also originate from the lung itself. It is clinically characterised by progressing dyspnoea with or without cough even at an early stage. We report the case of a patient with squamous cell lung cancer presenting with asymptomatic lymphangitis carcinomatosa.

[Weekly paclitaxel therapy is useful for gastric carcinoma as second-line chemotherapy]

The patient was a 58-year-old man who suffered from non-resectable gastric cancer, staged intraoperatively for peritoneal dissemination and paraaorta lymph node metastasis at another hospital in December 2002. He was initially treated with TS-1 as an outpatient. However, he was readmitted on March 4, 2003 for hematuria, general fatigue, jaundice and dyspnea. He was diagnosed with gastric cancer duodenum invasion, obstructive jaundice and lymphangitis carcinomatosa, and began weekly TXL as second-line chemotherapy on March 26. TXL (70 mg/ m2) was infused once a week for 3 weeks followed by a 1-week interval as one cycle. One week after the first infusion therapy, the jaundice and dyspnea were greatly improved. CT scan showed the lymphangitis carcinomatosa had disappeared and paraaorta lymph node metastasis was reduced to 60% after one cycle of the treatment. The toxic events were leukopenia (grade 1) and alopecia (grade 1).

The efficacies of affected-limb care with penicillin, diethylcarbamazine, the combination of both drugs or antibiotic ointment, in the prevention of acute adenolymphangitis during bancroftian filariasis

Repeated attacks of adenolymphangitis (ADL) contribute significantly to the progression of chronic lymphoedema in lymphatic filariasis. They are a cause of stigma and, since they may prevent work and require treatment for which payment must be made, of economic loss. The aim of the present study was to improve the treatment of ADL attacks, which is currently mostly empirical. In a double-blind, placebo-controlled, clinical study, 150 subjects who had each suffered at least two ADL attacks in the preceding year were enrolled and randomly allocated to a programme of self-care of the affected limb (after an intensive training programme) and one of five treatments for 12 months. The subjects were supplied with tablets and ointment so that they could take oral penicillin (800 mg/day), oral diethylcarbamazine (DEC; 1 mg/kg.day) or both of these drugs (at the same doses), or apply framycetin ointment to the affected limb, or just take placebo tablets and apply placebo (zinc-oxide) ointment. Placebo tablets and placebo ointment were used so that neither the subjects nor those assessing the responses to treatment were aware of the treatment arm to which each subject had been assigned. The subjects were requested to continue with the affected-limb care after they had stopped taking the tablets and applying the cream, and were followed-up for 24 months from the first treatment.Overall, the mean incidence of ADL attacks decreased from 2.7 episodes/person-year in the pre-treatment year to just 0.38 episode/person-year during the treatment year (P< 0.01). The greatest reduction in incidence was seen in the 58 subjects who received penicillin (with or without DEC). Even in the placebo group, however, the incidence of ADL in the treatment year was significantly lower than that seen in the pre-treatment year, indicating that affected-limb care on its own helps to prevent some attacks. In all groups except the placebo, the incidence of ADL attacks in the year post-treatment exceeded that seen in the treatment year, indicating that chemoprophylaxis needs to be continued for more than a year if such attacks are to be prevented. In most (84%) of the attacks recorded, titres of anti-streptococcal antibodies were seen to be elevated (compared with those recorded during convalescence),indicating that streptococci have a role in the aetiology of ADL. It is recommended that a combination of penicillin prophylaxis and affected-limb care be incorporated into filariasis-control programmes, to decrease morbidity.

Squamous cell carcinoma of the cervix presenting as lymphangitic carcinomatosis: a case report and review of the literature

BACKGROUND

Lymphangitic carcinomatosis (LC) secondary to carcinoma of the cervix is rare. The presenting symptoms are misleading and nonspecific, which often leads to delayed diagnosis.

CASE

We present the case of a 24-year-old woman with dyspnea and lower back pain, who was found to have stage IIIb squamous cell carcinoma of the cervix complicated by pulmonary LC.

CONCLUSIONS

Pulmonary LC is a rare but important manifestation of metastatic cervical cancer. Patients present with severe respiratory compromise, which mimics other, more common disease states. Diagnosis can be achieved by transbronchial biopsy. Optimal treatment of the patient with LC is not well defined, but a trial of chemotherapy and/or intravenous steroids may be warranted. Prognosis for this condition is poor.

Lymphangitis carcinomatosis of unknown origin presenting as severe pulmonary hypertension

An apparently healthy 46-year-old woman was admitted because of progressive shortness of breath that had begun 2 months before her admission. Physical examination revealed a patient with respiratory distress, tachycardia, and mild jugular venous distention; otherwise, results were unremarkable. Our investigation revealed hypoxia and severe pulmonary hypertension with signs of right heart dysfunction, but no primary cause was found. The patient died 5 days after admission. Autopsy revealed pulmonary lymphangitis carcinomatosis caused by papillary carcinoma. No primary tumor was found.

Lymphangitic spread of hepatocellular carcinoma

Pulmonary lymphangitic carcinomatosis is a well-documented phenomenon caused by spread of carcinoma to the pulmonary vasculature and lymphatics, often resulting in respiratory failure and cor pulmonale. It has been described in numerous types of carcinoma, most commonly occurring with carcinomas of the breast and stomach and with choriocarcinoma. We report the case of a patient who presented with increasing shortness of breath and dyspnea on exertion. Autopsy findings revealed diffuse pulmonary vascular spread of a hepatocellular carcinoma to the lungs. To our knowledge, this is the first reported case of lymphangitic spread of a hepatocellular carcinoma causing respiratory compromise (lymphangitic carcinomatosis).

Skin relapse from cervical cancer

BACKGROUND

Cutaneous lymphangitis carcinomatosis from cervical carcinoma is a very rare form of tumor metastatization; only anecdotal cases are reported in the literature. Most of the patients with skin relapse experienced metastasis as a single or multiple nodules.

CASE

A case of cutaneous lymphangitis carcinomatosis mimicking contact dermatitis was diagnosed at our institution in a patient affected by cervical carcinoma stage IIB. Palliative chemotherapy with paclitaxel was started and the patient experienced complete clinical response. The hypothetical mechanism of spread and the unusual manifestation of relapse are described.

CONCLUSION

In a woman with a history of cervical cancer, a diffuse pruritic skin eruption should alert the clinician to the possibility of cutaneous carcinomatous lymphangitis. If a lymphangitis carcinomatosis is diagnosed, systemic intravenous chemotherapy should be considered.

Lymphangitis of the foot demonstrating lymphatic drainage pathways from the sole

BACKGROUND

There are two main lymphatic routes from the lower extremity: the fibular route to the popliteal node and the tibial route to the distant groin node. However, little is known about lymphatics from the sole.

OBJECTIVE

We attempted to obtain detailed knowledge of the lymphatics from the sole.

METHODS

Eight patients with lymphangitis were examined and compared with the drainage patterns visualized by blue-dye injection in 7 cases of melanoma.

RESULTS

Six lymphangitic streaks started from the lateral edge of the plantar surface, 2 from the heel, and 1 each from the center of the sole and the little toe. All streaks ran to the tibial side and went up along the foot branch of the great saphenous vein. These findings were similar to those of the dye-injected melanoma cases.

CONCLUSION

Lymphangitis makes visualization of lymphatic routes possible and may provide useful information about drainage.

The histopathology of bancroftian filariasis revisited: the role of the adult worm in the lymphatic-vessel disease

Although morphology is generally limited to static images, the histopathological features of bancroftian lymphatic disease are presented here in a way that is as dynamic as possible and closely associated with the clinical, ultrasonographic and surgical characteristics. The protean spectrum of alterations seen in the host's lymphatic vessels is discussed, and the changes caused by the live and dead worms are highlighted, as independent events. Evidence of a remodelling process, in which the lymphatic endothelial cells appear to have a key role, is provided for the first time. Despite many new pieces of information, there remain many 'blank pages' in the natural history of bancroftian filariasis.

Granulomatous lymphangitis of the scrotum and penis. Report of a case and review of the literature of genital swelling with sarcoidal granulomatous inflammation

BACKGROUND

Acquired lymphedema of the genitalia is a rare childhood presentation and is more common in elderly individuals secondary to pelvic/abdomenal malignancy or its therapy or worldwide due to filariasis.

OBJECTIVE

Herein, we report a case of a healthy 11-year-old boy who presented with a 1-year history of chronic, asymptomatic scrotal and penile swelling. Biopsy revealed edema, lymphangiectases and peri- and intralymphatic sarcoidal type granulomas. This histologic pattern of granulomatous lymphangitis is most commonly associated with orofacial granulomatosis (granulomatous cheilitis and Melkersson-Rosenthal syndrome) and Crohn's disease. Treatment with topical steroids and physical support has resulted in marked improvement. No systemic disease (Crohn's disease) is evident 1 year later. Literature review revealed 44 cases of genital lymphedema with non-infectious granulomas. The majority of these young patients had Crohn's disease, frequently with anal involvement and a minority, both with and without Crohn's disease, had orofacial granulomatosis.

CONCLUSIONS

Granulomatous lymphangitis should be considered in the differential diagnosis of chronic idiopathic swelling of the genitalia, particularly in younger individuals. Further clinical examination, additional laboratory studies and close follow-up for co-existing or subsequent development of Crohn's disease should be performed. The overlap between granulomatous lymphangitis of the genitalia, Crohn's disease and orofacial granulomatosis suggest that granulomatous lymphangitis of the genitalia may represent a forme fruste of Crohn's disease.

Carcinomatous lymphangitis mimicking pulmonary thromboembolism

A 41-year-old woman was admitted with rapidly worsening dyspnea. Echocardiography disclosed interventricular septal flattening and a markedly decreased left ventricle, although left ventricular contraction remained normal. Computed tomography of the chest demonstrated slightly dilated main pulmonary arteries and fine reticulonodular densities in the lung. Examination of a transbronchial lung biopsy specimen revealed carcinomatous lymphangitis, and the patient died 7 days after admission. The clinical presentation of this patient was difficult to discriminate from that seen with pulmonary thromboembolism.

[Mycobacterium marinum nodular lymphangitis]

BACKGROUND

Mycobacterium marinum has been recognized for some forty years. It generally occurs after trauma in a patient who manipulates tropical fish living in an aquarium.

CASE REPORT

We report the case of an exotic fish seller who developed M. marinum nodular lymphangitis after being bitten by one of the fish.

DISCUSSION

Nodular lesions occurring after trauma in subjects living in France who are in contact with exotic fish suggest the diagnosis of M. marinum. Nodular lymphangitis is seen in about 50% of the cases. Prolonged antibiotic therapy is required. Several antibiotics are effective including minocycline used in our case for 2 months after complete healing of the wound. Surgery is exceptionally required.

Pathogenesis of lymphatic disease in bancroftian filariasis: a clinical perspective

The pathogenesis of lymphatic filariasis has been a matter of debate for many decades. Here, Gerusa Dreyer and colleagues propose a dynamic model of bancroftian filariasis, integrating clinical, parasitological, surgical, therapeutic, ultrasonographic and histopathological data. This model has profound implications for filariasis control programs and the management of the individual patient.

Cutaneous histiocytic lymphangitis: an unusual manifestation of rheumatoid arthritis

Two cases are presented of unusual cutaneous lesions associated with rheumatoid arthritis in underlying joints. The lesions were evanescent, erythematous and violaceous partly macular and partly indurated plaques, with a livedo-like pattern of erythema at the edge in one case. Histological changes were identical in the two cases. The major features were dilated, dermal lymphatics containing aggregates of inflammatory cells, mainly histiocytes, with adjacent perivascular lymphoid aggregates. An appropriate name for this reaction would appear to be cutaneous histiocytic lymphangitis.

Acute adenolymphangitis due to bancroftian filariasis in Rufiji district, south east Tanzania

A longitudinal prospective surveillance for acute adenolymphagitis (ADL) was carried out in three villages in Rufiji district. A sample population of 3000 individuals aged 10 years and above was monitored fortnightly for a period of 12 months. The annual incidence of ADL was found to be 33 per 1000 population and was significantly higher in males than females (52.7/1000 and 18.7/1000 respectively). ADL episodes were more frequent in the age group of 40 years and above. Individuals with chronic manifestations seemed to be more vulnerable to ADL attacks with 62.2% of the total episodes occurring in this group. Furthermore, individuals with lymphoedema experienced more frequent acute episodes compared to those with hydrocele and 'normal exposed'. ADL episodes ranged from one to five per annum and the majority of the affected (60.4%) experienced a single episode. The average duration of an ADL episode was 8.6 days and in 72.5% of the episodes the affected individuals were incapacitated and unable to do their normal activities for an average duration of 3.7 days. The physical incapacitation associated with ADL episodes emphasizes the significance of lymphatic filariasis as a major public health problem of substantial socio-economic consequences.

Melkersson-Rosenthal syndrome: new clinicopathologic findings in 4 cases

OBJECTIVE

To define the clinicopathologic features of eyelid involvement in Melkersson-Rosenthal syndrome (MRS).

METHODS

Four patients with eyelid edema consistent with MRS were evaluated clinically, including diagnostic imaging in 2 patients. Eyelid tissue from these patients was examined by light microscopy and immunohistochemistry. Polymerase chain reaction for herpes simplex virus was performed in 1 case.

RESULTS

The 3 men and 1 woman ranged in age from 33 to 74 years. All patients had insidious, painless, nonpitting eyelid edema. Three patients had unilateral edema; one had bilateral, asymmetric involvement. Ipsilateral lip edema was present in 1 case. Computed tomography demonstrated periorbital heterogeneous thickening that corresponded to the microscopic finding of scattered granulomas. All 4 patients demonstrated epithelioid granulomas inside and adjacent to dilated lymphatic vessels. Polymerase chain reaction testing was negative for herpes simplex virus.

CONCLUSIONS

Isolated eyelid swelling that mimics thyroid-associated ophthalmopathy may occur in MRS. Computed tomography may be useful in the diagnosis. Biopsy should be performed in all cases of unexplained nonpitting eyelid edema. In the eyelid, MRS is characterized histopathologically by a granulomatous lymphangitis, a finding that seems to be unique to this condition.

Rickettsia mongolotimonae: a rare pathogen in France

We report a second case of laboratory-confirmed infection caused by Rickettsia mongolotimonae in Marseille, France. This rickettsiosis may represent a new clinical entity; moreover, its geographic distribution may be broader than previously documented. This pathogen should be systematically considered in the differential diagnosis of atypical rickettsioses, especially rashless fevers with lymphangitis and lymphadenopathy, in southern France and perhaps elsewhere.

[Carcinomatous lymphangitis]

DEFINITION

Carcinomatous lymphangitis is a radioclinical entity accounting for about 8% of all cases of lung metastasis defined as the presence of tumoral cells in lymph vessels and lung interstitium.

DIAGNOSIS

Biopsy specimens or bronchial brushings obtained by fibroendoscopy or bronchioalveolar lavage fluid usually reveal adenocarcinoma.

PRACTICAL MANAGEMENT

In clinical practice, the patient presents with dyspnea and non-specific infiltration on the chest x-ray. The clinical situation worsens rapidly. Millimetric CT-scan shows highly suggestive polygonal images in the subpleural area. Respiratory function tests may be helpful for the differential diagnosis, particularly in difficult cases, showing a mixed ventilation disorder without altered carbon monoxide diffusion and hypoxemia at rest without hypercapnia.

SEARCH FOR THE PRIMARY CANCER

Primary lesions must be identified for specific treatment. Pathology findings help guide the search. Despite the highly unfavorable prognosis (median survival = 3 months), etiological treatment when possible can improve quality of life and possibly survival. Symptomatic treatment is indicated and must be adapted to each individual case.

Comparison of high resolution CT findings of sarcoidosis, lymphoma, and lymphangitic carcinoma: is there any difference of involved interstitium?

PURPOSE

The purpose of this study was to determine distinguishing features of three diseases that are distributed along the lymphatics.

METHOD

CT scans of 40 patients with lymphangitic carcinomatosis, 41 with sarcoidosis, and 44 with malignant lymphoma were retrospectively reviewed. We evaluated the degree of involvement of the interlobular septa, bronchovascular structures, subpleural interstitium, and other CT findings.

RESULTS

The number of thickened interlobular septa and the extent of involvement of the subpleural interstitium in lymphangitic carcinomatosis were higher than those in sarcoidosis and malignant lymphoma (p<0.0001). Nodules of >1 cm in diameter were more often seen in malignant lymphoma (41.0%) than in the other two diseases (p < 0.001). Bilateral distribution was more common in sarcoidosis (100%) than in the others (p<0.001).

CONCLUSION

The major difference among lymphangitic carcinomatosis, sarcoidosis, and malignant lymphoma is the greater involvement of the interlobular septa and subpleural interstitium in lymphangitic carcinomatosis than in either sarcoidosis or malignant lymphoma.

Pulmonary lymphangitis carcinomatosa and acute pancreatitis: a rare presentation of choledochal cyst

Pulmonary lymphangitis carcinomatosa is an unusual cause of death in a young adult. This case describes an apparently healthy young woman who presented with severe acute pancreatitis, which is a recognized complication of a choledochal cyst. Autopsy examination revealed advanced malignancy with poorly differentiated adenocarcinoma penetrating the wall of the choledochal cyst and metastatic adenocarcinoma in the lymph nodes, lungs and kidneys. This case emphasises the unusual presentation of a choledochal cyst with acute pancreatitis and the aggressive nature of malignancy associated with this congenital anomaly.

Cutaneous manifestations of the Hemiscorpius lepturus sting: a clinical study

BACKGROUND AND DESIGN

Scorpion stings are a serious problem in Khuzestan, a southwestern province of Iran. In around 5 years, 36,463 patients with scorpion stings have been seen. Most of the patients had no cutaneous findings, but a small group of patients developed various local and generalized skin manifestations. Patients were evaluated in terms of cutaneous findings early in and during the course of their illness. The correlation between the site of the sting and the severity of the cutaneous and systemic problems is discussed.

RESULTS

Hemiscorpion (Hemiscorpius) lepturus (HL), which is responsible for more than 10% of the scorpion stings in this area, was found to be the only scorpion with related cutaneous findings. Different species of the Buthidae family, which were responsible for the remaining 90% of scorpion stings, have a neurotropic and noncytotoxic venom and, as a result, induce no cutaneous reaction.

CONCLUSIONS

HL venom is cytotoxic, and HL is the only scorpion whose venom induces a toxic reaction. Erythema, purpuric changes, bullae, necrosis, and ulcers, or a combination of these, may be seen at different stages. The site and the severity of the cutaneous reaction may aid in the prediction of the clinical outcome for the patients and in estimating the interval between the sting and presentation.