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Lung Cancer |

Pulmonary Lymphangitic Carcinomatosis as the Primary Manifestation of Pancreatic Adenocarcinoma

Krittika Teerapuncharoen, MD; Joanna Sta Cruz, MD; Kuan-Hsiang Huang, MD; Jedrzej Wykretowicz, MD; Ganesan Murali, MD
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Albert Einstein Medical Center, Philadelphia, PA


Chest. 2013;144(4_MeetingAbstracts):618A. doi:10.1378/chest.1701694
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Abstract

SESSION TITLE: Cancer Cases I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Pulmonary lymphagitic carcinomatosis (PLC) or lymphangitic spread of tumor is characterized by infiltration of pulmonary lymphatic channels by tumor cells. 80% of PLC results from metastases of adenocarcinomas of the breast, stomach or lung, with 4% of pancreatic origin. PLC as an initial presentation of pancreatic cancer is rare. We report a case of metastatic pancreatic adenocarcinoma presenting primarily with dyspnea on exertion (DOE) and pulmonary infiltrates.

CASE PRESENTATION: A 52-year old African American female with a 15-pack-year history of smoking and cocaine use presented with progressive DOE and cough with scanty whitish sputum for 2 months. She was afebrile with oxygen saturation of 85% on room air and had bibasilar crackles. Chest x-ray revealed bilateral patchy infiltrates. Chest CT confirmed diffuse reticulo-nodular densities in a peribronchovascular distribution, thickened bronchioles and septa, supraclavicular and mediastinal lymphadenopathy, and small pleural effusions. Prior pulmonary function testing had revealed a restrictive pattern with decreased DLCO. HIV antibody and PPD were negative. Broncho-alveolar lavage was negative for micro-organisms including Pneumocystis jirovecii. Transbronchial lung biopsy (TBB) was positive for adenocarcinoma. Further cancer staging revealed a 2.6 cm solid pancreatic mass with regional metastatic lymphadenopathy. An ultrasound-guided biopsy of the pancreatic mass revealed adenocarcinoma with similar histologic features as of her lung biopsy. Immunohistochemistry staining (IHC) noted CK7+, CK20+ and TTF1-, suggesting a primary pancreatic adenocarcinoma. The patient received 5 cycles of FOLFOX (leucovorin, 5-fluorouracil and oxaliplatin). She died 6 months after the diagnosis of her malignancy.

DISCUSSION: Our patient had an unusual presentation of pancreatic adenocarcinoma, which manifested initially with symptoms and radiographic features compatible with PLC. The characteristic findings of PLC on HRCT are nodular thickening of interlobular septa with thickened bronchovascular bundles from hilum to periphery. TBB can confirm the diagnosis. Tobacco smoking increases the risk of both pancreatic and lung cancer. IHC is useful to distinguish between primary lung adenocarcinoma (CK7+CK20-TTF1+) and metastatic adenocarcinoma of the pancreas (CK7+CK20+TTF1-).

CONCLUSIONS: PLC can be an initial presentation of pancreatic adenocarcinoma. TBB is useful both to confirm the diagnosis and exclude other interstitial lung diseases. Imaging and IHC are helpful in distinguishing between primary and metastatic lung adenocarcinoma.

Reference #1: Stein MG, et al. Pulmonary lymphangitic spread of carcinoma: Appearance on CT scans. Radiology. 1987;162(2):371-5.

Reference #2: Jayne L, et al. Markers of adenocarcinoma characteristic of the site of origin: Development of a diagnostic algorithm. Clin Cancer Res. 2005;11:3766-72.

Reference #3: Bruce DM, et al. Lymphangitis carcinomatosa: A literature review. J R Coll Surg Edinb. 1996;41:7-13.

DISCLOSURE: The following authors have nothing to disclose: Krittika Teerapuncharoen, Joanna Sta Cruz, Kuan-Hsiang Huang, Jedrzej Wykretowicz, Ganesan Murali

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