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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24597
Letter to the Editor
Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis
Bhattacharjee Sulagna 1https://orcid.org/0000-0001-8671-6875

Prasanna Mrudula 2https://orcid.org/0000-0003-1071-4982

Maitra Souvik 3https://orcid.org/0000-0002-2328-9201

Ray Bikash Ranjan 4https://orcid.org/0000-0003-1461-1518

1–4 Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
Mrudula Prasanna, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India, Phone: +91 9740485625, e-mail: mruds19@gmail.com
1 2024
31 12 2023
28 1 8283
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Bhattacharjee S, Prasanna M, Maitra S, Ray BR. Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis. Indian J Crit Care Med 2024;28(1):82–83.

Keywords

Breast cancer
Lung ultrasound
Pulmonary lymphangitic carcinomatosis
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pmc Dear Editor,

Lymphangitic carcinomatosis is the malignant infiltration of the lymphatic vessels secondary to metastatic spread of malignancy from a primary—usually breast, lung, and stomach with pulmonary being the common one.1 Multiple imaging modalities like chest X-ray, CT scan, and positron emission tomography (PET) scan are available for evaluation. But lung ultrasound findings of the same have not been ascertained which may aid the diagnosis in the future, especially in resource-limited settings. Hence, we present the case of a woman with bilateral breast cancer and lymphangitic carcinomatosis.

A female in her 30s presented with complaints of a lump in both breasts for 2 years and dyspnea 3 days. The workup revealed bilateral pleural effusion which was drained. Despite this, her respiratory distress worsened and she was put on mechanical ventilation. She was 12 weeks pregnant at the presentation.

On arrival to the ICU, her ventilatory mechanics were extremely poor, with persistently high driving pressures even after lung protective ventilation and secondary measures like sedation, paralysis, positive end expiratory pressure (PEEP) titration, or prone positioning. Lung ultrasound revealed uniformly thickened pleural lines with occasional shreds with no underlying air bronchograms or no significant B lines (Fig. 1) in all the lung areas. However, no solid pleural anechoic abnormalities were seen.

Fig. 1 Ultrasound image of the pleura with its thickness measured. The pleural thickness was ranging from 0.6 to 0.7 cm

Pleural fluid analysis was negative for malignant cells. Bronchoalveolar lavage cytology and cultures were repeatedly negative. Biopsy from the breast lumps revealed invasive carcinoma no special type (NST). Contrast enhanced computerized tomography (CECT) thorax revealed thickened enhancing pleura, no pleural nodes, nodular irregular interlobular septal thickening with associated ground glass opacities in the bilateral lung with basal predominance, subpleural nodules, few peripheral areas of patchy consolidation—suggestive of lymphangitic carcinomatosis (Fig. 2).

Fig. 2 Axial view of CT thorax showing the presence of subpleural nodules with interlobular nodular thickening with few ground glass opacities

Radiologic findings of lymphangitis carcinomatosis have previously been described with the chest X-ray being normal in many patients.2 Although histopathology is the accurate measure to diagnose it, it may not be feasible in many clinical circumstances. Bronchoscopy and lavage may show malignant cytology, but a negative report does not exclude malignancy as it did with our patient.3

Visceral and parietal pleura are normally apposed with a thickness of 0.2–0.3 mm. Pleural thickness >10 mm with underlying effusion, diaphragmatic thickness >7 mm, pleural nodularity predicted malignant pleural effusion with high specificity.4 The pleural thickness in our patient was significant ranging from 6 to 7 mm in different segments.

A characteristic differentiating feature in CT chest is the preservation of general as well as lobular architecture of the lung, which corroborated with our USG finding of sparing of lung parenchyma.

We believe that the bedside demonstration of uniformly thickened pleura without significant lung parenchymal abnormality on point-of-care ultrasound (POCUS) in the background of a suspected or proven malignancy can help us clinch the diagnosis even when chest X-ray does not reveal significant findings and when cardiorespiratory instability in a critically ill patient can potentially delay CT chest examination.

The overall prognosis of this condition remains poor, and the management involves addressing of the underlying malignancy with chemotherapy and supportive care like steroids. To conclude, in a patient with appropriate clinical history, a lung ultrasound picture with a thickened pleura should raise the suspicion of malignancy.

Orcid

Sulagna Bhattacharjee https://orcid.org/0000-0001-8671-6875

Mrudula Prasanna https://orcid.org/0000-0003-1071-4982

Souvik Maitra https://orcid.org/0000-0002-2328-9201

Bikash Ranjan Ray https://orcid.org/0000-0003-1461-1518

Source of support: Nil

Conflict of interest: None
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References

1. Klimek M Pulmonary lymphangitis carcinomatosis: Systematic review and meta-analysis of case reports, 1970–2018 Postgraduate Medicine 2019 131 5 309 318 10.1080/00325481.2019.1595982 30900501
2. Kazerooni EA Gross BH Cardiopulmonary imaging. Lippincott Williams & Wilkins 2004 ISBN: 0781736552. p 651
3. Kumar AKA Mantri SN Lymphangitic Carcinomatosis. [Updated 2023 Jul 4]. In: StatPearls [Internet] Treasure Island (FL) StatPearls Publishing 2023 Available from: https://www.ncbi.nlm.nih.gov/books/NBK560921/
4. Soni NJ Franco R Velez MI Schnobrich D Dancel R Restrepo MI et al. Ultrasound in the diagnosis and management of pleural effusions J Hosp Med 2015 10 12 811 816 10.1002/jhm.2434 26218493
