1. A Reinders Department of Radiology UFS

2. 52 year old female patient Retroviral disease negative Previously known with right sided breast carcinoma Had right mastectomy and axillary clearance Now clinically showed progression CXR shows scattered infiltrates Pleural effusion Pleural changes on the right

3. Medical/social history No significant Special investigations Nuclear medicine Bone Scintigram “Degenerative lesions in thoracic spine – unable to exclude metastases” Radiology CXR CT Chest/abdomen and pelvis

7. 6 – 8% of all pulmonary metastases Tumor cell accumulation within connective tissue 1 Tumor cell embolization of blood vessels Subsequent lymphatic obstruction Interstitial oedema Collagen deposition Associated cancers Cervic/colon Stomach Breast Pancreas Thyroid Larynx “Certain cancers spread by plugging the lymphatics” 1

8. CXR 1 Reticular/reticulonodular opacities Coarsenend bronchovascular markings Kerley A and B lines Small lung volumes Hilar/mediastinal lymphadenopathy Pleural effusions

10. Normal lung architecture 1 Focal/diffuse/unilateral/bilateral distribution Thickenend interlobular septa Thickenend centrilobular bronchovascular bundle “Dot in box” appearance Pleural effusions (30 – 50%) Lymphadenopathy (30 – 50%)

12. Pulmonary lymphangitic carcinomatosis. Available from URL:http://www.radiopedia.org 2

13. Pulmonary Tuberculosis Hypersensitivity pneumoniae Sarcoidosis Cardiogenic Pulmonary Edema Thinking cap.....

14. Primary TB 3,4 Consolidation Lymphadenopathy Pleural effusion Regresses Secondary TB “Reactivation” Consolidation apical segments/superior segment lower lobes Cavitation Miliary TB 2 – 3 mm nodules in random distribution throughout lung

15. Clinial history Immunocompromised “Tree -in-bud appearance” Endobronchial spread Simultaneous occurance with LCM Rare May also present with septal thickening Almost impossible to distinguish radiologically Incidental findings in immunocompromised patients Secondary reactivation of Tuberculosis 5 Tuon FF, Miyaji KT, DE Vidal PM et al. Simultaneous occurence of pulmonary tuberculosis and carcinomatous lymphangitis. Rev. Oc Bras Med Trop. 2007 Jan-Feb; 40(1) :76-7

16. Right: Tree in bud appearance indicating endobronchial spread Left: Active pulmonary Tuberculosis with cavitation in the apical segment of right lower lobe

17. Extrinsic Allergic Alveolitis “Farm worker’s lung” “Bird fancier’s lung” Stages 3 Acute Subacute Ill defined centrilobular nodules Mosaic pattern Bronchiolitis with air trapping (lucencies) + patchy areas of infiltration (ground glass) Chronic Mosaic pattern Fibrosis and parenchymal distortion in midzone distribution Fibrosis typically through whole lung From periphery to centrum

18. Morissa AM, Nishimurab S, Huanga L. Subacute hypersensitivity pneumonitis in an HIV infected patient receiving antiretroviral therapy. Thorax 2000;55:625-627 doi:10.1136/thorax.55.7.625 6

19. Systemic disorder of unknown origin 3,4 Non caseating granulomas in multiple organs 90% of patients have lung involvement Lobar predominance Upper and midzone predominance Small nodules in perilymphatic distribution 1-2-3 Sign + calcifications Silzbach classification Stage 0 = normal lungs Stage 1 = Lymphadenopathy only Stage 2 = Lung involvement and lymphadenopathy Stage 3 = Lung involvement only Stage 4 = Fibrosis

20. Pulmonary sarcoidosis. Available from URL: http://www.radiopedia.org 2

21. HRCT 3 Bilateral smooth septal thickening Ground glass opacity Perihilar and gravitational distribution of fluid Cardiomegaly Pleural effusion

22. Smithuis R, Van Delden O, Schaefer-Prokop C. HRCT part II: Key findings in Interstitial Lung Diseases. 3 Available from URL: http://www.radiologyassistant.nl/en/http://www.radiologyassistant.nl/en/

23. 1. Chest Disorder. In: Dahnert W. Editor. Radiology Review Manual. 6 th Edition. Lippincot Williams & Wilkins. 2007; p509 2. Images available from URL: http://www.radiopedia.orghttp://www.radiopedia.org 3. Smithuis R, Van Delden O, Schaefer-Prokop C. HRCT part II: Key findings in Interstitial Lung Diseases. Available from URL: http://www.radiologyassistant.nl/en/http://www.radiologyassistant.nl/en/ 4. Chest Imaging. In: Weissleder R, Wittenberg J, Harisinghani MG, Chen JW. Editors. Primer of Diagnostic Imaging. 4 th Edition. Mosby Elsevier 2007; p34 - 35 5. Tuon FF, Miyaji KT, de Vidal PM et al. Simultaneous occurence of pulmonary tuberculosis and carcinomatous lymphangitis. Rev. Oc Bras Med Trop. 2007 Jan-Feb; 40(1) :76-7 6. Morissa AM, Nishimurab S, Huanga L. Subacute hypersensitivity pneumonitis in an HIV infected patient receiving antiretroviral therapy. Thorax 2000;55:625-627 doi:10.1136/thorax.55.7.625