AbstractDuodenal lymphangitis carcinomatosa has been sporadically described, and little attention has been paid so far. To our knowledge, no data on radiological findings for this rare entity has been published. We report a case of duodenal lymphangitis carcinomatosa secondary to gallbladder mass in a 44-year-old Indian man to focus on the radiological diagnosis, which was further confirmed by endoscopic-guided biopsy and immunohistochemical analysis

Anand, Rajamani

Radhan, Prabhu

Ramachandran, Rajoo

Sai, Venkata

Subramanian, Ilanchezhian

Swaminathan, Rajendiran

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Duodenal lymphangitis carcinomatosa: A rare case 

Introduction
Lymphangitis carcinomatosa is a diffuse infiltration of  
the lymphatic channels by malignant or metastatic cells and 
is common in lung malignancy (1). Pulmonary lym-
phangitic carcinomatosis occurs in 6–8% of  patients with 
pulmonary metastases (2). Although virtually any metastatic 
neoplasm can cause lymphangitic carcinomatosis, the 
common locations of  the primary tumor are the breasts, 
stomach, lungs, pancreas, and prostate. The incidence of  
duodenal lymphangitic carcinomatosa secondary to gall-
bladder mass has not been documented as yet.
Case report
   A 44-year-old male patient presented with persistent 
chronic epigastric pain and constipation for 6 months. He 
had a history of  significant weight loss of  7 kilograms over 
six months and loss of  appetite with intermittent vomiting. 
He also had a history of  smoking  and alcoholism for 20 
years. Baseline investigations showed leukocystosis and ele-
vated bilirubin, SGOT, SGPT, and alkaline phosphatase 
levels. 
In view of  the epigastric pain, contrast-enhanced com-
puted tomography (CECT) of  the abdomen was advised. It 
was performed with a GE 64-slice VCT Light speed, and 
images were acquired before and after administration of  
the contrast agent. CECT images showed an enhancing, 
irregular, infiltrating mass lesion within the gallbladder (Fig. 
1). No evidence of  pericholecystic fluid/fat stranding was 
seen. In addition to the gallbladder mass, the second and 
third part of  the duodenum showed a long segment of  cir-
cumferential wall thickening with loss of  mural stratifica-
tion, mural enhancement, and periserosal fat stranding (Fig. 
2A). Multiple peripherally enhancing enlarged necrotic 
RCR Radiology Case Reports | radiology.casereports.net! 1! 2014 | Volume 9 | Issue 2
Duodenal lymphangitis carcinomatosa: A rare case 
Ilanchezhian Subramanian MBBS, MD; Prabhu Radhan MBBS, MD; Rajoo Ramachandran MBBS, 
MD; Rajamani Anand MBBS; Venkata Sai MBBS, DMRD, DNB, PhD; and Rajendiran Swaminathan,  
MBBS, MD
Duodenal lymphangitis carcinomatosa has been sporadically described, and little attention has been paid 
so far. To our knowledge, no data on radiological findings for this rare entity has been published. We re-
port a case of  duodenal lymphangitis carcinomatosa secondary to gallbladder mass in a 44-year-old In-
dian man to focus on the radiological diagnosis, which was further confirmed by endoscopic-guided bi-
opsy and immunohistochemical analysis. 
Citation: Subramanian I, Radhan P, Ramachandran R, Anand R, Sai V, Swaminathan 
R. Duodenal lymphangitis carcinomatos: A rare case. Radiology Case Reports. (On-
line) 2014;2;932.
Copyright: © 2014 The Authors. This is an open-access article distributed under the 
terms of the Creative Commons Attribution-NonCommercial-NoDerivs 2.5 License, 
which permits reproduction and distribution, provided the original work is properly 
cited. Commercial use and derivative works are not permitted.
Drs. Subramanian, Radhan, Ramchandran, Anand, and Sai are in the Department of 
Radio Diagnosis, and Dr. Swaminathan in the Department of Pathology, all at Sri 
Ramachandra Medical College, Chennai India. Contact Dr. Subramanian at 
msilan1984@gmail.com.
Competing Interests:  The authors have declared that no competing interests exist.
DOI: 10.2484/rcr.v9i2.932
Radiology Case Reports
Volume 9, Issue 2, 2014
Figure 1. Axial, contrast-enhanced CT of abdomen in the portal 
venous phase demonstrates an asymmetrical, enhancing, infiltrat-
ing gallbladder mass lesion (arrow).
lymph nodes with an average size 10-15 mm were noted in 
the periduodenal region and at the root of  the mesentery 
(Fig. 2B).
Initially, the above imaging findings raised the possibili-
ties of  inflammatory etiology or a synchronous malignancy. 
UGI scopy showed multiple white polypoid granular lesions 
involving the second and third part of  duodenum (Figs. 3A 
and B). An endoscopic-guided biopsy of  the granular le-
sions in the duodenum was sent for immunohistochemical 
analysis. Microscopic examination revealed the presence of 
nests of  tumor cells within the dilated lymphatics (Fig. 4), 
which suggested metastatic lymphatic spread of  the malig-
nancy. In view of  the following:
* An infiltrating mass lesion in the gallbladder 
* Diffuse, circumferential, long-segment duodenal wall 
thickening with adjacent lymphadenopathy 
* Immunohistochemical evidence of  tumor cells within 
dilated lymphatics
We diagnosed duodenal lymphangitis carcinomatosa with 
primary gallbladder malignancy. The patient succumbed in 
6 months due to advanced metastatic malignancy.
Discussion
Duodenal lymphangitis carcinomatosa has been sporadi-
cally described in the recent past. To our knowledge, no 
published data is available on the incidence of  this rare 
entity. By definition, lymphangitis carcinomatosa is a dif-
fuse infiltration of  the lymphatic channels by malignant 
metastatic cells and is commonly encountered in lung ma-
lignancy (1). The other common malignancies that can 
metastasize to the intestine include end-stage adenocarci-
nomas of  the pancreas, stomach, colon, and cervix (3). Ma-
lignant melanoma is the most common extragastrointesti-
nal primary carcinoma that can metastasize to the small 
bowel (4).
The etiology of  lymphangitis carcinomatosa remains 
unclear; however, two possible mechanisms have been sug-
gested. One hypothesis is that hematogenous tumor emboli 
first cause endarteritis obliterans; subsequently, an egress of 
tumor cells extends through the vascular walls into the 
perivascular lymphatics. Another theory states that there is 
diffuse retrograde lymphatic permeation and embolization 
of  malignant cells. It is thought that the former is the main 
mode of  the spread, but both mechanisms might be in-
volved simultaneously (5).
Duodenal lymphangitis carcinomatosa: A rare case 
RCR Radiology Case Reports | radiology.casereports.net! 2! 2014 | Volume 9 | Issue 2
Figure 2. A. Axial section of abdomen with contrast in arterial phase 
shows long-segment circumferential wall thickening, loss of mural 
stratification, mural hyperenhancement, and periserosal fat strand-
ing noted in the second and third part of duodenum (arrow). B. CT 
coronal section of abdomen with contrast in portal venous phase 
shows multiple enlarged necrotic paraduodenal and mesenteric 
lymph nodes (arrow). Also seen is a mass lesion involving the gall-
bladder (arrowhead).
Figure 3. Upper gastrointestinal endoscopy of the second and third 
parts of the duodenum shows diffuse, nonulcerative, white, granu-
lar mucosal plaques (arrow) consistent with lymphangitis 
carcinomatosa.
Figure 4. A. High-power (x400) view showing the tumor cell within 
the dilated lymphatics. B. Dilated lymphatics in the duodenal mu-
cosa filled with tumor cells (H & E x100).
The imaging features of  duodenal neoplasm or any ma-
lignant mass lesion involving the gastrointestinal tract in-
clude focal or diffuse wall thickening of  the involved bowel 
loop, loss of  mural stratification, mural hyperenhancement,  
periserosal fat stranding, and adjacent lymphadenopathy 
(6).The imaging findings in our patient with involvement of 
the duodenum agreed with this.
Endoscopically, metastatic lesions to the duodenum have 
shown various appearances, with no single endoscopic ap-
pearance characteristic for any specific cancer or metastatic 
pattern (7). However, a study done by Masahiko et al 
showed that endoscopic findings of  duodenal lymphangitis 
carcinomatosa are unique: multiple polypoid lesions along 
the Kerckring’s folds covered by characteristic white, granu-
lar, nonulcerated mucosa (7). Microscopically, the tumor 
cells were seen in the dilated lymphatics (7). The endo-
scopic findings and the microscopic findings were similarly 
observed in our patient.
In our patient, given the presence of  an infiltrating mass 
lesion in the gallbladder and diffuse circumferential long-
segment duodenal wall thickening with adjacent lympha-
denopathy, we considered a diagnosis of  synchronous ma-
lignancies. Endoscopic and immunohistochemical analysis 
confirmed the presence of  duodenal lymphangitis 
carcinomatosa.
Duodenal lymphangitis carcinomatosa is rare and has an 
extremely poor prognosis. Knowledge of  this entity is very 
important, and it should be distinguished from ordinary 
metastatic duodenal carcinoma. Imaging and endoscopy-
guided biopsy is mandatory, plays an important role in di-
agnosis, and helps the clinician provide effective manage-
ment and prevent further complications. 
References
1.	 Anish Thomas, Robert Lenox et al, Primary Lym-
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Duodenal lymphangitis carcinomatosa: A rare case 
RCR Radiology Case Reports | radiology.casereports.net! 3! 2014 | Volume 9 | Issue 2


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Duodenal lymphangitis carcinomatosa: A rare case

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