15/9/23 11:01 Cutaneous Lymphangitis Carcinomatosa: Dermoscopic and Reflectance Confocal Microscopy Features - PMC Indian J Dermatol. 2022 May-Jun; 67(3): 316. PMCID: PMC9644753 doi: 10.4103/ijd.ijd_913_21: 10.4103/ijd.ijd_913_21 PMID: 36386063 Cutaneous Lymphangitis Carcinomatosa: Dermoscopic and Reflectance Confocal Microscopy Features Emilio Lopez-Trujillo,1 Ferran Olmos-Alpiste,1 Ramon M. Pujol,1,2 and Sonia Segura1 1 From the Department of Dermatology, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain E-mail: emilio08tr@gmail.com 2 Department of Medicine, Universitat Autònoma de Barcelona, Spain Received 2021 Oct; Accepted 2022 Apr. Copyright : © 2022 Indian Journal of Dermatology This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution- NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non- commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Sir, Cutaneous lymphangitis carcinomatosa (CLC) lesions can be polymorphous, often mimicking infections, inflammatory or tumoral processes. Dermoscopic features of CLC have been scarcely described and the diagnostic usefulness of other non-invasive techniques, such as re‐ flectance confocal microscopy (RCM) for the management of CLC has not been reported. A 70-year-old woman was referred for evaluation of several lesions on the chest that had pro‐ gressively appeared for the last 2 months. Past medical history included left breast ductal car‐ cinoma, pT3 pN2 M0, triple negative, treated with mastectomy, standard chemotherapy and ra‐ diotherapy 6 years before. Physical examination revealed multiple erythematous to violaceous patches, papules and plaques, arranged in a reticular distribution with diffuse telangiectasia [ Figure 1a]. Dermoscopy showed reddish to purple structureless areas with a patchy distribu‐ tion along with well-defined diffuse serpentine vessels and focal thin arborizing vessels [ Figure 1b]. The differential diagnosis could be established between CLC and radiotherapy-induced an‐ giosarcoma (RIA). A hand-held RCM examination with Vivascope® 3000 (Caliber I.D., Rochester, NY, USA) was performed, showing a thinned epidermis and flattening of dermal-epi‐ dermal junction. Besides, in the upper dermis, multiple dark, round to tubular spaces filled with aggregates of round atypical reflective cells were observed [Figure 1c]. These findings supported the diagnosis of CLC and helped to select an optimal area to perform a biopsy. Histopathological examination showed superficial dermal congestive blood vessels, and several groups of atypical pleomorphic cells inside dilated lymphatic vessels in the superficial and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9644753/?report=printable 1/4 15/9/23 11:01 Cutaneous Lymphangitis Carcinomatosa: Dermoscopic and Reflectance Confocal Microscopy Features - PMC reticular dermis [Figure 1d–e]. Immunohistochemical stains [Figure 1f] revealed CKAE1-3, GATA-3, GCDFP15 positive cells corresponding to a breast cancer origin located inside lym‐ phatics vessels (podoplanin/D2-40 positive). A close structural correlation between RCM im‐ ages and histology was observed. The patient was diagnosed with a skin recurrence of breast cancer. CLC is an unusual form of cutaneous metastasis (CM) characterised by an occlusion of dermal lymphatic vessels by neoplastic cells. It can often mimic a wide range of benign cutaneous in‐ flammatory conditions such as erysipelas or cellulitis, herpes zoster or even eczema.[1,2] Our patient had a previous diagnosis of breast carcinoma treated with radiation therapy, which raised the differential diagnosis with RIA. Dermoscopically, RIA can show homogeneous struc‐ tureless purple-pink-whitish areas in different arrangements.[3,4] Dermoscopy of CLC has not been reported so far. In our case, diffuse serpentine vessels and some focal thin arborizing vessels were evident overlying reddish to purple structureless areas with a patchy distribution. These well-defined vessels could be a hallmark in the dermoscopical differentiation between CLC and RIA in breast cancer patients previously treated with radiotherapy because many au‐ thors have highlighted the absence of well-defined vascular dermoscopical structures, such as lacunae and vessels, in cases of cutaneous angiosarcoma.[5] Our case shows clinical, dermo‐ scopic, RCM and histopathological features of CLC, highlighting a high correlation between RCM images and the histopathology. We suggest that RCM can be a useful tool in the diagnosis of CLC confirming clinical and dermoscopical suspicion. Further studies are necessary to widely describe RCM features of CLC and to correlate RCM findings with histopathologic features. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and ini‐ tials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. References 1. Prat L, Chouaid C, Kettaneh A, Fardet L. Cutaneous lymphangitis carcinomatosa in a patient with lung adenocarcinoma: Case report and literature review. Lung Cancer. 2013;79:91–3. [PubMed: 23164553] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9644753/?report=printable 2/4 15/9/23 11:01 Cutaneous Lymphangitis Carcinomatosa: Dermoscopic and Reflectance Confocal Microscopy Features - PMC 2. Marneros AG, Blanco F, Husain S, Silvers DN, Grossman ME. Classification of cutaneous intravascular breast cancer metastases based on immunolabeling for blood and lymph vessels. J Am Acad Dermatol. 2009;60:633–8. [PubMed: 19293011] 3. Zalaudek I, Gomez-Moyano E, Landi C, Lova Navarro M, Fernandez Ballesteros MD, De Pace B, et al. Clinical, dermoscopic and histopathological features of spontaneous scalp or face and radiotherapy-induced angiosarcoma. Australas J Dermatol. 2013;54:201–7. [PubMed: 22943153] 4. Cozzani E, Chinazzo C, Ghigliotti G, Pastorino C, Gasparini G, Parodi A. Cutaneous angiosarcoma: The role of dermoscopy to reduce the risk of a delayed diagnosis. Int J Dermatol. 2018;57:996–7. [PubMed: 29570226] 5. Minagawa A, Koga H, Okuyama R. Vascular structure absence under dermoscopy in two cases of angiosarcoma on the scalp. Int J Dermatol. 2014;53:e350–2. [PubMed: 24601957] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9644753/?report=printable 3/4 15/9/23 11:01 Cutaneous Lymphangitis Carcinomatosa: Dermoscopic and Reflectance Confocal Microscopy Features - PMC Figures and Tables Figure 1 Clinical, dermoscopic, RCM and histopathological findings of CLC. a) Clinical features on the areas previously treated with radiotherapy: Multiple erythematous to violaceous patches, papules and plaques with diffuse telangiectasia. b) Dermoscopic findings: Reddish to purple structureless areas with a patchy distribution along with well-defined diffuse serpentine vessels and focal thin arborizing vessels. c) RCM features: Round to tubular dark spaces in the dermis, filled with aggregates of round atypical reflective cells. d) Histopathological findings: Flattened epidermis, multiple dilated lymphatic vessels in the superficial and reticular dermis filled with aggregates of atypical pleomorphic cells along with congestive superficial blood vessels (Haematoxylin and eosin × 100). e) Higher magnification section: Pleomorphic atypical aggregates of cells inside lymphatic vessels (Haematoxylin and eosin ×400). f) Immunohistochemical studies: CKAE1-3 positive cells, which were also positive for GATA-3 and GCDFP15 (×400), corresponding to breast cancer cells inside of podoplanin/D2-40 positive lymphatics (inset) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9644753/?report=printable 4/4