520 likes | 1.7k Views
75 y.o. Man with NSCLCa and a pleural effusion. Lorriana Leard, M.D. Tri-Hospital Chest Conference Feb. 25, 2003. Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003. History. 75 y.o. WM with h/o NSCLCa who presents with SOB & increasing DOE over the past 3 months.
E N D
75 y.o. Man with NSCLCa and a pleural effusion Lorriana Leard, M.D. Tri-Hospital Chest Conference Feb. 25, 2003 Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003
History 75 y.o. WM with h/o NSCLCa who presents with SOB & increasing DOE over the past 3 months
Pertinent Pulmonary History In 9/01: • Presented with 80 lb wt. loss, cough, SOB
Pertinent Pulmonary History In 9/01: • Presented with 80 lb wt. loss, cough, SOB • Chest CT scan: • large subcarinal mass with RLL collapse
Pertinent Pulmonary History In 9/01: • Presented with 80 lb wt. loss, cough, SOB • Chest CT scan: • large subcarinal mass with RLL collapse • Bronchoscopy 9/7/01: • Near complete compression of bronchus intermedius • Wang needle biopsies from R side of carina poorly differentiated AdenoCa NSCLCa
Pertinent Pulmonary History • Staged as IIIB
Pertinent Pulmonary History • Staged as IIIB • Treated with Chemotherapy / XRT 9/01-12/01
Pertinent Pulmonary History • Staged as IIIB • Treated with Chemotherapy / XRT 9/01-12/01 • Repeat Chest CT 2/21/02: • Resolution of 5 x 6 x 6 cm subcarinal mass • New bilateral pleural effusions R>L
Pertinent Pulmonary History • Thoracentesis 4/02: 1400 mL serous fluid • Chemistries: GLUCOSE 125 mg/dl PROTEIN, TOTAL 5.2 g/dl (Serum 7.1) LDH 95 U/L (Serum 116) TRIGLYCERIDE 26 mg/dl • Cell Count RBC 990 #/cmm WBC 600 #/cmm (PMNs 2%, Lymphs 75%, Other 21%, Eos 1%) • Cultures: Fungal, AFB, Bacterial Cx negative • Cytology: Few atypical cells, probably reactive
Current Presentation • Now presents w/ increased DOE over 3 mo.
Current Presentation • Now presents w/ increased DOE over 3 mo. • R chest pain (intermittently) for past year • No CP with deep inspiration
Current Presentation • Now presents w/ increased DOE over 3 mo. • R chest pain (intermittently) for past year • No CP with deep inspiration • No hemoptysis • Cough productive of clear to white phlegm
Current Presentation • Now presents w/ increased DOE over 3 mo. • R chest pain (intermittently) for past year • No CP with deep inspiration • No hemoptysis • Cough productive of clear to white phlegm • Gaining weight since discontinuation of chemotherapy --113 --> 181
Past Medical History • NSCLCa per HPI • COPD: FVC 3.30 (80%) TLC 6.29 (94%), FEV1 1.98 (70%) DLCO 21.17 (88%) FEV1/FVC 60% • Atrial fibrillation • HTN • DM2 • CVA
Albuterol MDI Atrovent MDI Azmacort MDI Metoprolol Lasix Lisinopril Prazosin Aspirin Metformin Medications
Social History • Lives with his wife of 52 years in Cloverdale • Employment: • Air Force in saw mills rancher handyman • Retired since 1994 • Tobacco - 45 pack yr hx, quit 10 yrs ago • EtOH- prior socially, but none x 20 yrs • Drugs - never
Physical Examination VS: T 97, HR 56, BP 176/84, RR 24, O2S 95% on RA , Wt 182 lbs. Gen: alert WM, ambulatory in NAD Neck: supple, no JVD Lungs: decreased BS with DTP and decreased fremitus at R base CV: s1 s2 with RRR Abd: NABS, soft, NT, ND, Extrem: no edema, + clubbing
Labs 9.6 7.6 >-----< 218 29 Coags normal Creat 0.9 LFTs normal LDH 117
Comparison CXRs 4/24/2002 10/23/2002 2/7/2003
Differential Diagnosis for Pleural effusion? • Next diagnostic step? Management?
Differential Diagnosis of Exudative Pleural Effusion • Infectious: Bacterial, TB, Fungal • Iatrogenic: drug induced, central line misplacement • Malignant Pleural Effusion • Inflammatory disorders: PE, BAPE, XRT, • Connective Tissue Disease • Lymphatic abnormalities: Chylothorax, malignancy • Traumatic: Esophageal rupture, Hemothorax
Thoracentesis GLUCOSE 113 mg/dl ALBUMIN 2.0 gm/dL PROTEIN, TOTAL 3.7 g/dl (Serum 7.2) LDH 108 U/L (Serum 117)
Thoracentesis GLUCOSE 113 mg/dl ALBUMIN 2.0 gm/dL PROTEIN, TOTAL 3.7 g/dl (Serum 7.2) LDH 108 U/L (Serum 117) RBC 3300 #/cmm WBC 1370 #/cmm NEUTROPHILS 1 % LYMPHOCYTES 80 % OTHER 19 % (Others = monocytes, macrophages, histiocytes)
Thoracentesis Gram Stain • Occasional WBCs • No Organisms Seen Culture Negative Fungal Smear Negative AFB Smear Negative Cytology Negative
Thoracentesis • Appearance: LIPEMIC • TRIGLYCERIDE 1040 mg/dl
Diagnosis Chylothorax
Diagnosis and Management of a Chylothorax • Chylothorax vs. Pseudochylothorax • Etiology of a Chylothorax • Management of a Chylothorax
Diagnosis of Chylothorax • Pleural fluid triglyceride level >110 mg/dL • Ratio of pleural to serum triglyceride > 1.0 • Ratio of pleural to serum cholesterol < 1.0 • Lipoprotein analysis of pleural fluid: chylomicrons
Chyle Chyle: • High triglyceride content (Chylomicrons) • produces milky, opalescent appearance • BUT milky appearance may clear during a fast and rapidly returns after ingestion of fat • Not irritating (does not evoke thickening of pleura) • Bacteriostatic • Cellular component of chyle: T-lymphocytes • Prolonged loss of chyle nutritional depletion, water and electrolyte loss, hypolipemia, lymphopenia
Chyle Chylomicrons formed in gut enter intestinal lacteal vessels travel to cisterna chyli thoracic duct leaves cisterna chyli, travels up through mediastinum, and terminates in region of L jugular and subclavian veins
Etiology of Chylothorax Disruption of Thoracic duct • anatomy determines location of effusion • thoracic duct crosses the mediastinum at 5-6th vertebral body therefore • Lymphatic injury below = R pleural effusion • Lymphatic injury above = L pleural effusion • Wide anatomic variation • Flow through duct 1.5-2.5 L/day
Etiology of Chylothorax • Tumors: > 50% (lymphoma 75%) • Trauma: • CV or thoracic surgical procedure • 0.5%CV surgery • 4% of esophageal resections • Nonsurgical trauma • Penetrating injuries involving neck or thorax • Nonpenetrating: spine hyperextended or vertebral fx • Minor “traumas:” weight lifting, straining, coughing or vomiting, childbirth, vigorous stretching while vigorous stretching while yawning
Etiology of Chylothorax Other reported etiologies: • Pulmonary lymphangiomyomatosis • SVC or subclavian vein thrombosis • Filariasis • Lymph node enlargement • Mediastinal tuberculosis • Lymphangitis of the thoracic duct • Aneurysms of thoracic aorta that erode duct • Tuberous sclerosis • Amyloidosis
Etiology of Chylothorax From UpToDate.com
Etiology of Chylothorax From Light RW: Pleural Diseases 3rd Ed.
Etiology of Chylothorax Post-thoracic-XRT described in few case reports • Etiology unclear: • ? lymphatic obstruction due to mediastinal fibrosis • spontaneous rupture of duct which has been 'damaged' by prior XRT and, therefore, more susceptible to minimal trauma • Must rule out recurrent malignancy
Etiology of Chylothorax • McWilliams and Gabbay describe 52 y.o. man with R chylothorax 23 yrs after mantle XRT for Hodgkin’s lymphoma • thoracentesis, pleural biopsies, thoracoabdominal imaging and thoracoscopy performed to r/o recurrent lymphoma • Treated with talc pleurodesis • Van Renterghem reported chylothorax 6 years after mantle XRT for Stage IA Hodgkin's disease
Clinical Manifestations • Incidence: 2.3-4.4% of nontraumatic effusions • Onset of symptoms usually gradual • fatigue • dyspnea on exertion • heaviness and discomfort in affected side • Rarely pleuritic chest pain / fever because chyle is not irritating to pleural surface
Treatment Traumatic Chylothorax: • Spontaneous closure • Pleuroperitoneal shunt: chyle shunted to peritoneal cavity, where absorbed w/o sig. ascites • Tube thoracostomy: w/ minimization of chyle flow • Minimization of Chyle flow: • Keep stomach empty with NG suction and use TPN • Feed pt. low-fat diet with most fats in form of medium-chain triglycerides
Treatment If Persists: • Pleurodesis (talc) • Repair or ligation of thoracic duct (Thoracotomy or VATS) with attempt to find actual site of leakage from duct • Preop: lymphangiogram to identify site of leak • Case report: Thoracoscopic high-frequency ultrasonic coagulation of the thoracic duct without clipping • Parietal pleurectomy to obliterate pleural space
Treatment Non-Traumatic Chylothorax: If known diagnosis or lymphoma / malignancy: • Mediastinal radiation • Pleuroperitoneal shunt, if not controlled by XRT • Reports of Pleurodesis If unknown etiology: • Treat as Traumatic • Aggressively pursue diagnosis (CT / lymphangiogram)
Treatment Future Potential Treatments: • Percutaneous catheterization and embolization of thoracic duct • Somatostatin / octreotide reported to decrease chyle production in postop chylothorax and in dog models
Summary • Chylothorax results from disruption of thoracic duct • Must be distinguished from Pseudochylothorax • Most common cause tumor, then surgical trauma. IF undiagnosed etiology, must evaluate for malignancy • Management depends upon etiology, but may include: • Treatment of underlying malignancy (Chemo / XRT) • Dietary restriction and Chest tube drainage • Thoracotomy / VATS with Thoracic Duct Ligation • Pleurodesis • Avoid prolonged drainage which can lead to immunosuppression / malnutrition