A RARE CASE OF CHYLOTHORAX SHROUDING A MALIGNANT PLEURAL EFFUSION

Abstract

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chylothorax is the collection of lymph in the pleural space and it is extremely rare to find an underlying malignant pleural effusion. Chylothorax is also usually unilateral and seldom a bilateral finding. Here we present a patient with underlying gastric malignancy with chylothorax and underlying malignant pleural effusion. CASE PRESENTATION: This was a 38 year old male who was diagnosed with gastric adenocarcinoma a month prior and completed the first round of chemotherapy, and presented to the hospital with shortness of breath and cough. Clinical exam showed a patient in no respiratory distress at rest and pulmonary exam shows stony dullness on percussion of the posterior lower lung zones. Auscultation revealed diminished vesicular breath sounds in the same area. A computerized tomography (CT) scan of the chest showed large bilateral pleural effusions and significant mediastinal lymphadenopathy. Patient underwent thoracentesis bilaterally which revealed large amount of turbid orange colored fluid. Analysis showed 58375 RBC/mm3, 2170 WBC/mm3, glucose of 64mg/dL, protein of 3.3g/dL, LDH of 873U/L, cholesterol of 64mg/dL, and triglycerides of 123mg/dL. Cytopathology revealed malignant cells positive for adenocarcinoma with gastric primary. Unfortunately, he developed recurrent pleural effusions. In view of developing recurrent episodes of respiratory distress, placement of a PleurX® catheter was planned. Unfortunately, the patient went into multi-organ system failure and eventually expired. DISCUSSION: In the review of articles of patients with gastric carcinoma, as in this case presenting with chylothorax as one of the presenting manifestations, there have been 14 accessible case reports so far and only one of them reports the fluid being malignant. A review of the primary malignancies showed that 9 exhibited signet ring cell carcinoma and 3 had poorly differentiated gastric adenocarcinoma and has been associated with high mortality and morbidity. Gastric malignancy with underlying chylothorax is a rare presentation. The mechanism is likely from tumor cells invading lymphatic channels diffusely. This obstruction causes the chylothorax however less likely is the cause for the malignant pleural effusion. The local invasion of metastatic cells into the pleural lining may have caused the malignant component. Chylothorax can also be associated with lymphedema. The chylothoraces have been treated by therapeutic thoracentesis, intercostal tube drainage and restriction of oral intake and continued treatment of the underlying cause. CONCLUSIONS: Although gastric adenocarcinoma has known to metastasize to pleural space to cause pleural effusion, this is the second case known to the best of our knowledge to have concurrent findings of chylothorax with a malignant pleural effusion. This also stands true for chylothorax from other reasons as well with the rarity of underlying malignant effusion. Reference #1: Devaraj U, Ramachandran P, Correa M, D'souza GA. Chylothorax in gastric adenocarcinoma: A case report and systematic review of the English literature. Lung India. 2014 Jan-Mar;31(1):47-52. https://doi.org/10.4103/0970-2113.125906. PubMed PMID: 24669083; PubMed Central PMCID: PMC3960811. Reference #2: Wu J, Lv L, Zhou K, Huo J. Chylothorax and lymphedema as the initial manifestations of gastric carcinoma: A case report and review of the literature. Oncol Lett. 2016 Apr;11(4):2835-2838. https://doi.org/10.3892/ol.2016.4285. Epub 2016 Feb 29. PubMed PMID: 27073560; PubMed Central PMCID: PMC4812189. DISCLOSURES: No relevant relationships by Jacob Mathew, source=Web Response No relevant relationships by Anish Samuel, source=Web Response No relevant relationships by Ahmed Sharaan, source=Web Response