AN UNCOMMON MALIGNANT PLEURAL EFFUSION

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Malignant pleural effusions (MPE) are usually related to metastatic disease, most commonly from lung cancer and breast cancer. We present a case of primary pleural low-grade B-cell lymphoma, presenting with a right pleural effusion, which management defers from other etiologies of MPE. CASE PRESENTATION: An 84-year-old man with a past medical history of laryngeal cancer and atrial fibrillation, who presented to the emergency department with progressive exertional shortness of breath associated with dry cough and onset of right-sided pleuritic chest pain the past 3 days. Review of Systems was otherwise negative. Social history was non-contributory. On physical examination he was in mild-to-moderate respiratory distress, tachycardic, tachypneic and afebrile, with decreased breath sounds and dullness to percussion over the right hemithorax. Chest radiograph revealed a large right-sided pleural effusion (Fig. 1). Thoracentesis was performed and one and a half liters of cloudy exudative fluid was drained. Repeat radiograph showed adequate interval lung re-expansion (Fig. 2). Cytology analysis demonstrated low grade B cell lymphoma with CD20 positive. Staging CT/PET scan and bone marrow biopsy were normal. The patient was started on rituximab and bendamustine with no intrapleural catheter (IPC) placement after the oncologist and pulmonologist were consulted. There were no immediate complications or recurrence of pleural effusion and the patient was discharged home with outpatient follow up. DISCUSSION: Malignant pleural effusions are the second leading cause of exudative effusions. Pleural involvement by metastatic disease, including lymphoma is common, however primary pleural lymphoma remains an extremely rare condition, representing only 7% of all lymphomas (1). From all the reported cases, low-grade B-cell lymphoma representing 1.34% (2). Recent guidelines published by the American Thoracic Society regarding management of malignant pleural effusion take in consideration lung re-expansion and life expectancy before moving forward with therapeutic interventions. Outweighing benefits and risk regarding IPC, pleurodesis and combination of both should be discussed with patients and the multidisciplinary team for the benefit of the patients. As in our case, due to the high chemotherapeutic response, he will benefit from holding any unnecessary interventional procedures, avoided increased risk for infections, periprocedural complications and limitation of daily activities. Chemotherapy was initiated with close monitoring for newly developing pleural effusion. CONCLUSIONS: We submit a unique case of primary pleural low-grade B cell lymphoma presenting with large malignant pleural effusion in which management can differ from recommended guidelines. This also outlines the importance of multidisciplinary approach to avoid unnecessary procedures with better outcomes for patients with this condition. Reference #1: Mei-Lin S, Bin S, Jian-hua G & Shu-juan J. Rare case of primary lymphoma presenting with pleural effusion. Thoracic Cancer 7. 2016. 145-150 Reference #2: Vega F, Padula A, Valbuena JR et al. Lymphomas Involving the pleura. Arch Pathol Lab Med. 2006;130.1497-1502 DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response No relevant relationships by Kathlyn Camargo Macias, source=Web Response No relevant relationships by Abed Madanieh, source=Web Response No relevant relationships by Chirin Orabi, source=Web Response No relevant relationships by jorge otoya, source=Web Response