Groin Node Research Articles

Pelvic Lymphadenectomy in Vulvar Cancer - Does it make sense?

Since the publication of the updated German guideline in 2015, the recommendations for performing pelvic lymphadenectomy (LAE) in patients with vulvar cancer (VSCC) have changed considerably. The guideline recommends surgical lymph node staging in all patients with a higher risk of pelvic lymph node involvement. However, the current data do not allow the population at risk to be clearly defined, therefore, the indication for pelvic lymphadenectomy is still not clear. There are currently two published German patient populations who had pelvic LAE which can be used to investigate both the prognostic effect of histologically verified pelvic lymph node metastasis and the relation between inguinal and pelvic lymph node involvement. A total of 1618 patients with primary FIGO stage ≥ IB VSCC were included in the multicenter AGO CaRE-1 study (1998 – 2008), 70 of whom underwent pelvic LAE. During a retrospective single-center evaluation carried out at the University Medical Center Hamburg-Eppendorf (UKE), a total of 514 patients with primary VSCC treated between 1996 – 2018 were evaluated, 21 of whom underwent pelvic LAE. In both cohorts, around 80% of the patients who underwent pelvic LAE were inguinally node-positive, with a median number of three affected groin lymph nodes. There were no cases of pelvic lymph node metastasis without inguinal lymph node metastasis in either of the two cohorts. Between 33 – 35% of the inguinal node-positive patients also had pelvic lymph node metastasis; the median number of affected groin lymph nodes in these patients was high (> 4), and the maximum median diameter of the largest inguinal metastasis was > 40 mm in both cohorts. Pelvic lymph node staging and pelvic radiotherapy is therefore probably not necessary for the majority of node-positive patients with VSCC, as the relevant risk of pelvic lymph node involvement was primarily found in node-positive patients with high-grade disease. More, ideally prospective data collections are necessary to validate the relation between inguinal and pelvic lymph node involvement.

Radiotherapy is not indicated in patients with vulvar squamous cell carcinoma and only one occult intracapsular groin node metastasis

ObjectiveMost guidelines advise no adjuvant radiotherapy in vulvar squamous cell carcinoma and a single occult intracapsular lymph node metastasis. However, several recent studies have questioned the validity of this recommendation. The aim of this study was to analyze the groin recurrence rate in patients with a single intracapsular positive lymph node treated without adjuvant radiotherapy. MethodsPatients with a single clinically occult intracapsular lymph node metastasis, treated without adjuvant radiotherapy, formed the basis for this study. Groin recurrences, and the risk of death, were analyzed in relation to the size of the metastasis in the lymph node and the lymph node ratio. Data were analyzed using SPSS, version 26.0 for Windows. ResultsAfter a median follow-up of 64 months, one of 96 patients (1%) was diagnosed with an isolated groin recurrence and another two (2.1%) were diagnosed with a combination of a local and a groin recurrence. The only isolated groin recurrence occurred in a contralateral lymph node negative groin. Size of the metastasis and lymph node ratio had no impact on the groin recurrence risk, nor on survival. The 5-year actuarial disease-specific and overall survivals were 79% and 62.5% respectively. The 5-year actuarial groin recurrence-free survival was 97%. ConclusionBecause of the low risk of groin recurrence and the excellent groin recurrence-free survival, we recommend that adjuvant radiotherapy to the groin in patients with vulvar squamous cell carcinoma and a single occult intracapsular lymph node metastasis can be safely omitted to prevent unnecessary toxicity and morbidity.

Treatment and Survival Outcomes of Surgery for Carcinoma Vulva

To study treatment and survival outcomes of carcinoma vulva. The electronic charts of 30 patients with carcinoma vulva operated between October 2010 and December 2015 were reviewed. Univariate cox-proportional hazard tests were done for potential risk factors. Survival analysis was done using Kaplan–Meier plots and the log rank test. The median age was 59 with a range of 27–82 years. Most common (90%) histological type was squamous cell carcinoma. Most (66.7%) patients had early stage disease, while stage III was seen in 23.3% and stage IV in 10%. Primary surgery was done in 27/30 (90%) patients while three with stage IV had surgery following neoadjuvant therapy. Complications included wound dehiscence in 6/30 (20%), lymphocysts in 11/30 (36.7%), urinary infections in 3/30 (10%) and one death within 30 days. There were 6 recurrences (20%) and 10 deaths (33.3%). Mean recurrence-free survival was 84.6 (95% CI 67.6–101.6) months. Mean overall survival time was 70 (95% CI 53.1–86.9) months. Radical wide local excision with groin node dissection is possible in most early cases. Flaps can reduce wound breakdown. A multidisciplinary approach can ensure long-term survival with good quality of life.

Molecular identification of severe fever with thrombocytopenia syndrome viruses from tick and bitten patient in Southeast China

BackgroundSevere fever and thrombocytopenia bunyavirus (SFTSV) infection causes severe fever and thrombocytopenia syndrome with high mortality. It is extremely rare that a transmitting tick can be directly captured in bite wounds, and that SFTSV can be isolated from both the captured tick and patient’s serum to establish a solid pathogen diagnosis.Case presentationWe report a case infected with severe fever and thrombocytopenia bunyavirus. The 69-year-old male patient presented with fever and tenderness on two lymph nodes in the right groin. A visible tick bite mark appeared on right upper quadrant of the patient’s abdomen, and a live tick was captured in the bite wound upon physical examination. The virus was detected in both the blood of the patient and in the tick that stayed in the bite wound for 7 days. The phylogenetic analysis indicated that the SFTSV isolated from the tick and the patient’s serum sample belonged to type B, in which the L/S segment of these two isolates shared 100% homology, while the M segment had 99.9% homology. The bitten patient was given various supportive care, but eventually died of multiple organ failure.ConclusionThe present case provides strong evidence of SFTSV transmission from H. longicornis to humans, and suggests that direct cross-species transmission can occur without additional intermediate hosts.

Superparamagnetic iron oxide: a novel tracer for sentinel lymph node detection in vulvar cancer

ObjectivesSuperparamagnetic techniques for sentinel lymph node (SLNs) biopsy in breast cancer is well recognized but remains novel in the literature in relation to early stage vulvar cancer. The aim of...

Tumor-free margins and local recurrence in squamous cell carcinoma of the vulva

ObjectiveTo investigate the relation of pathologic tumor-free margins and local recurrence in patients who underwent primary surgery for vulvar squamous cell carcinoma. MethodsIn this retrospective analysis, patients with stage I-III vulvar squamous cell carcinoma who underwent primary surgery between 2000 and 2018 were identified from the Mayo Clinic Cancer Registry. ResultsA total of 335 patients were included and divided into three groups according to tumor-free margins: group 1 (<3 mm, n = 32); group 2 (≥3 to <8 mm, n = 151); group 3 (≥8 mm, n = 152). The median follow-up time was 73 months (range 2–240). A total of 78 (23.3%) patients developed local recurrence. With the inverse propensity score weighing method adjusting baseline characters, margins <8 mm had inferior local control (HR 1.98, 95% CI 1.13–3.41). The 5-year local disease-free survival (DFS) was 48.2%, 81.5% and 84.6% for group 1, 2 and 3 respectively (p < 0.001). There were no differences in groin lymph nodes relapse (p = 0.850), distant metastases (p = 0.253), or disease-specific survival (DSS) (p = 0.289) among the three groups. Margins <8 mm, midline involvement, multifocal disease, precancerous lesions on margins and depth of invasion >1 mm were found to be poor prognosticators for local DFS in univariate analysis. Multifocal disease was the strongest predictor for local recurrence in multivariate analysis (HR 4.32, 95% CI 2.67–6.99). ConclusionPatients undergoing primary surgery for vulvar squamous cell carcinoma with tumor free-margins <8 mm have a higher local recurrence rate.

Radiologic Assessment of Groin Lymph Nodes in Pelvic Malignancies

IntroductionMetastatic involvement of groin nodes can alter radiation therapy planning for pelvic tumors. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) can identify nodal metastases; however, interpretation of PET/CT-positive nodes can...

Complication rates and lymph node count between two different skin incisions at time of inguino-femoral lymph node dissection in vulvar cancer

IntroductionInguino-femoral lymph node dissection plays a crucial role in the management of vulvar cancer. The procedure is associated with high complication rates, including infection, lymphocysts/lymphoedema and wound dehiscence. Several skin...

A preseason booster prolongs the increase of allergen specific IgG4 levels, after basic allergen intralymphatic immunotherapy, against grass pollen seasonal allergy

BackgroundAllergen specific IgG4 levels have been monitored as a surrogate marker for the tolerance inducing effect of subcutaneous immunotherapy (SCIT) in many studies. Its accuracy at group level has been well established, but IgG4 has not yet found its place in the daily care of immunotherapy patients.MethodsIntralymphatic immunotherapy (ILIT) is a novel route for allergy vaccination against pollen allergy, where an ultrasound-guided injection of 1000 SQ-U Alutard is given directly into a groin lymph node. The suggested standard dosing so far has been one injection with 4 weeks in-between. In total 3000 SQ-U with the treatment completed in 2 months. IgG4 was measured with Immulite technique and rhinoconjunctivitis symptoms were estimated with daily online questionnaires. Mann–Whitney U-test and Wilcoxon Signed Rank test were applied for comparisons between groups and within groups, respectively.ResultsThe present study demonstrates that a single, preseason ILIT booster of 1000 SQ-U Alutard 5-grasses®, re-increases the allergen specific timothy-IgG4 levels, in patients already treated with ILIT before the previous pollen season. It also shows the feasibility of the ILIT-route for allergy vaccination of rhinitis patients, with or without concomitant asthma, with low degree of side effects and reconfirms high and sustained patient satisfaction.ConclusionsIt is tempting to suggest that the allergen specific IgG4 levels can be used to build an intuitive algorithm for future clinical guidance of ILIT patients.Trial registration Is Intralymphatic Allergen Immunotherapy Effective and Safe?, ClinicalTrials.gov Identifier NCT04210193. Registered 24 December 2019—Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT04210193?term=NCT04210193&draw=2&rank=1

Signification pronostique du ratio d’atteinte ganglionnaire inguinale dans le carcinome épidermoide vulvaire

ObjectivesThe aim was to review the clinical impact of lymph node ratio (LNR) of groin metastatic nodal disease in women with vulvar squamous cell carcinoma. Material and methodsCohort study of women with vulvar squamous cell carcinoma, managed between January 2005 and December 2015, in five institutions in France with prospectively maintained databases (French multicenter tertiary care centers). PopulationIn total, 636 women managed for VSCC of whom 508 (79.9%) underwent surgical groin nodal staging. Main outcome measuresComparison of overall and recurrence free survival between women according to LNR. ResultsIn total, 176 women (34.6%) had at least one positive lymph node (LN). There was a significant differences for the 5-year overall survival and recurrence free survival rates between women with LNR>0.2 and women with LNR<0.2. ConclusionLNR seems to be a significant prognostic factor in women with vulvar squamous cell carcinoma.

Lymph node transfer combined with deep inferior epigastric perforators and transverse rectus abdominis myocutaneous procedures: a systematic review.

The surgical treatment of lymphedema can be conducted alone or in combination with microsurgical autologous breast reconstruction. We performed a systematic review of the literature at PubMed database regarding autologous breast reconstruction for deep inferior epigastric perforators (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) and vascularized lymph node transfer (VLNT) in patients with lymphedema following breast cancer surgery. We hypothesized that autologous breast reconstruction combined with VLNT has positive outcomes. Eligibility criteria included investigations reporting data studies evaluating female patients with lymphedema in an upper extremity after breast cancer who underwent autologous breast reconstruction combined with VLNT. The search resulted in 93 potential papers, but only 6 studies fulfilled the study eligibility criteria. The total number of patients was 103. Most of the studies evaluated the outcomes in patients treated with DIEP or ms-TRAM combined with VLNT. The studies described groin lymph node transfer as treatment for lymphedema. In most of the studies, all patients reported a reduction of arm circumference, volume, and symptoms of the upper extremity with lymphedema comparing the preoperative to the postoperative period. Overall, patients experienced successful breast reconstruction. All authors reported reduction of the circumferential size of the affected upper limb, as well as a decrease in cellulitis, in addition to favorable breast reconstruction results.

Cancer of the Penis

Objectives: To review the outcomes of modification of groin lymph nodes dissection on morbidity from surgical treatment of a patient with penile cancer and to find out accurate treatment plan according to stages of the primary lesion from current literatures. Methods: We searched the pubmed database for English Language published in the past for years using incidence, etiology, pathology, clinical presentation, staging and management of penile cancer. Result: From retrieved literatures better understanding of pathologic features allow for stratification of patients into low, intermediate, or high risk for lymph node involvement. Lymphatic mapping to this stratification improves selection of patients who might benefit from lymph node dissection after excision of the primary lesion. The recent use of a modified lymph node dissection has minimized morbidity. Current chemotherapy agents are ineffective in this disease. Conclusion: Patholoigc features of the primary lesion and the incorporation of lymphatic mapping have improved the selection of patients who might benefit from lymph node dissection. The use of a modified lymph node dissection in selection patients has decreased morbidity. Effective chemotherapy agents are needed in the management of advanced penile cancer. Bangladesh Journal of Urology, Vol. 15, No. 2, July 2012 p.48-55

Hypereosinophilia in a patient with refractory eczema and ALK-negative anaplastic large cell lymphoma

A 41-year-old man with refractory eczema on immunosuppressants developed swinging fever and dyspnoea, with left pleural effusion and left axillary and groin lymphadenopathy (2–3 cm) found in physical examination. Clinically there was no eczema flare-up. Laboratory tests showed hypereosinophilia (79.1×109/L) and elevated LDH (520 U/L) and ALP (187 U/L). Some dysplastic eosinophils showing hyposegmented nuclei and hypogranular cytoplasm were noted on blood smears. Workup for parasites, allergy and autoimmune markers was unremarkable. Thoracentesis yielded exudative effusate with numerous lymphocytes (WBC >1000/mm3) but no malignant cell was evident. FNAC of lymph nodes found eosinophilic infiltrate only. Bone marrow examination revealed marked eosinophilia with similar dysplastic features and megakaryocytic hyperplasia, raising suspicion of myeloproliferative neoplasms. Karyotyping, molecular tests for JAK2 mutation and BCR-ABL1 fusion, and FISH for FIP1L1-PDGFRA, PDGRFB and FGFR1 rearrangements were unremarkable. Excisional biopsy of left groin lymph node was then pursued and demonstrated sheets of pleomorphic neoplastic cells with focal ‘hallmark cells’. Anaplastic large cell lymphoma (ALK–CD30+CD3+CD8+) was diagnosed. PET/CT scan revealed a stage-IV disease with extensive supra- and infra-diaphragmatic hypermetabolic lymph nodes and multiple bone involvements. The patient opted for brentuximab vedotin plus combination chemotherapy. This case underscores the importance of exhaustive investigations and clinicopathological corroboration in the workup of hypereosinophilia.

Vulvar cancer: surgical management and survival trends in a low resource setting

BackgroundThis study aims to analyze risk factors, clinical profiles, treatment protocols, and disease outcomes in histologically proven resectable vulvar cancer (VC) patients according to tumor stage. This is a retrospective analysis of a prospectively collected database of 20 VC patients from May 2014 to June 2019.ResultsThe mean age of VC diagnosis was 55 years, with a range of 38–84 years. The incidence was four cases per year. The disease incidence was significantly more in post-menopausal (65%) and multiparous (90%) women. According to FIGO staging of vulvar cancer, stages I, II, and III were assigned to 6, 1, and 11 patients respectively. Two patients suffered from stage IVa vulvar melanoma. All patients had undergone surgical interventions. Patients treated with only nonsurgical (chemotherapy/radiotherapy/chemo-radiotherapy) treatment modalities were excluded from the study. Fifteen patients were treated with wide local excision (WLE), bilateral inguinofemoral dissection (B/L IFLND), and primary repair. Four and one patients were treated with radical vulvectomy (RV) and modified radical vulvectomy (MRV) [with or without B/L IFLND and PLND] respectively. Reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps were done in two patients. Therapeutic groin nodal dissection was performed in 19 patients except in one patient who was treated by palliative radical vulvectomy. In the final histopathology reports, tumor size varies from 0.5 to 6.5 cm (mean 3.35 cm) with the predominance of squamous cell carcinoma (18 out of 20 patients). Only 10 out of 18 eligible patients received adjuvant treatment. Poor patient compliance has been one of the major reasons for adjuvant treatment attrition rate. Systemic and loco-regional metastasis occurred in 3 patients each arm respectively. Poor follow up of patients is the key limitation of our study.ConclusionVulvar cancer incidence was significantly high in post-menopausal and multiparous women. The most important prognostic factors were tumor stage and lymph node status. Oncological resection should be equated with functional outcome. The multidisciplinary team approach should be sought for this rare gynecological malignancy.

Management of clinically node-negative groin in patients with penile cancer.

Malignant penile neoplasms are commonly squamous etiology, with the inguinal nodes being the first echelon of spread. The disease spreads to the pelvic lymph nodes only after metastases to the groin nodes, and this is the most important prognostic factor in penile carcinoma. While treatment of penile carcinoma with proven metastases to the inguinal lymph nodes mandates ilioinguinal lymph node dissection, the treatment of patients with impalpable nodes is more controversial. Overtreatment leads to excessive treatment-related morbidity in these patients, while a wait-and-see policy runs the risk of patients presenting with inguinal and distant metastases, which would have been curable at presentation. Unfortunately, no single imaging modality has been proved to be convincingly superior in the staging, and hence, management of the clinically negative groin has been subject to debate. While some high volume centers have promoted the use of dynamic sentinel lymph node biopsy, others advocate the use of the modified inguinal lymph node template to stage the groin adequately. Newer techniques such as video endoscopic inguinal lymph node dissection have been introduced as an alternative to the original radical inguinal lymphadenectomy to reduce morbidity.

Small-cell carcinoma of the lung with inguinal lymph node metastasis at initial presentation

Groin node metastases are predominantly seen in primary malignancies of infradiaphragmatic location. However, sparse cases of inguinal metastases from tumors above the diaphragm have been reported in the medical literature. Here, we report a case of small-cell carcinoma of the lung with metastatic inguinal lymph node at the initial presentation in a 57-year-old man. The case was diagnosed and managed congruously as per the stage of the disease, which was metastatic. However, the patient was died due to disease progression after 8 months of diagnosis. This case edifies to a clinical oncologist's knowledge that patients with commodious and disseminated malignancies of supradiaphragmatic location may present with lymph nodes in the inguinal region.

Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review.

Lymph node transfer is a surgical treatment that is becoming more prevalent. The lymph nodes from the groin and neck are most frequently used. Iatrogenic lymphedema can be a consequence of the dissection of the groin nodes; thus, some surgeons prefer to use the neck as a donor site. Literature reporting surgical algorithms for the treatment of lymphedema is scarce. Thus, we conducted a systematic review of vascularized omentum lymph node transfer (VOLT) in patients with lymphedema to provide more information about this increasingly common procedure. We hypothesize that the analyzed studies will show that VOLT has positive outcomes. Two reviewers (G.J.C., D.B.) performed independent searches using the PubMed database without timeframe limitations initially through title and abstract descriptions and then by full-text review. The search was done using the following keywords: Breast cancer lymphedema OR lymphedema AND lymph node transfer OR lymph node flap OR lymph node graft AND omental OR omentum OR gastroepiploic. Eligibility criteria included publications evaluating patients with lymphedema in the upper extremity and lower extremity, who underwent VOLT. Our search yielded 35 potential papers in the literature, but only six studies fulfilled the study eligibility criteria. The total number of patients was 137. Three studies described single VOLT, two studies described double VOLT and one study described two cohort patients, one that was treated with single VOLT and another one that was treated with double VOLT. Postoperative reduction of arm circumference, arm volume, and symptoms of the upper extremity were reported in all patients. Nonetheless, in one study, seven patients did not notice any extremity circumference reduction during the follow-up period and four patients noticed an increase in arm volume. Flap loss was reported by two authors in a total of two patients. Overall, patients experienced successful lymphedema treatment with VOLT. All authors presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications.

Recurrence and survival rates in node negative patients after sentinel node biopsy for early-stage vulva cancer – A nationwide study

ObjectiveThe sentinel node (SN) procedure is adopted in selected patients with early-stage vulva cancer (VC) in Denmark. Due to the low incidence of VC, large population-based studies on the safety of SN outside multicenter clinical trials are lacking. The current study evaluated the risk of recurrence and survival in SN- negative VC patients. MethodsNationwide data was collected and registered prospectively in the Danish Gynecologic Cancer Database from January 2011 to July 2017. Patients with clinically stage IB-II unifocal vulva squamous cell carcinoma, tumor <4 cm and no clinically suspicious groin nodes or distant metastases, who underwent SN-procedure, were included. ResultsThe SN-procedure was performed in 286 patients, of these 190 (66.4%) patients were SN-negative. Twenty-three of the 190 SN-negative patients (12.1%) had one or more recurrences during a median follow-up of 30 months (range 1–83). Four patients (2.1%) had an isolated groin recurrence identified from 5 to 17 months after primary surgery. Fourteen patients (7.4%) experienced a local recurrence in vulva, 1 patient (0.5%) had a recurrence in the vulva and the groin and 4 patients (2.1%) had distant recurrences. The 3-year overall (OS) and disease-specific survival (DSS) for SN-negative patients was 84% and 93%, respectively. The 3-year OS for patients with recurrent disease was 58%. ConclusionsThis is the largest prospective nationwide study on SN-procedure in vulva cancer. The study confirms the safety of the SN-procedure in selected early-stage VC patients with a low isolated groin recurrence rate and a good DSS.

Histopathological risk scoring system as a tool for predicting lymph nodal metastasis in penile squamous cell carcinoma

Penile cancer is an aggressive neoplasm and nodal metastasis is a key factor in determining the outcome. While there is a paucity of tools predicting nodal metastasis, an elective groin node dissection (GND) may cause severe morbidity. We aimed to devise a histopathology-based risk stratification system to predict the risk of nodal metastasis in penile squamous cell carcinoma (SCC) patients. In this retrospective clinicopathological analysis, consecutive penile SCC patients who had undergone primary surgical treatment with GND from 2007 to 2012 were included. Histopathology slides were reviewed and a histopathological risk scoring system (ranging from 3 to 9) was devised by adding the values assigned to the following pathological variables: tumour grade (1-3); anatomical level of infiltration (1-3); and tumour infiltration pattern (1-3). Three risk groups were created based on histopathological risk scores. Final scores and risk groups were correlated with nodal metastasis, disease-free survival (DFS) and overall survival (OS). We also validated the earlier described prognostic index score (PIS) on our set of patients and compared it to our proposed scoring system. A total of 162 cases of primary penile resections with unilateral or bilateral groin node dissection were identified during the study period. Sixty-two of 68 patients (91.17%) and 58 of 94 patients (61.7%) had nodal metastasis on upfront and follow-up nodal basin surgeries, respectively. Chances of nodal metastasis for each risk group were as follows: low risk (score 3 and 4) 14.3%; intermediate risk (score 5) 52.6%; and high risk (scores 6-9) 83.7%. Follow-up was available in 145 patients (89.5%). Median follow-up was 21 months (1-96 months). The histopathological scoring system (p=0.04) and risk groups (p=0.005) had a statistically significant correlation with DFS but not with OS. Logistic regression model demonstrated that this stratification system was a good predictor of nodal metastasis. Further, this scoring system had better predictive sensitivity for detecting true node-negative cases and marginally better accuracy in detecting nodal metastasis as compared to the PIS. Our study demonstrates that the histopathological risk stratification can predict nodal metastasis and aid in planning management of penile cancer patients with judicious implementation of the morbid procedure of GND.

CONSIDERATIONS FOR CHYLOTHORAX IN PATIENTS WITH CHRONIC LYMPHOCYTIC LEUKEMIA

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: Chylothorax is a rare complication of chronic lymphocytic leukemia (CLL). Diagnosis is challenging due to its rarity and nonspecific clinical presentation. We report a case of CLL-associated chylothorax. CASE PRESENTATION: A 71 year-old woman with no known medical history presented with dyspnea, weakness, and weight loss. Exam was significant for cachexia and respiratory distress with absent left-sided breath sounds. Labs were notable for WBC 376,800 cells/μL (91% lymphocytes and smudge cells), Hgb 7.1g/dL, platelets 557,000 cells/μL, LDH 408U/L, protein 6.6g/dL. A large left-sided pleural effusion was noted on chest radiograph. CT demonstrated a large left effusion with left lung atelectasis, hepatosplenomegaly, and mediastinal and abdominal lymphadenopathy. Peripheral flow cytometry was consistent with CLL (Rai Stage III). Lung ultrasonography demonstrated multiple septations. Thoracentesis and 8-French chest tube placement were performed. Pleural fluid studies: WBC 4,010 cells/μL (61% neutrophils, 34% lymphocytes), protein 4.4g/dL, LDH 568U/L, amylase 35U/L, and triglycerides 49mg/dL. Pleural fluid was sent for cytology and empiric antibiotics were started. Intrapleural alteplase and DNAse were instilled for 6 doses in attempt to reexpand the lung. Initial cytology and cultures were negative. Pleural fluid analysis was repeated hospital day 11, demonstrating triglycerides 189mg/dL and cholesterol 10mg/dL, consistent with chylothorax. Low fat diet, octreotide, chlorambucil and prednisone were initiated. Daily chest tube output was >500mL and she underwent CT venography. Interventional radiology attempted thoracic duct embolization but were unable to successfully cannulate it. Lymphoscintigraphy identified the thoracic duct leak. Cisterna chyli access via groin lymph node was aborted due to distress when the patient was supine. The patient chose to focus on comfort and the chest tube was removed. She was discharged to home hospice. DISCUSSION: Chylothorax from CLL is uncommon, reported in few cases. The rarity may be attributed to infrequent mediastinal lymphadenopathy in CLL.1,2 In the setting loculated pleural effusions, diagnosis may be difficult due to sampling error; chylothorax is diagnosed by pleural fluid triglycerides >110mg/dl. If levels are indeterminate, repeat analysis is warranted if suspicion remains high. Management focuses on treating the underlying disease and implementing a low fat diet with medium-chain triglycerides. Thoracic duct embolization may be an option for poor surgical candidates failing initial therapy.3 CONCLUSIONS: High suspicion for chylothorax must be maintained in CLL patients with pleural effusion to avoid delaying directed intervention. Reference #1: Zimhony et al. Chronic lymphocytic leukaemia complicated by chylothorax. Journal of internal medicine. 1994 Apr;235(4):375-7. Reference #2: Antón E. Chylothorax in hematologic malignancies. Chest. 2005 May 1;127(5):1866. Reference #3: Bender et al. The changing management of chylothorax in the modern era. European Journal of Cardio-Thoracic Surgery. 2015 Mar 1;49(1):18-24. DISCLOSURES: No relevant relationships by Scott Ferrara, source=Web Response No relevant relationships by Yonatan Greenstein, source=Web Response No relevant relationships by Omry Zuckerman, source=Web Response