Recurrent Effusion Research Articles

Intrapericardial cisplatin combined with oral colchicine resulted in long term control of malignant pericardial effusion in the course of metastatic renal cancer.

Background Neoplastic pericardial effusion (NPE) represents a common cause of morbidity and mortality in patient with cancer. NPE presents frequently as cardiac tamponade, requiring urgent pericardiocentesis or pericardiotomy, with subsequent pericardial fluid drainage. Despite high effectiveness of such procedures, the recurrence of effusion is noted in 30- 60% of patients. Intrapericardial therapy with cisplatin was found to be effective in NPE due to lung and breast cancer. Its role in cardiac tamponade due to renal cancer is unknown. Case presentation We presented 82-year-old man with renal cancer who was admitted to the Intensive Care Unit because of threatening pericardial tamponade due to NPE . Urgent subxiphoid pericardiotomy was performed with subsequent evacuation of 1000ml of bloody fluid. On the inner surface of the pericardium several pink nodules were found. Histological examination revealed carcinoma clarocellulare. In view of the persistent high drainage of the pericardium, intrapericardial cisplatin therapy was performed. The first day after surgery colchicine 0.5 mg/day/po was also introduced. No side effects of this treatment were observed. The patient died 12- month later due to cancer progression and cachexia. No recurrence of pericardial effusion was observed. Conclusion This is the first case study demonstrating long-term efficacy and safety of intrapericardial cisplatin combined with oral colchicine in NPE due to metastatic renal cell carcinoma.

Bortezomib-Induced Cardiac Tamponade in a 49-Year-Old Man.

Proteasome inhibitors such as bortezomib and carfilzomib have been used effectively to treat patients who have certain hematologic malignancies. Proteasome activity is elevated in the heart, and potent inhibition results in accumulation of misfolded intracellular protein aggregates and apoptosis. Heart failure, conduction disturbances, and premature atherosclerosis have been associated with bortezomib therapy. We describe the case of a 49-year-old man who was taking bortezomib for graft-versus-host disease, when he developed cardiac tamponade and needed emergency pericardiocentesis. At that time, there was no evidence of graft-versus-host disease. To our knowledge, this is the first time that a pericardial effusion without underlying cardiac dysfunction has been reported in relation to bortezomib therapy. The diagnosis of pericardial effusion during bortezomib therapy, the absence of other causative agents-including graft-versus-host disease-and no recurrence of pericardial effusion after discontinuing bortezomib therapy suggest that bortezomib caused our patient's tamponade.

Chylothorax as a Post-Operative Complication of Orthotopic Heart Transplantation

Objectives Recognize chylothorax as a complication of OHT, and LVAD implantation and explantation. Introduction Chylothorax is a rare complication of thoracic surgery with a reported incidence of 0.24% - 0.5%, however there have been only two previous reports of chylothorax after orthotopic heart transplantation (OHT). We report the first instance of chylothorax complicating OHT at the time of ventricular assist device (VAD) explantation. Case report A 47 y.o. man with ischemic cardiomyopathy who required TandemHeart, and subsequent HeartMate 2 VAD placement with closure of ASD. He underwent a HeartMate 2 exchange four months later, and OHT 14 months later. After OHT, on post-operative day (POD) 8, he had milky fluid from a mediastinal Blakemore tube. Fluid triglyceride level was 1477 mg/dl. The patient was placed on a very low fat diet and the drainage decreased from 235mL/24hrs to 90mL/24hrs. When challenged with a high fat diet, he had a recurrent chylous effusion. On POD 28 he reported Discussion The appearance of this complication after VAD explantation may be of particular importance as continued developments and improvements in VAD technology lead to an increase in patient survival, VAD implantation, and exchange. As this occurs, awareness of this rare complication becomes more important. Chylothorax provides a particular challenge in the management of the transplant patient, as indwelling chest tubes, effects on nutritional status and the immune system are noteworthy. The primary treatment for chylothorax is low fat or medium-chain fatty acid diet. If this fails, nil per os status with total parenteral status is the second line therapy. In a patient post OHT, who is immunosuppressed, maintaining adequate nutrition is of paramount importance. Additionally, loss of chyle has potential implications in the management of post-transplant immunosuppression. Cyclosporine is secreted in chyle. The loss of chyle into the pleural cavity decreases the circulating levels of cyclosporine, which render achieving a therapeutic level difficult. Furthermore, cyclosporine has been demonstrated to increase chyle formation, which makes resolution of chylothorax more difficult in patients who require cyclosporine therapy. Lastly, chyle contains numerous lymphocytes, with a typical cell count revealing >50% lymphocytes. Loss of chyle, then, leads to a rapid and abnormal loss of lymphocytes. This may complicate administration and monitoring of lymphocyte-reducing anti-rejection therapies which are paramount to graft health in the early post-operative period. Conclusion Post-OHT chylothorax is an uncommon, but noteworthy complication. Management is similar to non-transplant patients, requires close follow-up and may adversely affect outcomes, due to effects on nutritional status and immunological risk.

Thoracoscopic versus subxiphoid pericardial window in patients with end-stage renal disease

BackgroundPericardial effusion is a common problem in patients with end-stage renal disease (ESRD). There are many surgical approaches to perform a pericardial window in those patients. This study compared the safety and efficacy of VATS and subxiphoid approaches in performing a pericardial window for pericardial effusion in patients with ESRD. MethodsFrom February 2015 to March 2017, a prospective study included a total number of 30 patients of ESRD who were prepared for pericardial window. Patients were randomly divided into two groups: group A (15 patients who underwent VATS pericardial window), and group B (15 patients who underwent subxiphoid pericardial window). Patients were followed-up for 12 months postoperatively. ResultsBoth procedures were safe and effective in the management of pericardial effusion. Preoperative data showed no significant difference between both groups. In VATS group, there were significant increased operative times (p-value = 0.031) but with a significantly shorter length of hospital stay (p-value = 0.037) when compared to the subxiphoid group. In both groups, no mortality was recorded. Recurrent pericardial effusion was detected in 5 patients (33.3%) in the subxiphoid group while it was detected in 1 patient (6.7%) in VATS group (p-value = 0.169). VATS approach was the independent predictor of freedom from recurrence (hazard ratio: 0.054; p-value = 0.020). ConclusionsVATS is a safe and effective procedure in the management of pericardial effusion in patients with ESRD. VATS approach decreased total length of hospital stay and decreased the incidence of recurrence of pericardial effusion.

Risk factors for pleural effusion recurrence in patients with malignancy.

The main purpose of treatment in patients with malignant pleural effusion (MPE) is symptom palliation. Currently, patients undergo repeat thoracenteses prior to receiving a definitive procedure as clinicians are not aware of the risk factors associated with fluid recurrence. The primary objective of this study was to identify risk factors associated with recurrent symptomatic MPE. Retrospective multicentre cohort study of patients who underwent first thoracentesis was performed. The primary outcome was time to fluid recurrence requiring intervention in patients with evidence of metastatic disease. We used a cause-specific hazard model to identify risk factors associated with fluid recurrence. We also developed a predictive model, utilizing Fine-Gray subdistribution hazard model, and externally validated the model. A total of 988 patients with diagnosed metastatic disease were included. Cumulative incidence of recurrence was high with 30% of patients recurring by day 15. On multivariate analysis, size of the effusion on chest X-ray (up to the top of the cardiac silhouette (hazard ratio (HR): 1.84, 95% CI: 1.21-2.80, P = 0.004) and above the cardiac silhouette (HR: 2.22, 95% CI: 1.43-3.46, P = 0.0004)), larger amount of pleural fluid drained (HR: 1.06, 95% CI: 1.04-1.07, P < 0.0001) and higher pleural fluid LDH (HR: 1.008, 95% CI: 1.004-1.011, P < 0.0001) were associated with increased hazard of recurrence. Negative cytology (HR: 0.52, 95% CI: 0.43-0.64, P < 0.0001) was associated with decreased hazard of recurrence. The model had low prediction accuracy. Pleural effusion size, amount of pleural fluid drained, LDH and pleural fluid cytology were found to be risk factors for recurrence.

Bilateral lipoma arborescens –A proliferative case demonstrating progression in an adolescent male

CaseWe describe a case of extensive symptomatic bilateral lipoma arborescens of the knee in a 19-year-old man who suffered from recurrent knee effusions for many years. This patient had MRI evidence of progression of disease prior to arthroscopic intervention. He was treated with bilateral complete arthroscopic synovectomies, demonstrating no evidence of cartilage wear. ConclusionLipoma arborescens is a progressive disease. Timely diagnosis and treatment may prevent disease evolution and sequela.

Conventional versus pigtail chest tube-are they similar for treatment of malignant pleural effusions?

The optimal chest tube type and size for drainage and chemical pleurodesis of malignant pleural effusions remains controversial. This retrospective study was conducted to compare the efficacy of conventional versus pigtail chest tube in the treatment of malignant pleural effusions. Patients submitted to chest tube drainage and slurry talc pleurodesis due to malignant pleural effusion in our pulmonology ward from 2012 to 2016 were eligible. According to the type of chest tube, they were divided into two groups: group I-conventional chest tube and group II-pigtail chest tube. Number of deaths, recurrence of malignant pleural effusion, and timelines associated with the procedures were reviewed and compared between groups. Out of the 61 included patients, 46 (75.4%) were included in group I and 15 (24.6%) in group II. Only one patient had pigtail chest tube obstruction, with posterior insertion of conventional chest tube. Death during hospital stay and up to 3months, recurrence at 4weeks, total duration of hospital stay, time from chest tube insertion to pleurodesis, and time from chest tube insertion to removal were not significantly different between the two groups (all p > 0.05). These findings suggest that pigtail chest tube can be an alternative on palliation, with no compromise in pleurodesis performance.

Wet M1a non-small cell lung cancer: is it possible to predict recurrence of pleural effusion?

The propose was to recognize risk factors of malignant pleural effusion (MPE) recurrence in patients with symptomatic M1a non-small cell lung cancer (NSCLC). All patients with NSCLC and MPE submitted to pleural palliative procedures were enrolled in a prospective study. Group I contained patients who had pleural recurrence, and Group II with no pleural recurrence. Prognostic factors for pleural recurrence were identified by univariable analysis, using Fisher's exact test for categorical variables and Student's t test for quantitative variables. Afterwards the significant variables were entered into a multivariable logistic regression analysis (with P<0.05 considered significant). Receiver operating characteristics (ROC) analysis determined the cutoff points for continuous variables. A total of 82 patients were included in the analysis. There were 15 patients (18.3%) in Group I and 67 patients (81.7%) in Group II. Univariable analysis regarding factors affecting postoperative recurrence was: adenosine deaminase concentration in pleural fluid <16 mg/dL (P=0.04), albumin concentration in pleural fluid <2.4 mg/dL (P=0.03), administration of second-line palliative chemotherapy (P=0.018) and type of procedure [therapeutic pleural aspiration (TPA)] (P=0.023). At the multivariable analysis, only the type of procedure (TPA) (P=0.031) was identified as independent predictor of recurrence. The identification of this factor may assist the choice of the optimal palliative technique; at the first episode of MPE in NSCLC patients and definitive procedure as pleurodesis or indwelling pleural catheter are recommended.

PATELLOFEMORAL CHONDRAL DEFECT IN A PREADOLESCENT SKIER: A CASE REPORT IN EARLY SPORT SPECIALIZATION

Early sport specialization (ESS) refers to intense training year round in a specific sport starting at a young age with no or limited participation in other sports. This approach to training is highly controversial; recent literature suggests that this type of specialized training could be a contributing source to overuse injuries in youth athletes. The purpose of this case report was to describe a patellofemoral articular cartilage defect of the knee in a preadolescent skier due to overuse and repetitive microtrauma as a result of ESS. Case Report. A healthy 11-year-old male competitive alpine skier presented with recurrent swelling of his right knee and persistent anterior knee pain while skiing without evidence of any specific history of injury or traumatic event. The patient failed a conservative treatment regimen including rest and formal physical therapy focused on generalized knee strengthening. Magnetic resonance imaging was ordered and revealed an articular cartilage defect of the medial patellar facet. The patient was treated with an arthroscopic debridement of his articular cartilage defect. At 12 weeks postoperatively, the patient presented with a normalized gait pattern, no evidence of knee effusion, full knee range of motion and patellar mobility symmetric to his contralateral limb, and no patellar crepitation or painful palpation on physical exam. The patient was released to begin return to sport progression at 12 weeks, and was cleared for full activities/returned to competitive skiing at 15 weeks postoperatively. At 16 weeks postoperatively, he won an international alpine ski race in Europe for his age group. Cartilage injuries and osteochondral defects are very common in adolescent athletes and often go undiagnosed. Allied healthcare professionals must be educated on the known causes of recurrent knee effusions and how early sport specialization may result in overuse injuries to knee joint cartilage. 4.

Efficacy and safety of intrapleural cisplatin versus silver nitrate in treatment of malignant pleural effusion

IntroductionMalignant pleural effusion is a frequent problem. Pleurodesis is performed to prevent its recurrence. New, effective, and safe sclerosing agents are needed.AimThe aim of this was to compare efficacy and safety of silver nitrate solution 0.5% versus cisplatin in achievement of pleurodesis in malignant pleural effusion.Patients and methodsProspective randomized single-blinded clinical trial performed at Chest, Clinical Oncology and Nuclear Medicine and Pathology Departments, Mansoura University, from February 2016 to March 2017. A total of 60 patients (26 male and 34 female) with malignant pleural effusion were divided into two groups: first group included 30 patients who were managed with silver nitrate pleurodesis, and second group included 30 patients who were managed by intrapleural cisplatin injection. The success rate of pleurodesis was considered if there was no clinical or radiological recurrence of effusion for 1 month after intervention.ResultsThere were significant improvements in cough, chest pain, and dyspnea in the two groups after 1 month versus that before pleurodesis. The success rate of pleurodesis in silver nitrate group was 90 versus 76.7% in cisplatin group, without significant difference (P=0.166). Chest pain was reported in 26.7% in silver nitrate group and 13.3% in cisplatin group, and fever was reported in 33.3% in silver nitrate group and 20.0% in cisplatin group. Recurrence was reported in 10% in silver nitrate group and in 23.3% in cisplatin group.ConclusionSilver nitrate and cisplatin were nearly equally effective, safe, and less expensive agents in achievement of pleurodesis in patients with malignant effusion with high success rate and low complications.

A novel approach for preventing recurrence of malign pleural effusion: early phase pleurodesis.

IntroductionThe effective control of malignant pleural effusion (MPE) is of paramount importance in the treatment of patients with disseminated cancer. In this study, we compared two different approaches (early pleurodesis versus late pleurodesis) to MPE.Material and methodsPatients (188 cases) whose primary tumor type was known and who were confirmed to have MPE, were included in the study and were separated into two groups. One group consisted of patients who were asymptomatic and who underwent early phase pleurodesis (group I, n = 79). The other group (group II, n = 109) was composed of patients who were symptomatic and whose pleurodesis was performed later. In all cases, pleural effusion was evaluated by means of direct radiography. Computed tomography was performed with the goal of confirming the parenchymal or mediastinal lesions accompanying the pleural fluid.ResultsThe rate of complete success in group I cases was observed to be higher, while the rate of recurrence was lower (p = 0.001 and p = 0.002, respectively) than group II. In multiple logistic regression analysis, co-morbidities and the group that patient belong were found to be significant in terms of pleurodesis success (p = 0.02 and p = 0.03). There was a significant difference in survival time between group I and group II, with group I exhibiting longer average survival time (log rank test p < 0.001).ConclusionsWe observed that the success rate was lower and the rate of recurrence higher in the late pleurodesis group, whose members already had greater volumes of pleural effusion.

Hemangiosarcoma at the base of the left atrium of a dog with mitral and tricuspid valve degeneration – case report

Hemangiosarcoma (HSA) is a malignant neoplasm originating from the vascular endothelium, with high metastatic power and commonly described in the spleen, liver, and right atrium. Thus, the objective of the present study is to report the occurrence of HSA at the base of the left atrium of a male, elderly, Lhasa Apso dog, treated with cyanosis, orthopedic position, cough. In the physical examination, the presence of crackling was observed in pulmonary lobes, murmur in focus of mitral and tricuspid grade IV\VI. The recommended emergency therapy was performed until the clinical improvement of the animal. After echocardiography, mitral and tricuspid valvular degeneration was confirmed, as well as the presence of an irregular, mixed echocardiogram, extra-cardiac, immobile at the base of the left atrium, measuring 2.9 x 1.44 cm in diameter. The clinical therapy established stabilized the clinical picture for 128 days, with recurrence of pulmonary edema and severe hemorrhagic pleural effusion, with the owners opting for euthanasia of the animal and necropsy confirming the definitive diagnosis of extrahepatic SAH at the base of the left atrium.

ES 06.05 Approach to Malignant Pleural Effusions

The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p =0.001).1 In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumor type or method of palliation but was related to leucocytosis (p<0.0001), hypoxemia (p =0.014) and hypoalbumenaemia (p<0.0001).2 The summative effect of these factors is shown in the table. How this information might be used to personalize treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients.3 However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time.4 Pleurectomy is rarely indicated in the palliation of MPE. 1. Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. 2. Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. 3. Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. 4. Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000. Malignant effusions, palliation, pleural malignancyTabled 1No of factorsnMedian survival (days)95% CIpNone39702473-931<0.00001One or two74200111-289Three234223-61 Open table in a new tab

The analysis of synovial fluid in total knee arthroplasties with flexion instability.

Patients with flexion instability after total knee arthroplasty (TKA) often present with a recurrent effusion, which may be a haemarthrosis. While the radiographic factors contributing to flexion instability have been elucidated, the clinical diagnosis remains challenging. Our aim, in this study, was to determine the mean white cell count and differential profile in pre-operative aspirations of synovial fluid in a consecutive series of patients undergoing revision TKA for flexion instability. Between 2000 and 2010, 60 patients undergoing aseptic revision TKA for flexion instability were identified. The results of the pre-operative aspiration of synovial fluid were available for 53 patients (88%). These patients were 1:2 matched to 106 patients who underwent aseptic TKA for indications other than flexion instability. The mean age of the patients at revision TKA was 65 years (44 to 82) and 55% were women. The mean follow-up was 4.3 years (2 to 10.2). In the flexion instability group, the median total cell count was 312 cells/µL (interquartile range (IQR) 104 to 624), with a mean distribution of 45% macrophages (2% to 90%), 30% lymphocytes (1% to 69%), 18% neutrophils (0% to 80%), 0.5% eosinophils (0% to 6%) and 7% other cells (0% to 42%; mainly synovial cells). There was no significant difference in the median total cell count (p = 0.14) or mean distribution of macrophages (p = 0.42), lymphocytes (p = 0.38), neutrophils (p = 0.19) and eosinophils (p = 0.89) between the flexion instability and control groups. There was a significant difference in the percentage of bloody serosanguineous aspirations which was 58% in the flexion instability group and 18% in the control group (odds ratio = 6.5; p = 0.0001). In the group of patients who underwent revision TKA for flexion instability, most had a mean cell count and differential similar to those who underwent revision for other aseptic indications. However, bloody serosanguineous aspirations were 6.5 times more common in those with flexion instability confirming that many of the recurrent effusions seen in this condition are haemarthroses. Cite this article: Bone Joint J 2017;99-B:1477-81.

P2.10-006 Prognostic Factors of Mortality and Recurrence of Malignant Pleural Effusion in High-Risk Tumors According to the LENT Score Study

P2.10-006 Prognostic Factors of Mortality and Recurrence of Malignant Pleural Effusion in High-Risk Tumors According to the LENT Score Study

Prevention of cardiac herniation and left artery descending obstruction in cases of extensive surgical pericardial window procedure.

The thoracotomy approach for pericardial window surgery was shown to be more effective at preventing effusion recurrence and the need for repeat surgery. However, cardiac herniation remains a common complication after extensive pericardial excision. This technical note describes a simple and effective technique to prevent potential heart herniation through the pericardial window and at the same time to avoid potential obstruction of the left artery descending.

Recurrent chylothorax: a clinical mystery

Chylothorax is an unusual cause of pleural effusion, typically caused by trauma or malignancy. Waldenstrom’s macroglobulinaemia (WM) is a clinicopathological entity demonstrating lymphoplasmacytic lymphoma in the bone marrow with an...

Malignant Pseudo-Meigs Syndrome Presenting as Recurrent Eosinophilic Pleural Effusion

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pseudo-Meigs’ syndrome is a clinical syndrome where pleural effusion (PEf) and/or ascites are associated with ovarian tumor other than fibroma. We report a challenging case of pseudo-Meigs’ syndrome associated with ovarian mucinous carcinoma in a patient with recurrent right-sided exudative, eosinophilic PEf without cytologic evidence of malignancy in effusion. CASE PRESENTATION: A 51-year-old woman with a history of chronic lymphedema and venous stasis was admitted to the hospital for acute hypoxemic respiratory failure presenting with shortness of breath for 24 hours. On examination, she was in respiratory distress. Her temperature was 38.1°C; pulse 114 beats/minute; respiratory rate 22 breaths/minute; and oxygen saturation 93% breathing 3L/minute of supplemental oxygen through nasal cannula. Auscultation of the chest revealed crackles in her lower lung fields, pronounced on the right. Laboratory findings include white blood cells 19,500/mm3, erythrocyte sedimentation rate 130 mm/hour, and creatinine kinase 18 U/L. Computed tomography (CT) of the chest showed a large right-sided PEf. 900 mL of exudative fluid was drained by thoracentesis with improvement of symptoms. PEf was remarkable for eosinophilia (17%) with no malignant cells. On day 2 of hospitalization, her shortness of breath recurred. Chest radiograph showed recurrent right sided PEf. Another thoracentesis drained 1000 ml of eosinophilic effusion with no malignant cells. Repeat CT showed no underlying lung pathology. 48 hours later, her symptoms worsened and chest radiograph showed right sided PEf for the third time. Given the recurrent effusion with persistent negative cytology, CT of the abdomen was performed for a possible underlying malignancy. This revealed a large multiloculated cystic pelvic mass extending into the abdomen with omental caking and/or peritoneal carcinomatosis and lymph node involvement. Her labs then revealed CA 125 of 78 U/mL and CEA of 4.8 ng/mL. A debulking surgery was performed, revealing a 27x25x20cm ovarian mucinous carcinoma, histologic type G2: moderately differentiated without other organ involvement. Peritoneal ascetic fluid and lymph nodes were negative for malignancy. Three days later, 1000mL was drained via thoracentesis with cytology negative for malignant cells. 17 days later, follow up chest radiograph showed persistent effusion, however the fourth thoracentesis drained only 150 cc, and she remained asymptomatic. DISCUSSION: Recurrent right-sided exudative eosinophilic PEf, even without the presence of malignant cells, may be a marker for underlying malignancy when no obvious lung pathology is found. CONCLUSIONS: Ruling out an underlying malignant tumor, is essential as this could be from pseudo-Meig’s syndrome as seen in our case. Reference #1: Pleural Effusion in Meigs' Syndrome-Transudate or Exudate?: Systematic Review of the Literature. Krenke R, Maskey-Warzechowska M, Korczynski P, Zielinska-Krawczyk M, Klimiuk J, Chazan R, Light RW. Medicine. 12/2015 DISCLOSURE: The following authors have nothing to disclose: Reema Qureshi, Anna Hilton, Humnah Khudayar, Somwail Rasla, Taro Minami No Product/Research Disclosure Information

Cancer Masking as a Parapneumonic Effusion

SESSION TITLE: Lung Cancer 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 07:30 AM - 08:30 AM INTRODUCTION: Pleural effusions often present a diagnostic dilemma. Light’s criteria has helped to narrow the focus but still may leave a broad differential. Here we present a case of a pleural effusion masked as a parapneumonic effusion but ultimately found to be secondary to a pleural based adenocarcinoma. CASE PRESENTATION: 67 yo M with COPD presented to the ED with c/o dyspnea, cough, f/c. His WBC was 23.7. CTA of chest performed showed a loculated right pleural effusion and mildly enlarged subcarinal lymph node. He was started on ceftriaxone/minocycline and admitted to the hospital. Thoracic US showed no evidence of loculations/septations. Thoracentesis removed 1.5L of serosangious fluid with pH of 7.35; exudative by Light’s criteria and presumed due to clinic context and lab findings to be a parapneumonic effusion. One week later patient presented to clinic with complaint of dyspnea. CXR showed re-accumulation of right sided pleural effusion and thoracentesis was performed, again removing 1.5L of serosanginous fluid. Culture remained negative, however cytology ultimately was reported as “Suspicious for malignancy.” Seven days later patient re-presented to clinic with increasing dyspnea, CXR showed reaccumulation of right sided effusion, and thoracentesis was performed, cytology resent and was negative. Chest CT was performed immediately after thoracentesis and revealed; resolution of the effusion, a mildly enlarged subcarinal LN but no mass. Six days later, patient had increasing dyspnea and recurrent right pleural effusion. Chest tube was placed and cytology re-sent, which remained negative. CT surgery performed VATS/pleural biopsy revealing pleural based poorly differentiated adenocarcinoma. PET scan showed diffusely enhancing pleura in the right lung with no dominant mass. DISCUSSION: Bloody pleural effusions are most commonly due to malignancy (47%), post-traumatic (12%), or parapneumonic (10%). Our patient had multiple signs/symptoms suggestive of pneumonia complicated by a parapneumonic effusion including; elevated WBC, acute onset, fevers, and cough. However, given the recurrence, malignancy rose higher on the differential. Interestingly, the patient had no dominant mass and ended up having the rare diagnosis of pleural adenocarcinoma. CONCLUSIONS: Recurrent effusions should suggest an alternate diagnosis and therefore workup should be broadened. Reference #1: Vilenna, V. et al. “Clinical Implications of Appearence of Pleural Fluid at Thoracentesis” Chest. 2004 Jan;125(1):156-9. DISCLOSURE: The following authors have nothing to disclose: Amit Bharara, Rebecca Potfay No Product/Research Disclosure Information

Histopathological Audit of Arthroscopic Synovial Biopsies Done for Persistent Knee Effusions

This study aims to educate medical practitioners on possible synovial disoders that may be the cause of persistent knee pain and recurrent effusions. Histopathological audit of arthroscopic synovial biopsies done for persistent knee effusions. Monoarticular knee pain and swelling has a plethora of differential diagnoses. In South Africa tuberculosis is a common treatable cause that needs to be excluded. The presence of multiple comorbidities and unremarkable septic markers may pose a diagnostic challenge. This necessitates the need for synovial biopsy. We review the clinical presentation and histopathological diagnoses of patients who had arthroscopic knee synovial biopsies for persistent undiagnosed knee effusions. A retrospective review of patients who had knee arthroscopy was done. Those who had diagnostic arthroscopy and synovial biopsy done were included in the study. Comorbidities, blood results (white cell count, C-reactive protein and erythrocyte sedimentation rate) and histopathological diagnoses were recorded. Descriptive statistical analysis of continuous and categorical variables was perfomed. Out of 194 arthroscopies, 19 patients had biopsy done. Only 10 histopathology results were found. Mean age was 40.6 SD 10.3 years (range 24-55 years). All cases presented with knee effusion and pain. Duration of symptoms ranged from 1-8years with a median of 3.25 years (IQR 1.25-6.5). Two patients were documented HIV positive with one having co-existing systemic lupus erythematosus. One had previous tuberculosis treatment and there was one rheumatoid arthritis patient on treatment. Mean white cell count was 6.13x10?/L (SD 1.57x10?) with range 4.56-8.60x10?. Median ESR was 17mm/hr (IQR 15-19) and CRP range was 3-20mg/L. Histopathology revealed 3 cases of pigmented villonodular synovitis (30%), 2 cases of synovial lipomatosis (20%) and 1 each of mycobacterium tuberculosis, rheumatoid arthritis, connective tissue disease, chronic synovitis and combined necrotising and non-necrotising granulomatous inflammation. Diagnostic arthroscopies are overshadowed by the need for therapeutic intervention for ligament or meniscal repair. However it has a role in clinching a diagnosis in cases of long standing knee effusions that pose a diagnostic dilemma. The majority of patients had biopsy done mainly to rule out tuberculous infection. These were patients with persistent knee pain and effusions despite treatment with DMARDs in the setting of coexistent immunosuppression. This study reveals a wide range of synovial disorders that may be the underlying cause of chronic knee pain and effusions. PVNS and synovial lipomatosis were the leading histopathological diagnoses. Arthroscopic synovial biopsy is reliable in reaching a histopathological diagnosis in cases of persistent undiagnosed painful knee effusions.