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Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma
European Journal of Internal Medicine 19 (2008) 63 – 64 www.elsevier.com/locate/ejim
Brief report
Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma Kaushik Guha, Daniel Jones, James H.K. Hull, Timothy B.L. Ho ⁎ Department of Respiratory Medicine, Knight Centre for Cystic Fibrosis, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK Received 23 November 2006; received in revised form 7 March 2007; accepted 9 March 2007 Available online 23 July 2007
Abstract A 73-year-old former smoker with previous occupational exposure to asbestos presented with a pneumothorax that was initially managed by simple aspiration. Despite this, it re-accumulated and a bronchopleural fistula was suspected. A video-assisted thoracoscopic procedure was performed and revealed an abnormally thickened pleura that turned out to be a mesothelioma. All persistent pneumothoraces should be investigated. © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Pneumothorax; Treatment; Mesothelioma; Malignancy
1. Introduction Pneumothoraces are common. Most will resolve spontaneously. Failure to do so should prompt thorough investigation to rule out underlying pathology including malignancy. 2. Case report
A chest radiograph performed one month later revealed a re-accumulation of the right hydropneumothorax. Further investigations were undertaken. A computed tomogram (CT) of the chest confirmed the persistent right-sided hydropneumothorax along with multiple non-calcified pleural plaques (Fig. 1). Fibre-optic bronchoscopy revealed no abnormalities.
A 73-year-old man presented with a 3-week history of right-sided pleuritic chest pain and shortness of breath. He denied any additional symptoms of productive cough, fever, weight loss or haemoptysis. His only significant past medical history consisted of hypertension and hypercholesteraemia, for which he took lisinopril, bendrofluazide and simvastatin. He had worked predominantly in the aluminium trade but had also worked for 10 years at a coal-fired power station. He was an ex-smoker, having accumulated a 40-pack-year history but having stopped 13 years previously. A chest radiograph revealed a moderate right hydropneumothorax. A pleural aspiration was performed and 1020 ml of air was aspirated that appeared to resolve the pneumothorax.
⁎ Corresponding author. Tel.: +44 1276 526660; fax: +44 1276 604032. E-mail address: [email protected] (T.B.L. Ho).
Fig. 1. CT scan of the chest demonstrating a right-sided pneumothorax and surrounding non-calcified pleural thickening.
0953-6205/$ - see front matter © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2007.03.010
64
K. Guha et al. / European Journal of Internal Medicine 19 (2008) 63–64
In view of the persistent hydropneumothorax, the patient was admitted and an intercostal drain was inserted into the right pleural space. Over the next 72 h, the chest drain demonstrated continued bubbling when the patient coughed, suggesting a bronchopleural fistula. The patient was therefore referred to the cardiothoracic surgeons. A videoassisted thoracoscopy (VATS) was undertaken. Marked pleural thickening was observed and extensively biopsied prior to pleurodesis. These biopsies subsequently revealed a malignant epitheloid mesothelioma. The patient was referred to the oncologists for further treatment including prophylactic port-site radiotherapy to his right chest wall. 3. Discussion Spontaneous pneumothoraces are classified into primary or secondary depending on whether they are associated with underlying lung pathology. There are a number of lung disorders to consider when confronted with a spontaneous pneumothorax. These include chronic diseases, such as emphysema, asthma, tuberculosis, cystic fibrosis and, on rare occasions, malignancy [1]. These conditions are often apparent at presentation but occasionally need to be actively excluded, as in this case. Primary pneumothoraces are common, with a reported incidence of 18–28/100,000 in men. The natural rate of resolution of a spontaneous pneumothorax has been estimated at 1.8% of the pneumothorax volume per day. For instance, a 15% pneumothorax will take approximately 12 days to resolve [1]. Accordingly, a persistent pneumothorax should arouse suspicion and precipitate further investigations. The incidence of malignant mesothelioma is increasing, with the estimated peak predicted in the year 2020 [2]. This is due to the long interval between asbestos exposure and the first clinical manifestations of the disease. The clinician must be aware of both commonly associated symptoms, such as chest wall pain, breathlessness, weight loss and haemoptysis in a patient with a history of previous asbestos exposure, and other atypical presentations. These include persistent or recurrent pneumothoraces. The development of a hydropneumothorax is not an uncommon consequence of a persistent pneumothorax. It indicates the presence of both air and fluid within the pleural space. It may be associated with sub-pleural malignancy, trauma, bronchopleural fistulae, necrotizing infections, pulmonary infarction, previous radiotherapy or rheumatoid lung disease [3]. Rarer causes also include pulmonary endometriosis and lymphangioleiomyomatosis [4].
Pneumothoraces are associated with malignancy in less than 0.02% of cases [5]. However, persistent pneumothoraces need to be investigated to explain the failure of lung re-expansion. This can be due to pathologies surrounding the lung that prevent lung inflation, such as pleural malignancies that act as a constrictive band, or processes preventing the closure of a parenchymal fistula, such as infection. Interestingly, mesotheliomas are associated with pneumothoraces in up to 11% of cases [6]. A CT scan of the chest is often required to delineate the cause. It allows a rapid assessment of the pleura and excludes gross abnormalities of the lung parenchyma. Fibre-optic bronchoscopy allows direct visualisation of the larger airways and the opportunity to obtain histological material. In many cases, additional investigations are required. If a pneumothorax is associated with a persistent air-leak into the pleural space (a bronchopleural fistula), a direct examination of the pleural surface is required. This is easily achieved by using video-assisted thoracoscopic surgery (VATS). The procedure is both diagnostic and therapeutic as it allows histological samples to be taken and a pleurodesis to be performed, if necessary. Although malignancies are an uncommon underlying cause of pneumothoraces, they should be borne in mind if a pneumothorax persists despite appropriate management. 4. Learning points • Spontaneous pneumothoraces are common. • Most will resolve at a rate of 1.8% of the pneumothorax volume per day. • Failure of a pneumothorax to resolve suggests that rigorous further investigations should be performed to rule out any significant underlying pathology. References [1] Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl 2):ii39–52. [2] Robinson BW, Lake RA. Advances in malignant mesothelioma. N Engl J Med 2005;353:1591–603. [3] Tahir H, Allard SA, Jawed S. Spontaneous hydropneumothorax in a man with rheumatoid arthritis. Rheumatology (Oxford) 2001;40:232–3. [4] Hancock E, Osborne J. Lymphangioleiomyomatosis: a review of the literature. Respir Med 2002;96:1–6. [5] Steinhauslin CA, Cuttat JF. Spontaneous pneumothorax. A complication of lung cancer? Chest 1985;88:709–13. [6] Sheard JD, Taylor W, Soorae A, Pearson MG. Pneumothorax and malignant mesothelioma in patients over the age of 40. Thorax 1991;46:584–5.
Brief report
Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma Kaushik Guha, Daniel Jones, James H.K. Hull, Timothy B.L. Ho ⁎ Department of Respiratory Medicine, Knight Centre for Cystic Fibrosis, Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey GU16 7UJ, UK Received 23 November 2006; received in revised form 7 March 2007; accepted 9 March 2007 Available online 23 July 2007
Abstract A 73-year-old former smoker with previous occupational exposure to asbestos presented with a pneumothorax that was initially managed by simple aspiration. Despite this, it re-accumulated and a bronchopleural fistula was suspected. A video-assisted thoracoscopic procedure was performed and revealed an abnormally thickened pleura that turned out to be a mesothelioma. All persistent pneumothoraces should be investigated. © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Pneumothorax; Treatment; Mesothelioma; Malignancy
1. Introduction Pneumothoraces are common. Most will resolve spontaneously. Failure to do so should prompt thorough investigation to rule out underlying pathology including malignancy. 2. Case report
A chest radiograph performed one month later revealed a re-accumulation of the right hydropneumothorax. Further investigations were undertaken. A computed tomogram (CT) of the chest confirmed the persistent right-sided hydropneumothorax along with multiple non-calcified pleural plaques (Fig. 1). Fibre-optic bronchoscopy revealed no abnormalities.
A 73-year-old man presented with a 3-week history of right-sided pleuritic chest pain and shortness of breath. He denied any additional symptoms of productive cough, fever, weight loss or haemoptysis. His only significant past medical history consisted of hypertension and hypercholesteraemia, for which he took lisinopril, bendrofluazide and simvastatin. He had worked predominantly in the aluminium trade but had also worked for 10 years at a coal-fired power station. He was an ex-smoker, having accumulated a 40-pack-year history but having stopped 13 years previously. A chest radiograph revealed a moderate right hydropneumothorax. A pleural aspiration was performed and 1020 ml of air was aspirated that appeared to resolve the pneumothorax.
⁎ Corresponding author. Tel.: +44 1276 526660; fax: +44 1276 604032. E-mail address: [email protected] (T.B.L. Ho).
Fig. 1. CT scan of the chest demonstrating a right-sided pneumothorax and surrounding non-calcified pleural thickening.
0953-6205/$ - see front matter © 2007 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2007.03.010
64
K. Guha et al. / European Journal of Internal Medicine 19 (2008) 63–64
In view of the persistent hydropneumothorax, the patient was admitted and an intercostal drain was inserted into the right pleural space. Over the next 72 h, the chest drain demonstrated continued bubbling when the patient coughed, suggesting a bronchopleural fistula. The patient was therefore referred to the cardiothoracic surgeons. A videoassisted thoracoscopy (VATS) was undertaken. Marked pleural thickening was observed and extensively biopsied prior to pleurodesis. These biopsies subsequently revealed a malignant epitheloid mesothelioma. The patient was referred to the oncologists for further treatment including prophylactic port-site radiotherapy to his right chest wall. 3. Discussion Spontaneous pneumothoraces are classified into primary or secondary depending on whether they are associated with underlying lung pathology. There are a number of lung disorders to consider when confronted with a spontaneous pneumothorax. These include chronic diseases, such as emphysema, asthma, tuberculosis, cystic fibrosis and, on rare occasions, malignancy [1]. These conditions are often apparent at presentation but occasionally need to be actively excluded, as in this case. Primary pneumothoraces are common, with a reported incidence of 18–28/100,000 in men. The natural rate of resolution of a spontaneous pneumothorax has been estimated at 1.8% of the pneumothorax volume per day. For instance, a 15% pneumothorax will take approximately 12 days to resolve [1]. Accordingly, a persistent pneumothorax should arouse suspicion and precipitate further investigations. The incidence of malignant mesothelioma is increasing, with the estimated peak predicted in the year 2020 [2]. This is due to the long interval between asbestos exposure and the first clinical manifestations of the disease. The clinician must be aware of both commonly associated symptoms, such as chest wall pain, breathlessness, weight loss and haemoptysis in a patient with a history of previous asbestos exposure, and other atypical presentations. These include persistent or recurrent pneumothoraces. The development of a hydropneumothorax is not an uncommon consequence of a persistent pneumothorax. It indicates the presence of both air and fluid within the pleural space. It may be associated with sub-pleural malignancy, trauma, bronchopleural fistulae, necrotizing infections, pulmonary infarction, previous radiotherapy or rheumatoid lung disease [3]. Rarer causes also include pulmonary endometriosis and lymphangioleiomyomatosis [4].
Pneumothoraces are associated with malignancy in less than 0.02% of cases [5]. However, persistent pneumothoraces need to be investigated to explain the failure of lung re-expansion. This can be due to pathologies surrounding the lung that prevent lung inflation, such as pleural malignancies that act as a constrictive band, or processes preventing the closure of a parenchymal fistula, such as infection. Interestingly, mesotheliomas are associated with pneumothoraces in up to 11% of cases [6]. A CT scan of the chest is often required to delineate the cause. It allows a rapid assessment of the pleura and excludes gross abnormalities of the lung parenchyma. Fibre-optic bronchoscopy allows direct visualisation of the larger airways and the opportunity to obtain histological material. In many cases, additional investigations are required. If a pneumothorax is associated with a persistent air-leak into the pleural space (a bronchopleural fistula), a direct examination of the pleural surface is required. This is easily achieved by using video-assisted thoracoscopic surgery (VATS). The procedure is both diagnostic and therapeutic as it allows histological samples to be taken and a pleurodesis to be performed, if necessary. Although malignancies are an uncommon underlying cause of pneumothoraces, they should be borne in mind if a pneumothorax persists despite appropriate management. 4. Learning points • Spontaneous pneumothoraces are common. • Most will resolve at a rate of 1.8% of the pneumothorax volume per day. • Failure of a pneumothorax to resolve suggests that rigorous further investigations should be performed to rule out any significant underlying pathology. References [1] Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl 2):ii39–52. [2] Robinson BW, Lake RA. Advances in malignant mesothelioma. N Engl J Med 2005;353:1591–603. [3] Tahir H, Allard SA, Jawed S. Spontaneous hydropneumothorax in a man with rheumatoid arthritis. Rheumatology (Oxford) 2001;40:232–3. [4] Hancock E, Osborne J. Lymphangioleiomyomatosis: a review of the literature. Respir Med 2002;96:1–6. [5] Steinhauslin CA, Cuttat JF. Spontaneous pneumothorax. A complication of lung cancer? Chest 1985;88:709–13. [6] Sheard JD, Taylor W, Soorae A, Pearson MG. Pneumothorax and malignant mesothelioma in patients over the age of 40. Thorax 1991;46:584–5.