- Email: [email protected]
Benign Pleural Effusion and Ascites Associated with Adenocarcinoma of the Body of the Pancreas
Benign Pleural Effusion and Ascites Associated with Adenocarcinoma of the Body of the Pancreas * EMIL ROTHSTEIN, MD., F.C.C.P. Wood, Wisconsin In 1937, Dr. Joseph V. Meigs l of Massachusetts General Hospital brought to the attention of the medical profession the not infrequent occurrence of pleural effusion and ascites associated with benign ovarian tumors. Cases thought to be hopeless because of alleged pleural metastasis (postulated upon the finding of unilateral or bilateral pleural effusions) were cured by oophorectomy; after this surgical procedure the effusions were spontaneously and permanently absorbed. Meigs' syndrome has been reported in association with various sorts of ovarian tumors, including fibromata (the subject of Meigs' original report), cystadenoma, thecoma, granulosa cell tumor and Brenner tumor, as well as with uterine fibromata. About fifty cases of this syndrome have been reported to date. Two recent articles, containing reviews of the literature and bibliography, are those of Calmenon, Dockerty and Btancos and Nora and Davtson," I have been unable to find any reports of a similar syndrome in association with any tumors other than those of the female genitalia. The case which gave rise to the present report presents a similar syndrome in a male patient with a carcinoma of the body of the pancreas. This offers a challenge to the internist and the surgeon, since, just as in the case of Meigs' syndrome, the presence of recurring pleural effusions with ascites was considered evidence of hopeless metastasis. Case Report: The patient was a 58 year old man who entered Wood Veterans Hospital April 3,1947. In the summer of July 1946 he had coronary thrombosis, necessitating two months of hospitalization. At this time mild diabetes mellltus was discovered, which was controlled by diet alone . The complaints upon his last admission were referred chiefly to the chest and consisted of dyspnea, chest pain, cough and expectoration. All had been present for ten weeks. Upon examination he appeared
-From the Medical Service, Veterans Administration Hospital, Wood, Wisconsin, Mark Garry, MD ., Chief of Service, with whose permission and cooperation this case is reported. Published with permlssion of the Chief Medical Director, Department of Medicine and Surgery, Veterans Administration, who assumes no responsib1l1ty for the oplnlons expressed or-conclusions drawn by the author. 603
604
EMIL ROTHSTEIN
May . 1949
chronically ill and presented the findings of a bilateral pleural effusion. In addition, a rounded mass was discovered in the left upper quadrant
of the abdomen. This was about 8 em. in diameter, firm and not tender, and moved slightly with respiration. Moderate hypertension was present. Laboratory tests revealed the following pertinent findings : Diabetic type of glucose tolerance curve; slight anemia; sedimentation rate of 11 mm.; total plasma protein 6.6 gm. per cent; plasma albumin 5.1 gm , per cent; and an ECG showing myocardial damage on the basis of T-wave changes. There was x-ray evidence of a bilateral pleural effusion (Fig. 1). In addition x-ray findings were indicative of an extrinsic mass 8 em. in diameter displacing the stomach anteriorly and to the left. These findings were considered to indicate a carcinoma of the body of the pancreas with extensive pleural and peritoneal metastases. The clinical course was steadily downhill. The pleural effusions were aspirated repeatedly but recurred. The fluid was cloudy and amber. No tumor cells, tubercle bacilli, or other bacteria were found. About three weeks after admission, leg edema and marked ascites developed. A second total protein was 4.5 gm , per cent with albumin of 2.7 gm, per cent. After one of the numerous thoracenteses a traumatic left pneumothorax developed and despite repeated decompressions the patient presented progressive dyspnea and shock and expired on July 23, 1947.
FIGURE 1
Autopsy (Dr. A. Swingle): The pertinent findings were as follows : The tumor was a cystic adenocarcinoma of the body of the pancreas. The only metastases were two minute nodules in the liver, measuring 1 and 4 em. respectively. Microscopically these were identical with the main tumor mass. The peritoneum was grossly normal and free of any metastatic deposits. Two thousand cc. of reddish yellow fluid were present. The omental veins were markedly distended and tortuous as were the inferior mesenteric veins and other branches of the portal system. Both pleurae
Volume XV
BENIGN PLEURAL EFFUSION AND ASCITES
605
were entirely free, grossly and microscopically. of any tumor tissue. Bilateral pleural effusion was found and in , a~dition there was a tear in the collapsed left lung. The heart presented an old healed infarction in the lower portion of the left ventricle and the apex. Discussion
This patient had a large well encapsulated carcinoma of the body of the pancreas. Two small metastatic nodules were present in the liver. While the age of these nodules cannot be determined one may assume from their small size that they may have been of recent origin. It is not unreasonable to suppose that a tumor of this sort could have been extirpated in toto before metastases occurred. This is dependent upon ruling out distant metastases preoperatively. In the past, pleural effusion, in the presence of an abdominal tumor has been considered evidence of hopeless metastasis. May it not be that this situation will change in a manner similar to that now current in the field of gynecological surgery? Until Meigs clarified the benign nature of pleural effusion in the course of pelvic tumors a number of otherwise operable cases were denied surgery because of the presumably fatal significance of this finding. Perhaps the same benign evaluation may, at least occasionally, be given to the presence of pleural effusion accompanying other abdominal tumors. The mechanism of the ascites in this case can probably be explained by the large tumor mass in the pancreas causing obstruction to the return venous circulation of the portal system. After the ascites developed, the low blood protein was a factor in the development of generalized edema. The extensive hydrothorax, recurring as it did, in the absence of any evidence of obstruction to the azygos vein or to the superior vena cava presented a much more difficult problem. In the numerous articles on Meigs' syndrome (for I assume the mechanism is probably similar in this case) several explanations are given. None of these explanations fits all of the facts nor satisfies the authors who propose them and I am unable to clarify that question here. Several cases have had the serum proteins studied, but as in this case, (upon the first examination) they were essentially normal. Air introduced into the pleural space or into the peritoneal cavity was not found to go through the diaphragm into the neighboring cavity.2.3 India ink particles introduced into the abdomen have been found in the pleural fiuid 48 hours later. 2.3 In several cases reported in the literature, examination of the two fiuids has shown that they are apparently identical as to protein content and other chemical constituents. These last two observations seem to indicate that the two fiuids are derived from a single source and it is believed that the ascitic fiuid may reach the pleura
606
EMIL ROTHSTEIN
May. 1949
via diaphragmatic lymphatics. The direct relation between the effusions and the pelvic tumors has been established by the fact that the fluid recurs after repeated aspirations but upon removal of the tumor the fluid is absorbed rapidly and permanently. Perhaps some pathogenetic significance may lie in the fact that of the pleural .eff usions in Meigs' syndrome about 80 per cent are right-sided, about 10· per cent left sided, and the remainder bilateral. . SUMMARY
A case has been presented which was characterized by the presence of bilateral pleural effusion and ascites in the presence of an abdominal tumor. At autopsy the tumor was found to be a pancreatic carcinoma with two small and probably recent metastases in the liver. The eUusions were found to be due to causes obscure in nature but not carcinomatous in origin. It is suggested that this case may be analogous to cases of Meigs' syndrome, associated with a pancreatic tumor. Every procedure should be exhausted to demonstrate the benign or malignant nature of the effusions in this type of syndrome. If pleural metastases cannot be demonstrated and the abdominal tumor is amenable to surgery such surgery would then seem to be indicated. RESUMEN
Se ha presentado un caso caracterizado por la presencia de derrame pleural bilateral, ascitis y tumor abdominal. Durante la autopsia se descubri6 que el tumor fue un carcinoma pancreattco . con dos pequenas metastasis en el higado, probablemente de origen reciente. Se descubri6 que los derrames se debieron a causas obscures, pero no de origen carcinomatoso. Se sugiere que este caso puede ser analogo a casas del sindrome de Meig asoctados con un tumor pancreattco. Deben agotarse todos los procedimientos a fin de demostrar la naturaleza benigna 0 maligna de derrames en este tipo de sindrome. Si no se pueden demostrar metastasis pleurales y el tumor abdominal es tratable por medios quirurgtcos, parecerfa que esta indicada la operaci6n. REFERENCES
1 Meigs, J . V. and CaBS, J . W.: "Fibroma of the Ovary with Ascites and Hydrothorax with Report of seven Cases," Am. J. Obs. and Gyn., 33: 249,1937. . 2 Calmenson, Mo, Dockerty, M. B. and Bianco, J. J.: "Certain Pelvic Tumors Associated with Ascites and Hydrothorax," Surg., Gyn. and Obs., . 84:181,1947. 3 Nora, E. D. and Davison R. M.: "Pleurisy with Effusion Associated with Pseudomuc1nous Cystadenoma' (Meig's Syndrome)," Dis. 01 Chest, 13: 423,1947. .
-From the Medical Service, Veterans Administration Hospital, Wood, Wisconsin, Mark Garry, MD ., Chief of Service, with whose permission and cooperation this case is reported. Published with permlssion of the Chief Medical Director, Department of Medicine and Surgery, Veterans Administration, who assumes no responsib1l1ty for the oplnlons expressed or-conclusions drawn by the author. 603
604
EMIL ROTHSTEIN
May . 1949
chronically ill and presented the findings of a bilateral pleural effusion. In addition, a rounded mass was discovered in the left upper quadrant
of the abdomen. This was about 8 em. in diameter, firm and not tender, and moved slightly with respiration. Moderate hypertension was present. Laboratory tests revealed the following pertinent findings : Diabetic type of glucose tolerance curve; slight anemia; sedimentation rate of 11 mm.; total plasma protein 6.6 gm. per cent; plasma albumin 5.1 gm , per cent; and an ECG showing myocardial damage on the basis of T-wave changes. There was x-ray evidence of a bilateral pleural effusion (Fig. 1). In addition x-ray findings were indicative of an extrinsic mass 8 em. in diameter displacing the stomach anteriorly and to the left. These findings were considered to indicate a carcinoma of the body of the pancreas with extensive pleural and peritoneal metastases. The clinical course was steadily downhill. The pleural effusions were aspirated repeatedly but recurred. The fluid was cloudy and amber. No tumor cells, tubercle bacilli, or other bacteria were found. About three weeks after admission, leg edema and marked ascites developed. A second total protein was 4.5 gm , per cent with albumin of 2.7 gm, per cent. After one of the numerous thoracenteses a traumatic left pneumothorax developed and despite repeated decompressions the patient presented progressive dyspnea and shock and expired on July 23, 1947.
FIGURE 1
Autopsy (Dr. A. Swingle): The pertinent findings were as follows : The tumor was a cystic adenocarcinoma of the body of the pancreas. The only metastases were two minute nodules in the liver, measuring 1 and 4 em. respectively. Microscopically these were identical with the main tumor mass. The peritoneum was grossly normal and free of any metastatic deposits. Two thousand cc. of reddish yellow fluid were present. The omental veins were markedly distended and tortuous as were the inferior mesenteric veins and other branches of the portal system. Both pleurae
Volume XV
BENIGN PLEURAL EFFUSION AND ASCITES
605
were entirely free, grossly and microscopically. of any tumor tissue. Bilateral pleural effusion was found and in , a~dition there was a tear in the collapsed left lung. The heart presented an old healed infarction in the lower portion of the left ventricle and the apex. Discussion
This patient had a large well encapsulated carcinoma of the body of the pancreas. Two small metastatic nodules were present in the liver. While the age of these nodules cannot be determined one may assume from their small size that they may have been of recent origin. It is not unreasonable to suppose that a tumor of this sort could have been extirpated in toto before metastases occurred. This is dependent upon ruling out distant metastases preoperatively. In the past, pleural effusion, in the presence of an abdominal tumor has been considered evidence of hopeless metastasis. May it not be that this situation will change in a manner similar to that now current in the field of gynecological surgery? Until Meigs clarified the benign nature of pleural effusion in the course of pelvic tumors a number of otherwise operable cases were denied surgery because of the presumably fatal significance of this finding. Perhaps the same benign evaluation may, at least occasionally, be given to the presence of pleural effusion accompanying other abdominal tumors. The mechanism of the ascites in this case can probably be explained by the large tumor mass in the pancreas causing obstruction to the return venous circulation of the portal system. After the ascites developed, the low blood protein was a factor in the development of generalized edema. The extensive hydrothorax, recurring as it did, in the absence of any evidence of obstruction to the azygos vein or to the superior vena cava presented a much more difficult problem. In the numerous articles on Meigs' syndrome (for I assume the mechanism is probably similar in this case) several explanations are given. None of these explanations fits all of the facts nor satisfies the authors who propose them and I am unable to clarify that question here. Several cases have had the serum proteins studied, but as in this case, (upon the first examination) they were essentially normal. Air introduced into the pleural space or into the peritoneal cavity was not found to go through the diaphragm into the neighboring cavity.2.3 India ink particles introduced into the abdomen have been found in the pleural fiuid 48 hours later. 2.3 In several cases reported in the literature, examination of the two fiuids has shown that they are apparently identical as to protein content and other chemical constituents. These last two observations seem to indicate that the two fiuids are derived from a single source and it is believed that the ascitic fiuid may reach the pleura
606
EMIL ROTHSTEIN
May. 1949
via diaphragmatic lymphatics. The direct relation between the effusions and the pelvic tumors has been established by the fact that the fluid recurs after repeated aspirations but upon removal of the tumor the fluid is absorbed rapidly and permanently. Perhaps some pathogenetic significance may lie in the fact that of the pleural .eff usions in Meigs' syndrome about 80 per cent are right-sided, about 10· per cent left sided, and the remainder bilateral. . SUMMARY
A case has been presented which was characterized by the presence of bilateral pleural effusion and ascites in the presence of an abdominal tumor. At autopsy the tumor was found to be a pancreatic carcinoma with two small and probably recent metastases in the liver. The eUusions were found to be due to causes obscure in nature but not carcinomatous in origin. It is suggested that this case may be analogous to cases of Meigs' syndrome, associated with a pancreatic tumor. Every procedure should be exhausted to demonstrate the benign or malignant nature of the effusions in this type of syndrome. If pleural metastases cannot be demonstrated and the abdominal tumor is amenable to surgery such surgery would then seem to be indicated. RESUMEN
Se ha presentado un caso caracterizado por la presencia de derrame pleural bilateral, ascitis y tumor abdominal. Durante la autopsia se descubri6 que el tumor fue un carcinoma pancreattco . con dos pequenas metastasis en el higado, probablemente de origen reciente. Se descubri6 que los derrames se debieron a causas obscures, pero no de origen carcinomatoso. Se sugiere que este caso puede ser analogo a casas del sindrome de Meig asoctados con un tumor pancreattco. Deben agotarse todos los procedimientos a fin de demostrar la naturaleza benigna 0 maligna de derrames en este tipo de sindrome. Si no se pueden demostrar metastasis pleurales y el tumor abdominal es tratable por medios quirurgtcos, parecerfa que esta indicada la operaci6n. REFERENCES
1 Meigs, J . V. and CaBS, J . W.: "Fibroma of the Ovary with Ascites and Hydrothorax with Report of seven Cases," Am. J. Obs. and Gyn., 33: 249,1937. . 2 Calmenson, Mo, Dockerty, M. B. and Bianco, J. J.: "Certain Pelvic Tumors Associated with Ascites and Hydrothorax," Surg., Gyn. and Obs., . 84:181,1947. 3 Nora, E. D. and Davison R. M.: "Pleurisy with Effusion Associated with Pseudomuc1nous Cystadenoma' (Meig's Syndrome)," Dis. 01 Chest, 13: 423,1947. .