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Malignant Chylothorax Successfully Treated With Serial Talc Pleurodesis
Disorders of the Pleura SESSION TITLE: Pleural Effusions SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Malignant Chylothorax Successfully Treated With Serial Talc Pleurodesis Eric Bondarsky* Neil Patel Lina Miyakawa and Alfredo Astua Mount Sinai Beth Israel, New York, NY INTRODUCTION: Chylothorax is the result of thoracic duct compromise with subsequent leakage of chyle into the pleural space. Ovarian carcinoma is a rare cause of chylothorax. CASE PRESENTATION: 77 year-old female with recent DVT and relapsed metastatic ovarian carcinoma presented with dyspnea. Point-of-care ultrasound (POCUS) revealed a large right pleural effusion and thoracentesis of 2.4L was performed, revealing chylothorax with 1508mg/dL triglycerides. 13 days later, she returned to the ED with dyspnea, tachycardia, and hypoxia with recurrent right pleural effusion. An indwelling pleural catheter was placed (day 2). Pleural fluid studies were consistent with lymphocyte predominant exudative chylothorax which was positive for ovarian adenocarcinoma. Subsequent CT was unrevealing for source of thoracic duct compromise but abdominal lymphadenopathy was present. Serial POCUS revealed reaccumulation of chyle despite a total of 3.55L drained over 5 days (table). She received nutritional supplementation including MFCA. On day 9, talc pleurodesis was performed due to dyspnea. After an additional 150mL of chyle was drained, a subsequent POCUS revealed further reaccumulation. She underwent a second talc pleurodesis (day 10). During the rest of her hospitalization no chyle was drained and hypoxia resolved. She was discharged with a plan to receive liposomal doxorubicin for recurrent ovarian carcinoma.
CONCLUSIONS: This case represents an alternative treatment of a rare condition. We conclude that this is the first reported case of an ovarian carcinoma-related chylothorax that was resolved with sequential pleurodesis without palliative chemotherapy. Reference #1: Mayo Clin Proc. 2005;80(7):867-70. DISCLOSURE: The following authors have nothing to disclose: Eric Bondarsky, Neil Patel, Lina Miyakawa, Alfredo Astua No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.566
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
537A
DISORDERS OF THE PLEURA
DISCUSSION: Conservative management of chylothorax consists of replacing nutrients lost in the chyle including MCFA. Our patient did not respond to conservative management. Due to poor functional status, this patient was unable to undergo chemotherapy. Therefore, she underwent talc pleurodesis, which has proven efficacy in chylothorax. However, it has never been performed in a chylothorax related to ovarian malignancy until this case. Our patient continued to produce chyle despite initial pleurodesis. Indwelling pleural catheters have lower morbidity than other interventions such as thoracic duct ligation. Therefore, we opted for repeat pleurodesis. The second pleurodesis effectively sealed the potential space for chyle reaccumulation (Fig). The decision was made to retain the indwelling pleural catheter in the event of future reaccumulation.
Malignant Chylothorax Successfully Treated With Serial Talc Pleurodesis Eric Bondarsky* Neil Patel Lina Miyakawa and Alfredo Astua Mount Sinai Beth Israel, New York, NY INTRODUCTION: Chylothorax is the result of thoracic duct compromise with subsequent leakage of chyle into the pleural space. Ovarian carcinoma is a rare cause of chylothorax. CASE PRESENTATION: 77 year-old female with recent DVT and relapsed metastatic ovarian carcinoma presented with dyspnea. Point-of-care ultrasound (POCUS) revealed a large right pleural effusion and thoracentesis of 2.4L was performed, revealing chylothorax with 1508mg/dL triglycerides. 13 days later, she returned to the ED with dyspnea, tachycardia, and hypoxia with recurrent right pleural effusion. An indwelling pleural catheter was placed (day 2). Pleural fluid studies were consistent with lymphocyte predominant exudative chylothorax which was positive for ovarian adenocarcinoma. Subsequent CT was unrevealing for source of thoracic duct compromise but abdominal lymphadenopathy was present. Serial POCUS revealed reaccumulation of chyle despite a total of 3.55L drained over 5 days (table). She received nutritional supplementation including MFCA. On day 9, talc pleurodesis was performed due to dyspnea. After an additional 150mL of chyle was drained, a subsequent POCUS revealed further reaccumulation. She underwent a second talc pleurodesis (day 10). During the rest of her hospitalization no chyle was drained and hypoxia resolved. She was discharged with a plan to receive liposomal doxorubicin for recurrent ovarian carcinoma.
CONCLUSIONS: This case represents an alternative treatment of a rare condition. We conclude that this is the first reported case of an ovarian carcinoma-related chylothorax that was resolved with sequential pleurodesis without palliative chemotherapy. Reference #1: Mayo Clin Proc. 2005;80(7):867-70. DISCLOSURE: The following authors have nothing to disclose: Eric Bondarsky, Neil Patel, Lina Miyakawa, Alfredo Astua No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.566
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
chestjournal.org
537A
DISORDERS OF THE PLEURA
DISCUSSION: Conservative management of chylothorax consists of replacing nutrients lost in the chyle including MCFA. Our patient did not respond to conservative management. Due to poor functional status, this patient was unable to undergo chemotherapy. Therefore, she underwent talc pleurodesis, which has proven efficacy in chylothorax. However, it has never been performed in a chylothorax related to ovarian malignancy until this case. Our patient continued to produce chyle despite initial pleurodesis. Indwelling pleural catheters have lower morbidity than other interventions such as thoracic duct ligation. Therefore, we opted for repeat pleurodesis. The second pleurodesis effectively sealed the potential space for chyle reaccumulation (Fig). The decision was made to retain the indwelling pleural catheter in the event of future reaccumulation.