Ann Thorac Surg 2005;80:1124-1126
© 2005 The Society of Thoracic Surgeons
Case report
Postoperative Pleural Effusion in Bronchioloalveolar Cancer
Natalie D. Shaw, BS,
Eddie L. Hoover, MD
*
Division of Thoracic Surgery, VA Western New York Healthcare System, and State University of New York at Buffalo, Buffalo, New York, USA
Accepted for publication March 8, 2004.
* Address reprint requests to Dr Hoover, 3495 Bailey Ave, Buffalo, NY14215; (Email: eddie.hoover{at}med.va.gov).
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Abstract
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Bronchioloalveolar carcinoma occasionally presents with bronchorrhea and can appear on roentgenogram as cavitary lesions similar to a lung abscess. We present a case of multifocal, cavitary bronchioloalveolar cancer, which was originally treated unsuccessfully as lung abscesses. At surgery, two cavities were identified without evidence of tumor or chronic infection and were left open. The postoperative course was complicated by 5 weeks of massive chest tube drainage, which was finally controlled with radiation and time. This report chronicles our difficulty with diagnosis and management and suggests recommendations for future providers.
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Introduction
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Bronchioloalveolar carcinoma (BAC) is a rare lesion with the unique feature of bronchorrhea, which can cause electrolyte imbalances and cachexia. This occurs late, usually in medically-treated patients, and thoracic surgeons rarely encounter this complication [1–3]. We present a case of excessive and prolonged pleural effusion after thoracotomy for presumed lung abscesses. We were perplexed as to the pathogenesis of the fluid and appropriate treatment, even after the diagnosis was known. Barsky and coworkers [4] reported an increase in BAC from 5% to 24% of their total lung cancer population with the largest increase occurring in females. This observation, the difficulty we encountered in this case, and recommendations for others, constitute the basis of this report.
A 53-year-old white man with a 30 pack-year smoking history presented with fatigue and a minimally productive cough. Laboratory tests were normal, and chest roentgenogram showed a 3-cm cavitary lesion in the left upper lobe and a 5-cm left lower lobe cavity (Fig 1). Computed tomographic scans were interpreted as lung abscesses and intravenous clindamycin began. Bronchoscopy and biopsies were negative. The patient was discharged home to complete a 6-week antibiotic course, but he was admitted 1 month later with the same symptoms. Computed tomographic scan was read again as abscesses. Computed tomographic-guided biopsy of the left lower lobe lesion showed inflammatory cells. Interventional radiology opted not to attempt percutaneous drainage. Thoracic surgery was consulted for thoracotomy after informed consent. During induction, a stream of clear odorless fluid drained from the double-lumen tube. Cultures and cytology were subsequently negative. Exploration showed no palpable lesions or induration in either lobe. Equipment was being assembled for "blind" aspirations when two areas of "dimpling" were noted on the surface of the collapsed lung. They were opened and appeared normal without tumor, fluid, infection, or induration. The left upper lobe cavity was 1.5 cm and the other was 2.5 cm. Cultures and random biopsies were obtained. These were believed to be sterile abscess cavities, which were left open for drainage. Frozen sections were not obtained, absent a clinical indication.
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Fig 1. Posteroanterior chest roentgenogram showing lesions in the left upper and lower lobes (arrows).
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The postoperative course was complicated by a large amount (
1,000 mL/d) of chest tube drainage immediately and continuing for 7 weeks (Fig 2). The volume suggested a chylous leak, but the protein content of 0.5 g/dL was lower than the typical 2 to 6 g/dL. When the pathology report showed stage IIIb (T4N0M0) BAC, we still did not make the association, but did assume that the fluid must be coming from the open areas. On day 16, suction was discontinued to attempt to tamponade the fluid, assuming there was some degree of adhesion between the lung and chest wall as suggested by roentgenograms. However, the patient had severe chest pain develop, and this was abandoned. Throughout the 7 weeks, he had a low-grade temperature of approximately 38°C. All cultures were negative, although he eventually developed Candidiasis. Presentation at the Tumor Board resulted in a consultation to radiotherapy for an attempt at inducing scarring in the open areas as had been reported by Krawtz and associates in a patient with massive bronchorrhea [5]. The fluid production decreased significantly after 2 weeks of radiation, and suction was discontinued. After an additional 2 weeks of radiation, the tubes were clamped for 72 hours without pain or dyspnea, and they were removed despite a bizarre chest roentgenogram. There was no reaccumulation or bronchorrhea. His weight had decreased from 156 pounds preoperatively to 129 pounds. Of interest, his albumin level at this time was 2.9 g/dL with a pre-albumin level of 14.6 mg/dL. He was discharged on the postoperative day 53, but he failed to thrive and was readmitted 2 months later with dyspnea, cachexia, and right lower lobe pneumonia with a weight of 115 pounds. He expired 3 weeks later. Autopsy revealed adhesions in the left hemithorax without fluid, residual carcinoma in the left upper lobe and left lower lobe without metastases, right-sided pneumonia, and severe triple-vessel coronary artery disease as the probable causes of death.
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Comment
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Multifocal BAC is not usually amenable to surgical intervention, but thoracic surgeons may see it in consultation after percutaneous biopsies or after opening procedures. The initial drainage from the endotracheal tube should have alerted us to the possibility of BAC, but that clue was missed. Had a frozen section been obtained, a pneumonectomy would have been required, which this patient could not have tolerated, and the senior author would have been reluctant to perform this because of the low, but real risk of bilaterality, which is estimated at 3% [4]. The other issue related to a correct diagnosis at surgery is whether the lesions could have been removed with wedge resections. Again, there was absolutely no palpable pathology to direct the extent of any wedge resection. The pleural effusion may have been prevented with oversewing of the cavities. However, this lesion was secretory and could have resulted in bronchorrhea instead. Nevertheless, we would recommend oversewing any such lesions in this setting. We speculate that the fluid was coming from the parenchymal lymphatics, and that the vacuum effect probably potentiated the flow. A literature review at the time we were considering radiation showed that others had reported limited success in non-BAC-pleural effusions using steroids, indomethicin, atropine, and adrenocorticotropic hormone, which were discussed and dismissed [2, 6, 7]. We present these for future consideration only.
In conclusion, should a thoracic surgeon encounter this rare entity either after surgery or in consultation for pleural effusion after percutaneous lung biopsy by radiology or pulmonary medicine, early and aggressive measures must be taken to avoid the loss of lung function and the cachexia associated with persistent drainage. This may be especially important if the incidence of BAC is increasing.
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References
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- Barkley JE, Green MR. Bronchioloalveolar carcinoma J Clin Oncol 1996;14:2377-2386.[Abstract]
- Edwards CW. Alveolar carcinomaa review. Thorax 1984;39:166-174.[Free Full Text]
- Furak J, Trojan I, Szoke T, Tiszlavicz L, et al. Bronchioloalveolar lung canceroccurrence, surgical treatment and survival. Eur J Cardiothorac Surg 2003;23:818-823.[Abstract/Free Full Text]
- Barsky SH, Cameron R, Osann KE, Tkomita D, Holmes EC. Rising incidence of bronchioloalveolar lung carcinoma and its unique clinicopathologic features Cancer 1994;73:1163-1170.[Medline]
- Krawtz SM, Mehta AC, Vijajakumar S, Stoller JK. Palliation of massive bronchorrhea Chest 1988;94:1313-1314.[Medline]
- Homma S, Kawabata M, Kish K, et al. Successful treatment of refractory bronchorrhea by inhaled indomethacin in two patients with bronchiolo-alveolar carcinoma Chest 1999;115:1465-1468.[Abstract/Free Full Text]
- Nakajima T, Terashima T, Nishida J, Onoda M, Koide O. Treatment of bronchorrhea by corticosteroids in a case of bronchioloalveolar carcinoma producing CA19–9 Int. Med 2002;41:225-228.
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Abstract
Introduction
