lorriana leard m d tri hospital chest conference february 25 2003 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003 PowerPoint Presentation
Download Presentation
Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003

Loading in 2 Seconds...

play fullscreen
1 / 52

Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003 - PowerPoint PPT Presentation


  • 975 Views
  • Uploaded on

75 y.o. Man with NSCLCa and a pleural effusion. Lorriana Leard, M.D. Tri-Hospital Chest Conference Feb. 25, 2003. Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003. History. 75 y.o. WM with h/o NSCLCa who presents with SOB & increasing DOE over the past 3 months.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Lorriana Leard, M.D. Tri-Hospital Chest Conference February 25, 2003' - adamdaniel


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
lorriana leard m d tri hospital chest conference february 25 2003

75 y.o. Man with NSCLCa

and a pleural effusion

Lorriana Leard, M.D.

Tri-Hospital Chest Conference

Feb. 25, 2003

Lorriana Leard, M.D.

Tri-Hospital Chest Conference

February 25, 2003

history
History

75 y.o. WM with h/o NSCLCa who presents with SOB & increasing DOE over the past 3 months

pertinent pulmonary history
Pertinent Pulmonary History

In 9/01:

  • Presented with 80 lb wt. loss, cough, SOB
pertinent pulmonary history1
Pertinent Pulmonary History

In 9/01:

  • Presented with 80 lb wt. loss, cough, SOB
  • Chest CT scan:
    • large subcarinal mass with RLL collapse
pertinent pulmonary history2
Pertinent Pulmonary History

In 9/01:

  • Presented with 80 lb wt. loss, cough, SOB
  • Chest CT scan:
    • large subcarinal mass with RLL collapse
  • Bronchoscopy 9/7/01:
    • Near complete compression of bronchus intermedius
    • Wang needle biopsies from R side of carina  poorly differentiated AdenoCa  NSCLCa
pertinent pulmonary history4
Pertinent Pulmonary History
  • Staged as IIIB
  • Treated with Chemotherapy / XRT 9/01-12/01
pertinent pulmonary history5
Pertinent Pulmonary History
  • Staged as IIIB
  • Treated with Chemotherapy / XRT 9/01-12/01
  • Repeat Chest CT 2/21/02:
    • Resolution of 5 x 6 x 6 cm subcarinal mass
    • New bilateral pleural effusions R>L
pertinent pulmonary history6
Pertinent Pulmonary History
  • Thoracentesis 4/02: 1400 mL serous fluid
    • Chemistries:

GLUCOSE 125 mg/dl

PROTEIN, TOTAL 5.2 g/dl (Serum 7.1)

LDH 95 U/L (Serum 116)

TRIGLYCERIDE 26 mg/dl

    • Cell Count

RBC 990 #/cmm

WBC 600 #/cmm

(PMNs 2%, Lymphs 75%, Other 21%, Eos 1%)

    • Cultures: Fungal, AFB, Bacterial Cx negative
    • Cytology: Few atypical cells, probably reactive
current presentation
Current Presentation
  • Now presents w/ increased DOE over 3 mo.
current presentation1
Current Presentation
  • Now presents w/ increased DOE over 3 mo.
  • R chest pain (intermittently) for past year
  • No CP with deep inspiration
current presentation2
Current Presentation
  • Now presents w/ increased DOE over 3 mo.
  • R chest pain (intermittently) for past year
  • No CP with deep inspiration
  • No hemoptysis
  • Cough productive of clear to white phlegm
current presentation3
Current Presentation
  • Now presents w/ increased DOE over 3 mo.
  • R chest pain (intermittently) for past year
  • No CP with deep inspiration
  • No hemoptysis
  • Cough productive of clear to white phlegm
  • Gaining weight since discontinuation of chemotherapy --113 --> 181
past medical history
Past Medical History
  • NSCLCa per HPI
  • COPD:

FVC 3.30 (80%) TLC 6.29 (94%),

FEV1 1.98 (70%) DLCO 21.17 (88%)

FEV1/FVC 60%

  • Atrial fibrillation
  • HTN
  • DM2
  • CVA
medications
Albuterol MDI

Atrovent MDI

Azmacort MDI

Metoprolol

Lasix

Lisinopril

Prazosin

Aspirin

Metformin

Medications
social history
Social History
  • Lives with his wife of 52 years in Cloverdale
  • Employment:
    • Air Force  in saw mills  rancher handyman
    • Retired since 1994
  • Tobacco - 45 pack yr hx, quit 10 yrs ago
  • EtOH- prior socially, but none x 20 yrs
  • Drugs - never
physical examination
Physical Examination

VS: T 97, HR 56, BP 176/84, RR 24,

O2S 95% on RA , Wt 182 lbs.  

Gen: alert WM, ambulatory in NAD

Neck: supple, no JVD

Lungs: decreased BS with DTP and

decreased fremitus at R base

CV: s1 s2 with RRR

Abd: NABS, soft, NT, ND,

Extrem: no edema, + clubbing

slide18
Labs

9.6

7.6 >-----< 218

29

Coags normal

Creat 0.9

LFTs normal

LDH 117

comparison cxrs
Comparison CXRs

4/24/2002 10/23/2002 2/7/2003

slide23
Differential Diagnosis for Pleural effusion?
  • Next diagnostic step? Management?
differential diagnosis of exudative pleural effusion
Differential Diagnosis of Exudative Pleural Effusion
  • Infectious: Bacterial, TB, Fungal
  • Iatrogenic: drug induced, central line misplacement
  • Malignant Pleural Effusion
  • Inflammatory disorders: PE, BAPE, XRT,
  • Connective Tissue Disease
  • Lymphatic abnormalities: Chylothorax, malignancy
  • Traumatic: Esophageal rupture, Hemothorax
thoracentesis
Thoracentesis

GLUCOSE 113 mg/dl

ALBUMIN 2.0 gm/dL

PROTEIN, TOTAL 3.7 g/dl (Serum 7.2)

LDH 108 U/L (Serum 117)

thoracentesis1
Thoracentesis

GLUCOSE 113 mg/dl

ALBUMIN 2.0 gm/dL

PROTEIN, TOTAL 3.7 g/dl (Serum 7.2)

LDH 108 U/L (Serum 117)

RBC 3300 #/cmm

WBC 1370 #/cmm

NEUTROPHILS 1 %

LYMPHOCYTES 80 %

OTHER 19 %

(Others = monocytes, macrophages, histiocytes)

thoracentesis2
Thoracentesis

Gram Stain

  • Occasional WBCs
  • No Organisms Seen

Culture Negative

Fungal Smear Negative

AFB Smear Negative

Cytology Negative

thoracentesis3
Thoracentesis
  • Appearance: LIPEMIC
  • TRIGLYCERIDE 1040 mg/dl
diagnosis1
Diagnosis

Chylothorax

diagnosis and management of a chylothorax
Diagnosis and Management of a Chylothorax
  • Chylothorax vs. Pseudochylothorax
  • Etiology of a Chylothorax
  • Management of a Chylothorax
diagnosis of chylothorax
Diagnosis of Chylothorax
  • Pleural fluid triglyceride level >110 mg/dL
  • Ratio of pleural to serum triglyceride > 1.0
  • Ratio of pleural to serum cholesterol < 1.0
  • Lipoprotein analysis of pleural fluid: chylomicrons
chyle
Chyle

Chyle:

  • High triglyceride content (Chylomicrons)
    • produces milky, opalescent appearance
    • BUT milky appearance may clear during a fast and rapidly returns after ingestion of fat
  • Not irritating (does not evoke thickening of pleura)
  • Bacteriostatic
  • Cellular component of chyle: T-lymphocytes
  • Prolonged loss of chyle  nutritional depletion, water and electrolyte loss, hypolipemia, lymphopenia
chyle1
Chyle

Chylomicrons formed in gut

 enter intestinal lacteal vessels

 travel to cisterna chyli

 thoracic duct leaves cisterna chyli, travels up through mediastinum, and terminates in region of L jugular and subclavian veins

etiology of chylothorax
Etiology of Chylothorax

Disruption of Thoracic duct

  • anatomy determines location of effusion
    • thoracic duct crosses the mediastinum at 5-6th vertebral body therefore
      • Lymphatic injury below = R pleural effusion
      • Lymphatic injury above = L pleural effusion
    • Wide anatomic variation
  • Flow through duct 1.5-2.5 L/day
etiology of chylothorax1
Etiology of Chylothorax
  • Tumors: > 50% (lymphoma 75%)
  • Trauma:
    • CV or thoracic surgical procedure
      • 0.5%CV surgery
      • 4% of esophageal resections
    • Nonsurgical trauma
      • Penetrating injuries involving neck or thorax
      • Nonpenetrating: spine hyperextended or vertebral fx
      • Minor “traumas:” weight lifting, straining, coughing or vomiting, childbirth, vigorous stretching while vigorous stretching while yawning
etiology of chylothorax2
Etiology of Chylothorax

Other reported etiologies:

  • Pulmonary lymphangiomyomatosis
  • SVC or subclavian vein thrombosis
  • Filariasis
  • Lymph node enlargement
  • Mediastinal tuberculosis
  • Lymphangitis of the thoracic duct
  • Aneurysms of thoracic aorta that erode duct
  • Tuberous sclerosis
  • Amyloidosis
etiology of chylothorax3
Etiology of Chylothorax

From UpToDate.com

etiology of chylothorax4
Etiology of Chylothorax

From Light RW: Pleural Diseases 3rd Ed.

etiology of chylothorax5
Etiology of Chylothorax

Post-thoracic-XRT described in few case reports

  • Etiology unclear:
    • ? lymphatic obstruction due to mediastinal fibrosis
    • spontaneous rupture of duct which has been 'damaged' by prior XRT and, therefore, more susceptible to minimal trauma
    • Must rule out recurrent malignancy
etiology of chylothorax6
Etiology of Chylothorax
  • McWilliams and Gabbay describe 52 y.o. man with R chylothorax 23 yrs after mantle XRT for Hodgkin’s lymphoma
    • thoracentesis, pleural biopsies, thoracoabdominal imaging and thoracoscopy performed to r/o recurrent lymphoma
    • Treated with talc pleurodesis
  • Van Renterghem reported chylothorax 6 years after mantle XRT for Stage IA Hodgkin's disease
clinical manifestations
Clinical Manifestations
  • Incidence: 2.3-4.4% of nontraumatic effusions
  • Onset of symptoms usually gradual
    • fatigue
    • dyspnea on exertion
    • heaviness and discomfort in affected side
  • Rarely pleuritic chest pain / fever because chyle is not irritating to pleural surface
treatment
Treatment

Traumatic Chylothorax:

  • Spontaneous closure
  • Pleuroperitoneal shunt: chyle shunted to peritoneal cavity, where absorbed w/o sig. ascites
  • Tube thoracostomy: w/ minimization of chyle flow
  • Minimization of Chyle flow:
    • Keep stomach empty with NG suction and use TPN
    • Feed pt. low-fat diet with most fats in form of medium-chain triglycerides
treatment1
Treatment

If Persists:

  • Pleurodesis (talc)
  • Repair or ligation of thoracic duct (Thoracotomy or VATS) with attempt to find actual site of leakage from duct
      • Preop: lymphangiogram to identify site of leak
      • Case report: Thoracoscopic high-frequency ultrasonic coagulation of the thoracic duct without clipping
  • Parietal pleurectomy to obliterate pleural space
treatment2
Treatment

Non-Traumatic Chylothorax:

If known diagnosis or lymphoma / malignancy:

  • Mediastinal radiation
  • Pleuroperitoneal shunt, if not controlled by XRT
  • Reports of Pleurodesis

If unknown etiology:

  • Treat as Traumatic
  • Aggressively pursue diagnosis (CT / lymphangiogram)
treatment3
Treatment

Future Potential Treatments:

  • Percutaneous catheterization and embolization of thoracic duct
  • Somatostatin / octreotide reported to decrease chyle production in postop chylothorax and in dog models
summary
Summary
  • Chylothorax results from disruption of thoracic duct
  • Must be distinguished from Pseudochylothorax
  • Most common cause tumor, then surgical trauma. IF undiagnosed etiology, must evaluate for malignancy
  • Management depends upon etiology, but may include:
    • Treatment of underlying malignancy (Chemo / XRT)
    • Dietary restriction and Chest tube drainage
    • Thoracotomy / VATS with Thoracic Duct Ligation
    • Pleurodesis
  • Avoid prolonged drainage which can lead to immunosuppression / malnutrition
references
References
  • McWilliams, A. and Gabbay E. Chylothorax occurring 23 years post-irradiation: Literature review and management strategies.Respirology.2000 Sep 5:301-3.
  • Murray & Nadel: Textbook of Respiratory Medicine, 3rd ed 2058-2059
  • Romero S. Nontraumatic chylothorax. Current Opinion in Pulmonary Medicine. 2000;6:287-291.
  • Van Renterghem D, Hamers J, De Schryver A et al. Chylothorax after mantle field irradiation for Hodgkin's disease. Respiration 1985.
  • UpToDate.com