INTRODUCTION: Bilateral chylothoraces occurring secondary to malignancy are rare. We describe the case of a 30 year old female with metastatic nasopharyngeal carcinoma presenting with bilateral chylothoraces.
CASE PRESENTATION: The patient is a 30 year old Chinese female with history of nasopharyngeal carcinoma stage II diagnosed in February 2004. She re-presented in June 2007 complaining of decreased appetite, increased abdominal girth, nausea, vomiting, and cough for 1 month. She was a cachectic female with decreased breath sounds at the bases of both lungs with dullness to percussion two-thirds of the way up the back on the right and one-third on the left. Her abdomen was distended but soft. CT scan of the abdomen revealed a 5.2 cm mass in the liver, mediastinal and abdominal lymphadenopathy, multiple small hypervascular hepatic metastases, large right and moderate left pleural effusions, and moderate abdominal ascites. The patient was referred to Bellevue Hospital Center where bronchoscopy with trans-bronchial nodal aspiration confirmed that the new lesions were consistent with nasopharyngeal carcinoma. A large volume thoracentesis performed on the right revealed a milky-white exudative effusion with pH of 7.59, LDH of 152 U/L (serum LDH was 309), glucose of 138 mg/dL, protein of 2.8 g/dL (serum protein was 3.8), triglycerides of 125. Based on the patient's progressive shortness of breath and increasing bilateral effusions, bilateral chest tubes were placed. The left chest tube drained a milky-white effusion with similar characteristics consistent with an exudative chylothorax. We attempted a conservative approach using a non-fat, high protein, high calorie diet, substituting medium-chain triglycerides (MCT) for fat, with no success. The patient was then placed on complete bowel rest and given TPN, which resulted in moderate control of the chylothoraces; however, output continued up to 400 cc per day on each side. The patient was referred for percutaneous thoracic duct ligation; however she did not receive the procedure because she developed methicillin-sensitive staph aureus pneumonia. After successful treatment of the pneumonia, she underwent radiation and chemotherapy with cisplatin with better control of the chylothoraces. Pleurodesis was performed with bleomycin with good result and the chest tubes were discontinued.
DISCUSSIONS: Our patient is unique in that bilateral chylothoraces in the setting of nasopharyngeal carcinoma and the absence of prior surgical instrumentation is rarely encountered. As our patient was not a candidate for surgical intervention, a multimodality approach was used applying the minimally invasive strategies that have been described in the medical literature, including a consideration for percutaneous thoracic duct ligation. Percutaneous thoracic duct ligation was an ideal alternative for our patient given its high success rates and safety profile. This technique involves localizing of the cisterna chyli via lymphography. These structures are then catheterized and platinum microcoils are passed through to the proximal thoracic duct. Cope et al performed these techniques in 42 patients with persistent chylothoraces. The success rate was 73.8%. Complications of this procedure are intra-abdominal hemorrhage, peritonitis, chylous ascites, thoracic duct rupture, and microcoil misplacements. In comparison, surgical techniques to ligate the thoracic duct have mortality rates up to 25%.
CONCLUSION: Patients with high-output chylothoraces who fail conservative management should be referred promptly for more aggressive intervention to avoid nutritional and immunological compromise. Percutaneous thoracic duct ligation is a potential option with a high success rate and should be considered if conservative management fails.
DISCLOSURE: Khader Abounasr, None.