Tunneled PleurX catheters are an alternative outpatient option for the palliation of recurrent malignant effusions. They are associated with very little morbidity. Forty percent of patients achieve pleurodesis with the catheter in place, allowing for removal of the catheter1. We report the first development of subcutaneous metastasis in the tract of a PleurX catheter following its removal after successful pleurodesis.
The patient is a 43 year old Puerto Rican female with a history of recurrent metastatic adenocarcinoma of the right breast originally diagnosed in 1994. At the time of diagnosis, she underwent right mastectomy and lymph node dissection followed by adjuvant chemotherapy and tamoxifen. She had a chest wall recurrence in 2001 treated with additional chemotherapy. In 2003, she developed a right-sided malignant pleural effusion requiring 3 thoracenteses, each with radiographically proven reexpansion of her right lung and improvement in dyspnea. She underwent an uncomplicated right PleurX catheter placement in August of 2004. She drained her effusion every 3 to 4 days initially and then noted progressively decreased drainage. The PleurX catheter was removed in the outpatient office 8 weeks after it had been placed. A CXR at that time showed minimal residual pleural effusion. Since then, the patient has been asymptomatic and has not required any thoracentesis on the right side. Four months after the removal of the catheter, the patient noticed a painful lump on her right chest, at the site of the old PleurX catheter. The lump was more noticeable when she slept on her right side and was progressively increasing in size. On exam, she had a 2 by 1.5 cm firm subcutaneous nodule along the site of the old tunnel. A CT of the chest done 4 weeks prior showed the presence of a small subcutaneous nodule. A fine needle aspiration was performed and confirmed the presence of metastatic adenocarcinoma.
Local tumor recurrence or seeding following pleural drainage, pleural biopsy, tube thorascopy and surgical video assisted thoracoscopic surgery has been described but it is uncommon in non-mesothelioma malignancies234. PleurX catheters, a relatively newer device, are an option in the palliative management of recurrent malignant effusions. These catheters offer the advantage over tube thorascopy and chemical pleurodesis of being an outpatient procedure and allowing the patients to rapidly return to their pre-procedure functional status. They do require some training of the patients and their caregivers so that they can be intermittently drained using vacuum bottles when the patients become symptomatic. Approximately 40% of patients will achieve successful pleurodesis and can have their catheter removed1. Thus far, there had been no reported cases of tumor seeding from removal of a PleurX catheter. The clinical significance is uncertain since most of the patients undergoing placement of PleurX catheter already have metastatic disease. However, as it was the case in our patient, pain secondary to the subcutaneous nodule can be an issue.
Seeding of the tunnel tract and subcutaneous metastasis after removal of PleurX catheters can occur. It should be considered in a patient presenting with pain and a palpable nodule at the prior site of a PleurX catheter.
Cristina Reichner, None.