Disorders of the Pleura |

Include This in Your Differential Diagnosis! FREE TO VIEW

Vijaya Sivalingam Ramalingam*, MD; Ramapriya Sinnakirouchenan, MD; James Kumar, MD
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University of Illinois, Urbana-Champaign, Urbana, IL

Chest. 2012;142(4_MeetingAbstracts):510A. doi:10.1378/chest.1380586
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SESSION TYPE: Pleural Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Effusions resulting from direct infiltration of the pleura by cancer cells are called malignant pleural effusions (MPE). Vascular endothelial growth factor, by increasing vascular permeability and vascular leakage of fluid, plays an important role in the formation of MPEs. The annual incidence of MPE in the United States is about 150,000.

CASE PRESENTATION: A 34 year old Caucasian man presented to the Emergency Department with shortness of breath - insidious in onset and progressively worsening over nine days. The patient appeared acutely ill with pulse rate of 100 beats per minute, respiratory rate of 22 breaths per minute, and room air oxygen saturation of 97 percent. Lung fields were dull to percussion and breath sounds were diminished on the right hemithorax. Chest X-ray revealed a right pleural effusion (Panel A, Image 1). CT of the chest with intravenous contrast revealed a large right-sided pleural effusion associated with generalized thickening and enhancement of the right-sided pleural reflections. Some areas of pleural thickening were nodular (arrow, panel B, Image 1). Images of the upper abdomen from CT chest revealed a complex cystic mass involving the upper pole of the left kidney (arrow, panel C, Image 1). CT of the abdomen and pelvis demonstrated a low attenuation upper pole left renal mass (blue arrow, panel D, Image 1). Thoracentesis yielded serosanguinuos, exudative and lymphocyte predominant fluid. Cytological evaluation of pleural fluid revealed the presence of cells positive for vimentin, CD 10 and focal epithelial membrane antigen suggestive of metastatic renal cell carcinoma. Pleural and diaphragmatic biopsies confirmed high grade metastatic sarcomatoid renal cell carcinoma (Image 2). Radical left nephrectomy demonstrated clear cell type renal cell carcinoma (RCC). A chronic indwelling pleural catheter was required for recurrent effusion refractory to therapeutic thoracentesis and chemical pleurodesis. The patient is currently on Temsirolimus.

DISCUSSION: The most common manifestations of RCC are hematuria, abdominal mass, pain, and weight loss. Pleural metastases and pleural effusion seem to be late events, occurring in only 12% of autopsies performed on patients with metastatic RCC. Metastatic RCC constitute only one to two percent of MPEs and are associated with median survival of four months regardless of underlying cancer cell type. There is no standard treatment for RCC with sarcomatoid differentiation. Neither immunotherapy nor chemotherapy has consistently improved survival in this subgroup of patients.

CONCLUSIONS: With this report, we emphasize the importance of including renal cell carcinoma in the workup of pleural metastasis and malignant pleural effusion.

1) Teresa, P et al. Malignant effusion of chromophobe renal-cell carcinoma: Cytological and immunohistochemical findings. Diagn. Cytopathol 2011:40:56-61.

2) Light RW. Pleural effusions. Med Clin North Am 2011;95(6):1055-70

DISCLOSURE: The following authors have nothing to disclose: Vijaya Sivalingam Ramalingam, Ramapriya Sinnakirouchenan, James Kumar

No Product/Research Disclosure Information

University of Illinois, Urbana-Champaign, Urbana, IL




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