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Aurora’s Harbinger: Chylothorax as the Initial Presentation of Metastatic Pancreatic Cancer FREE TO VIEW

Denyse Lutchmansingh, MBBS; Changwan Ryu, MD; Anupa Nadkarni, MBBS
Chest. 2013;144(4_MeetingAbstracts):601A. doi:10.1378/chest.1695111
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SESSION TITLE: Cancer Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Chylothorax is a rare condition typically associated with a traumatic etiology, most notably thoracic surgery. However, there are rare occurrences of non-traumatic chlyothorax, and we present a patient with a chlyothorax from metastatic pancreatic cancer.

CASE PRESENTATION: An 86 year old Caucasian woman with a past medical history of chronic obstructive pulmonary disease presented with respiratory failure requiring intubation. Her pulmonary examination was significant for decreased breath sounds on the right side without wheezes or crackles. Chest X-ray showed complete opacification of the right lung, and CT chest revealed a massive pleural effusion. We performed thoracocentesis with chest tube insertion, draining 2.3 liters of milky white fluid. Pleural fluid was exudative by Light’s criteria and significant for triglyceride level of 649mg/dl and cholesterol of 25mg/dl. Further studies, including a peripheral smear, liver function tests, lactate dehydrogenase, and uric acid, were normal. CT abdomen showed a pancreatic mass encasing the superior mesenteric artery and hepatic artery, ascites, and abdominal lymphadenopathy. CA 19-9 and CA 125 were elevated with a normal CEA level. Paracentesis revealed chylous ascites. Both pleural and ascitic fluid samples revealed atypical cells and positive immunohistochemical staining for CEA and CA 19-9, all consistent with a pancreatic malignancy. After consulting our gastroenterology colleagues, we diagnosed the patient with metastatic pancreatic carcinoma; given the poor prognostic nature of her findings, the family opted for palliative care.

DISCUSSION: The most frequent cause of non-traumatic chlyothorax is malignancy, with lymphomas accounting for 70% of cases.1 Rarely, gastrointestinal tumors can contribute to the formation of chylous ascites as a result of elevated intra-abdominal pressures with translocation of fluid from the abdominal cavity into the pleural space.2 Patients experience considerable malnutrition and immunosuppression from the loss of protein, fats, vitamins, immunoglobulins, and lymphocytes into the pleural space.1 Quality of life becomes a major consideration when investigating for an underlying etiology.

CONCLUSIONS: We aimed to illustrate the significance of recognizing the unusual presentations of common diagnoses. In the case of non-traumatic chlyothorax, which can be an unfortunate harbinger of an underlying malignancy, timely diagnosis is instrumental for optimal management. In patients with metastatic disease and poor prognosis, avoiding unnecessary invasive medical testing and prolonging hospitalizations are paramount for patient-centered care.

Reference #1: 1. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010 Jan;104(1):1-8. doi: 10.1016/j.rmed.2009.08.010. Epub 2009 Sep 18.

Reference #2: 2. Maldonado F et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009 Feb;84(2):129-33. doi: 10.1016/S0025-6196(11)60820-3.

DISCLOSURE: The following authors have nothing to disclose: Denyse Lutchmansingh, Changwan Ryu, Anupa Nadkarni

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