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Intrapleural Cisplatin for Management of Malignant Pleural Effusion in a Patient With Plasma Cell Leukemia FREE TO VIEW

Abhishek Agarwal, MD; Jagpal Klair, MD; Karim Nathan, MD; Abhinav Agrawal, MD; Kevin Kuriakose, MD; Setu Patolia, MD; Nikhil Meena, MD
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Cooper University Hospital, Philadelphia, PA

Chest. 2015;148(4_MeetingAbstracts):649A. doi:10.1378/chest.2262658
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SESSION TITLE: Miscellaneous Cases - Student/Resident

SESSION TYPE: Student/Resident Case Report Slide

PRESENTED ON: Tuesday, October 27, 2015 at 04:30 PM - 05:30 PM

INTRODUCTION: Plasma cell leukemia (PCL) is defined by the presence of >20 % plasma cells in the peripheral blood and an absolute plasma cell count of > 2×109/L.1 Management of PCL requires early induction therapy with intensive chemotherapy regimens to control the disease activity followed by autologous stem-cell transplantation to decrease the risk of early death.1 MMPEs (Myelomatous Malignant Pleural Effusion) when present portend a poorer prognosis which may be due to the lack of standard treatment for MMPEs.2

CASE PRESENTATION: A 64 yr old with history of plasma cell leukemia receiving chemotherapy was admitted for treatment of osteomyelitis. He was transferred to ICU for hypercarbic respiratory failure; likely from a large recurrent left sided pleural effusion. The pleural fluid on sampling had 85% plasma cells while the plasma cells comprised 5% of the peripheral blood; consistent with aggressive loco-regional disease. Approximately, 1.5 Liters were drained twice a week prior to the pulmonary consultation. We placed an indwelling tunneled pleural catheter (TPC) and instilled Cisplatin (20mg/m2) via the catheter to treat the local disease and to assure easy drainage. The pleural plasma cell count and output decreased to zero within a week. During the same period his plasma cells in peripheral blood increased from 5 to 34 % and his general debilitation precluded systemic chemotherapy or autologous stem cell transplantation. With this knowledge even though there was significant improvement in his symptoms he elected comfort as his primary goal.

DISCUSSION: Plasma cell leukemia can also rarely involve pleura causing MMPE. Although pleural effusions occur in 6% of MM patients, effusions due to pleural myelomatous involvement, are very rare occurring in less than 1% of the patients.2 Presence of pleural effusion is associated with worse prognosis.1-2 Treatment of MPE’s depend on the size of pleural effusion, the rate of accumulation, patients’ symptoms and overall prognosis. In some cases, systemic chemotherapy for the primary cancer can completely resolve the MPE.2 Symptomatic patients are usually managed by therapeutic thoracentesis or pleurodesis. Numerous sclerosing agents have been studied including talc, doxycycline, antineoplastics such as bleomycin.1-2 Success rates for these treatments range between 40 to 100%.

CONCLUSIONS: To the best of the authors’ knowledge, this is the first case of pleural involvement of PCL managed by intrapleural cisplatin instilled via a TPC.

Reference #1: Fernández de Larrea C, Kyle RA, Durie BG, Ludwig H, Usmani S, Vesole DH, et al. Plasma cell leukemia: Consensus statement on diagnostic requirements, response criteria and treatment recommendations by the International Myeloma Working Group.Leukemia. 2013; 27:780-91

Reference #2: Ramsingh G, Mehan P, Luo J, Vij R, Morgensztern D. Primary plasma cell leukemia: a Surveillance, Epidemiology, and End Results database analysis between 1973 and 2004. Cancer. 2009; 115:5734-5739

DISCLOSURE: The following authors have nothing to disclose: Abhishek Agarwal, Jagpal Klair, Karim Nathan, Abhinav Agrawal, Kevin Kuriakose, Setu Patolia, Nikhil Meena

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