Procedures: Fellow Case Report Slide: Procedures |

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Zachary Dreyfuss, MD; Anoop Nambiar, MD
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University of Texas Health Science Center San Antonio, San Antonio, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):994A. doi:10.1016/j.chest.2016.08.1100
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SESSION TITLE: Fellow Case Report Slide: Procedures

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM

INTRODUCTION: Disruptions of the lymphatic channels near the pleural cavity can result in a chylothorax. We present a case of bilateral chylothoraces that were treated with lymphatic duct embolization.

CASE PRESENTATION: A 74-year-old male presented with worsening dyspnea. He had been diagnosed with stage IV follicular lymphoma four months prior and was being actively treated with chemotherapy (bendamustine and rituximab monthly). Radiographic bulky lymphadenopathy had shrunken in size by serial imaging. On presentation, a chest X-ray showed bilateral pleural effusions that were subsequently drained. Pleural fluid analysis of the bilateral effustions revealed elevated triglyceride levels (greater than 1100 mg/dl) consistent with bilateral chylothoraces. Cultures and cytology were negative. The patient returned less than two weeks later with persistent shortness of breath and imaging showed a recurrence of the chylous effusions. A lymphangiogram was performed and showed a persistent leak. The thoracic duct was then embolized throughout its entire length. The patient’s effusions did not recur and his symptoms improved.

DISCUSSION: The majority of chylothoraces are secondary to trauma (50% of cases). This case, however was attributed to lymphoma, which is the cause of 11% of cases. Other causes include congenital diseases or systemic diseases (systemic lupus erythematosus, Behçet disease). They generally present as unilateral effusions, but 20% may be bilateral. Surgical treatment had been the preferred modality; however noninvasive procedures have become more commonplace with reduced morbidity and mortality. Percutaneous treatment of a chylothorax was developed as a minimally invasive alternative to surgical treatment. The treatment consists of transabdominal catheterization of the cysterna chyli with embolization of the thoracic duct proximal to the chyle leak. Embolization coils are used to pack the lumen of the thoracic duct and impede flow. In addition to lowering morbidity and mortality, lymphangiograms lend the ability to identify the chyle leak and variations in thoracic duct anatomy which potentially improve the outcome.

CONCLUSIONS: Bilateral chylothoraces due to thoracic duct leak in the setting of treatment-responsive lymphoma without history of trauma is rare. Lymphangiography may be diagnostic as well as therapeutic with or without thoracic duct embolization.

Reference #1: Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: experience in 34 patients. Chest. 2013 Jan;143(1):158-63.

DISCLOSURE: The following authors have nothing to disclose: Zachary Dreyfuss, Anoop Nambiar

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