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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 424-426  

An unusual case of massive pleural effusion


1 Department of Pulmonary, Critical Care and Sleep Medicine, AICTS, Pune, Maharashtra, India
2 Department of Pathology, Command Hospital Southern Command, Pune, Maharashtra, India
3 Department of Anaesthesia, AFMC, Pune, Maharashtra, India

Date of Submission12-Apr-2020
Date of Decision02-Aug-2021
Date of Acceptance20-Sep-2021
Date of Web Publication26-Feb-2022

Correspondence Address:
Robin Choudhary
Department of Pulmonary, Critical Care and Sleep Medicine, AICTS, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_166_20

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  Abstract 


Lung carcinoma is a major cause of mortality worldwide. Small-cell lung cancer (SCLC) constitutes of about 10%–15% of cases of all lung cancer. It generally affects males more commonly than females and has smoking as a high-risk factor. It is generally a solid central tumor which spreads very rapidly to mediastinal lymph nodes and distant organs. It generally presents with mass effects such as cough, wheezing, superior vena cava syndrome and hemoptysis and also causes paraneoplastic syndrome. It is very rare for SCLC to present as isolated massive pleural effusion. Here in, we describe a case of massive pleural effusion which was diagnosed as small cell carcinoma with thoracoscopic pleural biopsy, and was managed with pleurodesis and cisplatin-based chemotherapy.

Keywords: Massive pleural effusion, small-cell lung carcinoma, thoracoscopic biopsy


How to cite this article:
Marwah V, Choudhary R, Verma S, Singh S. An unusual case of massive pleural effusion. Med J DY Patil Vidyapeeth 2022;15:424-6

How to cite this URL:
Marwah V, Choudhary R, Verma S, Singh S. An unusual case of massive pleural effusion. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:424-6. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/424/338618




  Case Presentation Top


A54-year-old male, chronic smoker presented with a history of insidious onset dry cough and progressive breathlessness on exertion of 2 months duration. On examination, he was tachypneic and breath sounds were absent over the right mammary, interscapular, infrascapular, and infra-axillary regions. His blood counts, liver function, and renal parameters were within the normal limits. His chest radiograph showed right-sided massive pleural effusion with mediastinal shift to the left side. His chest ultrasonogram showed pleural effusion on the right side [Figure 1]a. Computed tomography (CT) of chest (postdrainage) showed collapse of the entire right lobe, most part of the right middle lobe, and subsegments of the right upper lobe with cut off of several bronchi. The apical segment of the right lower bronchus showed heterogeneous enhancement representing the primary lesion with multiple mediastinal lymph nodes and right pleural effusion [Figure 1]b. There were numerous enhancing nodules along the entire pleura (mediastinal, diaphragmatic, and costal) including the fissures [Figure 1]c. He initially underwent diagnostic pleurocentesis which showed exudative lymphocytic fluid but cytology was inconclusive for malignancy. He thereafter underwent thoracoscopic pleural biopsy which showed nodular lesions along the entire pleura from which biopsy was taken. The histopathological biopsy report of these lesions showed tumor cells composed of hyperchromatic, pleomorphic, and spindle cells in fibrous stroma [Figure 1]d which on biopsy was positive for thyroid transcription factor 1, synaptophysin, chromogranin and CD56, and negative for calretinin, Wilms' tumor 1, and leukocyte common antigen. The patient was then managed with chest tube drainage and later pleurodesis with 2% betadine was done. He was started chemotherapy with two-drug regimens of cisplatin and etoposide.
Figure 1: (a) Chest radiograph showing massive pleural effusion (right). (b) Thoracoscopic image showing multiple pleural nodules. (c) Computed tomography of the chest showing mass right lung with right pleural effusion. (d) Photomicrograph of thoracoscopic pleural biopsy at ×40 with Hematoxylin and eosin stain showing tumor cells composed of hyperchromatic, spindle and pleomorphic cells in fibrous stroma and with nuclear molding. The tumor cells show scant cytoplasm with the areas of necrosis

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  Discussion Top


Pleural effusion can develop due to numerous. The massive pleural effusion documented in the literature of which includes mainly malignancies, followed by idiopathic etiology followed by parapneumonic effusion. Other less reported causes may include cirrhosis of the liver and rarely infective causes such as T. B, trauma. However, these are causes of submissive pleural effusion.[1] There is various investigational modality to assess the pleural effusion. Beginning from the basic chest radiograph, the amount of pleural effusion can be estimated based on standard frontal and lateral radiographs. At least 75 mL are needed to obliterate the posterior costophrenic sulcus, and a minimum of 175 mL is necessary to obscure the lateral costophrenic sulcus on an upright chest radiograph.[2] A pleural effusion of 500 mL will obscure the diaphragmatic contour on an upright chest radiograph; if the pleural effusion reaches the level of the fourth anterior rib, close to 1000 mL are present. On decubitus radiographs and CT scans, <10 mL, and possibly as little as 2 mL, can be identified. For quantitation on decubitus views, the rind of layering pleural effusion is measured: Small effusions are thinner than 1.5 cm, moderate effusions are 1.5–4.5 cm thick, and large effusions exceed 4.5 cm. Effusions thicker than 1 cm are usually large enough for sampling by thoracentesis, since at least 200 mL of liquid are already present.[2] Further the CT detects small pleural effusions, i.e., <10 mL and possibly as little as 2 mL of liquid in the pleural space. Other uses of CT scanning in the evaluation of pleural disease including facilitating measurement of pleural thickness, distinguishing an empyema from a lung abscess, and visualizing small pneumothoraxes in supine patients. Visualizing underlying lung parenchymal processes that are obscured on the chest radiograph by a large pleural effusion, determining the exact location of pleural masses and characterization of their composition and occasionally identifying peripheral bronchopleural fistulae, occasionally identifying a diaphragmatic defect in a cirrhotic patient with hepatic hydrothorax. Identifying lung parenchymal or upper abdominal abnormalities that may provide a clue to the etiology of the pleural effusion (e.g., lung mass, apical cavities, aortic dissection, infra diaphragmatic abscess, and liver cirrhosis with ascites leading to hepatic hydrothorax), guiding thoracentesis, and tube thoracotomy of loculated empyema.

The medical thoracoscopy developed in recent years is an invasive surgical technique that may be accomplished independently by a pulmonary physician under local anesthesia. Research has demonstrated that medical thoracoscopy is able to markedly increase the positive diagnostic rate of undiagnosed pleural effusions. The sensitivity of thoracoscopy for diagnosis of pleural effusion is 83% and the specificity of the same is 100% with a predictive value of a negative result being 25%.[3]

The majority of the pleural disease may be diagnosed using simple techniques but thoracoscopy can be very helpful in more complex cases. Moreover, inconclusive histology following thoracoscopy is an indication for further investigation if the condition does not improve. Many studies have been done in the recent past evaluating the diagnostic value of the medical thoracoscopy for the diagnosis of undiagnosed pleura effusion. In a similar retrospective study by Chen et al., they found that 86 patients with undiagnosed pleural effusion, the etiology was established in 79 cases with the help of diagnostic thoracoscopy. Moreover among the diagnosed cases lung cancer was the most common etiology, followed by infective etiology such as tubercular pleuritis. Moreover neither mortality nor major complications were observed in patients who received medical thoracoscopy examination. Hence, medical thoracoscopy is a safe and effective examination method and has an important diagnostic value for unidentified pleural effusion in patients.[4]

Small-cell carcinoma is unique and highly malignant tumor. It constitutes 10%–15% of all lung carcinoma. Its primary etiologic factor is related to smoking, but there are other risk factors such as bischloromethyl esters, nickel, and radiation.[5],[6] It is cytologically described as small cell (<4 lymphocytes) with inconspicuous, fine granular nuclei (salt and pepper chromatin) with scant cytoplasm, and it also shows nuclear molding.[7] Smallcell lung cancer (SCLC) usually has positive epithelial markers (keratin, epithelial membrane antigen) and neuroendocrine markers such as neuronspecific enolase, chromogranin A, CD56, and synaptophysin. The SCLC generally presents in middle-aged person with a history of insidious cough, breathlessness on exertion, hemoptysis, and constitutional symptoms. The patients can also have features of the central nervous system, abdominal, bone, and hepatic metastasis.[5] The patients with SCLC have a short life expectancy of 4–6 months and 5–9 weeks if presenting with metastasis.[5],[6] According to the current literature, adenocarcinoma lung generally presents as pleural effusion, SCLC can also involve the pleura but presentation with massive pleural effusion is rarely reported in the literature which makes our case very unique.[5],[8]

There have been case reports of small cell carcinoma with associated minimal pleural effusion and it usually denotes metastatic spread and worse prognosis.[8] There is paucity of data reporting the association of massive pleural effusion with SCLC. In a recent study by Shojaee et al., they reported that among the patients with SCLC, malignant pleural effusion (MPE) was present in only in 11.16% and the probability of MPE was higher in older patients with larger tumors and mediastinal lymph node involvement at presentation. The median overall survival (3 vs. 7 months), estimated 1-year survival (17% vs. 30%), and 2-year survival (6% vs. 14%) were significantly lower in patients with MPE than without MPE. They also concluded that MPE was also found as an independent factor for worse survival in multivariate analysis.[9]

The SCLC can be classified into limited stages (30%–35%) which include one hemithorax with hilar, mediastinal and ipsilateral supraclavicular lymph nodes and extensive stage with distant metastases (60%–65%), like in present case.[5],[10] The prognostic effect of pleural effusion was mainly limited in the stage I-III, but it disappeared in stage IV disease. The mechanism of pleural effusion in the SCLC is poorly understood. An indirect mechanism representing mediastinal lymphadenopathy is attributed responsible for the accumulation of fluid in the case of SCLC in the majority of the cases with minimal pleural effusion.[11] The radiological features of SCLC are central mass lesion with mediastinal involvement. It usually involves lobar subsegmental bronchi, like in our case.[6] Since SCLC is a highly active tumor with rapid doubling time so it shows good response to chemotherapy. The standard treatment includes two-drug regimens off cisplatin-etoposide which is given over 3 days every 3 weeks for 4–6 cycles.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jiménez D, Díaz G, Gil D, Cicero A, Pérez-Rodríguez E, Sueiro A, et al. Etiology and prognostic significance of massive pleural effusions. Respir Med 2005;99:1183-7.  Back to cited text no. 1
    
2.
Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology 1973;109:33-5.  Back to cited text no. 2
    
3.
Kendall SW, Bryan AJ, Large SR, Wells FC. Pleural effusions: Is thoracoscopy a reliable investigation? A retrospective review. Respir Med 1992;86:437-40.  Back to cited text no. 3
    
4.
Chen RL, Zhang YQ, Wang J, Wu H, Yang SM. Diagnostic value of medical thoracoscopy for undiagnosed pleural effusions. Exp Ther Med 2018;16:4590-4.  Back to cited text no. 4
    
5.
Dowell JE, Gerber DE, Johnson DH. Small Cell Lung Cancer: Diagnosis, Treatment, and Natural History. Fishman's Pulmonary Diseases and Disorders, Michael A. Grippi, MD. McGraw-Hill Education. United states of America. 2015;2:1770-85.  Back to cited text no. 5
    
6.
Lee D, Rho JY, Kang S, Yoo KJ, Choi HJ. CT findings of small cell lung carcinoma: Can recognizable features be found? Medicine (Baltimore) 2016;95:e5426.  Back to cited text no. 6
    
7.
Chhieng DC, Ko EC, Yee HT, Shultz JJ, Dorvault CC, Eltoum IA. Malignant pleural effusions due to small-cell lung carcinoma: A cytologic and immunocytochemical study. Diagn Cytopathol 2001;25:356-60.  Back to cited text no. 7
    
8.
Takeda T, Saitoh M, Fukita S, Takeda S. Small cell carcinoma presenting with massive pleural spread mimicking malignant pleural mesothelioma. Intern Med 2014;53:613-6.  Back to cited text no. 8
    
9.
Shojaee S, Singh I, Solsky I, Nana-Sinkam P. Malignant pleural effusion at presentation in patients with small-cell lung cancer. Respiration 2019;98:198-202.  Back to cited text no. 9
    
10.
Ryu JS, Lim JH, Lee JM, Kim WC, Lee KH, Memon A, et al. Minimal pleural effusion in small cell lung cancer: Proportion, mechanisms, and prognostic effect. Radiology 2016;278:593-600.  Back to cited text no. 10
    
11.
Marwah V, Bhattacharyya D, Ali MF, Rajput AK, Sengupta P, Bhati G. Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural effusions. Med J DY Patil Vidyapeeth 2020;13:525-8  Back to cited text no. 11
    


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