A Case of Chylothorax

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A Case of Chylothorax

  1. 1. Dr.E.Thirulogachandar PROF.S.TITO’S UNIT
  2. 2. <ul><li>Karthik a 15 yr male admitted with </li></ul><ul><li>c/o </li></ul><ul><li>swelling of Rt.chest-1 week </li></ul><ul><li>breathlessness -1 week </li></ul><ul><li>dry cough- 1week </li></ul><ul><li>fever -4 days </li></ul>
  3. 3. <ul><li>HOPI; </li></ul><ul><li>H/o Swelling Rt.upper chest -1 week </li></ul><ul><li>Onset was spontaneous, progressively increased to face over a period of 3 weeks after admission. </li></ul><ul><li>No h/o trauma. </li></ul><ul><li>H/o breathlessness -1 week grade 3 on onset progressed to grade 4 after 3 weeks. </li></ul><ul><li>H/o dry cough -1 week. </li></ul><ul><li>H/o fever -4 days low grade. </li></ul><ul><li>Noh/o chestpain, </li></ul><ul><li>syncope, </li></ul><ul><li>haemoptysis, </li></ul><ul><li>hoarseness of voice </li></ul>
  4. 4. <ul><li>Past history:nil relevant </li></ul><ul><li>Personal history :mixed diet </li></ul><ul><li>Family history : nil significant illness </li></ul><ul><li>General examn: pt conscious, </li></ul><ul><li>oriented, </li></ul><ul><li>febrile </li></ul><ul><li>comfortable, </li></ul><ul><li>pallor+, </li></ul><ul><li>not jaundiced, </li></ul><ul><li>no cyanosis, </li></ul><ul><li>no clubbing, </li></ul><ul><li>no lymphadenopathy. </li></ul><ul><li>Pulse:82/mt,BP 96/72 mmHg,RR-17/mt </li></ul>
  5. 6. <ul><li>Inspection&palpation: </li></ul><ul><li>Rt. Upper chest is swollen with fullness supraclavicular region, </li></ul><ul><li>Trachea in midline, </li></ul><ul><li>AI in normal place, </li></ul><ul><li>movements diminished Rt.side, </li></ul><ul><li>vocal fremitus increased in </li></ul><ul><li>Rt.infraclavicular,axillary&suprascapular regions </li></ul><ul><li>Percussion : impaired resonance present in Rt.infraclavicular,axillary and suprascapular regions. </li></ul>
  6. 7. <ul><li>Auscultation :Bilateral air entry prtesent </li></ul><ul><li>NVBS+bilaterally </li></ul><ul><li>Br.breath sounds present in Rt.infraclavicular,axillary suprascapular and areas. </li></ul><ul><li>VR increased in same regions </li></ul><ul><li>CVS: S1,S2 heard,no murmurs </li></ul><ul><li>Abd:soft,no organomegaly </li></ul><ul><li>CNS:no FND. </li></ul>
  7. 8. <ul><li>MASS lesion Rt. Upper lobe-?cause </li></ul>
  8. 9. CBC-Hb-8.6 BLOOD-SUGAR-96 TC-7400 UREA-18 DC-P72L27E3 CREATININE-0.7 ESR-12/24 Na-134,K-3.9 PCV-24% LFT-WNL PLT-1.OLAC MCV-72.5 MCH-27.4 MCHC-30.1 RBC 3.0 MILLIONS URINE-ALB-nil sug-nil dep-1-4pc/hpf
  9. 15. <ul><li>Pleural fluid Analysis: </li></ul><ul><li>colour-milky white </li></ul><ul><li>Gram’s stain&AFB- neg </li></ul><ul><li>culture-neg </li></ul><ul><li>Cholesterol-214mg/dl </li></ul><ul><li>TGL-2800mg/dl </li></ul><ul><li>USG Abd;NORMAL WITH Lt.pleural effusion </li></ul>
  10. 16. <ul><li>CT guided FNAC-Necrotic mass with inflammation </li></ul><ul><li>Biopsy-skeletal muscle bundles with blood clot-non diagnostic </li></ul>
  11. 17. <ul><li>β HCG-neg </li></ul><ul><li>α -FP-neg </li></ul><ul><li>LDH-neg </li></ul><ul><li>Ab to Ach receptor-not done </li></ul>
  12. 19. <ul><li>CTS OPINION:As he had massive pleural effusion-chylothorax with respiratory distress Lt.ICD was placed chyle was drained. </li></ul><ul><li>about 200 ml of chyle was draining daily. </li></ul>
  13. 21. <ul><li>In view of diagnostic dilemma -5 weeks and GC deterioration of the pt, he was sent to CTS Dept,GGH,Chennai . </li></ul>
  14. 22. <ul><li>CT-guided biopsy repeated-nondiagnostic </li></ul><ul><li>Planned open biopsy and deferred. </li></ul><ul><li>Finally median sternotomy and whole tumour was excised and sent for HPE. </li></ul>
  15. 24. <ul><li>Thymoma –stage B 1 </li></ul>
  16. 25. <ul><li>CHYLOTHORAX: </li></ul><ul><li>1.Malignancy (50%) </li></ul><ul><li>lymphoma(3/4),Br.car </li></ul><ul><li>2.trauma,surgery-25% </li></ul><ul><li>3.Miscellaneous- </li></ul><ul><li>sarcoidosis,ccf </li></ul><ul><li>lymphangiomatosis, </li></ul><ul><li>yellow nail syndrome, </li></ul><ul><li>kaposi’s sarcoma, </li></ul><ul><li>post RT, </li></ul><ul><li>Tb,filariasis,histoplasmosis,cirrhosis </li></ul><ul><li>4.Idiopathic-neonatal </li></ul>
  17. 26. <ul><li>Conservative 50% resolve </li></ul><ul><li>Octreotide </li></ul><ul><li>Cessation of oral intake </li></ul><ul><li>Total parenteral nutrition </li></ul><ul><li>SURGICAL TREATMENT: </li></ul><ul><li>Thoracic duct ligation </li></ul><ul><li>Pleurodesis </li></ul><ul><li>Pleuro peritoneal shunt </li></ul><ul><li>pleurectomy </li></ul><ul><li>SURGICAL INDICATION:>1litre/day for 2 days or persistent leak for 2 weeks, </li></ul><ul><li>nutritional,metabolic complications, </li></ul><ul><li>post oesophagectomy status </li></ul>Treatment of chylothorax MEDICAL
  18. 27. anterior anterior Anterior Posterior-Des.aorta,azygosvein,nodes,ganglia Middle-Heart,tachea,bronchus,nodes,vessels THYMUS,FAT,NODES
  19. 30. <ul><li>the functional unit of the thymus gland is the Lobule </li></ul><ul><ul><li>composed of a cortex & medulla </li></ul></ul><ul><ul><li>epithelial cells </li></ul></ul><ul><ul><li>lymphocytes </li></ul></ul><ul><li>thymomas are, by definition, primary tumors of benign-appearing thymic epithelial cells </li></ul>
  20. 31. <ul><li>Separated into three histologic categories— </li></ul><ul><li>1. Thymoma. </li></ul><ul><li>2. Thymic carcinoma. </li></ul><ul><li>3.Neuroendocrine tumor. </li></ul>
  21. 32. <ul><li>Given this definition, most thymomas are “benign” </li></ul><ul><ul><li>the majority behave in an indolent fashion </li></ul></ul><ul><ul><li>however, they can invade and metastasize (uncommon) </li></ul></ul><ul><ul><li>when a thymoma is contained within the thymic capsule, it is referred to as “benign” or “noninvasive” </li></ul></ul><ul><ul><li>when it penetrates through the capsule, it is referred to as “malignant” or “invasive” </li></ul></ul>
  22. 33. <ul><li>Represent 20% of all mediastinal neoplasms in adults </li></ul><ul><li>Most common anterior mediastinal neoplasm in adults (less common in children) </li></ul><ul><li>incidence of thymoma is 0.15 cases per 100,000 </li></ul><ul><li>Age range is generally 40-60 </li></ul><ul><li>Equal prevalence on gender. </li></ul><ul><li>No known risk factors (+/- myasthenia gravis) </li></ul><ul><li>Thymic carcinoma represents less than 1% of thymic malignancies. </li></ul>
  23. 34. <ul><li>95% in anterior mediastinum. </li></ul><ul><li>Neck. </li></ul><ul><li>Left hilar region. </li></ul><ul><li>Within lung parenchynma. </li></ul><ul><li>Anterior cardiophrenic angle. </li></ul>
  24. 35. <ul><li>Most important gross feature — The presence or absence of encapsulation of tumor and the gross invasion into adjacent structure. </li></ul><ul><li>The invasion present — The thymoma must be considered malignant lesion regardless the microscopic appearance. </li></ul><ul><li>Extensive spread. </li></ul><ul><li>Incidence of distal metastasis is 3%. </li></ul>
  25. 38. <ul><li>Stage I: Intact capsule or growth within the capsule </li></ul><ul><li>Stage II: Invasion into surrounding fatty tissue or mediastinal plura </li></ul><ul><ul><li>Stage IIA: microscopic invasion through the capsule </li></ul></ul><ul><ul><li>Stage IIB: macroscopic and microscopic invasion through the capsule </li></ul></ul><ul><li>Stage III: Macroscopic invasion into neighboring organs (pericardium, great vessels, lung) </li></ul><ul><li>Stage IVA: Pleural or pericardial dissemination </li></ul><ul><li>Stage IVB: Lymphogenous or hematogenous metastases </li></ul><ul><ul><li>Masaoka et al. Cancer 1981;48:2484-2492 </li></ul></ul>
  26. 41. <ul><li>40-60 yrs. </li></ul><ul><li>Sex distribution — Equal. </li></ul><ul><li>- asymptomatic in 1/3 of pts </li></ul><ul><li>- chest pain, breathlessness, cough, SVC </li></ul><ul><li>syndrome, paralysis of hemidiaphragm </li></ul><ul><li>-hoarseness, weight loss, fatigue, fever, </li></ul><ul><li>If ass. With MG-Mc in women </li></ul><ul><li>Fatiguablity,ptosis,diplopia,dysphagia, </li></ul><ul><li>weakness </li></ul>
  27. 43. <ul><li>Standard posteroanterior and lateral chest radiographies. </li></ul><ul><li>CXR—Smooth or lobulated mas, right side the silhouette sign present, left side the sign abscent. </li></ul><ul><li>Calcification — 10%. </li></ul><ul><li>CT—Delineate the extent of mass, cannot not differentiating benign and malignant, assessing intrathoracic spread of an invasive thymoma. </li></ul><ul><li>Ach receptor Ab </li></ul>
  28. 44. <ul><li>Unnecessary for a suspected locally symptomatic thymoma, because the capsule of tumor may be violated by invasive procedure. </li></ul><ul><li>Only distinguish the tumor from the other malignant tumour. It is to establish the diagnosis before making decision of therapy. </li></ul><ul><li>Fine needle biopsy by CT or sono-guide. </li></ul><ul><li>Extend substernal mediastinoscopy. </li></ul><ul><li>VATS. </li></ul>
  29. 45. <ul><li>Stage-Directed </li></ul><ul><ul><li>Stage I: Surgical resection only </li></ul></ul><ul><ul><li>Stage II: Surgical resection +/- adjuvant radiotherapy </li></ul></ul><ul><ul><li>Stage III: Surgery with adjuvant radiotherapy or neoadjuvant chemotherapy, surgery, and adjuvant radiotherapy </li></ul></ul><ul><ul><li>Stage IV: Chemoradiotherapy without surgical resection </li></ul></ul>
  30. 46. <ul><li>Cisplatin remains cornerstone of therapy </li></ul><ul><li>“ CODE” regimen: neoadjuvant cisplatin, epirubicin/doxorubicin, etoposide. Improved survival in pts with stage III and IV dz when compared with historic controls. </li></ul><ul><li>Somatostatin or somatostatin analogs with prednisolone have been reported to induce both PR and CR in pts with refractory disease </li></ul>
  31. 49. <ul><li>Thymoma is associated with a wide variety of paraneoplastic syndromes </li></ul><ul><li>Mechanism is unknown </li></ul><ul><li>Theory: </li></ul><ul><ul><li>medullary/dendritic cell areas are required for induction of tolerance. </li></ul></ul><ul><ul><li>If these areas are abnormal, positively selected autoreactive CD4+ T-cells may escape surveillance and generate autoantibody-producing B-cells </li></ul></ul>
  32. 52. <ul><li>Most commonly associated disease. </li></ul><ul><li>30-50%of patient with thymoma associate with MG. </li></ul><ul><li>Only 10-15% patient with MG have thymoma. </li></ul><ul><li>Little effect on local presention, clinical behavior, prognosis. </li></ul>
  33. 53. <ul><li>In the Johns Hopkins series 10%of pts with thymoma had PRCA, 2 nd most common paraneoplastic syndrome </li></ul><ul><li>Antigen has not been determined </li></ul><ul><li>Usually responds to rx with corticosteroids </li></ul>
  34. 54. <ul><li>Def: thymoma, hypogammaglobulinemia, defects in cell-mediated immunity (low or absent B cells, CD4 lymphopenia, and inverted CD4:CD8 ratio </li></ul><ul><li>Develops in 3-6% of pts with thymoma </li></ul><ul><li>Most develop syndrome within six years of dx of thymoma </li></ul><ul><li>Immunologic abnormalities do not correct with corticosteroids or thymectomy </li></ul><ul><ul><ul><ul><ul><li>Tarr et al. Medicine. Vol 80 No 2 March 2001 </li></ul></ul></ul></ul></ul>
  35. 55. <ul><li>Recurrent sinopulmonary infections </li></ul><ul><li>Mucocutaneous candidiasis </li></ul><ul><li>Encapsulated organisms </li></ul><ul><li>CMV, HSV, VZV </li></ul><ul><li>PCP </li></ul><ul><li>MTB </li></ul><ul><ul><ul><ul><ul><li>Tarr et al. Medicine. Vol 80 No 2 March 2001 </li></ul></ul></ul></ul></ul>
  36. 56. THANK YOU
  37. 57. Mayo Clin Proc. 2005;80(7):867-870 Tumourrs of mediastinum –CHEST 2005;126; 2693-2909 European journal of CTS 2010;37;13-25 European journal of CTS 2002;21;307-313

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