A Case of Chylothorax
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A Case of Chylothorax

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A Case of Chylothorax A Case of Chylothorax Presentation Transcript

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