Chylothorax and Superior Vena Cava Syndrome Case Study

Chylothorax and Superior Vena Cava Syndrome Case Study Title: Chylothorax and Superior Vena Cava Syndrome as the Initial Presentation of Non small Cell Lung Cancer, which was Successfully Resolved by Systemic Chemotherapy We define a case report of 35 year old male presented with shortness of breath, dyspnea, heaviness of left chest wall, engorgement of vein in left side chest wall and upper left neck, swelling in left side of the neck, chest pain and cough. At the time of admission, an abnormal round opacity presented in left upper lung lobe and histology shows non-small cell carcinoma with superior vena cava syndrome was diagnosed. MSCT scan report heterogeneous enhancing large soft tissue density mass lesion of size approximately 96 100 mm seen in left upper lobe extending in to whole mediastinum encasing all major vessel including arch of aorta, descending aorta, trachea, esophagus, pulmonary trunk,M PA and all major neck vessels origin. Lesion causing significant luminal narrowing of left main bronchus. Lesion causing obliteration of left brachio-cephalic.Left moderate pleural effusion seen. Heterogeneous attenuated right lung field is seen due to mosaic perfusion. Left sided thoracocentesis done milky white fluid drained from pleural cavity. Ultrasonography guided FNAC left lung done is suggestive of non-small cell carcinoma. Superior vena cava syndrome associated with lung carcinoma with massive chylothorax. Patient received cisplatin and gemcitabine chemotherapy. After chemotherapy taken chylothorax resolution almost completely. Key words: Lung cancer; squamous cell carcinoma; chylothorax; superior vena cava syndrome INTRODUCTION Lung cancer in India commonly accounts 80-85% of non-small cell carcinoma. In Acharya tulsi regional cancer treatment and research institute Bikaner hospital squamous cell carcinoma interpretation for 15% of all cases of NSCLC according to registry. In advanced lung cancer chemotherapy play main role in quality of life and survival. Chylothorax initial symptom of NSCLC is rare but pleural effusion is commonly seen. Chylothorax is mostly seen after complication of lung surgery. But in this case chylothorax is initial presentation with NSCLC with SVC. Incidence of chylothorax is .3-2.4%.[3-5]. Few report of this disorder in current year[2]. We report this case of NSCLC with initial appearance with SVC and chylothorax which resolved almost entirely with chemotherapy CASE REPORT A case report of 35 year old male presented with shortness of breath, dyspnea, heaviness of left chest wall, engorgement of vein in left side chest wall and upper left neck, swelling in left side of the neck, chest pain and cough. He is heavy smoker for 13 year and also chronic alcohol drinker. Patient vital signs at the time of admission pulse rate is 88 per minute, respiratory rate is 26 per minute, BP is 128/84 and temperature in normal limit. On auscultation breathe sound decreased in left side of chest. At the time of admission, an abnormal round opacity presented in left upper lung lobe and histology shows non-small cell carcinoma with superior vena cava syndrome was diagnosed. MSCT scan report heterogeneous enhancing large soft tissue density mass lesion of size approximately 96 100 mm seen in left upper lobe extending in to whole mediastinum encasing all major vessel including arch of aorta,descending aorta, trachea, esophagus, pulmonary trunk,M PA and all major neck vessels origin. Lesion causing significant luminal narrowing of left main bronchus. Lesion causing obliteration of left brachio-cephalic. Left moderate pleural effusion seen.Heterogeneous attenuated right lung field is seen due to mosaic perfusion. Multiple para-esophageal,perigastric, supra-clavicular,superior mediastinum, pre, paratracheal, subcarinal AP window lymphadenopathy are seen,larger measuring approx. 18 mm size. Left sided thoracocentesis done milky white fluid drained from pleural cavity. Ultrasonography guided FNAC left lung done is suggestive of non-small cell carcinoma. Superior vena cava syndrome associated with lung carcinoma with massive chylothorax. Patient received cisplatin and paclitaxil chemotherapy. cisplatin given D1 and D2 schedule. After two cycle chemotherapy taken chylothorax resolve almost completely.Laboratory investigation shows serum creatinine e 1.1 mg /dl, albumin 3.2 mg/dl, total cholesterol 193 mg/dl, serum; triglyceride, 93 mg/dl, LDH is 425 IU/l. thoracocentesis done and 2000 ml milky white coloured fluid drained. Milky fluid biochemistry done and shows triglyceride, 867 mg/dl; l actate dehydrogenase, 332 IU/l; and carcinoembryonic antigen, 6.16 ng/ml.The cytological analysis of fluid revealed no malignant cells. Intercostal tube inserted and fluid is drained and symptom is improved. The clinical stage was T3N2aM0 stage IIIb. Therefore, SCC of the lung complicated by chylothorax and SVCS was diagnosed. . Chemotherapy with paclitaxel (175 mg/m2) and cisplatin (75 mg/m2) was administered on days 1, and cisplatin give in two days in divided dose respectively of six cycle repeat 21-day. The dyspnea and shortness of breath improved after two cycle of chemotherapy and amount of milky fluid drained is gradually tapered in intercostal tube after chemotherapy given. After five cycles chemotherapy patient symptoms improved and neck swelling is disappear and intercostal drained is 230 ml/day so intercostal tube come out and remaining one cycles is given. After 6 cycle complete again CECT chest revealed tumor size significantly decreases and also pleural fluid almost di sappear but superior vena cava symptoms is minimally improved . Then subsequently, the patient put another chemotherapy with gemcitabine and carboplatin, and radiotherapy is given to chest wall 30 gy 300cGy per fraction total 10 fraction in 2 weeks, but the tumor eventually progressed. Discussion The relationship between lung cancer and chylothorax may occur after compression of tumor to thoracic duct so increase pressure to duct and ruptured [6]. Secondly in obstruction in superior vena cava so venous pressure is increased significantly so leakage of chyle from thoracic duct to pleural cavity [7-9]. Another Couse of chylothorax is side effect of radiotherapy because after radiotherapy fibrosis is there and diminishing of lymph circulation [10-13]. This complication of radiation treatment is also observed in many disease like Hodgkin lymphoma (mantle field technique), squamous cell carcinoma in esophagus, breast carcinoma and also lung carcinoma[ 10,11, 12, 13, ]. With out lung surgery chylothorax is rare but this case present chylothorax without surgery. In current year 3 case reported with non small cell carcinoma[2,10,14-16].table 1 shows patient have chylothorax with clinical manifestation and resolve after management. In this table include our case report. The three case report series have 2 male and one female and median age af all three case was 47 yrs. All case non small cell carcinoma sub group is squamous cell carcinoma. Dahlbalk et al.[17] shows squamous cell carcinoma of lung cancer present with thorasic duct fluid in pleural cavity and nodular depositation. All case presented with right side lung carcinoma. Pleural fluid cytology present wih malignant cell. Main dominant feature in case is chylothorax and its present in mainly right pleural space. Treatment of chylothorax is mainly frequently repeated aspiration of pleural fluid, low fatty diet, intercostal tube drainage, and pleurodesis with chemical substance. [6,18] surgical management of chylothorax is thorasic duct ligation and pieuroperitonial shunt are mainly used in when milky coulred fluid is more than 550 ml or more then continues 14 days. In Dahlbalk et al study mainly two case successfully treated with chemical pleurodesis. One patient any intervention not done because general condition is very poor give only paliiative treatment. If chylothorax associated with cloot in brachiocephalic vein or subclavian and jugular vein is treated with anticoagulant therapy. Beghetti et al[8]. studied resistant case of chylothorax associated with superior vena cava syndrome manage with chemotherapy. Our case usual taken four cycle chemotherapy and mostly resoved chylothorax . Thrombus in superior vena cava are correct with treatment of underlying couse. Symptoms of superior vena cava syndrome is extremlly improved with two cycle chemotherapy. It is revealing of a promising response to chemotherapy Table 1 three patients of non-small cell lung cancer presented with Chylothorax Abbreviations: SCC=squamous cell carcinoma; ; RML=right middle lung; RT= radiotherapy; C/T=chemotherapy; NA=not available