Malignancy | PulmPEEPs

As we approach the end of the year, we know that the hospital and clinic keep on rolling, so here is a CXR and pulmonary differential based #RadiologyRounds if you’re on for the holiday blocks A woman in her 50s has hypoxemia after being admitted with a femur fracture

The CXR shows signs of a left upper lobe collapse. The upper lungs should be the most lucent, with increased opacity as you go down. LUL collapse can be subtle, but you can see increased haziness at the lung apex. There is also rib crowding and left hemidiaphragm elevation. You can also see a small luftsichel sign. Luftsichel sign is a thin strip of air that can be seen between the collapsed LUL and the superior mediastinum created by the still-aerated superior segment of the lower lobe. The collapse is better appreciated on CT.

Bronchoscopy was performed to investigate the etiology of the lobar collapse. On the bronchoscopy there was an endobronchial lesion completely occluding the left upper lobe bronchus. The mass was biopsied and sent for histopathology

Endobronchial lesions can be malignant or benign, and within malignancy then can be primary or secondary. This patient had no clinical signs of pneumonia and no clear reason to mucus plug so malignancy was top of the differential. Here are differential considerations:

The pathology returned positive for a carcinoid tumor, which can typically arise as endbronchial lesions. PET/CT showed only local disease (femur fracture unrelated), and she is planned for rigid bronchoscopy with laser therapy and corecath ablation for definitive resection.

We’re diving back into some pleural fluid today (okay that is kind of gross to think about and we apologize). If you haven’t listened to our prior pleural effusion episodes and want to start from the top, then check out Episode 36 for a general approach to pleural effusions, and Episode 37 to hear about parapneumonic effusions. Malignant effusions are another common consult question and we’ll talk about everything from detection to monitoring, to definitive management.

Meet Our Guests

Dr. David DiBardino is an Assistant Professor of Medicine at the University of Pennsylvania Medicine and is the Associate Director for Clinical Research within the Section of Interventional Pulmonology. He is also the Program Director for the Interventional Pulmonary Fellowship there.

Dr. Jamie Bessich is an Assistant Professor of Medicine and Cardiothoracic Surgery at NYU Grossman School of Medicine. She is the Section Chief of Interventional Pulmonology and is the Director of Bronchoscopy at Tisch Hospital.

Dr. Van Holden is an Associate Professor of Medicine at the University of Maryland School of Medicine and is the Pulmonary and Critical Care Fellowship Program Director there. She was last on the show for our very first Fellows’ Case Files when we discussed a fascinating case of pulmonary alveolar proteinosis.

Case Presentation

The page: 72M smoker, new effusion, concern for malignancy, tap?

Further history: 72 year old man with PMH of GOLD B COPD, tobacco use (55 pack years), HTN, HLD, and diabetes. He presented to the ED with progressive dyspnea and fatigue. He is on LAMA/LABA for his COPD, and he does not frequently have exacerbations. He has no increased sputum production or wheezing, but he has been feeling progressively fatigued and lethargic. H Over the past few weeks he has had more dyspnea on exertion, and now has it at rest too. It is a bit worse when he lies flat. He has had no weight gain or edema in his legs and has actually lost 10-15 pounds in the last 3 months. In the ED, he is newly requiring 3-4L NC, has decreased breath sounds on the right, and a CXR shows a large right-sided pleural effusion, as well as a large apical nodule with some spiculation, both of which are new from prior.

Key Learning Points

Causes of malignant pleural effusion

–Lung cancer is the most common in men

–Breast cancer is the most common cause in women

–Lung and breast cancer account for > 50% of all malignant pleural effusions

–Other less common causes are lymphoma, GU or GI tract cancer

–Remember to consider mesothelioma

Prognosis of MPE

–Malignant pleural effusion means the cancer is advanced and stage 4 by definition

–The average life expectancy after a diagnosis of MPE is 3-12 months, depending on the patient and the malignancy

Imaging and MPE

–Make sure to get a CT scan after drainage so no lesions are missed

–Ultrasound can be helpful to look for disruptions of the pleural line, loculated fluid, or pleural nodules

Pleural fluid analysis

–Make sure to send common labs (gram stain, culture, pH)

–Cell count is very important as most MPE are lymphocyte-predominant

–Triglycerides can be helpful as well (more on chylothorax in future episodes)

–Cytology is essential and makes the diagnosis. The sensitivity is 65 – 75 percent so repeat taps may be needed and you need to send at least 60 cc of fluid (often more)

–If you have high suspicion and no diagnosis after two taps, pleuroscopy and pleural biopsy is warranted

Management of MPE

–First you need to determine if the MPE is recurrent. This requires drainage and then monitoring

— The main options are repeat thoracenteses, pleurodesis, or indwelling pleural catheter. A combination can often be used, and shared decision making is essential to the determining the best option

–The three things to consider with recurrent malignant pleural effusion are:

Did the patient feel better after drainage?
Did the lung fully re-expand?
What is the best option for this specific patient to optimize quality of life and time outside of the hospital?

–In AMPLE, pleural cetehters and talc pleurodesis were compared, and both are reasonable options with equivalent outcomes on quality of life; although pleural catehters had fewer hospital days overall.

References and Further Reading