Delayed Chylothorax during Treatment of Follicular Lymphoma with a Malignant Pleural Effusion

Abstract

Chylothorax occurs following dysfunction or disruption of the lymphatic drainage along the thoracic duct. Malignant and traumatic causes account for the majority of these occurrences, with lymphoma accounting for 11-37% of chylothoraces. The clinical course of chylothorax may include dehydration, malnutrition, immunosuppression, electrolyte disturbances, infection, and ultimately death. Management of chylothorax is patient-specific and is based on etiology and surgeon experience. Initially, most chyle leaks are managed with nonoperative strategies, such as gut rest, hyperalimentation, and pleural drainage, and, at times, medium-chained fatty acid diet or octreotide, with hopes to decrease chyle production (Zabeck et al. (2011)). High-output chyle leaks following iatrogenic injury or trauma are commonly managed with thoracic duct ligation. Lymphangiography with or without thoracic duct embolization has become increasingly popular and efficacious with the possible benefit of less morbidity (Cope et al. (2002)). We report a case of a 61-year-old male with delayed chylothorax while having an indwelling pleural catheter for malignant pleural effusion during treatment of follicular lymphoma. Percutaneous thoracic duct embolization was attempted but was unsuccessful. Chemotherapy, fluid management, and nutritional support allowed this to resolve over the course of ninety days from diagnosis. We describe the patient’s clinical course and highlight nonoperative management of delayed chylothorax in the setting of follicular lymphoma treatment.

Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders

“…This is corroborated by the fact that patients in the present cohort all had non-malignant effusions making direct infiltration of larger lymph-vessels unlikely. This is in line with a previously reported low rate of only 20% of lymphoma cells in chylous effusions [ 12 , 18 – 22 ].…”

“…This is particularly helpful for further treatment planning in non-traumatic chylous effusions as, in contrast to traumatic lymph vessel injuries, the underlying lymphatic abnormality is typically unknown prior to imaging. In addition, iodized-oil used for XRL can also have a therapeutic effect by sealing of leakage sites with considerably less morbidity compared to surgical approaches [ 1 , 8 , 11 , 18 , 33 ]. It is currently assumed that leaking iodized-oil directly blocks the leakage and that secondary sterile inflammation leads to formation of scar tissue [ 11 , 34 , 35 ].…”