Chylous pleural effusion in a clinical case of large B-cell non-Hodgkin lymphoma

The article was written by Dr. Pham Thi Viet Huong - Doctor of Hematology - Oncology - Hematology and Cell Therapy Unit - Vinmec Times City International General Hospital.

Chylous pleural effusion is a rare complication of both traumatic and non-traumatic events, occurring in approximately 2% of adult pleural effusions. An estimated 2.4 liters of chyme is transported each day through the lymphatic system. Injury or rupture of the thoracic duct can cause a rapid and massive accumulation of chyme in the pleural space.

First, increased pressure in the thoracic duct can cause retrograde chyme outflow through the parietal pleura lymph into the pleural space. Another mechanism is the invasion of lymphoma into the thoracic duct, which makes the thoracic duct susceptible to rupture. Lymph drains into the pleural space, causing nutritional, metabolic, immunological and respiratory complications. The most common non-traumatic cause is malignancy, especially lymphoma. Chylous pleural effusion is a rare complication of both Hodgkin lymphoma and non-Hodgkin lymphoma (ULAKH). The pleural effusion in lymphoma is different from the pleural effusion due to other cancers and has both transudative and exudative features. This condition can be dangerous and fatal, with an estimated 10% of mortality and morbidity on average. Chylous pleural effusions are uncommon and are rarely described in ULAKH of any histology or malignancy. Although patients often have diffuse lymphoma, lesions on the diaphragm are not always present. This serious clinical complication may not be apparent at the time of diagnosis. It is usually a chronic complication, and its course does not reflect successful treatment of the lymphoma. Confirm the diagnosis by quantifying cholesterol and triglycerides in the pleural fluid. Treatment can be either conservative or aggressive depending on the clinical setting.
Treatment of chylous pleural effusion is often long and depends on the type, its duration, the degree of chylous loss and the general health of the patient. In general, the important solutions to the treatment of chylous pleural effusion include effective cancer therapy and complementary interventions such as parenteral nutrition, treatment of concomitant infections as well as rehabilitation. power. Recurrent cancer-associated chylous effusions are generally managed pleurally with talcum powder or by indwelling pleural catheter (IPC) in a palliative care setting to reduce complications. symptoms and improve quality of life. We report a clinical case of persistent, persistent chylous effusion in a patient with ULAKH who had long-term remission and complete resolution of the chylous pleural effusion after combined chemotherapy and emergency treatment. by placing drainage of the membrane. The objective of this paper is to present our experience in the conservative management of malignant non-traumatic chylous pleural effusion.

A 72-year-old female patient was diagnosed with non-Hodgkin lymphoma, 4 weeks before admission, the patient appeared fatigue, anorexia, acute shortness of breath, or night sweats. In addition, the patient presented with a feeling of heaviness in the head and transient facial swelling. The patient before being admitted to the Emergency Department (ICU) of Vinmec Times City Hospital at 10 pm on August 7, 2020. At the time of admission, the patient felt increased shortness of breath, swelling of the legs and face, and oliguria. The patient had a 10-year history of hypertension and a 6-year history of stroke. No history of pre-existing lung or autoimmune disease, recent trauma or surgery, no smoking.
At the Intensive Care Unit from August 7, 2020 to August 12, 2020, the patient was very tired and weak; Blood pressure 140/79 mmHg, heart rate 79 beats/min, respiratory rate 28 beats/min and SpO2 92% when breathing air, ECOG is 3. Clinical examination decreased ventilation, the patient's alveolar murmur gradually decreased in Right chest with low-grade percussion. The patient had generalized edema and had a firm, non-motile left supraclavicular node, measuring 3 cm. Abdominal examination revealed a nodular mass occupying the hypogastrium and umbilicus. Chest X-ray showed a large right pleural effusion. Whole-body computed tomography revealed a tumor of the superior mediastinum and mediastinum measuring 102 x 104 mm, numerous cervical, axillary, aorta and mesenteric lymph nodes with the largest size of 190 x 120 mm and surrounds the abdominal aorta and the iliac arteries. Full-body computed tomography also showed pelvic dilatation, 46 mm of free intra-abdominal fluid, bilateral pleural effusion and pericardial effusion, and no hepatosplenomegaly. The patient's dyspnea improved significantly after thoracoscopy, which aspirated 500ml of milky white fluid from the right pleural space daily (Figure 1). Pleural fluid is usually an exudate with a triglyceride level of 5.25 mmol/L, lipase 19.8 U/L and cholesterol 3.13 mmol/L. The number of white blood cells in the pleural fluid is 5018 cells/mm3, lymphocytes 20%, neutrophils 80%. Pleural fluid has a protein content of 41.7 g/l and pleural fluid LDH is 368 IU/L. The pleural fluid analysis was negative for malignant cells. Pleural fluid culture was negative. Diagnosis of chylous pleural effusion was confirmed by lipoprotein electrophoresis of the pleural fluid, demonstrating the presence of chylomicrons; Triglyceride in pleural fluid is 5.25 mmol/L. Our patient has acute renal failure. Echocardiography showed atrial fibrillation with a heart rate of 134-170 beats/min, arrhythmias, normal cardiac function with an ejection fraction of 67%, and pericardial effusion. Bone marrow aspiration could not be performed because the patient had difficulty breathing. Real-time PCR MTB/NTM test showed that the patient was not infected with mycobacterium tuberculosis, not infected with non-tuberculosis mycobacteria.

Initial tests: Patient has mild microcytic anemia, normal electrolytes, urea 15 mmol/L, creatinine 247 μmol/L, coagulation tests normal, uric acid 1049 μmol/L, NT- proBNP 1691 pg/ml, and LDH 480 U/L, urine albumin 80 mg/l. The patient had no evidence of filariasis in the blood. Blood culture negative.
The patient was transferred to our Inpatient Department of Stem Cell Transplant Hematology Unit after 5 days of care in the ICU. Biopsy of the left supraclavicular lymph node suggested diffuse large B-cell ULAKH with CD 20+ germline type. Immunohistochemical staining results: CD20+; CD10+; BCl6+; MUM1-; CD79a+; PD1-; ALK-; CD30-; CD3- ; CD5-; CD4-; CD8-; TdT. The patient was classified as stage IIIB according to Ann Arbor and the International Prognostic Index was 5/5. We finally confirmed that the patient with stage IIIB ULAKH had tumor lysis syndrome, bilateral chylous pleural effusion, and chyloperitoneum (Figure 3). At that time, the patient's prognosis was poor. The patient's risk of death is very high due to renal failure, heart failure, respiratory failure, depression, immunosuppression, infections and electrolyte disturbances.

Our patient was treated with a combination of Rituximab and Cyclophosphamide, Vincristine, and Prednisolone (R-CVP protocol), pleural drainage, and a low-fat diet containing long- and medium-chain triglycerides (R-CVP). long-chain, medium-chain triglyceride), active treatment of tumor lysis syndrome, drugs for atrial fibrillation, heart failure, special regimen monitoring and close monitoring. The patient achieved a near complete response after 8 cycles of R-CVP chemotherapy. The right pleural tube was removed after 2 cycles of chemotherapy due to resolution of the pleural effusion both on physical examination and on chest radiograph (Figure 4). Considering the extent of the residual damage after 8 cycles of chemotherapy is not much, the elderly, have a background disease of high blood pressure and heart failure for many years, so we consulted and decided to continue chemotherapy step 2 of the treatment regimen. followed by R-CEOP regimen (Rituximab, Cyclophosphamide, Etoposide, Vincristin, Prednisolone).

Currently, the patient is receiving step 2 chemotherapy. The patient is healthy, eats and sleeps well, walks normally at home.
This is a late stage ULAKH disease, severe complications due to the disease, high risk of death from the time of diagnosis, but it has been accurately diagnosed, timely emergency, good treatment and initial positive results. Hopefully the treatment can help the patient live a long time.

Vinmec is one of the first hospitals in Vietnam to apply a multimodal cancer treatment model, in addition to traditional methods such as surgery, radiation therapy, and chemotherapy. Modern methods such as immunotherapy, combining active supportive therapies such as strengthening the autologous immune system, thermotherapy... are also included in Vinmec's treatment to help cancer patients improve their effectiveness. treatment outcomes and quality of life.
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