Oncology 36: 184-186 (1979)

Pleural Effusion Secondary to Tumor Regression Jacob J. Lokich Department of Medical Oncology. Sidney Färber Cancer Institute, Boston, Mass.

Key Words. Nonmalignant pleural effusion • Tumor regression induced effusion Abstract. 2 patients with metastatic cancer (Ewing’s sarcoma and breast cancer) developed pleural effusions while undergoing systemic therapy for pulmonary métastasés. Thoracenteses failed to reveal malignant cells and in both instances the characteristics of the fluids were those of transudates. The effusions developed in associa­ tion with dissolution of pulmonary lesions and presumably represent a reactive process to tumor regression

Case Reports Case /. D.C. is a 17-year-old boy who presented in September 1976 with a clinical syndrome of chronic low back pain with an acute exacerbation and progressive generalized weakness. At hospitalization

he was found by chest roentgenograph to have multiple pulmonary nodules. Radiographs of the bones revealed a large combined osteo­ blastic-osteolytic lesion in the right ilium. Surgical biopsy of the latter lesion was consistent with Ewing's sarcoma and the patient w'as initiated on a combination chemotherapy regimen of cyclophospha­ mide, adriamycin, and dimcthyl-triazeno-imidazole-carboxamide. 2 weeks following the initial course of chemotherapy, the patient had complete regression of all pain, but had developed dyspnea on exer­ tion and on examination was found to have physical signs consistent with a right pleural effusion. Chest roentgenogram demonstrated the right pleural effusion and. in addition, close inspection revealed dis­ solution of all previously noted pulmonary parenchymal nodules. A thoracentesis was performed and 1,400 cm’ of serous fluid was re­ moved which, on cytologic examination was found to contain only mesothelial cells. The fluid was. in addition, analyzed for protein content, LDH. SGOT, and specific gravity, all of which were normal and consistent with a transudate. Chemotherapy was continued at 3-week intervals and a follow-up chest X-ray, 4 weeks following the initial pleural effusion, demonstrat­ ed regression of the effusion and persistent regression of all pulmo­ nary nodules. A pictorial summary of the clinical events is seen in figure 1. Case 2. A.L. is a 51-year-old, gravida IV, para IV, woman who developed a left breast mass in 1972. A modified radical mastectomy for carcinoma revealed involvement of a single node. The patient was followed and in 1976 developed a subcutaneous lesion which was surgically removed. 9 months later the patient developed a left pleural effusion and a single pulmonary nodule was seen in the right lung field. She underwent cophorectomy while actively menstruating and 2 weeks later the left pleural effusion increased in size and the patient developed major dyspnea. Radiographic examination revealed dis­ appearance of the pulmonary nodule in the right lower lung and in­ creased left pleural effusion. Thoracentesis failed to reveal malignant

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The development of pleural effusion in patients with underlying malignant disease is generally a manifesta­ tion of hematogenous métastasés and the pathophysiol­ ogic mechanism for the production of the effusion is either lymphatic obstruction by the tumor with transuda­ tion secondary to increased oncotic pressure, or alter­ natively, a direct irritant effect of tumor implants on the pleural surface with exudation of high protein content fluid and tumor cells [1—3]. 2 patients develop­ ed acute symptomatic pleural effusions while undergoing systemic therapy (drug therapy and hormonal ablation respectively) for parenchymal metastatic disease within the lungs. The initial interpretation was that the tumor was progressing and resistant to therapy. However, the effusions resolved over a short period of observation and therapy was not interrupted. This report is intended to document the association of acute effusions with tumor regression and to empha­ size the need for evaluating all monitorable parameters of disease when acute effusions develop in patients undergoing therapy.

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Fig. 1. Sequential chest radiographs in Case 1 indicating pulmonary nodule circle which disappeared at 2 weeks with the develop-

mcnt of the right pleural effusion (center X-ray) that subsequently resolved.

Fig. 2. Sequential chest radiographs in Case 2 indicating solitary pulmonary nodule (circle) which disappeared with increasing left

pleural effusion (center). Resolution of effusion was evident at 6 weeks.

cells and chemical evaluation was consistent with a transudate. I month later, follow-up chest radiograph revealed complete dissolu­ tion of the previous effusion (fig. 2).

for a transudate and, in addition, cytologic examination failed to reveal malignant cells. The initial absence of inflammatory cells suggests that the effusions may be secondary to transient lymphatic obstruction rather than regional inflammation. The key issue in the patients reported is that pleural effusions in this setting do not necessarily imply failure of therapy. Fortuitously, the presence of parenchymal nodules permitted the appreciation of a clinical anti­ tumor response, but it is conceivable that subclinical disease in the lungs and pleura could respond similarly with secondary effusions and be misinterpreted as re­ presenting progressive unresponsive metastases. It is, therefore, critical to analyze all parameters of disease in the evaluation of therapeutic programs and pleural effusions should not be considered a measurable param­ eter of disease.

Discussion Pleural effusion is a not uncommon manifestation of metastatic cancer. In the cases cited, however, the effusions developed during the course of systemic ther­ apy (chemotherapy and ablation). The mechanism for the development of effusions secondary to therapy is inclear, but possible pathophysiologic processes are: (1) necrosis of pleural-based tumor with secondary inflammation; (2) obstruction to lymphatic channels within the pleural envelope by tumor cell debris and inflammatory cells; or (3) a combination of the two. The chemical characteristics of the fluid were typical

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Pleural Effusion Secondary to Tumor Regression

Lokich

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1 Black, L.F.: The pleural space and pleural fluid. Mayo Clin. Proc. 47: 493-506 (1972). 2 Light, R. W.; Macgregor, 1.; Luchsinger, P. C., et al.: The diagnostic separation of transudates and exudates. Ann. intern. Med. 77: 507-513 (1972).

3 Storey, D.D.; Dines, D.E., and Coles, D.T.: Pleural effusion: a diagnostic dilemma. J. Am. med. Ass. 236: 2183-2186(1976).

Jacob J. Lokich, MD, Sidney Farber Cancer Institute, 44 Binney Street Boston, MA 02115 (USA)

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References

Pleural effusion secondary to tumor regression.

Oncology 36: 184-186 (1979) Pleural Effusion Secondary to Tumor Regression Jacob J. Lokich Department of Medical Oncology. Sidney Färber Cancer Insti...
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