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Yang X, Zhang J, Sun P, Liu J, Wang J, Zhu H. Chylopericardium following esophagectomy: a case report and systematic review. J Cardiothorac Surg 2024; 19:50. [PMID: 38310296 PMCID: PMC10838423 DOI: 10.1186/s13019-024-02536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition. CASE PRESENTATION A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy. CONCLUSION Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.
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Affiliation(s)
- Xinglin Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jinghong Zhang
- Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
| | - Pengxia Sun
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jihai Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jiangshan Wang
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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Shintani R, Sekine A, Murohashi K, Otoshi R, Kasuya T, Oda T, Baba T, Komatsu S, Ogura T, Inoue Y. Successful Treatment of Chylothorax and Chylopericardium by Radiotherapy in Lung Cancer. Intern Med 2022; 61:2039-2043. [PMID: 34803099 PMCID: PMC9334222 DOI: 10.2169/internalmedicine.8293-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 58-year-old man was diagnosed with stage IVB lung adenocarcinoma in the right upper lobe and underwent systemic chemotherapy. Seven months after the diagnosis, large left pleural and pericardial effusion was detected. The patient developed both chylothorax and chylopericardium following superior vena cava (SVC) obstruction with mediastinal lymphadenopathy caused by lung carcinoma. Since conservative treatment of the chyle leakage was ineffective, we administered radiotherapy to treat the SVC obstruction and mediastinal lymphadenopathy. After radiotherapy, the chylothorax and chylopericardium gradually resolved, and no further chyle leaks were identified on follow-up computed tomography. This case indicates that radiotherapy can be used to ameliorate lung cancer-related chylothorax and chylopericardium.
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Affiliation(s)
- Ryota Shintani
- Department of Respiratory Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Akimasa Sekine
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Kota Murohashi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Ryota Otoshi
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Takeo Kasuya
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tsuneyuki Oda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Shigeru Komatsu
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Japan
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3
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Rochefort MM. Review of chylopericardium. MEDIASTINUM (HONG KONG, CHINA) 2022; 6:3. [PMID: 35340832 PMCID: PMC8841534 DOI: 10.21037/med-20-64] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/26/2021] [Indexed: 06/14/2023]
Abstract
Chylopericardium is a rare pathologic condition consisting of the accumulation of excess amounts of chylous fluid within the pericardial cavity. Most patients are asymptomatic at presentation; however, chest pressure, chest pain and lightheadedness have been reported, and the most common presenting symptom is shortness of breath. Patients are noted to have enlargement of the cardiac silhouette on routine chest radiograph, and evidence of a pericardial effusion on echocardiography. The diagnosis is only definitively confirmed with pericardiocentesis and fluid analysis. The fluid is typically turbid white or milky in appearance, with a triglyceride level in excess of 500 mg/dL. The mechanism by which chyle accumulates within the pericardium is believed to be secondary to abnormal or damaged lymphatics or due to elevated pressure within the thoracic duct that results in chyle reflux into the pericardium. Following drainage with a pericardiocentesis or pericardial drain, attempts at conservative therapy with nothing by mouth and parental nutrition can be made, but have a high rate of failure and subsequent reaccumulation of chyle. Surgical treatment provides the most definitive management and consists of ligation of the thoracic duct just above the level of the diaphragm and creation of a pericardial window. With this treatment, risk of recurrence is incredibly low (<5%).
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Chylopericardium due to Subclavian Vein Thrombosis in the Setting of Protein S Deficiency. Case Rep Cardiol 2021; 2021:2232057. [PMID: 34877021 PMCID: PMC8645413 DOI: 10.1155/2021/2232057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Chylopericardium is the accumulation of lymphatic fluid in the pericardial cavity. It can be idiopathic or secondary to trauma, cardiothoracic surgery, neoplasm, radiation, tuberculosis, lymphatic duct dysfunction, thrombosis, or other causes. We present a case of chylopericardium due to subclavian vein thrombosis in a patient with protein S deficiency. Clinical Case. A 48-year-old man with a history of protein S deficiency presented to the emergency department with shortness of breath and a productive cough. CT of the chest showed pulmonary emboli, moderate pericardial effusion, and a large thrombus of the superior vena cava, brachiocephalic vein, and subclavian veins. He developed echocardiographic evidence of cardiac tamponade so he underwent pericardiocentesis with drainage of milky-appearing fluid. Analysis of the fluid showed elevated triglycerides consistent with chylopericardium. The pericardial effusion reaccumulated, likely secondary to lymphatic duct obstruction due to his subclavian vein thrombus. Catheter-assisted thrombolysis was performed with resolution of the patient's effusion and symptoms. Conclusion Chylopericardium is a rare but important complication of subclavian vein thrombosis. Management is typically with surgical intervention, although our case represents successful treatment with catheter-assisted thrombolysis.
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Morris AL, Colbourne T, Kirkpatrick I, Banerji V. Complete resolution of chylopericardium after chemotherapy for chronic lymphocytic leukemia. ACTA ACUST UNITED AC 2019; 26:e696-e699. [PMID: 31708663 DOI: 10.3747/co.26.5039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nontraumatic chylous pleural effusions (chylothorax) and pericardial effusions (chylopericardium) are rare. They can, however, accompany intrathoracic malignancies and, most commonly, lymphomas. An association of chronic lymphocytic leukemia (cll) with chylopericardium has rarely been reported. A 68-year-old woman with cll, previously treated with single-agent fludarabine in the community, developed pleuritic chest pain and a new pericardial effusion. Computed tomography (ct) imaging of her chest revealed a large pericardial effusion with progressive lymphadenopathy. Pericardiocentesis identified a chylous effusion, and complete evacuation was achieved by catheter drainage. The cll was not treated. An asymptomatic pericardial effusion subsequently recurred. Pericardiocentesis was not repeated. Lymph node biopsy and flow cytometry revealed no evidence of large-cell lymphoma transformation. The patient was treated with 6 cycles of chlorambucil and obinutuzumab. Imaging of her chest by ct between cycles 2 and 3 revealed a marked resolution of the intrathoracic lymphadenopathy, with complete disappearance of the pericardial effusion. Repeat imaging at 5 months and again at 3 years after completion of chemotherapy demonstrated no recurrence of either the lymphadenopathy or the pericardial effusion. The mechanism of production and the treatment of chylous effusions are poorly defined. In this case, resolution of the pericardial effusion with effective chemotherapy is postulated to have alleviated obstruction of anterograde lymphatic flow facilitating drainage into the systemic venous system and allowing for spontaneous complete resolution of the pericardial effusion without surgical intervention.
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Affiliation(s)
- A L Morris
- St. Boniface Hospital, University of Manitoba, Winnipeg, MB.,Department of Internal Medicine, University of Manitoba, Winnipeg, MB
| | - T Colbourne
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB
| | - I Kirkpatrick
- St. Boniface Hospital, University of Manitoba, Winnipeg, MB.,Department of Internal Medicine, University of Manitoba, Winnipeg, MB.,Department of Radiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | - V Banerji
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB.,CancerCare Manitoba, Winnipeg, MB
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Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921-2964. [PMID: 26320112 PMCID: PMC7539677 DOI: 10.1093/eurheartj/ehv318] [Citation(s) in RCA: 1351] [Impact Index Per Article: 150.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Yehuda Adler
- Corresponding authors: Yehuda Adler, Management, Sheba Medical Center, Tel Hashomer Hospital, City of Ramat-Gan, 5265601, Israel. Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel, Tel: +972 03 530 44 67, Fax: +972 03 530 5118,
| | - Philippe Charron
- Corresponding authors: Yehuda Adler, Management, Sheba Medical Center, Tel Hashomer Hospital, City of Ramat-Gan, 5265601, Israel. Affiliated with Sackler Medical School, Tel Aviv University, Tel Aviv, Israel, Tel: +972 03 530 44 67, Fax: +972 03 530 5118,
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7
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Wait MA, Ramsay MAE, Hardaway BW, Capehart JE, Rosenblatt RL. Chylopericardium following orthotopic lung transplantation. Proc (Bayl Univ Med Cent) 2013; 26:280-2. [PMID: 23814391 DOI: 10.1080/08998280.2013.11928983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Chylopericardium is an uncommon condition, reported to occur following routine cardiac surgery, orthotopic heart transplantation, cardiac trauma, intrathoracic tumors, or infection. It has not, to date, been reported following uncomplicated orthotopic lung transplantation. This article describes chylopericardium following bilateral orthotopic lung transplantation.
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Affiliation(s)
- Michael A Wait
- Department of Thoracic and Cardiovascular Surgery, The University of Texas Southwestern Medical Center, Dallas Texas (Wait); and the Department of Anesthesiology (Ramsay), the Division of Cardiology (Hardaway) and Division of Pulmonary and Critical Care (Rosenblatt), Department of Internal Medicine, and the Department of Thoracic and Cardiovascular Surgery (Capehart), Baylor University Medical Center at Dallas
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8
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Erdoğan E, Bacaksiz A, Akkaya M, Tasal A, Sönmez O, Elbey MA, Göktekin Ö. An unusual presentation of lymphoma: chylotamponade. Heart Lung 2012; 41:617-20. [PMID: 22465579 DOI: 10.1016/j.hrtlng.2012.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/14/2012] [Accepted: 02/14/2012] [Indexed: 11/27/2022]
Abstract
Chylopericardium is an uncommon but potentially life-threatening clinic entity. Here we reported a case with chylopericardium causing tamponade and shock as an unusual presentation of lymphoma. The patient was managed by immediate pericardiocentesis. Further analysis of the pericardial fluid revealed immature T-cells compatible with precursor T-lymphoblastic lymphoma.
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Affiliation(s)
- Ercan Erdoğan
- Department of Cardiology, BezmiÂlem Foundation University, Fatih/Istanbul, Turkey.
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Chylopericardial tamponade masquerading as hemopericardium: an uncommon complication of cardiac surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 6:129-32. [PMID: 22437898 DOI: 10.1097/imi.0b013e318216af7e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chylopericardial tamponade occurs very rarely after heart surgery. It may be the result of lymphatic duct interruption during mammary artery harvest, division of a large thymic remnant, or thrombosis of the subclavian or internal jugular vein by an indwelling central line. Although relatively straightforward when the pericardial aspirate has the usual milky appearance, the correct diagnosis can easily be overlooked particularly early after surgery when the patient is still fasting. We present a case report that illustrates the importance of sending all aspirates for chemical analysis irrespective of their color to arrive at the correct diagnosis and institute the appropriate medical management of this rare condition.
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10
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Bhole V, Gozzini S, Stumper O, Advani S, Sullivan PB, Rodrigues AF, Gupte GL. Chylopericardium in a child with impaired venous access following small bowel transplantation. Pediatr Transplant 2011; 15:e39-41. [PMID: 19843235 DOI: 10.1111/j.1399-3046.2009.01250.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 10-yr-old child with impaired venous access (bilateral occlusion of internal jugular veins, subclavian veins, and inominate veins) underwent an isolated small bowel transplant. He presented with lethargy, shortness of breath 13 months into his follow-up and was diagnosed to have chylopericardium. MR venography and lymphangiography could not demonstrate the site of lymphatic leak. His chyloperciardium was treated with pericardiocentesis and MCT diet. The most likely cause for the chylopericardium was venous occlusion of the subclavian veins with backpressure resulting in a lymphatic leak. A brief review of literature along with treatment options is discussed.
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Affiliation(s)
- V Bhole
- Cardiology Unit, Birmingham Children's Hospital, Birmingham, UK
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11
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Abstract
We are presenting a rare case of cardiogenic shock caused by chylopericardium. After the initial pericardial drainage and failed conservative treatment, thoracic duct ligation was performed with good long-term outcome. Literature on the subject is reviewed.
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Affiliation(s)
- Dimitri Novitzky
- Department of Surgery, University of South Florida, Tampa General Hospital, Tampa, Florida 33606, USA
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12
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Tabry IF, Zacharoudis A, Constantini EM. Chylopericardial Tamponade Masquerading as Hemopericardium An Uncommon Complication of Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Imad F. Tabry
- Sections of Cardiac Surgery, Fort Lauderdale, FL USA
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13
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Chylopericardium in adults: a literature review over the past decade (1996-2006). J Thorac Cardiovasc Surg 2008; 136:650-6. [PMID: 18805268 DOI: 10.1016/j.jtcvs.2008.03.033] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 02/18/2008] [Accepted: 03/30/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We present a systematic overview of the literature on reported cases of chylous pericardial effusion in adults over the past 10 years, assessing clinical presentation, etiology, diagnosis, and treatment. METHODS We conducted an evidence-based literature review searching for all reported adult cases of chylopericardium in the past 10 years (January 1996-December 2006). RESULTS A total of 33 reported cases of chylopericardium were identified through a systematic literature search. There was no gender bias in the incidence of chylous pericardial effusion. Age at diagnosis varied from 18 to 68 years with a mean +/- standard deviation of 36.78 +/- 14.71 years. Time from symptom onset to diagnosis was variable (ranging from acute presentation to several years). The most common reported etiology was idiopathic. The diagnosis was made by pericardiocentesis in all patients. A search for secondary causes included computed tomography of the chest, lymphoscintigraphy, and lymphangiography along with radioactive oral (131)I-triolein. Conservative therapy was prescribed in 28 patients and failed in 16, in whom subsequent surgery was necessary. Overall, 21 patients underwent various types of surgery. Thoracic duct ligation with creation of a pericardial window was the most common surgical procedure. CONCLUSION Chylopericardium is a rare entity. The fluid appearance, triglyceride content, cytologic characteristics, and negative cultures are crucial to make the correct diagnosis. Treatment is dependent on the etiology. Surgical management is the most successful. Conservative therapy is reserved for patients with idiopathic chylopericardium, those with an untreatable etiology, those considered at high risk for surgical treatment, or those with a predictably short lifespan.
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Koksel O, Mavioglu I, Ocal K, Gul A, Yildirim C, Ozdulger A. Traumatic chylopericardium: a case report and review of the literature. THE JOURNAL OF TRAUMA 2007; 63:E13-6. [PMID: 17622859 DOI: 10.1097/ta.0b013e3180d0a46b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Oguz Koksel
- Department of Thoracic Surgery, Mersin Universitesi Tip FakOltesi Hastanesi, Mersin, Turkey.
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Lee YH, Im SA, Nam SH, Lee SN, Kim Y, Seong CM, Han WS, Lee SW, Park SH, Lee SN. Challenging problems in advanced malignancy: Case 1. Chylopericardium during the treatment of non-Hodgkin's lymphoma. J Clin Oncol 2003; 21:3168-70. [PMID: 12915608 DOI: 10.1200/jco.2003.11.128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- You-Hyun Lee
- College of Medicine, Ewha Women's University, Seoul, Korea
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