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Hussain S, Hayat J, Ibrahim F, Almutairi A, Alhajri B, Al-Gilani M. Bilateral Chylothorax Following Neck Dissection: A Systematic Review and Proposed Management Algorithm. Indian J Otolaryngol Head Neck Surg 2024; 76:4900-4909. [PMID: 39376331 PMCID: PMC11455751 DOI: 10.1007/s12070-024-04688-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/04/2024] [Indexed: 10/09/2024] Open
Abstract
Aims Bilateral chylothoraces are rare but potentially life-threatening complications of neck dissections (ND). The condition is generally treated with a combination of dietary, medical, procedural, and surgical approaches. The aim of this review is to highlight the management options currently utilized in clinical practice and propose a management algorithm for this condition. Methods In accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; utilizing the Pubmed, EMBASE, and Web of Science databases, a systematic review of all available literature on bilateral chylothoraces was conducted. Primary outcomes measures included clinical presentations and type of neck dissection performed with interventions employed to manage the condition. Secondary outcome measures included the time to resolution alongside patient outcomes. Results We identified 37 patients (female n = 27, male n = 10) who presented with bilateral chylothoraces within the years 1951-2018. The mean age was 51.4 ± 16.5 years within the age ranges of 17-78 years. Most common pathologies included papillary thyroid carcinoma (n = 16), squamous cell carcinoma (SCC) of the larynx (n = 3), supraglottic SCC (n = 3). Left sided ND was done in (n = 18); bilateral ND in (n = 17); central/left ND in (n = 2). Chylothorax was treated by surgery in n = 10, n = 5 of which performed lymph node embolization; and n = 5 used lymph node ligation. Resolution was found in all cases. Discharge times ranged from 2 to 40 days. Conclusions This systematic review highlights the different management modalities in treating bilateral chylothoraces alongside providing a decision algorithm in treating the condition by suggesting diagnostic tools and management modalities to optimize patient care.
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Affiliation(s)
- Salman Hussain
- Department of Otolaryngology - Head and Neck Surgery, University of Ottawa, Ottawa, ON Canada
| | - Jafar Hayat
- Department of Otolaryngology - Head and Neck Surgery, Jaber Alahmad Hospital, Kuwait City, Kuwait
| | - Fatma Ibrahim
- Department of Otolaryngology - Head and Neck Surgery, Jaber Alahmad Hospital, Kuwait City, Kuwait
| | | | - Bedour Alhajri
- Department of Otolaryngology - Head and Neck Surgery, Jaber Alahmad Hospital, Kuwait City, Kuwait
| | - Maha Al-Gilani
- Department of Otolaryngology - Head and Neck Surgery, University of Ottawa, Ottawa, ON Canada
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Wagenpfeil J, Hoß K, Henkel A, Kütting D, Luetkens JA, Feldmann G, Brossart P, Attenberger UI, Pieper CC. Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders. Clin Exp Med 2024; 24:63. [PMID: 38554229 PMCID: PMC10981590 DOI: 10.1007/s10238-024-01312-4] [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: 11/28/2023] [Accepted: 02/28/2024] [Indexed: 04/01/2024]
Abstract
To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.
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Affiliation(s)
- Julia Wagenpfeil
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany.
| | - Katharina Hoß
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Andreas Henkel
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Daniel Kütting
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Julian Alexander Luetkens
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Georg Feldmann
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Ulrike Irmgard Attenberger
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Claus Christian Pieper
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
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Muacevic A, Adler JR, Sircar S, Bassi R, Charles K, Okonoboh P. An Unusual Case of Non-traumatic Chylothorax. Cureus 2022; 14:e32506. [PMID: 36654639 PMCID: PMC9838086 DOI: 10.7759/cureus.32506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Chylothorax refers to the presence of chyle in the paraaortic space. This entity most commonly occurs from injury to the thoracic duct, which carries chyle from the gastrointestinal tract to the bloodstream. Common etiologies around traumatic chylothorax include iatrogenic causes, such as surgical procedures near the thoracic duct and penetrating and blunt injuries to the chest. We present a case of a 49-year-old female who initially presented to the hospital with progressively worsening dyspnea leading to acute hypoxic respiratory failure requiring intubation and admission to the ICU. The patient's presentation was initially thought to be due to and managed as an infectious process with empyema and septic shock until a diagnosis of nontraumatic chylothorax was established. In this article, we report a complicated case of chylothorax, initially masquerading as an infectious pulmonary process. We hope to raise this entity high on the differential when clinicians are confronted with the task of managing patients with similar presentations, which will, in turn, prevent delayed diagnosis and the unnecessary use of antibiotics.
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Management of lymphoma-associated chylothorax by interventional radiology and chemotherapy: a report of five cases. Int J Hematol 2022; 116:579-585. [PMID: 35819710 DOI: 10.1007/s12185-022-03397-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/26/2022] [Accepted: 05/26/2022] [Indexed: 10/17/2022]
Abstract
Chylous effusion is associated with lymphatic obstruction or leakage in mediastinal or abdominal lymph nodes, and is a rare but troublesome complication in patients with malignant lymphomas. Although there is no standard of care, it is often treated with simultaneous chemotherapeutic and non-chemotherapeutic interventions. Here, we describe the cases of five patients with lymphoma-associated chylothorax with the aim of clarifying an effective treatment strategy. All patients achieved a partial response or better for lymphoma. All patients underwent interventional radiology (IVR) procedures, including lymphangiography (LAG) and thoracic duct embolization (TDE). Complete resolution of chylothorax was eventually achieved by IVR procedures or pleurodesis in all patients. No patients experienced serious adverse events related to LAG/TDE. Treatment of chylous effusion required months for most patients (range: 0.2-4.8 months). Our data suggest that a combination of chemotherapy and LAG/TDE is effective for refractory lymphoma-related chylous effusion.
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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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Hautmann MG, Dietl B, Wagner L, Zeman F, Kölbl O, Pfister K, Schierling W. Radiotherapy of Lymphatic Fistulas after Vascular Surgery in the Groin. Int J Radiat Oncol Biol Phys 2021; 111:949-958. [PMID: 34324999 DOI: 10.1016/j.ijrobp.2021.07.1696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Lymphatic fistulas are common complications after vascular surgery especially in the groin, which can lead to a prolongation of the inpatient stay, wound infections and follow-up operations. Radiotherapy is one of the non-surgical treatment options. However, there is limited evidence and discussion about the ideal dosage and timing. METHODS AND MATERIALS The analysis was performed on patients from a German university hospital and included 191 patients with 206 lymphatic fistulas from 2005 to 2016. Four different endpoints were analyzed. The patients were irradiated with a fraction dose of 3 Gy up to a cumulative dose of 9 Gy (94/206 cases) or 18 Gy (112/206 cases). The median age of the patients was 70.5 years with 74% male and 26% female patients. Vascular surgery included bypass grafts (52%), thrombendarterectomy/patch angioplasty (26%), and vascular access for aortic endografts (22%). RESULTS The response to radiotherapy for the four different endpoints was 88% (25% decrease in secretion volume), 80% (secretion below 50 ml/24 hours), 81% (removal of the drainage) and 75% (freedom from any intervention), respectively. The overall response for all four endpoints was 63% (129/206) after completion of radiotherapy, and 34% (70/206) after one course with a total dose up to 9 Gy. The median lymphatic secretion was 150 ml/24 hours before radiotherapy and 60 ml/24 hours one day after the end of therapy. The drainage could be removed a median of 3 days after radiotherapy completion. There was no significant difference between patients starting the radiation within 5-9 days or ≥10 days postoperatively (p = .971 OR = 0.99; 95%-CI: 0.56 to 1.74). No relevant factors influencing the response rate could be identified. Re-operation was required in 50/206 cases (25%), in 24/206 cases (12%) due to persistent lymphatic fistula and complications and in 26/206 cases (13%) due to wound and/or vascular complications. CONCLUSION Radiotherapy seems to be an effective, non-surgical treatment option for reducing lymphatic secretion after vascular surgery in the groin. Starting radiation early (≤9 days) or late (≥10 days) postoperatively does not affect the success rate.
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Affiliation(s)
- Matthias G Hautmann
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany.
| | - Barbara Dietl
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Laura Wagner
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany; Public Health Department, Cologne, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
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Lau ACW, Hsu PYH, Ng D, Luecke K, Nayar S. Management of Malignant Chylothorax with Subcutaneous Octreotide Treatment. J Pain Palliat Care Pharmacother 2021; 35:48-51. [PMID: 33600270 DOI: 10.1080/15360288.2021.1883180] [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: 10/22/2022]
Abstract
There are currently limited published case reports and clinical studies looking at octreotide as a potential therapeutic agent for treating surgery- and malignancy-related chylothorax in adult patients. Few case reports have shown that low-dose subcutaneous octreotide can be used to treat malignant chylothorax. We report the case of a 57-year-old high-grade follicular lymphoma patient with malignant chylothorax which responded rapidly and was successfully treated with octreotide. Significant improvements were noted in her dyspnea, abdominal distention and pain, and chylous output. This case also highlights the importance of understanding the pharmacotherapeutic effects of octreotide when managing malignant chylothorax as it may help to benefit patients by improving symptoms, quality of life, and length of hospital stay. Further prospective studies are warranted to further evaluate the role of octreotide in the management of malignant chylothorax.
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Paul T, Yadav DK, Alhamar M, Dabak V. Primary Pleural Extranodal Marginal Zone Lymphoma Presenting as Bilateral Chylothorax. Case Rep Oncol 2020; 13:929-934. [PMID: 32884542 PMCID: PMC7443639 DOI: 10.1159/000508704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/19/2022] Open
Abstract
Here we describe a case of pleural extranodal marginal zone lymphoma presenting as bilateral chylothorax which has not been reported in the literature prior to this. Primary pleural lymphomas are a rare entity most commonly associated with chronic infections, autoimmune conditions or long-standing pyothorax which were not seen in this case. Chylous pleural effusions in this patient were successfully managed with chemotherapy for the underlying lymphoma.
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Affiliation(s)
- Thushara Paul
- Department of Hematology and Oncology, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Dhiraj Kumar Yadav
- Department of Hematology and Oncology, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Mohamed Alhamar
- Department of Pathology and Laboratory Medicine, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Vrushali Dabak
- Department of Hematology and Oncology, Henry Ford Health System, West Bloomfield, Michigan, USA
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Bilateral Chylothorax as a Unique Presentation of Pancreaticobiliary or Upper Gastrointestinal Cancer. Case Rep Pulmonol 2019; 2019:9387021. [PMID: 31355038 PMCID: PMC6633922 DOI: 10.1155/2019/9387021] [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: 04/24/2019] [Accepted: 06/17/2019] [Indexed: 11/17/2022] Open
Abstract
Chylothorax presents as exudate with lymphocytic predominance and high triglyceride-low LDH levels, usually due to a traumatic disruption of the thoracic duct, possibly iatrogenic. Other causes include malignancy, sarcoidosis, goiter, AIDS, or tuberculosis. Here we present a case of a 66-year-old male who came in with cough and shortness of breath for few weeks. A week earlier, at an ED visit, he was diagnosed with pneumonia based on CT angiogram of the chest without contrast that showed bilateral pleural effusion and bilateral pulmonary infiltrates. The CT-guided placement of bilateral chest tube drained 1160 cc of creamy yellow fluid on the right and 1200 cc of creamy yellow fluid on the left. CT chest/abdomen/pelvis showed bilateral ground-glass opacities within the lungs and possible bony metastasis. A whole-body bone scan showed multiple bony metastatic lesions throughout the skeleton. IR guided bone biopsy suggested upper GI or pancreaticobiliary cancer. Venous ultrasound with Doppler of left upper extremity showed findings suggestive of a nonocclusive DVT of proximal/mid left subclavian vein which is difficult to compress. Eventually, malignancy-related DVT of the left subclavian/brachiocephalic vein was identified as the possible etiology for the bilateral chylothorax.
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