Refractory Chylothorax and Lymphedema Caused by Advanced Gastric Cancer

Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.

Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report

BACKGROUND

Chylothorax is a rare condition due to leakage of chyle in the thoracic cavity. When large amounts of chyle leak into the thoracic cavity, it can lead to severe respiratory, immune, and metabolic complications. Chylothorax has many potential underlying etiologies, and the most common causes are traumatic chylothorax and lymphoma. Venous thrombosis of the upper extremities is a rare cause of a chylothorax.

CASE PRESENTATION

A 62-year-old Dutch man with a medical history of gastric cancer, treated with neoadjuvant chemotherapy and surgery 13 months prior, presented with dyspnea and a swollen left arm. Computed tomography thorax showed bilateral pleural effusion that was more prominent on the left side. The computed tomography scan further revealed thrombosis of the left jugular and subclavian veins and osseal masses suggesting cancer metastasis. Thoracentesis was performed to confirm the suspicion of gastric cancer metastasis. The obtained fluid was milky with a high level of triglycerides, but contained no malignant cells; hence, the diagnosis of the pleural effusion was chylothorax. Treatment with anticoagulation and a medium-chain-triglycerides diet was started. Furthermore, bone metastasis was confirmed with a bone biopsy.

CONCLUSION

Our case report demonstrates chylothorax as a rare cause of dyspnea in a patient with pleural effusion and a history of cancer. Therefore, this diagnosis should be considered in all patients with a history of cancer with new-onset pleural effusion and thrombosis of the upper extremities or clavicular/mediastinal lymphadenopathy.

Double trouble: Biochemically confirmed bilateral chylothorax with positive pleural fluid cytology due to breast adenocarcinoma

Although chylothorax is a well-described complication of malignancy, especially lymphoma, breast adenocarcinoma has not been a commonly implicated primary tumor. There has been only one published report of biochemically confirmed bilateral chylothorax in solid malignancy, and this was not associated with breast adenocarcinoma. Likewise, there has been only one published report of bilateral chylothorax in solid malignancy with positive pleural fluid cytology on both sides; again, the primary tumor was not breast adenocarcinoma. Herein we present a case that combines all three of these rarely reported features: a patient with metastatic breast adenocarcinoma who developed biochemically confirmed bilateral chylothorax with documented positive pleural fluid cytology on both sides. This report is accompanied by a literature review of published cases of bilateral chylothorax in solid malignancy.