Role of Vats in Management of Malignant Pleural Effusion with Suspected Diaphragmatic Fenestrations

Case Report

Austin J Cancer Clin Res 2015;2(6): 1053.

Role of Vats in Management of Malignant Pleural Effusion with Suspected Diaphragmatic Fenestrations

Raza A* and Amer K

Department of Cardiothoracic Surgery, Southampton University Hospital, UK

*Corresponding author: Adnan Raza, Department of Cardiothoracic Surgery, Southampton University Hospital, Tremona Road, Southampton-SO16 6YD, UK

Received: July 13, 2015; Accepted: August 10, 2015; Published: August 13, 2015

Abstract

We present a case of 65 years old woman with history of metastatic breast cancer and recurrent right sided pleural effusion. During video assisted Thoracoscopic surgery inspection two diaphragmatic fenestrations were noted with fluid flowing from abdomen to chest. The fenestrations were endoscopically repaired and talc pleurodesis performed. The presence of diaphragmatic fenestrations should be suspected when there is evidence of fluid collection on either side of the diaphragm. Active inspection for diaphragmatic fenestrations is advocated during the VATS procedure otherwise pleurodesis might fail. Simple stitching and talc pleurodesis control such effusions and prevent exacerbation of trans-coelomic spread of malignancy.

Keywords: VATS; Malignant pleural effusion; Diaphragmatic fenestrations; Pleurodesis; Transcaelomic spread

Case Presentation

A 65 years old woman was admitted to our unit for consideration of diagnostic drainage and pleurodesis of recurrent right pleural effusion. An intercostal drain was inserted in the medical ward with average drainage of 300-400mls of straw coloured fluid on daily basis. She had a background of metastatic right breast cancer in 2003 surgically treated by lumpectomy and nodal clearance. The tumour was ER positive, HER-2 negative on histology. Therefore, she received chemo/radiotherapy and hormonal manipulation treatment post-operatively. Her main presenting symptom was incapacitating shortness of breath and she was limited to walking 50-100 yards on the flat. Ascites and abdominal pain were investigated by computed tomography (CT) of the chest, abdomen and pelvis. CT revealed peritoneal metastatic deposits, small volume of ascitic fluid with no focal liver lesion and significant right-sided pleural effusion. Other findings included; subcutaneous lesions within the anterior abdominal wall suggestive of secondaries as well as body of T10 vertebral metastasis. Right VATS pleural biopsy and talc pleurodesis was discussed as a palliative procedure. If the lung would not expand fully intra-operatively then insertion of a permanent tunneled intrapleural catheter would have been contemplated.

At operation three-port video assisted thoracoscopic surgery (VATS) was fashioned. 3½ litres of pleural effusion were obtained for microbiology and cytology. The parietal pleura was studded with nodular lesions reminiscent of pleural malignant deposits. Full thickness pleural biopsies were taken for histology. Closer inspection of the diaphragm revealed clear ascitic fluid flowing into the chest through two fenestrations in the diaphragm (Figure 1). Endoscopic repair of the diaphragmatic fenestrations was performed by purse string stitching using Vicryl 2-0 (Figure 2). 6 gm of sterile Talc was evenly sprinkled under direct vision for chemical pleurodesis. The patient had an uncomplicated post-operative hospital stay and was asymptomatic at the time of discharge. At 6 months follow up there was no recurrence of effusion. Cytology from the pleural fluid and peritoneal tap confirmed the presence of malignant metastatic breast cancer. The histology of pleural biopsy also confirmed metastatic adenocarcinoma in keeping with breast origin.

Citation: Raza A and Amer K. Role of Vats in Management of Malignant Pleural Effusion with Suspected Diaphragmatic Fenestrations. Austin J Cancer Clin Res 2015;2(6): 1053. ISSN : 2381-909X