Archived case 197 · February 19-February 26, 2016
Pleural metastatic disease with malignant effusion
74-year-old female with dyspnea
The question posed to readers
What is your differential diagnosis based on provided images?
Images
Imaging findings
Radiologic Findings: AP portable chest radiograph shows complete opacification of the right hemithorax with mild leftward mediastinal shift most consistent with large pleural effusion. Changes consistent with left mastectomy and surgical clips in the right axilla suggestive of a prior axillary nodal dissection. CT axial and coronal images, soft tissue and lung window redemonstrate leftward displacement of mediastinal content secondary to mass effect from the large hydrothorax occupying the right thorax. There are relaxation atelectasis of the vast majority of the ipsilateral lung with a small island of remaining aerated right upper lobe. There is irregular parietal pleural thickening along the costal pleura and higher density material versus nodularity of the right diaphragmatic pleura. Answer Diagnosis: Pleural metastatic disease with malignant effusion
Diagnosis
Pleural metastatic disease with malignant effusion
Answer
Diagnosis: Pleural metastatic disease with malignant effusion
Follow up:
Subsequent radiographs (Fig.1) obtained post thoracentesis with removal of a large right pleural effusion show large pneumothorax and soft tissue pleura-based nodules concerning for malignancy. Near complete collapse of the right lung initially persisted despite chest tube placement (Fig.2) favoring a noncompliant lung. Gross irregular nodular pleural thickening of the ipsilateral parietal pleura is again seen consistent with neoplastic studding. The lung gradually reexpanded and the patient underwent CT-guided pleural nodule biopsy (Fig. 3). Pathology showed m ucinous adenocarcinoma, immunophenotype most consistent with a breast primary. The patient was a poor historian; however, had a history of breast cancer over 22 years ago.
Differential diagnosis in this case (pleural fluid with higher density material versus nodular pleural soft tissue):
A. Malignant pleural effusion
1. primary pleural malignancy, e.g. mesothelioma , primary pleural lymphoma
2. direct extension of adjacent tumor, e.g. lung cance r
3. metastatic disease from distant primary, most commonly from adenocarcinoma ( lung , breast, melanoma , ovarian, peritoneal, GI), also lymphoma / leukemia, liposarcoma , invasive thymoma
B. Hemothorax, especially if history of trauma (falls in an elderly), prior instrumentation, and/or anticoagulation
Of note, thoracic splenosis is a rare benign cause of pleural nodularity.
In this patient, a combination of pleural effusion and nodularity with ancillary imaging findings (mastectomy, axillary dissection) allows to suggest the correct diagnosis.
Selected Readings:
1. American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000;162:1987–2001.
2. Ebata T, Okuma Y, Nakahara Y, et al. Retrospective analysis of unknown primary cancers with malignant pleural effusion at initial diagnosis. Thoracic Cancer. 2016;7(1):39-43.
3. Hierholzer J, Luo L, Bittner RC et-al. MRI and CT in the differential diagnosis of pleural disease. Chest. 2000;118 (3):604-9.
4. Akulian J, Feller-Kopman D. The past, current and future of diagnosis and management of pleural disease. Journal of Thoracic Disease. 2015;7(Suppl 4):S329-S338.
5. Bonomo L, Feragalli B, Sacco R, et al. Malignant pleural disease. Eur J Radiol 2000; 34 :98-118.
6. Evans AL, Gleeson FV. Radiology in pleural disease: state of the art. Respirology 2004;9:300-12.
(Click for a larger image.)
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.