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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 4  |  Issue : 5  |  Page : 633-636

Carcinoma breast related metastatic pleural effusion: A thoracoscopic approach


Department of Respiratory Medicine and Pathology, J.L.N. Medical College, Ajmer, Rajasthan, India

Date of Web Publication9-Sep-2015

Correspondence Address:
Chetan Basavaraj Patil
Chest Hospital, J.L.N. Medical College, Ajmer, Rajasthan, India.
India
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2278-0513.162246

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  Abstract 

Background: Pleural effusions are common and devastating complication of advanced malignancies. Lung and breast cancers cause approximately 75% of all malignant pleural effusions. Pleural effusions associated with carcinoma breast (either malignant or paramalignant) pose diagnostic and therapeutic dilemmas for the treating chest physician. Materials and Methods: In a prospective study of analysis of unexplained pleural effusions, we performed medical thoracoscopy in 9 cases of carcinoma breast between April 2011 and September 2014. All the relevant clinical and paraclinical were collected and analyzed. Results: Sole pleural effusion was the most common radiological finding. This article reviews 9 cases of carcinoma breast patients, who had developed recurrent lymphocytic exudative pleural effusion, within a year of diagnosis. Thoracoscopy was diagnostic in all 9 cases with a histological diagnosis of metastatic carcinoma arising from the breast. Surprisingly malignant cells were negative in pleural fluid of all cases on three consecutive occasions. Conclusion: Carcinoma breast related pleural effusion is a common condition encountered in respiratory medicine and oncology. Thoracoscopic guided pleural biopsy is an effective and safe technique in patients with undiagnosed pleural effusion. It not only gives an accurate diagnosis but also gives a high degree of relationship between thoracoscopic appearance and primary disease or tumor classification.

Keywords: Carcinoma breast, malignant pleural effusion, medical thoracoscope


How to cite this article:
Patil CB, Gupta A, Gupta R, Dixit R, Gupta N, Indushekar V. Carcinoma breast related metastatic pleural effusion: A thoracoscopic approach. Clin Cancer Investig J 2015;4:633-6

How to cite this URL:
Patil CB, Gupta A, Gupta R, Dixit R, Gupta N, Indushekar V. Carcinoma breast related metastatic pleural effusion: A thoracoscopic approach. Clin Cancer Investig J [serial online] 2015 [cited 2019 Jul 23];4:633-6. Available from: http://www.ccij-online.org/text.asp?2015/4/5/633/162246


  Introduction Top


Carcinoma breast is the commonest malignant tumor in females. Pleural metastases are common in the course of breast cancer, affecting 10–50% of breast cancer patients.[1],[2],[3] This pleural involvement may be the first and only manifestation of recurrent disease in 20–40% of these patients.[1],[2],[4]

In our case series, we included 9 cases of carcinoma breast related lymphocytic exudative pleural effusion, whose pleural fluid cytology was negative for malignant cells on three consecutive occasions. Thoracoscopy showed certain characteristic features and guided pleural biopsy revealed metastasis from the primary carcinoma breast. Pleurodesis was done in all the cases.


  Materials and Methods Top


This is a prospective, nonrandomized and interventional study conducted at Department of Respiratory Medicine, J.L.N Medical College, Ajmer, India between April 2011 and September 2014. We performed thoracoscopy in 9 cases of known carcinoma breast patients, who had developed recurrent, lymphocytic exudative pleural effusion within a year of diagnosis of breast cancer and were treated by surgery alone or by multimodal therapy.

The pleural fluid analysis remained unexplained even after extensive diagnostic work up. Fluid cytology was prepared by conventional smear technique with 5 ml of fluid sample centrifuged at 2500 rpm for 15 min; smear was immediately fixed with 95% alcohol and stained, which showed negative for malignant cells thus failed to give any conclusive diagnosis on three consecutive occasions. Hence, we included these patients under undiagnosed category.

Undiagnosed pleural effusion in the present study was defined as a failure to achieve a diagnosis by initial pleural fluid analysis including pleural fluid adenosine deaminase (ADA) levels and at least three pleural fluid analyses negative for malignant cells.

After thorough physical examination, all routine hematological investigations were done; skiagram chest was taken to confirm the diagnosis of pleural effusion. Pleural fluid was aspirated by means of percutaneous thoracentesis and examined biochemically, cytopathologically, and microbiologically. Chest radiography was then repeated at regular intervals to see the re-expansion of the lung and the recurrence. Contrast-enhanced computed tomography of chest was also taken to look for the cause of pleural effusion.

After informed consent, medical thoracoscopy was done in all the patients, and the gross thoracoscopic appearances of the pleura and pleural cavity were videos recorded. Thoracoscopic guided pleural biopsy was taken and sent for histopathological analysis.


  Results Top


During the study period, 9 patients with past history of carcinoma breast were included with a mean age of 46.8 years. Presented with recurrent pleural effusion whose cause remained unexplained after extensive biochemical and cytological analysis.

Primary malignant tumor of the breast was localized on the left side in 7 cases, and right sided in 2 cases. Histological evaluation of pleural biopsy yielded the diagnosis of metastatic deposits from primary ductal carcinomas in 6 cases and lobular carcinomas of the breast in 3 cases.

Pleural effusion was present in all the cases, localized on the left side were 5 cases, on the right side in 2, and on both sides in 2 cases. In total, 7 cases showed pleural involvement on the same side as the primary breast cancer and 2 cases showed bilateral involvement. Pleural fluid was hemorrhagic in all the cases, with pleural fluid hematocrit <50% of peripheral blood.

Pleural fluid was negative for malignant cells on three consecutive occasions. The thoracoscopic view revealed thickened, nonsmooth pleura which was hyperemic in nature and bled on touch [Table 1]. Pleural nodules of varying sizes grossly studded on both the pleurae with/without the involvement of diaphragmatic pleura. At places, these conglomerated pleural nodules forming "grape like pattern" [Figure 1]a and [Figure 1]b. In some cases, isolated distribution of nodules on the parietal pleura mimicking that of "candle wax droplets" [Figure 2]a. Nodules were fragile and bled on touch. Thin fibrinous pleura-parenchymal adhesions were also noted [Figure 2]b in some cases. The diaphragmatic surface was involved in 5 cases. Pleurodesis was done in all the patients, and mean duration of chest tube drainage was 7.2 days (range of 3–15 days). Parietal pleural biopsy revealed metastatic deposits from the primary carcinoma breast [Figure 3].
Figure 1: (a) Multiple nodules of varying sizes grossly studded on both the pleurae with hyperemia. (b) Nodules coalesced to form "grape like pattern"

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Figure 2: (a) Nodules on parietal pleura mimicking that of "candle wax droplet" appearance. (b) Multiple large nodules with thin membranous adhesions

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Figure 3: Photomicrograph showing metastatic deposits to pleura from carcinoma breast with infiltrating malignant glands lined by irregular hyperchromatic nuclei, prominent nucleoli and foci of necrosis (H and E, ×40)

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Table 1: Gross thoracoscopic appearance of the pleura in metastatic carcinoma breast

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  Discussion Top


In the vast majority of cases, malignant pleural effusion (MPE) signifies as an incurable disease with high morbidity and mortality. Breast cancer is the most common malignancy of women. It is the second leading cause of cancer-related death among women, after lung cancer.[5] Breast cancer has two main histologic variants: Infiltrating ductal carcinoma and infiltrating lobular carcinoma. Although there are conflicting reports regarding survival in metastatic breast cancer, several studies have demonstrated distinct metastatic patterns for each histology.[6],[7],[8]

Metastatic patterns of breast cancer are variable. Thorax being the most common place for recurrent disease after local/regional sites and bone.[9] At autopsy, 57–77% of patients who had breast cancer have evidence of lung metastasis, usually multinodular.[10],[11] In addition to parenchymal disease, breast cancer frequently involves the lymphatics, pleura, and the tracheobronchial tree. The most common thoracic manifestation of metastatic breast carcinoma involves the lung parenchyma. Metastatic breast cancer is a common cause of MPE. Pleural effusion that occurs in the setting of malignant disease is due to a variety of mechanisms. Metastases can involve the pleura directly or indirectly by obstructing pleural lymphatics and interrupting lymphatic drainage.

Differentiating between malignant and para MPE in a patient with underlying carcinoma breast is a must in the further management of the patient. In approximately 50% of effusions caused by carcinomas, no malignant cells are identified. This can be because of an entity called paramalignant effusions in which there is no direct pleural infiltration such as lymphatic obstruction, bronchial obstruction with pneumonia, atelectasis, trapped lung, chylothorax, superior venacava syndrome, hypoalbuminaemia, thromboembolism and also due to chemo as well as radiotherapy etc., Hence to confirm the diagnosis the standard practice is to perform 3 repeated thoracenteses, which when combined, raise the yield of detecting malignant cells to about 80%. If the results of the pleural fluid are still negative after repeated thoracentesis; malignancy is still being considered as a differential diagnosis and pleural biopsy should be taken. It is in this context that the thoracoscopy becomes an important investigation modality where the pleural surface can be visualized, and appropriate sample can be easily picked up.

Pleural fluid cytology on all three occasions were negative for malignant cells and predominantly lymphocytic. Along with paramalignant causes of pleural effusion tuberculosis, (TB) is another important entity in patients with immunocompromised status. Thus one must rule it out by clinico-radiological analysis and pleural fluid appearance. Another important differentiating feature is an estimation of ADA enzyme activity. If the ADA level is more than 70 IU/L is highly suggestive of TB and a level of <40 IU/L virtually excludes the diagnosis.[12]

To the best of our knowledge, there were no case series or larger studies on thoracoscopic appearance in patients of carcinoma breast with pleural effusions are mentioned in the literature or in the available standard textbooks of thoracoscopy. Only a few books have described thoracoscopic appearance in the form of typical images seen in such patients.[13]

In this case study, all the cases of carcinoma breast presented with recurrent pleural effusion, within a year of diagnosis and were treated either by surgery alone or by means of multi-modal therapy.

Gross thoracoscopic pictures like "grape like pattern" and "candle wax droplets" appearances of pleural nodules were the characteristic features of carcinoma breast related metastatic pleural effusion. However, grape like the pattern of pleural nodules were also been described in cases of epithelioid mesothelioma.

Though it's a small case series, probably the first one from our country on thoracoscopic appearance in metastatic carcinoma breast with pleural effusion. Pleural infiltration is early, extensive and had a typical gross appearance. Larger case studies are needed on this entity for awareness and in decreasing the time lag in achieving the diagnosis, to initiate the treatment sooner.

Regarding pleural metastases secondary to breast cancer, medical thoracoscopy must be considered as the first choice for obtaining specimens from the pleura for histopathology, as pleurodesis is another advantage of medical thoracoscopy. Talc poudrage can be performed under visual control into the pleural cavity during a medical thoracoscopy, and is probably the most effective method.[14],[15],[16]


  Conclusion Top


Thoracoscopy should be considered in all cases of undiagnosed pleural effusion with a history of carcinoma breast without any evidence of local recurrence or pulmonary metastasis to prevent the delay in achieving the diagnosis and to initiate the treatment sooner.

Nil.

There are no conflicts of interest.



 
  References Top

1.
Weichselbaum R, Marck A, Hellman S. Pathogenesis of pleural effusion in carcinoma of the breast. Int J Radiat Oncol Biol Phys 1977;2:963-5.  Back to cited text no. 1
    
2.
Kreisman H, Wolkove N, Finkelstein HS, Cohen C, Margolese R, Frank H. Breast cancer and thoracic metastases: Review of 119 patients. Thorax 1983;38:175-9.  Back to cited text no. 2
    
3.
Fracchia AA, Knapper WH, Carey JT, Farrow JH. Intrapleural chemotherapy for effusion from metastatic breast carcinoma. Cancer 1970;26:626-9.  Back to cited text no. 3
    
4.
Fentiman IS, Rubens RD, Hayward JL. Control of pleural effusions in patients with breast cancer. A randomized trial. Cancer 1981;52:737-9.  Back to cited text no. 4
    
5.
Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998;48:6-29.  Back to cited text no. 5
    
6.
Harris M, Howell A, Chrissohou M, Swindell RI, Hudson M, Sellwood RA. A comparison of the metastatic pattern of infiltrating lobular carcinoma and infiltrating duct carcinoma of the breast. Br J Cancer 1984;50:23-30.  Back to cited text no. 6
    
7.
Lamovec J, Bracko M. Metastatic pattern of infiltrating lobular carcinoma of the breast: An autopsy study. J Surg Oncol 1991;48:28-33.  Back to cited text no. 7
    
8.
Jain S, Fisher C, Smith P, Millis RR, Rubens RD. Patterns of metastatic breast cancer in relation to histological type. Eur J Cancer 1993;29A: 2155-7.  Back to cited text no. 8
    
9.
Kamby C, Vejborg I, Kristensen B, Olsen LO, Mouridsen HT. Metastatic pattern in recurrent breast cancer. Special reference to intrathoracic recurrences. Cancer 1988;62:2226-33.  Back to cited text no. 9
    
10.
Libshitz HI, North LB. Pulmonary metastases. Radiol Clin North Am 1982;20:437-51.  Back to cited text no. 10
    
11.
Connolly JE Jr, Erasmus JJ, Patz EF Jr. Thoracic manifestations of breast carcinoma: Metastatic disease and complications of treatment. Clin Radiol 1999;54:487-94.  Back to cited text no. 11
    
12.
Aggarwal AN, Gupta D, Jindal SK. Diagnosis of tuberculous pleural effusion. Indian J Chest Dis Allied Sci 1999;41:89-100.  Back to cited text no. 12
    
13.
Astoul P, Tassi G, Tschopp JM. Diagnostic thoracoscopy-malignant pleural effusion: Springer's thoracoscopy for pulmonologists. Ch. 9. Berlin Heidelberg: Springer; 2014. p. 86-99.  Back to cited text no. 13
    
14.
Fentiman IS, Rubens RD, Hayward JL. A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer. Eur J Cancer Clin Oncol 1986;22:1079-81.  Back to cited text no. 14
    
15.
Hamed H, Fentiman IS, Chaudary MA, Rubens RD. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg 1989;76:1266-7.  Back to cited text no. 15
    
16.
American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000;162:1987-2001.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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[Pubmed] | [DOI]



 

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