Recurrent Pleural Effusion as Manifesting Feature of Primitive Chest Wall Hodgkin’s Disease
It is common opinion that pleural effusion, which accompanies 30 percent of thoracic Hodgkins disease (HD) is secondary to obstructed lymphatic return by enlarged hilar or mediastinal lymph nodes; this hypothesis also explains the common negativity of pleural fluid cytologic examination for malignant cells. We report a very unusual case of recurrent, cytologically benign pleural effusion which for months was the only manifestation of HD localized to the lateral inner thoracic wall as finally demonstrated by thoracic CT scan and closed needle biopsy. There was a remarkable absence of mediastinal or hilar lymph node involvement at any time, both on chest roentgenograms and CT scan. canada health and care mall
The patient, a 77-year-old man, was admitted in December 1986. He was well until ten months earlier when fever and dyspnea led to admission at another institution where chest x-ray film showed right pleural effusion without parenchymal abnormalities (Fig 1). Because of cutaneous reactivity for PPD, 5TU, and the finding of lymphocytosis in pleural fluid sediment without malignant cells, a diagnosis of tuberculosis was made and treatment started with isoniazid and rifampin. Four months later, fever and pleurisy recurred. Again, chest x-ray film did not produce evidence of parenchymal or mediastinal abnormalities, and cytologic examination was negative for malignant cells; antituberculosis drugs were continued and fever subsided. Twenty days before admission, shortness of breath and fever ensued with nightly sweats and general malaise. He had lost 5 kg in the last four months. Physical examination disclosed dullness and diminished breath sounds at the lower half of the right hemithorax. Spleen, liver, and superficial lymph nodes were normal. Chest x-ray film evidenced large right pleural effusion without other abnormalities as confirmed by tomography Evacuation of large volumes (ie, 1L) of pleural fluid was soon followed by recurrence. Cultures of blood, sputum, and urine gave negative findings. Bronchoscopic examination was negative as were bronchial washing culture and cytologic examination for malignant cells. Erythromycin was given without any effect on pleural effusion or fever. Thirty days after admission, a repeat chest x-ray film disclosed a small opacity along the lateral wall of the right hemithorax which was interpreted as fluid collection (Fig 2).
Thoracic CT scan evidenced residual right pleural effusion, pleural thickening, and two parenchymal nodules in the right lung (Fig 3). Real-time sonography of the lateral chest wall disclosed a rightsided hypoechoic mass (Fig 4), upon which a biopsy was performed using a 16-gauge needle. Histologic examination of the specimen disclosed a pleomorphic tissue with abundant connective tissue, fibroblasts, lymphocytes, and some large neoplastic elements with the features of Reed-Sternberg cells (Fig 5). Although subtyping was difficult, the abundant connective tissue and “lacunar” appearance of some neoplastic elements were suggestive of nodular sclerosis. Further investigations, including bone marrow biopsy and abdominal CT scan, yielded negative results. The patient was assigned to stage 4B and treated by MOPP therapy, following which fever and pleurisy dramatically improved. He subsequently was assigned to receive alternate MOPP/ABVD therapy, and at this writing, six months from initiation of treatment, the patient is well and free of pleural effusion.
Figure 1. Chest x-ray fifm, February 1986. Right pleural effusion without hilar or mediastinal abnormalities.
Figure 2. Chest x-ray film, January 1987. Persistent right pleural effusion and small opacity of the lateral chest wall. No hilar or mediastinal abnormalities.
Figure 3. Thoracic CT scan. Evident nodular thickening of the right parietal pleura. Note the absence of hilar or mediastinal enlarged lymph nodes.
Figure 4. Ultrasonography (real-time) of the lateral right chest wall; a hypoechoic irregular mass is evidenced through an intercostal frontal view
Figure 5. Right parietal mass echo-guided needle biopsy. Pleomorphic tissue with abundance of connective tissue, fibroblasts, lymphocytes, and lacunar neoplastic cells (hematoxylin-eosin, original magnification x 400). Typical lacunar Reed-Sternberg cell is demonstrated in the inset (hematoxylin-eosin, original magnification X 1000).