Recurrent Pleural Effusion as Manifesting Feature of Primitive Chest Wall Hodgkin’s Disease: Discussion
Tracheobronchial and mediastinal lymph nodes are the most common sites of thoracic HD. Pleural effusion is not frequent and is almost always associated with enlarged thoracic lymph nodes. In a review of 15 cases of primary pulmonary HD defined as restriction of disease to the lung without hilar or mediastinal lymph node involvement, 14 had neoplastic infiltration beneath visceral pleura, but only one pleural effusion was present. This occurrence was explained with the absence of obstructed lymphatic return by swollen lymph nodes in this series. In 18 cases of HD involving breast and chest wall, six of seven cases in which the thoracic wall was involved at initial presentation had mediastinal widening, and in one case, palpable lymph nodes were present in the neck. One case only of pleural effusion was reported. In a series of 44 patients with HD limited to intrathoracic sites, pleural effusion was present in seven, two of whom had cytologic findings consistent with HD and no better defined localization; five cases resulted from direct pleural involvement. No case of isolated pleural localization was evident. We were able to detect one case record only in which thoracic HD had a course very similar to that of our patient, in that recurrent benign pleural effusion and fever were, for a long time, the only clinical manifestations; however, neoplastic involvement of hilar lymph nodes became evident later and finally was proved by autopsy.
It is difficult to explain the early onset of pleural effusion in that case and in ours. Altered lymphatic drainage by very small intraparenchymal neoplastic infiltration may have been present from initiation; however, the incidence of pleural effusion is low in primary pulmonary HD despite the frequent involvement of visceral pleura.4 An alternative hypothesis is that parietal pleura was the original site of HD and this produced early alteration of pleural lymphatic drainage and consequent effusion. It is also of interest that pulmonary nodules were not contiguous with parietal pleura biopsied, and this induced us to assign the patient to stage 4.
We conclude that cytologically benign pleural effusion without any other obvious localization is exceptional in HD and is probably due to neoplastic infiltration of parietal pleura. However, in the presence of recurrent unexplained pleurisy, especially when typical B symptoms are present, more invasive procedures are worthwhile, even in the older patient, to rule out a potentially treatable disorder such as HD.