Pancreas to Lung- Broncho Re A

8/6/2019 Pancreas to Lung- Broncho Re A

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DOI 10.1378/chest.108.4.11611995;108;1161-1163Chest

Tony Lembo and Thomas J. DonnellyAbnormalitiesProduction and Electrolyte

Causing Massive Bronchial FluidA Case of Pancreatic Carcinoma

http://chestjournal.chestpubs.org/content/108/4/1161

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Copyright1995by the American College of Chest Physicians,Physicians. It has been published monthly since 1935.

is the official journal of the American College of ChestChest

1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANSat Rush University on June 1, 2011chestjournal.chestpubs.orgDownloaded from
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s e l e c t e d r e p o r t sA C a s e o f P a n c r e a t i cC a r c i n o m a C a u s i n g M a s s i v eB r o n c h i a l F l u i d P r o d u c t i o n a n dE l e c t r o l y t e A b n o r m a l i t i e s *T o n y L e m b o , M D ; a n d T h o m a s J . D o n n e l l y , MDA 3 9 - y e a r - o l d man d e v e l o p e d m a s s i v e b r o n c h o r r h e a ( 2t o 3 . 5 L / d ) w i t h e l e c t r o l y t e a n d v o l u m e d e p l e t i o n a b o u t2 y e a r s a f t e r u n d e r g o i n g a W h i p p l e ' s p r o c e d u r e f o rp a n c r e a t i c c a r c i n o m a . An o p e n l u n g w e d g e b i o p s ys p e c i m e n was c o n s i s t e n t w i t h m e t a s t a t i c a d e n o c a r c i nomaw i t h e x t e n s i v e g r o w t h a l o n g p r e e x i s t i n g p u l m o n a r y a r c h i t e c t u r e . C h e m i c a l a n a l y s i s o f t h e b r o n c h i a lf l u i d r e v e a l e d m a r k e d l y e l e v a t e d l e v e l s o f a m y l a s ec o n f i r m i n g t h e p a n c r e a t i c o r i g i n o f t h e tumor. T h em e c h a n i s m o f m a s s i v e b r o n c h o r r h e a i s n o t k n o w n .C h e m i c a l a n a l y s i s o f b r o n c h i al f l u i d i n c o m p a r i s o n t oserum a n d t h e t e m p o r a r y r e s p o n s e t o c h e m o t h e r a p yare most c o n s i s t e n t w i t h s e c r e t o r y a n d t r a n s u d a t i v em e c h a n i s m s .

( C H E S T 1 9 9 5 ; 1 0 8 : 1 1 6 1 - 6 3 )5 - F U = f l u o r o u r a c i l ; L D H = l a c t a t e d e h y d r o g e n a s e

K e y w o r d s : b r o n c h o a l v e o l a r c a r c i n o m a ; b r o n c h o r r h e a ; e l e c t r o l y t e a b n o r m a l i t i e s ; m e t a s t a t i c p a n c r e a t i c c a r c i n o m aC o p i o u s w a t e r y s p u t u m p r o d u c t i o n , u p t o 2 t o 4 L / d , w i t he l e c t r o l y t e a n d v o l u m e d e p l e t i o n i s a rar e c o m p l i c a t i o no f b r o n c h o a l v e o l a r c a r c i n o m a . 1 " 3 T h e m e c h a n i s m o f t h i s i n c r e a s e d s p u t u m p r o d u c t i o n h a s n o t b e e n w e l l d o c u m e n t e d .C o n c e n t r a t i o n d i f f e r e n c e s b e t w e e n s e r u m a n d f l u i d enz y m e s , 4 p e r s i s t e n t p r o d u c t i o n o f f l u i d d e s p i t e t h e p a t i e n t ' sv o l u m e s t a t u s , a n d e l e c t r o n m i c r o s c o p i c f i n d i n g s o f i n c r e a s e d e n d o p l a s m i c r e t i c u l u m i n t u m o r c e l l s 4 s u g g e s t t h a tan a c t i v e s e c r e t o r y m e c h a n i s m i s c o n t r i b u t i n g t o t h e i n c r e a s e d f l u i d p r o d u c t i o n . I n c o n t r a s t , t h e r e l a t i v e l y l o w p r o t e i n c o n t e n t o f t h e f l u i d a n d i t s i s o - o s m o l a l i t y w i t h serums u g g e s t a t r a n s u d a t i v e m e c h a n i s m m a y b e c o n t r i b u t i n g t o t h ei n c r e a s e d p r o d u c t i o n . We r e p o r t a case o f c o p i o u s w a t e r ys p u t u m p r o d u c t i o n s e c o n d a r y t o m e t a s t a t i c p a n c r e a t i c carc i n o m a t o t h e l u n g . C h e m i c a l s t u d i e s c o m p a r i n g f l u i d t o* F r o m t h e D e p a r t m e n t o f I n t e r n a l M e d i c i n e , UCLA M e d i c a lC e n t e r ( C H S ) , D i v i s i o n o f G a s t r o e n t e r o l o g y , L o s A n g e l e s ( D r .L e m b o ) ; a n d t h e D e p a r t m e n t o f I n t e r n a l M e d i c i n e , U n i v e r s i t y o fC o l o r a d o H e a l t h S c i e n c e s C e n t e r , D i v i s i o n o f P u l m o n a r y a n dC r i t i c a l C a r e , D e n v e r ( D r . D o n n e l l y ) .

s e r u m , t h e p a t i e n t ' s c l i n i c a l c o u r s e , a n d t h e t u m o r ' s h i s t o l o g i c f e a t u r e s ar e c o n s i s t e n t w i t h c o m b i n e d s e c r e t o r y a n dt r a n s u d a t i v e m e c h a n i s m s f o r i n c r e a s e d f l u i d p r o d u c t i o n .C as e R e p o r t

A 3 9 - y e a r - o l d p a t i e n t p r e s e n t e d i n J u n e 1 9 9 1 w i t h p a i n l e s sj a u n d i c e . T h e w o r k u p r e v e a l e d a l a r g e m a s s a t t h e h e a d o f t h ep a n c r e a s t h a t was h i s t o l o g i c a l l y d i a g n o s e d as p a n c r e a t i c c a r c i n o m a .I n A u g u s t 1 9 9 1 , a W h i p p l e ' s p r o c e d u r e wa s p e r f o r m e d . T h e m a r g i n s o f r e s e c t i o n we r e n e g a t i v e f o r t u m o r , b u t 4 o f 2 2 l y m p h n o d e swere p o s i t i v e .

P o s t o p e r a t i v e l y , t h e p a t i e n t r e c e i v e d f l u o r o u r a c i l ( 5 - F U ) a n d l o c a l r a d i a t i o n t h e r a p y . He d i d w e l l u n t i l M a r c h 1 9 9 2 a t w h i c h t i m eh e p r e s e n t e d w i t h i n c r e a s i n g d y s p n e a a n d was f o u n d t o h a v e m u l t i p l e b i l a t e r a l l u n g m e t a s t a s e s . An o p e n l u n g b i o p s y s p e c i m e n rev e a l e d m e t a s t a t i c a d e n o c a r c i n o m a w i t h e x t e n s i v e t u m o r g r o w t ha l o n g t h e p r e e x i s t i n g p u l m o n a r y a r c h i t e c t u r e . A s e c o n d c o u r s e o f5 - F U a n d l e u c o v o r i n wa s g i v e n f o l l o w e d b y c i s p l a t i n , c y t a r a b i n e ,a n d f i n a l l y h y d r o x y u r e a . He f a i l e d t o s h o w s i g n i f i c a n t c l i n i c a lr e s p o n s e t o a n y a g e n t .I n O c t o b e r 1 9 9 3 , h e b e g a n e x p e c t o r a t i n g t h i n l i q u i d . H i s i n i t i a lo u t p u t was 2 0 0 t o 3 0 0 m L / d , w h i c h g r a d u a l l y i n c r e a s e d a n dp e r s i s t e d a t 2 t o 3 L / d . He wa s g i v e n r a d i a t i o n t h e r a p y t o t h e l u n gf i e l d s i n h o p e s o f d e c r e a s i n g t h e f l u i d v o l u m e , y e t no s i g n i f i c a n tc h a n g e s i n f l u i d p r o d u c t i o n o c c u r r e d . V a r i o u s a n t i c h o l i n e r g i ca g e n t s s u c h a s s c o p o l a m i n e were u n s u c c e s s f u l i n s i g n i f i c a n t l yc h a n g i n g t h e v o l u m e o f b r o n c h i a l s e c r e t i o n s . He was a d m i t t e d t ot h e h o s p i t a l s e v e r a l t i m e s f o r i n t e n s i v e h y d r a t i o n a n d e l e c t r o l y t er e p l e t i o n b e t w e e n D e c e m b e r 1 9 9 3 a n d A p r i l 1 9 9 4 i n s p i t e o fr e c e i v i n g i n t r a v e n o u s l y 3 L / d o f 3% N a C l .I n A p r i l 1 9 9 4 , t h e p a t i e n t wa s r e a d m i t t e d t o t h e h o s p i t a l f o r f u r t h e r c h e m o t h e r a p y w i t h 5 - F U , 3 5 0 m g / d f o r 4 d a y s a n d l e u c o v o r i nw i t h h o p e s o f d e c r e a s i n g h i s b r o n c h o r r h e a . H i s e x a m i n a t i o nr e v e a l e d t h a t h e was c a c h e c t i c a n d u n a b l e t o l i e f l a t i n b e d b e c a u s eo f f r e q u e n t e x p e c t o r a t i o n o f t h i n , c l o u d y , n o n o d o r o u s s p u t u m .L u n g e x a m i n a t i o n r e v e a l e d l i g h t c r a c k l e s i n b o t h l u n g f i e l d s t h a twere o t h e r w i s e c l e a r . P e r t i n e n t l a b o r a t o r y d a t a i n c l u d e d a c h e s tr a d i o g r a p h t h a t s h o w e d b i l a t e r a l i n f i l t r a t e s a n d c o n s o l i d a t i o n s w o r s ei n t h e l e f t l o w e r l o b e a n d a s m a l l l e f t p l e u r a l e f f u s i o n . H i s WBCc o u n t was 1 4 . 6 x l 0 3 / m m 3 a n d h i s h e m a t o c r i t was 3 1 . 3 . C h e m i c a la n a l y s i s o f t h e b r o n c h i a l f l u i d a n d serum ar e s h o w n i n T a b l e 1 .S p u t u m G r a m ' s s t a i n r e v e a l e d G r a m - p o s i t i v e c o c c i i n p a i r s a n db l o o d c u l t u r e s f r o m h o s p i t a l a d m i s s i o n were n e g a t i v e . B e c a u s e o ft h e p o s s i b i l i t y o f a s u p e r i m p o s e d b a c t e r i a l i n f e c t i o n , i n t r a v e n o u sa n t i b i o t i c s were g i v e n f o r 7 d a y s . No s i g n i f i c a n t c h a n g e i n h i s c h e s tr a d i o g r a p h o r WBC c o u n t e n s u e d .P r i o r t o h o s p i t a l a d m i s s i o n , t h e p a t i e n t ' s b r o n c h i a l f l u i d p r o d u c t i o n h a d b e e n r a n g i n g b e t w e e n 2 a n d 3 . 5 L / d . F i g u r e 1 s h o w s t h ed a i l y t r e n d o f b r o n c h i a l f l u i d p r o d u c t i o n a n d u r i n e o u t p u t f o r e a c hh o s p i t a l d a y . D u r i n g t h e f i r s t h o s p i t a l d a y , 3 , 2 0 0 mL was e x p e c t o r a t e d . T r e a t m e n t w i t h a s o m a t o s t a t i n a n a l o g u e , o c t r e o t i d e , 1 0 0 p gs u b c u t a n e o u s l y t h r e e t i m e s a d a y , was s t a r t e d on t h e s e c o n d h o s p i t a l d a y . B r o n c h i a l f l u i d p r o d u c t i o n d e c r e a s e d t o 2 , 4 8 0 mL on t h es e c o n d h o s p i t a l d a y , a n d 2 , 5 0 0 mL on h o s p i t a l d a y 3 . T h e v o l u m eo f b r o n c h i a l f l u i d p r o d u c t i o n i n c r e a s e d s l i g h t l y t o 2 , 8 0 0 mL d u r i n gh o s p i t a l d a y 4 . T h e r e f o r e , t h e o c t r e o t i d e d o s e was i n c r e a s e d t o 2 5 0

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T a b l e 1 . C o n c e n t r a t i o n o f B i o c h e m i c a l C o m p o n e n t s i nt h e S e r u m a n d B r o n c h i a l F l u i dS e r u m B r o n c h i a l F l u i d

A l k a l i n e p h o s p h a t a s e , U / L 1 7 0A S T , I U / L 1 4N a + , m m o l / L 1 3 4K + , m m o l / L 4 . 2C L , m m o l / L 9 7H C O - , m m o l / L 2 4A l b u m i n , g / d L 3 . 1T p r o t e i n , g / d L 5 . 6G l u c o s e , m g / d L 3 1 8A m y l a s e , U / L 3 3L i p a s e , U / L 6T r i g l y c e r i d e , m g / d L 9 0C h o l e s t e r o l , m g / d L 1 4 5O s m , m O s m / k g 2 7 7L D H , U / L 1 9 6L D H 1 , % 2 0L D H 2 , % 4 3L D H 3 , % 2 7L D H 4 , % 6LDH 5 , % 4

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0 . 10 . 31 5 91 , 9 0 0221

2 8 81 7 71 13 02 41 32 2

p g s u b c u t a n e o u s l y t w i c e d a i l y on h o s p i t a l d a y 5 , y e t t h e v o l u m e o fb r o n c h i a l f l u i d r e m a i n e d a t 2 , 8 0 0 m L / d . On h o s p i t a l d a y 6 , t r e a t ment w i t h 5 - F U , 3 5 0 m g / d , was b e g u n . I n i t i a l l y , t h e v o l u m e o fb r o n c h i a l f l u i d d e c r e a s e d t o 1 , 7 5 0 m L ; h o w e v e r , on s u b s e q u e n th o s p i t a l d a y s , p r o d u c t i o n i n c r e a s e d t o 2 , 0 7 5 mL a n d t h e n 2 , 1 5 0 m L .D e s p i t e p r o g r e s s i v e w e i g h t l o s s , t h e p a t i e n t r e m a i n e d a l i v e 3m o n t h s a f t e r h o s p i t a l d i s c h a r g e ; t h e v o l u m e o f h i s b r o n c h i a l f l u i dr e m a i n e d b e t w e e n 2 a n d 3 L / d .D i s c u s s i o n

B r o n c h o r r h e a i s a r b i t r a r i l y d e f i n e d a s w a t e r y s p u t u mp r o d u c t i o n o f more t h a n 1 0 0 m L / d . I t i s s e e n c o m m o n l y i np a t i e n t s w i t h c h r o n i c b r o n c h i t i s a n d a s t h m a . 5 C o p i o u ss e c r e t i o n s m a y a l s o o c c u r i n p a t i e n t s w i t h b r o n c h i e c t a s i s( u s u a l l y p u r u l e n t ) , e n d o b r o n c h i a l t u b e r c u l o s i s , 6 a n d m a l i g n a n c i e s . M a s s i v e b r o n c h o r r h e a ( l i t e r s p e r d a y ) h a s b e e nd e s c r i b e d o n l y i n cases o f b r o n c h o a l v e o l a r c a r c i n o m a .S S 1 0 0 mg t i d

H o s p i t a l D a yF i g u r e 1 . B r o n c h i a l f l u i d o u t p u t ( b a r g r a p h ) i s s h o w n i n c o m p a r i s o n t o u r i n e o u t p u t ( s q u a r e s ) f o r e a c h h o s p i t a l d a y . B r o n c h i a l f l u i do u t p u t n e i t h e r c o r r e l a t e d w i t h t h e p a t i e n t ' s c l i n i c a l v o l u m e s t a t u snor d i d o c t r e o t i d e ( S S ) h a v e s i g n i f i c a n t e f f e c t on b r o n c h i a l f l u i dv o l u m e . A t e m p o r a r y d e c r e a s e was seen a f t e r r e c e i v i n g 5 - F U , 3 5 0mg e v e r y d a y .

T o t h e b e s t o f o u r k n o w l e d g e , t h i s i s t h e f i r s t r e p o r t e d caseo f m a s s i v e b r o n c h i a l f l u i d p r o d u c t i o n o c c u r r i n g s e c o n d a r y t op a n c r e a t i c c a r c i n o m a m e t a s t a t i c t o t h e l u n g . T h e p a t i e n t ' sb r o n c h o r r h e a b e g a n a b o u t 2 y e a r s a f t e r h a v i n g a W h i p p l e ' sp r o c e d u r e f o r p a n c r e a t i c c a r c i n o m a . O p e n l u n g w e d g eb i o p s y s p e c i m e n s s h o w e d m e t a s t a t i c a d e n o c a r c i n o m a w i t h ad i f f u s e m i l i a r y g r o w t h p a t t e r n a l o n g t h e p r e e x i s t i n g p u l m o n a r y a r c h i t e c t u r e , a p a t t e r n s i m i l a r t o d i f f u s e b r o n c h o a l v e o l a r c a r c i n o m a . M a r k e d e l e v a t i o n i n t h e a m y l a s e co ncent r a t i o n o f t h e b r o n c h i a l f l u i d i n c o m p a r i s o n t o t h e serumc o n f i r m s t h a t t h e p a n c r e a t i c tumor c e l l s were f u n c t i o n a l a n dc o n t r i b u t i n g t o t h e m a s s i v e f l u i d p r o d u c t i o n . D e s p i t e v a r i o u sc h e m o t h e r a p e u t i c a g e n t s , r a d i a t i o n t h e r a p y t o t h e l u n gf i e l d s , a n t i c h o l i n e r g i c a g e n t s , a n d s o m a t o s t a t i n t h e r a p y , t h ep a t i e n t ' s b r o n c h i a l f l u i d p r o d u c t i o n r e m a i n e d b e t w e e n 2 a n d3 . 5 L / d w i t h t h e e x c e p t i o n o f t e m p o r a r y d e c r e a s e s i n v o l u m e .C h e m o t h e r a p y f o r m a s s i v e b r o n c h o r r h e a h a s b e e n r e p o r t e dt o p r o v i d e o n l y b r i e f s u p p r e s s i o n o f f l u i d p r o d u c t i o n , w h i l et r e a t m e n t w i t h c o r t i c o s t e r o i d s a n d a n t i c h o l i n e r g i c s h a s b e e ni n e f f e c t i v e . 4 T h e r e i s one r e p o r t o f r a d i a t i o n t h e r a p y p r o v i d i n g l o n g e r - t e r m p a l l i a t i o n i n a p a t i e n t w i t h l o c a l i z e db r o n c h o a l v e o l a r c a r c i n o m a . 8S i m u l t a n e o u s c h e m i c a l a n a l y s i s o f b r o n c h i a l f l u i d a n d s e rum s u g g e s t t h a t s e c r e t o r y a n d t r a n s u d a t i v e m e c h a n i s m swere c o n t r i b u t i n g t o t h e m a s s i v e b r o n c h i a l f l u i d p r o d u c t i o n .E v i d e n c e s u p p o r t i n g a c t i v e s e c r e t i o n b y t h e m e t a s t a t i cp a n c r e a t i c a d e n o c a r c i n o m a i n t h e p r o d u c t i o n o f m a s s i v eb r o n c h i a l s e c r e t i o n s i s s e e n i n t h e m a r k e d e l e v a t i o n o f t h ef l u i d a m y l a s e c o n c e n t r a t i o n i n c o m p a r i s o n t o s e r u m . C o n c e n t r a t i o n s o f s o d i u m a n d c h l o r i d e were h i g h e r a n d p o t a s s i u m m u c h l o w e r t h a n t h o s e m e a s u r e d i n a s t h m a t i c s w i t hb r o n c h o r r h e a . 5 A l s o , s i g n i f i c a n t d i f f e r e n c e s i n t h e i s o e n z y m ep a t t e r n o f l a c t a t e d e h y d r o g e n a s e ( L D H ) were f o u n d i n t h eb r o n c h i a l f l u i d a s c o m p a r e d w i t h s e r u m . C o m p a r a b l ec h a n g e s i n t h e LDH i s o e n z y m e p a t t e r n h a v e b e e n r e p o r t e di n t h e b r o n c h i a l f l u i d f r o m p a t i e n t s w i t h b r o n c h o r r h e a seco n d a r y t o b r o n c h o a l v e o l a r c a r c i n o m a 4 S i m i l a r l y , t h e l a c k o fv a r i a t i o n i n b r o n c h i a l s e c r e t i o n p r o d u c t i o n i n c o r r e l a t i o nw i t h t h e p a t i e n t ' s v o l u m e s t a t u s a n d t h e t e m p o r a r y r e s p o n s et o 5 - F U ar e a l s o c o n s i s t e n t w i t h an a c t i v e s e c r e t o r y p r o c e s sc o n t r i b u t i n g t o t h e b r o n c h i a l f l u i d p r o d u c t i o n .E v i d e n c e i n s u p p o r t o f t r a n s u d a t i o n o f serum i n t h e p u l m o n a r y c i r c u l a t i o n t o a l v e o l a r f l u i d a s a m e c h a n i s m o f m a s s i v e b r o n c h i a l f l u i d p r o d u c t i o n i n c l u d e s t h e r e l a t i v e i s o -o s m o l a l i t y a n d t h e c o n c e n t r a t i o n d i f f e r e n c e s o f l a r g e mol e c u l a r w e i g h t e n z y m e s b e t w e e n b r o n c h i a l f l u i d a n d s e r u m .T r i g l y c e r i d e , c h o l e s t e r o l , a n d a l b u m i n c o n c e n t r a t i o n s wered e c r e a s e d m a r k e d l y i n t h e b r o n c h i a l f l u i d . A s p a r t a t e a m i n o t r a n s f e r a s e ( A S T ) , a l k a l i n e p h o s p h a t a s e , a n d l i p a s e werea l s o d e c r e a s e d i n b r o n c h i a l f l u i d , b u t l e s s s o . T h e s e f i n d i n g sar e c o n s i s t e n t w i t h t r a n s u d a t i o n o f f l u i d i n t o t h e a l v e o l a rs p a c e . T h e d a t a d o n o t s u p p o r t t h e h y p o t h e s i s t h a t i n c r e a s e dp e r m e a b i l i t y o f t h e e p i t h e l i u m l e a d s t o b r o n c h o r r h e a f o r m a t i o n . 5H i s t o l o g i c e x a m i n a t i o n o f l u n g t i s s u e f r o m an o p e n l u n gw e d g e b i o p s y s p e c i m e n i n t h i s p a t i e n t s h o w e d s h e e t s o fa d e n o c a r c i n o m a l i n i n g t h e l u n g p a r e n c h y m a . S u c h d i s t r i b u t i o n i s s i m i l a r t o t h a t f o u n d i n b r o n c h o a l v e o l a r c a r c i n o m a .E l e c t r o n m i c r o s c o p i c i m a g i n g o f b r o n c h o a l v e o l a r c a r c i n o m ai n a p a t i e n t a l s o w i t h m a s s i v e b r o n c h i a l f l u i d p r o d u c t i o ns h o w e d i n c r e a s e d c o n c e n t r a t i o n s o f r o u g h e n d o p l a s m i c

1 1 6 2 S e l e c t e d R e p o r t s1995 BY THE AMERICAN COLLEGE OF CHEST PHYSICIANS

at Rush University on June 1, 2011chestjournal.chestpubs.orgDownloaded from


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r e t i c u l u m w i t h d i l a t e d c i s t e r n a e a n d s e c r e t o r y g r a n u l e s , 4w h i c h s u p p o r t s a s e c r e t o r y f u n c t i o n o f t h e s e c e l l s .L e v i n s k y a n d K e r n 1 s p e c u l a t e d t h a t a c o m b i n a t i o n o f i n c r e a s e d s e c r e t o r y a c t i v i t y a n d e n h a n c e d f i l t r a t i o n across t h ea l v e o l a r c a p i l l a r y m e m b r a n e c o n t r i b u t e d t o t h e m a s s i v eb r o n c h i a l f l u i d p r o d u c t i o n i n t h e i r p a t i e n t w i t h b r o n c h o a l v e o l a r c a r c i n o m a . T h i s c a s e , w h i c h i n v o l v e s m e t a s t a t i cp a n c r e a t i c c a r c i n o m a t o t h e l u n g w i t h m a s s i v e b r o n c h i a lf l u i d p r o d u c t i o n , a l s o s u p p o r t s b o t h a c t i v e s e c r e t o r y a n dt r a n s u d a t i v e m e c h a n i s m s i n t h e f o r m a t i o n o f m a l i g n a n tb r o n c h o r r h e a .

R e f e r e n c e s1 L e v i n s k y W , K e r n R . F l u i d , e l e c t r o l y t e , a n d p r o t e i n d e p l e t i o ns e c o n d a r y t o t h e b r o n c h o r r h e a o f p u l m o n a r y a d e n o m a t o s i s : ac o m p l i c a t i o n h e r e t o f o r e u n r e p o r t e d . Am J Med S c i 1 9 5 2 ;2 2 3 : 5 1 2 - 2 12 H o m m a H , K i r a S , T a k a h a s h i Y , e t a l . A case o f a l v e o l a r c e l l carc i n o m a a c c o m p a n i e d b y f l u i d a n d e l e c t r o l y t e d e p l e t i o n t h r o u g hp r o d u c t i o n o f v o l u m i n o u s amount o f l u n g l i q u i d . Am R e v R e s p i rD i s 1 9 7 5 ; 1 1 1 : 8 5 7 - 6 23 S p i r o S G , L o p e z - V i v r i e r o M T , C h a r m a n J , e t a l . B r o n c h o r r h e a i n

a case o f a l v e o l a r c e l l c a r c i n o m a . J C l i n P a t h o l 1 9 7 5 ; 2 8 : 6 0 - 54 D w e k J , C h a r y t a n C , S t a c h u r a I , e t a l . S a l t - w a s t i n g b r o n c h o r r h e aa n d i t s m e c h a n i s m s . A r c h I n t e r n Med 1 9 7 7 ; 1 3 7 : 7 9 1 - 9 45 S h i m u r a S , S a s a k i T , S a s a k i H , e t a l . C h e m i c a l p r o p e r t i e s o fb r o n c h o r r h e a s p u t u m i n b r o n c h i a l a s t h m a . C h e s t 1 9 8 8 ; 9 4 :1 2 1 1 - 1 56 S o S , Lam K , S h a m M . B r o n c h o r r h e a : a p r e s e n t i n g f e a t u r e o fe n d o b r o n c h i a l t u b e r c u l o s i s . C h e s t 1 9 8 3 ; 8 4 : 6 3 5 - 3 67 S h i m u r a S , T a k i s h i m a T . B r o n c h o r r h e a f r o m d i f f u s e l y m p h a n g i t i cm e t a s t a s i s o f c o l o n c a r c i n o m a t o t h e l u n g . C h e s t 1 9 9 4 ; 1 0 5 : 3 0 8 - 1 08 K r a w t z S , M e h t a A , V i j a y a k u m a r S , e t a l . P a l l i a t i o n o f m a s s i v eb r o n c h o r r h e a [ l e t t e r ] . C h e s t 1 9 8 8 ; 9 4 : 1 3 1 3 - 1 4

S u r g i c a l T r e a t m e n t o fC o m p l i c a t i o n s 4 5 Y e a r s A f t e rE x t r a p e r i o s t e a l P n e u m o n o l y s i sa n d P l o m b a g e U s i n g A c r y l i cR e s i n B a l l s f o r C a v i t a r yP u l m o n a r y T u b e r c u l o s i s *G a i l E . T h o m a s , M D , P h D ;B a l a s u b r a m a n i a n C h a n d r a s e k h a r , M D ; a n dF r e d e r i c W . G r a n n i s , J r . , M D , FCCPAn i n f e c t e d a x i l l a r y s i n u s t r a c t d i s c h a r g e d b a l l s madeo f an a c r y l i c r e s i n c o n s i s t i n g e s s e n t i a l l y o f p o l y m e r i z e dm e t h y l m e t h a c r y l a t e ( L u c i t e ) 4 5 y e a r s f o l l o w i n g p e r f o r m a n c e o f an e x t r a p e r i o s t e a l p n e u m o n o l y s i s a n dL u c i t e b a l l p l o m b a g e f o r c o l l a p s e t h e r a p y o f r i g h t u p p e r l o b e c a v i t a r y t u b e r c u l o s i s . S u r g i c a l e x t r a c t i o n o f* F r o m t h e D e p a r t m e n t s o f G e n e r a l O n c o l o g i c S u r g e r y , P l a s t i c a n dR e c o n s t r u c t i v e S u r g e r y a n d T h o r a c i c S u r g e r y , C i t y o f H o p e N a

t i o n a l M e d i c a l C e n t e r , D u a r t e , C a l i f o r n i a .R e p r i n t s r e q u e s t s : D r . T h o m a s , D e p a r t m e n t o f G e n e r a l O n c o l o g i cS u r g e r y , C i t y o f H o p e N a t i o n a l M e d i c a l C e n t e r , D u a r t e R o a d ,D u a r t e , CA 9 1 0 1 0

t h e b a l l s was p e r f o r m e d , f o l l o w e d b y a p a r t i a l d e c o r t i c a t i o n o f t h e l u n g a n d i n t r a t h o r a c i c t r a n s p o s i t i o n o fa p e c t o r a l i s m a j o r m u s c l e f l a p t o f i l l t h e r e s i d u a lp l e u r a l s p a c e . P r i m a r y h e a l i n g was a t t a i n e d , a n d t h ep a t i e n t i s w e l l V A y e a r s a f t e r s u r g e r y .( C H E S T 1 9 9 5 ; 1 0 8 : 1 1 6 3 - 6 4 )K e y w o r d s : c o l l a p s e t h e r a p y ; c u t a n e o u s f i s t u l a ; L u c i t e b a l l ;p e c t o r a l i s m u s c l e s ; p l o m b a g e ; p n e u m o n o l y s i s ; p u l m o n a r yt u b e r c u l o s i s ; t h o r a c o p l a s t yC o l l a p s e t h e r a p y o f p u l m o n a r y t u b e r c u l o s i s was p r a c t i c e dw i d e l y i n t h e e r a b e f o r e e f f e c t i v e a n t i t u b e r c u l o s i sm e d i c a t i o n s b e c a m e a v a i l a b l e . One f o r m o f c o l l a p s e t h e r a p y ,e x t r a p e r i o s t e a l p n e u m o n o l y s i s w i t h p l o m b a g e u s i n g b a l l sm a d e o f an a c r y l i c r e s i n c o n s i s t i n g m a i n l y o f p o l y m e r i z e dm e t h y l m e t h a c r y l a t e ( L u c i t e ) , can r e s u l t i n d e l a y e d c o m p l i c a t i o n s m a n y y e a r s a f t e r t h e o r i g i n a l o p e r a t i o n , a s e x e m p l i f i e d b y t h i s case r e p o r t .

C a s e R e p o r tA 6 4 - y e a r - o l d w h i t e woman h a d an a x i l l a r y p l e u r o c u t a n e o u s f i s t u l a . An e x t r a p e r i o s t e a l p n e u m o n o l y s i s w i t h L u c i t e b a l l p l o m b a g eh a d b e e n p e r f o r m e d 4 5 y e a r s e a r l i e r a t t h e C i t y o f H o p e N a t i o n a lM e d i c a l C e n t e r as t r e a t m e n t f o r r i g h t u p p e r l o b e c a v i t a r y t u b e r c u l o s i s . T h e p a t i e n t d i d w e l l u n t i l 1 9 7 9 w h e n n o d u l a r , p o o r l y d i f f e r e n t i a t e d l y m p h o m a was d i a g n o s e d a n d t r e a t e d w i t h r a d i a t i o nt h e r a p y a n d c h l o r a m b u c i l ( L e u k e r a n ) . L y m p h o m a r e c u r r e d i n t h en e c k i n 1 9 8 9 a n d 1 9 9 1 ; t r e a t m e n t was w i t h l o c a l r a d i a t i o n a n dc h l o r a m b u c i l . I n A u g u s t 1 9 9 1 , a t a n o t h e r i n s t i t u t i o n , a r i g h t a x i l l a r yb i o p s y s p e c i m e n y i e l d e d " b r o w n f l u i d . " Two m o n t h s l a t e r , a L u c i t eb a l l was e x c i s e d f r o m t h e same a r e a . C h r o n i c d r a i n a g e f r o m t h ea x i l l a c o n t i n u e d ; c u l t u r e s o f t h e f l u i d were p o s i t i v e f o r S t a p h y l o c occ us aureus. S h e r e t u r n e d h e r e f o r t r e a t m e n t i n J u l y 1 9 9 2 . A

d r a i n i n g s i n u s t r a c t wa s n o t e d i n t h e r i g h t a x i l l a w i t h an u n d e r l y i n gp a l p a b l e mass. S u r g i c a l e x p l o r a t i o n o f t h e a x i l l a r e v e a l e d two moreL u c i t e b a l l s e x t r u d i n g f r o m a s i n u s t r a c t e x i t i n g t h e c h e s t c a v i t yb e t w e e n t h e u p p e r area o f t h e r i b s . C u l t u r e s were a g a i n p o s i t i v e f o rS a u r e u s , a n d no l y m p h o m a wa s f o u n d .On J u l y 2 0 , 1 9 9 2 , w i t h t h e p a t i e n t u n d e r g e n e r a l a n e s t h e s i a i nt h e s u p i n e p o s i t i o n , t h e p e c t o r a l i s m a j o r m u s c l e f l a p was e l e v a t e don i t s t h o r a c o a c r o m i a l p e d i c l e t h r o u g h an i n f r a m a m m a r y i n c i s i o n .An 8 b y 8 - c m s q u a r e o f t h e a n t e r o l a t e r a l c h e s t w a l l i n c l u d i n g p o r t i o n s o f r i b s 2 , 3 , a n d 4 , t h e s i n u s t r a c t , a n d t h e f i b r o u s w a l l o f a

F i g u r e 1 . C o m p u t e d t o m o g r a p h i c scan d e m o n s t r a t e s t h e a p e x o ft h e r i g h t h e m i t h o r a x f i l l e d w i t h L u c i t e b a l l s . E x t r u s i o n o f a b a l l i n t ot h e a x i l l a r y f i s t u l o u s t r a c t can b e seen.CHEST / 1 0 8 / 4 / O C T O B E R , 1 9 9 5 1 1 6 3



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DOI 10.1378/chest.108.4.11611995;108; 1161-1163Chest

Tony Lembo and Thomas J. DonnellyFluid Production and Electrolyte Abnormalities

A Case of Pancreatic Carcinoma Causing Massive Bronchial

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