A 42-year-old woman comes to the emergency department due to shortness of breath. Approximately 2 weeks ago, the patient developed shortness of breath on exertion that has become progressively worse. She also reports mild chest pain with deep inspiration. She has had no weight loss, fever, cough, or sputum production. Medical history includes diet-controlled type 2 diabetes mellitus and locally advanced infiltrating ductal carcinoma of the left breast, for which she underwent neoadjuvant chemotherapy followed by surgical resection and radiation approximately 2 years ago. The patient is a lifetime nonsmoker and has no significant second-hand tobacco exposure. She lives with her family and works as a teacher. Family history is notable for colon cancer in her father.
Temperature is 37.6 C (99.7 F) , blood pressure is 122/78 mm Hg, pulse is 92/min, and respirations are 20/min. Oxygen saturation is 92% on ambient air. Physical examination shows moist mucous membranes with no jugular venous distension or lymphadenopathy. Heart rate is regular with no murmurs or gallops. Auscultation reveals decreased breath sounds over the right lower lung with dullness to percussion. Extremities have no edema. The remainder of the examination is normal. Upright chest x-ray reveals the following:

The patient undergoes thoracentesis. Pleural fluid analysis shows 3,500/mm³ nucleated cells, predominantly lymphocytes. Additional pleural fluid analysis results are as follows:
Gram stain and culture of the pleural fluid are negative. What is the most appropriate next step in management of this patient?

Question

A 42-year-old woman comes to the emergency department due to shortness of breath. Approximately 2 weeks ago, the patient developed shortness of breath on exertion that has become progressively worse. She also reports mild chest pain with deep inspiration. She has had no weight loss, fever, cough, or sputum production. Medical history includes diet-controlled type 2 diabetes mellitus and locally advanced infiltrating ductal carcinoma of the left breast, for which she underwent neoadjuvant chemotherapy followed by surgical resection and radiation approximately 2 years ago. The patient is a lifetime nonsmoker and has no significant second-hand tobacco exposure. She lives with her family and works as a teacher. Family history is notable for colon cancer in her father.
Temperature is 37.6 C (99.7 F) , blood pressure is 122/78 mm Hg, pulse is 92/min, and respirations are 20/min. Oxygen saturation is 92% on ambient air. Physical examination shows moist mucous membranes with no jugular venous distension or lymphadenopathy. Heart rate is regular with no murmurs or gallops. Auscultation reveals decreased breath sounds over the right lower lung with dullness to percussion. Extremities have no edema. The remainder of the examination is normal. Upright chest x-ray reveals the following:

The patient undergoes thoracentesis. Pleural fluid analysis shows 3,500/mm³ nucleated cells, predominantly lymphocytes. Additional pleural fluid analysis results are as follows:

Gram stain and culture of the pleural fluid are negative. What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's exudative pleural effusion by Light criteria and history of recent breast cancer raise suspicion for malignant pleural effusion due to breast cancer recurrence. Most malignant pleural effusions are lymphocyte-predominant. The sensitivity of pleural fluid cytology for detecting malignancy varies with pH. Low pH suggests high malignant cell burden and is associated with high sensitivity of fluid cytology, whereas relatively high pH (≥7.3) is associated with low fluid cytology sensitivity. Light criteria When fluid analysis fails to confirm the etiology of pleural effusion, CT scan of the chest with pleural phase contrast enhancement is typically the most appropriate next step. In this case, it will allow evaluation for metastatic lesions or areas of pleural thickening that may be amenable to diagnostic tissue biopsy. (Choice A) Bronchoscopy with bronchoalveolar lavage (BAL) allows investigation for opportunistic pulmonary infection (eg, aspergillosis) or eosinophilic pneumonia, but moderate to large pleural effusion would be rare in these conditions. Bronchoscopy with BAL is sometimes used in the evaluation of nonresolving pneumonia (eg, endobronchial obstruction due to carcinoma), which would likely cause fever and cough. The sensitivity of BAL for detecting metastatic breast cancer is likely low. (Choice C) Nonsteroidal anti-inflammatory drugs are appropriate treatment for viral pleuritis. Associated pleural effusions are also typically exudative and lymphocyte-predominant, but the high suspicion for recurrent malignancy in this patient necessitates further diagnostic workup. (Choice D) Antibiotics and clinical follow-up are appropriate for community-acquired pneumonia with an uncomplicated parapneumonic effusion. However, the absence of fever and cough in this patient makes community-acquired pneumonia unlikely. parapneumonic effusion (Choice E) Thorascopic pleural biopsy can be useful in diagnosing suspected malignant pleural effusion or pleural effusion of unknown etiology; however, CT scan should be performed first to guide the location of biopsy. Educational objective: Malignant pleural effusions are exudative by Light criteria and usually lymphocyte-predominant. Pleural fluid cytology has low sensitivity for malignancy in the setting of high pH (≥7.3). When fluid analysis fails to confirm the etiology of pleural effusion, CT scan of the chest with pleural phase contrast enhancement provides guidance for diagnostic tissue biopsy. __________ References: Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/12711467)

A 42-Year-Old Woman Comes to the Emergency Department Due to Shortness