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A3614 - Late Onset Pneumonectomy Adenocarcinoma Recurrence Presenting as Empyema Necessitans
Author Block: W. Rodriguez1, D. Vazquez1, A. Cordero-Gomez1, J. Torres-Palacios2, J. Casal2; 1Pulm/CCM/Sleep, VA Caribbean Healthcare System, San Juan, PR, United States, 2VA Caribbean Healthcare System, San Juan, PR, United States.
Postpneumonectomy empyema (PPE) is a rare complication with an incidence rate of 4.4% to 16%. Twenty-five percent of PPE occur within the first three months of pneumonectomy; but it may occur even years after the procedure. We report an 84-year-old male that presented with findings suggestive of empyema necessitans involving the left chest wall and surrounding musculature seven years after completion left pneumonectomy. His past medical history is remarkable for prostate carcinoma, coronary artery disease with coronary artery bypass graft on 2008, chronic obstructive pulmonary disease, left lower lobectomy and wedge resection of left upper lobe nodule on 2008 due to moderately differentiated adenocarcinoma of the lung, Stage Ia and completion left pneumonectomy on 2010 due to adenocarcinoma recurrence, treated with adjuvant chemotherapy (4 cycles of carboplatin and taxol). He presented to the clinic for follow-up complaining of left hemithorax painful bulging at the area of pneumonectomy scar of one week of evolution. Computed tomography scan showed residual fluid collection within the pneumonectomy cavity and interval development of fluid accumulation and stranding of the surrounding soft tissues at the left lateral chest wall involving the musculature. The patient underwent diagnostic ultrasound guided aspiration of the left pleural collection. Purulent fluid was obtained with a cell count of 14,080 with polymorphonuclear predominance, Ph 7.01 and analysis consistent with an exudative effusion by Light’s criteria. In view of findings consistent with empyema a pleural drainage catheter was placed. The final culture showed no bacterial growth; however, the cytopathology analysis showed abundant bacterial organisms on the fluid obtained from initial aspiration and evidence of lung adenocarcinoma recurrence on the fluid obtained from the pleural catheter. He was evaluated by the cardiothoracic surgeon, who recommended percutaneous drainage as needed. The patient completed fourteen days of empirical antibiotics, then he
was started on chemotherapy regimen with carboplatin, pembrolizumab and pemetrexed.
The clinical signs of empyema are variable, and might be nonspecific such as low grade fever and leukocytosis. A high index of suspicion is required to make a prompt diagnosis. Although, several cases of late-onset postpneumonectomy empyema have been reported in the literature, this case is unique given the concomitant diagnosis of lung adenocarcinoma recurrence. The treatment of PPE depends on the stage of empyema and the overall patient’s condition. The alternatives include drainage and debridement and obliteration of the pneumonectomy among others. As in this case, drainage alone is considered palliative.