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Subcutaneous Metastatic Seeding After Removal of a Pleurx Catheter

Reichner, Cristina A. MD; Read, Charles A. MD, FCCP

doi: 10.1097/01.lbr.0000206234.61307.ba
Brief Communications

Indwelling pleural catheters (Pleurx; Denver Biomaterials, Golden, CO) are an alternative outpatient option for the palliation of recurrent malignant effusions. Twenty-one to 50% of patients achieve pleurodesis with the catheter in place, allowing for removal of the catheter. We report the first case of subcutaneous metastasis in the tract of a Pleurx catheter after its removal after successful pleurodesis.

Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Hospital, Washington, DC

Financial disclosure: none.

Reprints: Cristina A. Reichner, MD, Division of Pulmonary, Critical Care and Sleep Medicine, Georgetown University Hospital, 4 North Main Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (e-mail: reichnerc@aol.com)

Received for publication December 12, 2005; accepted December 27, 2005

One of the treatment options for recurrent malignant effusions includes the use of the Pleurx catheter, which has been shown to safely and effectively relieve dyspnea and maintain quality of life in patients with recurrent effusions.1–4 The Pleurx is an indwelling tunneled catheter inserted into the pleural space via Seldinger technique. This less invasive procedure can be done as an outpatient, offering the advantage over tube thorascopy and chemical pleurodesis of allowing rapid return to the patients' preprocedural functional status. With the catheter in place and using vacuum bottles, the patients can intermittently drain their effusion for symptomatic relief of shortness of breath. Very few morbidities, such as malfunctioning catheters, fluid reaccumulation, and empyemas, have been described with the use of Pleurx catheters.1 We report the first case of a patient who, after achieving successful pleurodesis and removal of her Pleurx catheter, developed metastatic seeding in the tunnel of the preexisting catheter.

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CASE PRESENTATION

The patient is a 43-year-old Puerto Rican female with a history of recurrent metastatic adenocarcinoma of the right breast originally diagnosed in 1994. In 2003, she developed a right malignant pleural effusion requiring 3 thoracenteses, each with radiographically proven reexpansion of her right lung and improvement in dyspnea. She underwent an uncomplicated right Pleurx catheter placement in August of 2004. She drained her effusion approximately every 3 to 4 days initially and then noted progressively decreased drainage. The catheter was removed within 8 weeks after its placement. Since then, the patient had been asymptomatic and did not require any right thoracentesis. Four months after the removal of the catheter, the patient noticed a painful “lump” on her right chest, at the site of the previous tunnel of the Pleurx catheter. The lump was more noticeable when she slept on her right side and was progressively increasing in size. On examination, she had a 2-by-1.5 cm firm subcutaneous nodule along the site of the old tunnel. A computed tomography of the chest showed the presence of a small subcutaneous nodule (Fig. 1). A fine needle aspirate was performed and confirmed the presence of metastatic adenocarcinoma (Fig. 2).

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

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DISCUSSION

Apart from mesothelioma, which is known to frequently invade incisions, pleural biopsy sites, or chest tube insertion sites,6 local tumor recurrence or seeding for other malignancies is uncommon. It has been described, mostly in case reports, after percutaneous lung biopsy,7–9 pleural biopsy,10,11 thoracentesis,12,13 tube thorascopy,14 and surgical video-assisted thoracic surgery.15 Although 89% of needle tracts from percutaneous needle biopsies for pulmonary malignancies will contain malignant cells,16 only 1 in 2500 patients will develop a chest wall tumor.7 The pathogenesis of subcutaneous metastasis is largely unknown. Contact of tumor cells with normal tissue leading to a malignant implant is one possibility, but this is probably an unlikely phenomenon as one would expect a higher incidence of tumor seeding after any type of biopsy.17 A more acceptable theory is hematogenous spread of malignant cells to a tissue undergoing repair after biopsies18 as this regenerating tissue seems to be a good substrate for tumor cells.19 There are also probably genetic factors involved, which have not been elucidated yet.17

Thus far, there had been no reported cases of tumor seeding from removal of a Pleurx catheter. The incidence is probably very low for 2 main reasons. As described above, tumor seeding in general is a rare occurrence. Additionally, many catheters are not removed as not all patients achieve successful pleurodesis. These patients die with the catheters in place. The clinical significance of seeding is uncertain as most of the patients undergoing placement of these catheters already have metastatic disease. Hence, it probably does not affect overall prognosis. It might be more of an issue for malignancies such as ovarian and breast cancer in which patients have a longer median survival after the diagnosis of malignant pleural effusion.1 Another potential issue is the development of pain secondary to a subcutaneous nodule as it was the case for our patient. This is especially important as the Pleurx catheter is primarily designed to be a palliative treatment.

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CONCLUSIONS

Seeding of the tunnel tract and subcutaneous metastasis after removal of Pleurx catheters can occur. It should be considered in a patient presenting with a palpable nodule at the prior site of one of these catheters. But the incidence is probably very low and may not affect prognosis. Therefore, this should not deter from inserting Pleurx catheters as they remain a safe and effective palliative treatment option for recurrent malignant effusions.

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REFERENCES

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Keywords:

pleural effusion; indwelling pleural catheter (Pleurx catheter); complications

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