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.
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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