Chylothorax Associated With Indolent Follicular Lymphoma

A 62-year-old woman with a history of indolent follicular lymphoma and multiple thoracic and abdominal lesions presented with massive right pleural effusion. A chest tube was placed, and about 1900 mL of cloudy, nonmalodorous pleural fluid was evacuated. The analysis of pleural fluid revealed high triglyceride levels, indicative of chylothorax. Conservative treatment, consisting of total parenteral nutrition and subcutaneous octreotide, was started. Chest computed tomography (CT) showed small residual right-sided pleural effusion but no lung parenchymal lesions. In the subsequent days, the amount of drained fluid decreased but still persisted. Therefore thoracoscopy was performed to identify and interrupt the chyle leak into the chest cavity. Oral cream administration allowed for observation of a diffuse leak of chyle during surgery in the posterior mediastinal pleura. The thoracic surgeon sprayed a fibrin sealant at the point of the greatest spill, followed by talc poudrage to achieve pleurodesis and reduce the risk of recurrence of chylothorax. Total parenteral nutrition and octreotide therapy was continued postoperatively for 4 days. No pleural effusion was evident 4 weeks after surgery. Chemotherapy was resumed, and complete remission of the lymphoma was achieved in 3 months. This chapter describes a challenging case and discusses the macroscopic appearance and etiology of chylothorax and the criticisms and pitfalls regarding its diagnosis and management. Differences in the types and sizes of chest drains are addressed as well.