Malignant Pleural Effusion in Metastatic Pulmonary Adenocarcinoma Complicated by Pulmonary Embolism

Claudio Sorino, David Feller-Kopman, Giampietro Marchetti, Mario Spatafora

Research output: Chapter in Book/Report/Conference proceedingChapter


A 71-year-old woman, who was a never-smoker, presented with low-grade fever, weakness, loss of appetite, chest pain, exertional dyspnea, and dry cough. Chest radiography showed lung opacity in the right upper pulmonary field. Symptoms persisted despite antibiotic therapy. Subsequent chest/abdominal computed tomography (CT) revealed a solid, round lesion in the right upper lobe and bilateral pleural effusion, with the majority on the right side. After discussing the possible diagnostic approach (including thoracentesis, bronchoscopy, transthoracic needle biopsy, thoracoscopy), doctors choose to start with the less invasive procedures. Thoracentesis was performed, and the result of cytology of the pleural fluid was positive for cancer cells, showing an immune-phenotypic pattern compatible with lung adenocarcinoma. The clinical course was soon complicated by severe hypoxemic respiratory failure caused by concomitant lower respiratory tract infection and bilateral pulmonary embolism (PE). The low amount of cancer cells in the pleural effusion did not allow for performance of further tests aimed at predicting patient response to targeted therapy or immunotherapy. Thus ultrasound-guided needle biopsy of a positron emission tomography (PET)-positive left supraclavicular lymph node was performed. However, neither mutation of the epidermal growth factor receptor (EGFR) gene nor rearrangements of anaplastic lymphoma kinase (ALK) and reactive oxygen species 1 (ROS1) was detected. Further staging tests revealed multimetastatic disease, with brain and bone involvement. The patient received the best supportive care possible. This chapter deals with molecular testing of advanced non-small cell lung cancer, venous thromboembolism in malignancy, and management of anticoagulant and antiplatelet agents in adults undergoing percutaneous interventions. A schematic for the optimal timing of drug withdrawal before procedures is provided.

Original languageEnglish (US)
Title of host publicationPleural Diseases
Subtitle of host publicationClinical Cases and Real-World Discussions
Number of pages10
ISBN (Electronic)9780323795418
StatePublished - Jan 1 2021


  • ALK
  • Anticoagulants
  • EGFR
  • Molecular testing
  • Non-small cell lung cancer
  • Pulmonary embolism
  • Transthoracic needle biopsy

ASJC Scopus subject areas

  • General Medicine


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