Neoplastik şilotoraksın tedavisinde somatostatinin etkis

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Introduction
Chylothorax is the accumulation of lymphatic fluid within the pleural space. Chylothorax can occur in
various clinical settings and arise from diverse causes.
Tumor has been the most common cause of the series and responsible for approximately one half of the
cases (1,2). Chylous leakage can result from either a
rupture of the duct secondary to back pressure or
direct tumor invasion of the duct (2). Traditionally,
lymphoma accounted for approximately three fourth
of the tumor group, with bronchogenic carcinoma
and other tumors making up the remainder (2).
The ideal management of the patient with chylothorax is still uncertain. Treatment of chylothorax can
be divided into conservative therapy, operative therapy, and radiation therapy (1,2). Conservative therapy
consists of maintaining; use of a low high protein
diet, supplemented with medium chain triglycerides
or total parenteral nutrition combined with effective
pleural drainage to provide the expansion of the lung
(2,3). Recent reports have suggested that octreotide,
by value of its direct action on lymphatic flow, has
been useful in resolution of neoplastic chylothorax
in the adult population (4). We herein report prompt
cessation of lymphorrhea in an adult patient with
chylothorax using octreotide, a long-acting somatostatin analog.
Case Report
A 50-year-old woman was diagnosed to have
non-Hodgkin lymphoma three years ago by bone
marrow examination. First complete remission
was achieved after the use of 6 cycles of CHOP
(Cyclophosphamide, doxorubicin, vincristine, prednisolone) and radiotherapy to the lumbar region for
her multiple vertebral hipodens lesions. Due to high
International Prognostic Index (IPI) score, autologous stem cell transplantation (ASCT) was planned.
She was given two cycles of ICE (Ifosfamid, carbopla-
* Department of Thoracic Surgery, Gulhane Military Medical Faculty
**Department of Medical Oncology, Gulhane Military Medical Faculty
Reprint request: Dr. Orhan Yücel, Department of Thoracic Surgery, Gulhane
Military Medical Faculty, Etlik-06018, Ankara Turkey
E-mail: orhanycl@gmail.com
Date submitted: February 08, 2008 • Date accepted: October 10, 2008252 • December 2009 • Gulhane Med J Yucel et al.
tin and etoposid) and as conditioning regimen BEAM
(BCNU, etoposid, cytarabine, and melphelan) was
performed. After completion of ASCT she was followed for 3 years without any complaint. She presented with cough, dypnea, weakness, chest and back
pain. Physical findings showed the absence of breath
sounds and dullness of percussion on the right chest.
Thorax computed tomography (CT) revealed pleural
effusion in the right hemithorax without significant
mass in the pulmonary parenchyma. She admitted
to hospital for pleural effusion. Laboratory tests on
admission revealed a hemoglobin level of 12.4 gr/dl
and a serum albumin level of 3.5 gr/dl. Thoracentesis
was performed. Pleural culture revealed no growth of
any bacteria. Biochemical analysis of the chest fluid
showed levels of cholesterol 44 mg/dl, LDH 165 U/L
and triglycerides 159 mg/dl. Cytologic smear of the
pleural fluid did not show any malignancy. Because
of laboratory and clinical findings diagnosis of pleural chylothorax was made. Chest tube drainage was
placed (after two days of admission) and tube drainage was followed (color, characteristics, volume, etc.).
Oral intake was withheld from the 2nd to 10th days
of hospitalization, and she was given parenteral nutrition. Octreotide (0.1 mg/sc, tid) treatment was started on the postoperative 4th day. The chylous chest
drainage decreased with the octreotide treatment on
the first day and just a little days later. In addition,
talc pleurodesis treatment was performed for recurrent pleural effusion (5th day). Octreotide treatment
was continued for a total of five days. Later, chest tube
was removed on the postoperative 9th day. The patient was well after the successful period of treatment
and the control chest roentgenogram improved. The
summary of the treatment stages of malign chylothorax is shown in Figure 1.
Discussion
Chylothorax, accumulation of a milky white fluid
from a pleural space, usually results from either a rupture
of the duct secondary to back pressure or direct tumor
invasion of the thoracic duct. More than 50% of chylothorax is due to malignancy, and lymphoma accounts
for 75%, followed by lung carcinoma (5). Management
of chylothorax includes treatment of the underlying
disease associated with other conservative measures,
such as drainage of pleural effusion, maintenance of
nutritional condition, operative therapy and radiation
therapy (1). Surgical therapy is proposed in selected
cases when conservative treatments fail. Octreotide,
which is an analog of somatostatin has been preferred
in the treatment of neoplastic chylothorax for 15 years
(4). The mechanism of action of somatostatin in chylothorax remains uncertain (6). Somatostatin causes
mild vasoconstriction of splanchnic vessels and reduces
gastric, pancreatic and intestinal secretions as well as
intestinal absorption and hepatic venous flow, which
collectively may act in concert to reduce chyle flow. As
a result somatostatin reduces the thoracic duct flow and
its triglyceride level (6). Octretide is a long acting somatostatin analogue. Octreotide is similar in action to
somatostatin, but selectivity is superior and has longer
half life (3,6). The use of octreotide as an adjunt to the
conservative management of neoplastic chylothorax is
a relatively new concept (1,4). The literature does not
specifically address the dose of octreotide in neoplastic
chylothorax in the adult. Recently, octreotide has been
successfully utilized in the treatment of neoplastic chylothorax and subcutaneous injection of 0.1 mg every 8
hours as advised by Nicholas et al. (4).
We report an adult patient in whom introduction
of somatostatin immediately diminished chyle production. The reported side effects of octreotide are arrhythmia, headache, nausea, vomiting, diarrhea, dizziness, thrombochytopenia, hepatotoxicity, and other
reactions (4,6). We did not observe any of these side
effects.
We believe that the effectiveness of octreotide therapy cannot prove its safety in only a few cases. However,
further controlled studies which contain larger series
are required for the confirmation of our result for designation of effectiveness of this agent, the definition of
the effective dosage, and the long-term effectiveness of
octreotide therapy. Additionally somatostatin therapy
has a financial advantage due to the avoidance of an
operation and the reduction of hospitalization time.
Our case and other reported cases showed acceptable
efficacy in the management of neoplastic chylothorax.
Further reports and studies assessing octreotide efficacy
in the management of chylothorax are warranted.