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000194824

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© 1985 S. Karger AG, Basel
0025-7931/8 5/0482-0188 S 2.75/0
Respiration 48: 188-189(1985)
Chylothorax after Mantle Field Irradiation for Hodgkin’s
Disease
Dirk Van Renterghem*. Jeannine Hamersb, André De Schryver0, Romain Pauwelsa,
Marcel Van der Straeten*
“ Department of Respiratory Diseases; b Department of Hematology, and
' Department of Radiotherapy and Nuclear Medicine, Academic Hospital,
State University, Ghent, Belgium
Key Words. Hodgkin’s disease ■Irradiation ■Chylothorax
Introduction
Tumor and trauma are the most fre­
quent etiologies of chylothorax. Numer­
ous other congenital and acquired condi­
tions can be responsible, but often no
etiology is apparent [3, 6],
Chylothorax results from obstruction
and disruption of the thoracic duct or its
collaterals. As narrowing of lymph vessels
and impairment of lymph flow have been
described after radiotherapy [4], irradia­
tion theoretically could also lead to chy­
lothorax. No cases have been reported,
however [2], and previous radiotherapy is
not usually included in the differential di­
agnosis of chylothorax [3,6].
Case Report
A man born in 1920 presented in June 1976 with
enlarged lymph nodes in the right spuraclavicular
fossa. Biopsy and further staging showed Hodgkin's
disease, stage IA. The patient was treated with man­
tle field irradiation. 46.6 Gy applied in 28 daily frac­
tions of 1.69 Gy in 42 days, and with vinblastine sul­
fate 10 mg every fortnight for 2 years. At the end of
this period the patient had developed marked radia­
tion dermatitis and fibrosis of the neck and the upper
thorax, and the chest X-ray showed radiation fibrosis
of both upper lobes. In 1980 an asymptomatic radia­
tion-induced hypothyrosis was found and substitu­
tion with thyroxine was started.
In August 1982 a nonproductive cough deve­
loped. Clinical examination showed decreased
breath sounds on the right base and radiation fibrosis
of the neck and the upper thorax. Chest radiograph
showed pleural fluid on the right side and radiation
fibrosis. Blood chemistry showed a slight increase in
sedimentation rate to 27/58 as the only abnormality.
Thoracocentesis revealed milky fluid with
750 mg/l cholesterol and 17,100 mg/l triglycerides.
Pleural biopsy showed chronic aspecific inflamma­
tion. Fiberbronchoscopy revealed slight edema of the
bronchial mucosa of right middle and lower lobe; bi­
opsy was normal. The aspirated bronchial fluid and
the bronchial lavage did not show malignant cells.
CAT-scan of the thorax showed mediastinal li­
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Abstract. 6 years after mantle field irradiation for stage IA Hodgkin’s disease, a pa­
tient presented with right-sided chylothorax. Even after thorough investigation no etiol­
ogy for the chylothorax was found. It is suggested that chylothorax can be due to previ­
ous radiotherapy.
Chylothorax after Mantle Field Irradiation for Hodgkin's Disease
pomatosis, paramediastinal lung fibrosis and pleural
fluid, but no tumor or pathologic lymph nodes.
Echography of the abdomen was normal.
Until now, 16 months after the diagnosis, the Xray has not changed and the patient has remained
well without signs of progressive disease.
189
ing radiation pneumonitis [3, 6], chylotho­
rax and pleural effusion related to lym­
phatic obstruction seem to occur years af­
ter radiation therapy. Increased alertness
and more experience with extended fol­
low-up, especially in Hodgkin’s disease,
will probably reveal additional cases.
Discussion
References
1 Donaldson, S.S.; Kaplan, H.S.: Complications of
treatment of Hodgkin's disease in children. Can­
cer Treat. Rep. 66: 977-989(1982).
2 Gross, N.J.: Pulmonary effects of radiation ther­
apy. Ann. intern. Med. 86: 81-92 (1977).
3 Hughes, R.L.; Mintzer, R.A.; Hidvegi, D.F.;
Freinkel, R.K.; Cugell, D.W.: The management
of chylothorax. Chest 76: 212-218(1979).
4 Jonsson, K.; Libshitz, H.I.; Osborne, B.M.: Lym­
phangiographie changes after radiation therapy.
Am. J. Roent. 131: 803-806(1978).
5 Kinsella, T.J.; Fraas, B.A.; Glatstein, E.: Late ef­
fects of radiation therapy in the treatment of
Hodgkin's disease. Cancer Treat. Rep. 66:
991-1001 (1982).
6 Light, R.W.: Chylothorax and pseudochylothorax: in Pleural Diseases, pp. 209-220 (Lea & Febiger. Philadelphia 1983).
7 Roy, P.H.; Orr, D.T.; Spencer Payne, W.: The
problem of chylothorax. Mayo Clin. Proc. 42:
457-467(1967).
8 Thar, T.L.: Million, R.R.: Complications of radi­
ation treatment of Hodgkin’s disease. Semin. On­
col. 7: 174-183(1980).
Received: January 17, 1984
Accepted: July 5, 1984
Prof. M. Van Der Straeten,
Department of Respiratory Diseases,
Academic Hospital,
State University, De Pintelaan 185,
B-9000 Ghent (Belgium)
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In our patient a right-sided chylothorax
occurred 6 years after mantle field irradia­
tion for Hodgkin’s disease stage IA. No
trauma had occurred. Extensive investiga­
tion could not confirm the initial suspi­
cion of recurrent Hodgkin’s disease or sec­
ond neoplasm. More than 1 year of fol­
low-up did not reveal any underlying pa­
thology. Finally the chylothorax could
only be related to the radiation therapy, if
it was not to be considered ’idiopathic’.
Hodgkin’s disease offers good opportu­
nity for prolonged follow-up after irradia­
tion, but chylothorax has never been ob­
served [1,5, 8], However, 2 patients treated
by high-dose mantle field irradiation for
Hodgkin’s disease in childhood developed
an asymptomatic pleural effusion 6 and 8
years later, that remained stable for a long
period. Although the effusion was not chy­
lous, it was considered to be possibly re­
lated to disturbance of lymphatic drainage
after irradiation [5],
Bilateral chylothorax has been de­
scribed in a 15-year old girl 11 years after
radiation therapy for a thoracic vertebral
hemangioma. Although the condition was
classified as neoplastic in origin it could
well have been due to irradiation [7].
Whereas pleural effusion can occur
early after radiation therapy accompany­
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