A Case of Pancreatic Carcinoma Causing Massive Bronchial Fluid Production and Electrolyte Abnormalities

Tony Lembo and Thomas J. Donnelly Chest 1995;108;1161-1163 DOI 10.1378/chest.108.4.1161 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/108/4/1161

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selected reports
A Case of Pancreatic Carcinoma Causing Massive Bronchial Fluid Production and Electrolyte Abnormalities*
Tony Lembo, MD; and Thomas J. Donnelly, MD
A 39-year-old man developed massive bronchorrhea (2
to 3.5 L/d) with

the patient's clinical course, and the tumor's histo features are consistent with combined secretory and logic transudative mechanisms for increased fluid production.
serum,

Case Report
A 39-year-old patient presented in June 1991 with painless jaundice. The workup revealed a large mass at the head of the pancreas that was histologically diagnosed as pancreatic carcinoma. In August 1991, a Whipple's procedure was performed. The mar gins of resection were negative for tumor, but 4 of 22 lymph nodes were positive. Postoperatively, the patient received fluorouracil (5-FU) and lo cal radiation therapy. He did well until March 1992 at which time he presented with increasing dyspnea and was found to have mul tiple bilateral lung metastases. An open lung biopsy specimen re vealed metastatic adenocarcinoma with extensive tumor growth along the preexisting pulmonary architecture. A second course of 5-FU and leucovorin was given followed by cisplatin, cytarabine, and finally hydroxyurea. He failed to show significant clinical response to any agent. In October 1993, he began expectorating thin liquid. His initial output was 200 to 300 mL/d, which gradually increased and persisted at 2 to 3 L/d. He was given radiation therapy to the lung fields in hopes of decreasing the fluid volume, yet no significant changes in fluid production occurred. Various anticholinergic agents such as scopolamine were unsuccessful in significantly changing the volume of bronchial secretions. He was admitted to the hospital several times for intensive hydration and electrolyte repletion between December 1993 and April 1994 in spite of receiving intravenously 3 L/d of 3% NaCl. In April 1994, the patient was readmitted to the hospital for fur ther chemotherapy with 5-FU, 350 mg/d for 4 days and leucovorin with hopes of decreasing his bronchorrhea. His examination revealed that he was cachectic and unable to lie flat in bed because of frequent expectoration of thin, cloudy, nonodorous sputum. Lung examination revealed light crackles in both lung fields that were otherwise clear. Pertinent laboratory data included a chest radiograph that showed bilateral infiltrates and consolidations worse in the left lower lobe and a small left pleural effusion. His WBC count was 14.6xl03/mm3 and his hematocrit was 31.3. Chemical analysis of the bronchial fluid and serum are shown in Table 1. Sputum Gram's stain revealed Gram-positive cocci in pairs and blood cultures from hospital admission were negative. Because of the possibility of a superimposed bacterial infection, intravenous antibiotics were given for 7 days. No significant change in his chest radiograph or WBC count ensued. Prior to hospital admission, the patient's bronchial fluid produc tion had been ranging between 2 and 3.5 L/d. Figure 1 shows the daily trend of bronchial fluid production and urine output for each hospital day. During the first hospital day, 3,200 mL was expecto rated. Treatment with a somatostatin analogue, octreotide, 100 pg subcutaneously three times a day, was started on the second hos pital day. Bronchial fluid production decreased to 2,480 mL on the second hospital day, and 2,500 mL on hospital day 3. The volume of bronchial fluid production increased slightly to 2,800 mL during hospital day 4. Therefore, the octreotide dose was increased to 250 1161

electrolyte and volume depletion about procedure for wedge biopsy specimen was consistent with metastatic adenocarci noma with extensive growth along preexisting pulmo nary architecture. Chemical analysis of the bronchial fluid revealed markedly elevated levels of amylase confirming the pancreatic origin of the tumor. The mechanism of massive bronchorrhea is not known. Chemical analysis of bronchial fluid in comparison to serum and the temporary response to chemotherapy are most with
2 years after undergoing a Whipple's pancreatic carcinoma. An open lung

consistent

mechanisms.

secretory and transudative (CHEST 1995; 108:1161-63)

5-FU=fluorouracil; LDH=lactate dehydrogenase

Keywords: bronchoalveolar carcinoma; bronchorrhea; elec trolyte abnormalities; metastatic pancreatic carcinoma watery sputum production, up to 2 to 4 L/d, with electrolyte and volume depletion is a rare complication of bronchoalveolar carcinoma.1"3 The mechanism of this in creased sputum production has not been well documented. Concentration differences between serum and fluid en zymes,4 persistent production of fluid despite the patient's volume status, and electron microscopic findings of in creased endoplasmic reticulum in tumor cells4 suggest that an active secretory mechanism is contributing to the in creased fluid production. In contrast, the relatively low pro tein content of the fluid and its iso-osmolality with serum suggest a transudative mechanism maybe contributing to the increased production. We report a case of copious watery sputum production secondary to metastatic pancreatic car cinoma to the lung. Chemical studies comparing fluid to

Copious

*From the Department of Internal Medicine, UCLA Medical Center (CHS), Division of Gastroenterology, Los Angeles (Dr. of Internal Medicine, University of Lembo); and the Colorado Health Department Sciences Center, Division of Pulmonary and Critical Care, Denver (Dr. Donnelly).

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Table 1.Concentration of Biochemical Components in the Serum and Bronchial Fluid

Serum

Bronchial Fluid
135 10 136 6.5 120 19 0.1 0.3 159

AST, IU/L 14 Na+, mmol/L 134 K+, mmol/L 4.2

Alkaline phosphatase, U/L

170

CL, mmol/L

97

HCO-, mmol/L 24

Albumin, g/dL 3.1 T protein, g/dL 5.6 Glucose, mg/dL 318

Amylase, U/L 33 Lipase, U/L 6 Triglyceride, mg/dL 90 Cholesterol, mg/dL 145 Osm, mOsm/kg 277
LDH, U/L 196 LDH1, % 20 LDH2, % 43 LDH3, % 27 LDH4, % 6 LDH 5, % 4

1,900
2 2 1 288 177 11 30 24 13 22

pg subcutaneously twice daily on hospital day 5, yet the volume of bronchial fluid remained at 2,800 mL/d. On hospital day 6, treat ment with 5-FU, 350 mg/d, was begun. Initially, the volume of bronchial fluid decreased to 1,750 mL; however, on subsequent hospital days, production increased to 2,075 mL and then 2,150 mL. Despite progressive weight loss, the patient remained alive 3 months after hospital discharge; the volume of his bronchial fluid remained between 2 and 3 L/d.

Discussion Bronchorrhea is arbitrarily defined as watery sputum 100 mL/d. It seen commonly in production of more thanbronchitis andis asthma.5 Copious patients with chronic secretions may also occur in patients with bronchiectasis (usually purulent), endobronchial tuberculosis,6 and malig nancies. Massive bronchorrhea (liters per day) has been described only in cases of bronchoalveolar carcinoma.

SS 100 mg tid

To the best of our knowledge, this is the first reported case of massive bronchial fluid production occurring secondary to pancreatic carcinoma metastatic to the lung. The patient's bronchorrhea began about 2 years after having a Whipple's carcinoma. Open lung procedure for pancreaticmetastatic adenocarcinomawedge with a biopsy specimens showed diffuse miliary growth pattern along the preexisting pulmo nary architecture, a pattern similar to diffuse bronchoalve olar carcinoma. Marked elevation in the amylase concen tration of the bronchial fluid in comparison to the serum confirms that the pancreatic tumor cells were functional and contributing to the massive fluid production. Despite various chemotherapeutic agents, radiation therapy to the lung fields, anticholinergic agents, and somatostatin therapy, the patient's bronchial fluid production remained between 2 and 3.5 L/d with the exception of temporary decreases in volume. Chemotherapy for massive bronchorrhea has been reported to provide only brief suppression of fluid production, while treatment with corticosteroids and anticholinergics has been ineffective.4 There is one report of radiation therapy pro viding longer-term palliation in a patient with localized bronchoalveolar carcinoma.8 Simultaneous chemical analysis of bronchial fluid and se rum suggest that secretory and transudative mechanisms were contributing to the massive bronchial fluid production. Evidence supporting active secretion by the metastatic pancreatic adenocarcinoma in the production of massive bronchial secretions is seen in the marked elevation of the fluid amylase concentration in comparison to serum. Con centrations of sodium and chloride were higher and potas sium much lower than those measured in asthmatics with bronchorrhea.5 Also, significant differences in the isoenzyme pattern of lactate dehydrogenase (LDH) were found in the bronchial fluid as compared with serum. Comparable changes in the LDH isoenzyme pattern have been reported in the bronchial fluid from patients with bronchorrhea sec the lack of bronchoalveolar carcinoma ondary to in bronchial secretion 4 Similarly, correlation in variation production with the patient's volume status and the temporary response to 5-FU are also consistent with an active secretory process to contributing in the bronchial fluid production. in the Evidence support of transudation of serum pul monary circulation to alveolar fluid as a mechanism of mas sive bronchial fluid production includes the relative isodifferences of large mo osmolality and the concentrationbronchial fluid and serum. lecular weight enzymes between and albumin concentrations were Triglyceride, cholesterol,the bronchial fluid. decreased markedly in Aspartate ami notransferase (AST), alkaline phosphatase, and lipase were also decreased in bronchial fluid, but less so. These findings are consistent with transudation of fluid into the alveolar space. The data do not support the hypothesis that increased permeability of the epithelium leads to bronchorrhea for

mation.5

Hospital Day

volume output neither correlated with the patient's clinicalbronchialstatus fluid nor did octreotide (SS) have significant effect on volume. A temporary decrease was seen after receiving 5-FU, 350 mg every day.
1162

ison to urine output

Figure 1. Bronchial fluid output (bar graph) is shown in compar

(squares) for each hospital day. Bronchial fluid

of Histologic examination in lung tissue from an open lung wedge biopsy specimenthe this patient showed sheets of adenocarcinoma lining lung parenchyma. Such distri found in bronchoalveolar carcinoma.

bution is similar to that Electron microscopic imaging of bronchoalveolar carcinoma in a patient also with massive bronchial fluid production showed increased concentrations of rough endoplasmic
Selected Reports

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reticulum with dilated cisternae and secretory granules,4 which supports a secretory function of these cells. Levinsky and Kern1 speculated that a combination of in creased secretory activity and enhanced filtration across the alveolar capillary membrane contributed to the massive bronchial fluid production in their patient with broncho alveolar carcinoma. This case, which involves metastatic pancreatic carcinoma to the lung with massive bronchial fluid production, also supports both active secretory and transudative mechanisms in the formation of malignant bronchorrhea.

the balls was performed, followed by a partial decor tication of the lung and intrathoracic transposition of a pectoralis major muscle flap to fill the residual pleural space. Primary healing was attained, and the patient is well VA years after surgery.

(CHEST 1995; 108:1163-64)

pectoralis muscles; plombage; pneumonolysis; pulmonary tuberculosis; thoracoplasty

One collapse therapy, extraperiosteal pneumonolysis with plombage using balls made of an acrylic resin consisting mainly of polymerized methyl methacrylate (Lucite), can result in delayed compli cations many years after the original operation, as exempli fied by this case report.

Key words: collapse therapy; cutaneous fistula; Lucite ball;

223:512-21 2 Homma H, Kira S, Takahashi Y, et al. A case of alveolar cell car cinoma accompanied by fluid and electrolyte depletion through production ofvoluminous amount of lung liquid. Am Rev Respir Dis 1975; 111:857-62 3 Spiro SG, Lopez-Vivriero MT, Charman J, et al. Bronchorrhea in a case of alveolar cell carcinoma. J Clin Pathol 1975; 28:60-5 4 Dwek J, Charytan C, Stachura I, et al. Salt-wasting bronchorrhea and its mechanisms. Arch Intern Med 1977; 137:791-94 5 Shimura S, Sasaki T, Sasaki H, et al. Chemical properties of bronchorrhea sputum in bronchial asthma. Chest 1988; 94: 1211-15 6 So S, Lam K, Sham M. Bronchorrhea: a presenting feature of endobronchial tuberculosis. Chest 1983; 84:635-36 7 Shimura S, Takishima T. Bronchorrhea from diffuse lymphangitic metastasis of colon carcinoma to the lung. Chest 1994; 105:308-10 8 Krawtz S, Mehta A, Vijayakumar S, et al. Palliation of massive bronchorrhea [letter]. Chest 1988; 94:1313-14

secondary to the bronchorrhea of pulmonary adenomatosis: a complication heretofore unreported. Am J Med Sci 1952;

References Kern R. Fluid, electrolyte, and protein depletion Levinsky W,

pulmonary Collapse therapy ofavailable. tuberculosis practiced widely the before effective antituberculosis medications became form of
was

in

era

Case Report
had been performed 45 years earlier at the City of Hope National Medical Center as treatment for right upper lobe cavitary tuber culosis. The patient did well until 1979 when nodular, poorly dif ferentiated lymphoma was diagnosed and treated with radiation therapy and chlorambucil (Leukeran). Lymphoma recurred in the neck in 1989 and 1991; treatment was with local radiation and chlorambucil. In August 1991, at another institution, a right axillary biopsy specimen yielded "brown fluid." Two months later, a Lucite ball was excised from the same area. Chronic drainage from the axilla continued; cultures of the fluid were positive for Staphylo coccus aureus. She returned here for treatment in July 1992. A draining sinus tract was noted in the right axilla with an underlying palpable mass. Surgical exploration of the axilla revealed two more Lucite balls extruding from a sinus tract exiting the chest cavity between the upper area ofthe ribs. Cultures were again positive for S aureus, and no lymphoma was found. On July 20, 1992, with the patient under general anesthesia in the supine position, the pectoralis major muscle flap was elevated on its thoracoacromial pedicle through an inframammary incision. An 8 by 8-cm square of the anterolateral chest wall including por tions of ribs 2,3, and 4, the sinus tract, and the fibrous wall of a
A 64-year-old white woman had an axillary pleurocutaneous fis tula. An extraperiosteal pneumonolysis with Lucite ball plombage

Surgical Treatment of Complications 45 Years After Extraperiosteal Pneumonolysis and Plombage Using Acrylic Resin Balls for Cavitary Pulmonary Tuberculosis*
Gail E. Thomas, MD, PhD; Balasubramanian Chandrasekhar, MD; and Frederic W. Grannis, Jr., MD, FCCP
An infected axillary sinus tract discharged balls made of an acrylic resin consisting essentially of polymerized methyl methacrylate (Lucite) 45 years following per

formance of an extraperiosteal pneumonolysis and Lucite ball plombage for collapse therapy of right up per lobe cavitary tuberculosis. Surgical extraction of
*From the Departments of General Oncologic Surgery, Plastic and Reconstructive Surgery and Thoracic Surgery, City of Hope Na tional Medical Center, Duarte, California. Reprints requests: Dr. Thomas, Department of General Oncologic

Surgery, City of Hope National Medical Center, Duarte, CA 91010

Duarte

Road,

Figure 1. Computed tomographic scan demonstrates the apex of the right hemithorax filled with Lucite balls. Extrusion of a ball into the axillary fistulous tract can be seen. 1163

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A Case of Pancreatic Carcinoma Causing Massive Bronchial Fluid Production and Electrolyte Abnormalities Tony Lembo and Thomas J. Donnelly Chest 1995;108; 1161-1163 DOI 10.1378/chest.108.4.1161 This information is current as of June 1, 2011
Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/108/4/1161 Cited Bys This article has been cited by 2 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/108/4/1161#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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