Thoracoscopic management of pleural effusions in Kaposi's Sarcoma: a rapid and effective alternative for diagnosis and treatment. (Case Reports).

ABSTRACT

Kaposi's sarcoma (KS) is one of the most common causes of pleural effusion in patients with acquired immunodeficiency syndrome (AIDS). Pleural effusions due to KS carry a high morbidity and mortality. Their treatment is difficult, and they respond poorly to chemical pleurodesis. Even systemic chemotherapy against KS has little effect on the pleural effusions. Commonly, repeated therapeutic thoracentesis or chest tube drainage is required. We present a case of advanced KS with bilateral pleural effusions. We believe this is the first reported case in which medical thoracoscopy with talc pleurodesis has been shown to achieve adequate control of the effusions.

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PLEURAL EFFUSIONS due to KS are common in patients with AIDS. (1) These pleural effusions are difficult to treat and carry a high morbidity and mortality. Chemical pleurodesis and systemic chemotherapy commonly fail to control these effusions, which tend to be bilateral. (2) These patients have progressive dyspnea and usually require repeated therapeutic thoracentesis. Eventually, chest tube drainage may be required. (2) Treatment of the effusions improves quality of life. We present a case of advanced KS with bilateral pleural effusions. For treatment we used medical thoracoscopy with talc pleurodesis, successfully controlling the effusions. This appears to be the first reported case in which this method of pleurodesis was used in KS with good response.

CASE REPORT

A 38-year-old white man with AIDS went to a community hospital for treatment of nonproductive cough, subjective fever, nausea, and vomiting for 1 week. He a]so reported progressive dyspnea over the preceding 6 months. He denied chills, nightsweats, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea, or edema. Review of systems disclosed an increasing number of violacious bluish skin lesions on the thorax. Human immunodeficiency virus infection had been diagnosed 3 years earlier. He also had a history of histoplasmosis, treated with intravenous antifungal agents for a month and followed by long-term antifungal therapy. Disseminated KS had been diagnosed a year earlier, and systemic chemotherapy had failed. Physical examination revealed multiple violaceous skin lesions on the face, torso, extremities, and mucosa of the hard palate and posterior pharynx, consistent with KS. Lung examination showed dullness to percussion and decreased breath sounds in both bases, without wheezes or crackles. The remainder of the examination was noncontributory. Arterial blood gas analysis on room air showed a pH of 7.49, [PCO.sub.2] 37 mm Hg, [PO.sub.2] 40.5 mm Hg, bicarbonate 29 mEq/L, and oxygen saturation 80%. Other laboratory results were unremarkable. A chest radiograph revealed multiple ill-defined opacities with pleural effusions (Fig 1). Profound dyspnea necessitated several thoracenteses, yielding noninfectious exudate. The patient was referred to us for further evaluation.

Fiberoptic bronchoscopy revealed multiple violaceous, red endobronchial vascular lesions in the left lower lobe and lingula, consistent with KS (Fig 2). Other airways were normal. The bronchoalveolar lavage was negative. Rightsided thoracoscopy was undertaken for diagnosis and treatment. Violaceous lesions involved the parietal, visceral, and diaphragmatic pleural surfaces. The lesions were typical of KS (Fig 2). Several parietal pleural biopsy specimens were obtained. After suctioning the pleural fluid, 5 g of talc was insufflated under video guidance. A chest tube was placed on low suction. The patient tolerated the procedure well. A week later he had thoracoscopically guided talc pleurodesis of the left side. The lesions involving the left cavity were of the same nature as those seen in the right side. The chest tubes were removed 4 days after each pleurodesis. With improved dyspnea, the patient was discharged home without the need for repeated thoracentesis. He survived approximately 8 more months.

DISCUSSION

Kaposi's sarcoma is one of the most common causes of pleural effusions in patients with AIDS. It has a predilection for homosexual populations and a prevalence of up to 52% in some series. (1) Parapneumonic effusions, tuberculosis, and Pneumocystis carinii are other common causes. Although primarily a cutaneous disease, KS frequently involves the lymph noes, the lungs, and the gastrointestinal tract. (3) Also, as many as 15% of cases of pleuropulmonary involvement have no concomitant mucocutaneous KS. (3)

Pulmonary involvement conveys a poor prognosis and is often accompanied by exertional dyspnea, dry cough, and hemoptysis. Radiographic findings may include diffuse interstitial densities, mediastinal adenopathy, pulmonary nodules, and pleural effusions. Approximately 50% of patients with pulmonary involvement have pleural effusions, which tend to be bilateral. (1,2,4) These effusions can be massive and cause chylothorax. (1,2,4) The average survival after diagnosis of KS pleural disease is around 4 months. (4) The classic appearance of KS lesions allows bronchoscopic diagnosis of pulmonary involvement without biopsy. (5) This approach avoids the risk of bleeding with biopsy, because of the vascular nature of the lesions. The diagnosis of KS-related pleural effusion is difficult. These patients are at high risk for infection-related effusions. Failure to identify and treat an infection carries high short-term mortality. Therefore, even if a KS pleural effusion is diagnosed, a concomitant infection must be rule d out. Since KS tends to involve only the visceral pleura, closed pleural biopsy is often nondiagnostic and the sampled fluid (usually serosangnineous or hemorrhagic exudates) is unlikely to contain cytologic material from which a diagnosis can be made. (4) Video-assisted thoracoscopy may be the only way to confirm the diagnosis of KS of the pleural space. The classical appearance of the lesions may obviate the need for biopsy as well. (1,4)

Despite therapeutic advances, the treatment of KS remains palliative. It may be either local or systemic, with treatment decisions based on the extent of disease. (3) With extensive or rapidly progressing cutaneous disease, KS-associated lymphedema, or symptomatic gastrointestinal or pulmonary involvement, systemic therapy is indicated. Systemic agents for AIDS-related KS include alfa-interferon and in more advanced disease, cytotoxic chemotherapeutic agents. (1,3) Additionally, the marked decline in incidence of KS since the widespread use of highly active antiretroviral therapy advocates its use in these patients. (3)

The treatment of KS-related pleural effusions has been disappointing, and chemical pleurodesis with tetracycline is unlikely to be successful. (1,2,4) Multiple therapeutic thoracenteses or chest tube drainage may be required to improve functional status. These carry the risk of provoking significant protein loss and a risk of infection. Unfortunately, even with systemic chemotherapy, the pleural disease is often unresponsive. (2) Whole-lung irradiation has been reported in pleuropulmonary KS. Half of the described patients had pleural effusions. Although the chest radiographs and clinical status improved, the course of the pleural effusions was not reported. (6)

Morbidity and mortality rates associated with procedures done on HIV-infected patients appear similar to rates among those without HIV. Thoracoscopy, especially for pneumothorax and empyema, has proven to be safe and efficacious. (7) As mentioned, the classical appearance of KS lesions allows confirmation of the diagnosis and pleurodesis in one session. Thoracoscopic talc pleurodesis has been reported extremely effective (90.2% success rate at 1 month) in the treatment of malignant pleural effusions. (8) It is well tolerated and leads to rapid resolution of symptoms. We believe this method has not been widely used in the treatment of KS-related pleural effusions.

After ruling out an infectious process in our patient, we undertook medical thoracoscopy to establish the diagnosis and achieve rapid control of symptoms. Talc pleurodesis was successful on each side and led to long-term palliation. Whereas closed chest tube pleurodesis with talc slurry may also provide control of the effusions, a thoracoscopic approach facilitates the diagnosis and allows maximal exposure for talc. We believe that in patients with KS-related effusions thoracoscopic talc pleurodesis is safe and effective and results in rapid improvement of symptoms and thus should be considered routinely in their treatment.

References

(1.) Light RW, Hamm H: Pleural disease and acquired immune deficiency syndrome. Eur Respir J 1997; 10:2638-2643

(2.) Beck JM: Pleural disease in patients with acquired immune deficiency syndrome. Clin Chest Med 1998; 19:341-349

(3.) Dezube BJ: Acquired immunodeficiency syndrome-related Kaposi's sarcoma: clinical features, staging, and treatment. Semin Oncol 2000; 27:424-430

(4.) O'Brien RF. Cohn DL: Serosanguineous pleural effusions in AIDS-associated Kaposi's sarcoma. Chest 1989; 96:460-466

(5.) Zibrak JD, Silvestri RC, Costello P, et al: Bronchoscopic and radiologic features of Kaposi's sarcoma involving the respiratory system. Chest 1986; 90:476-479

(6.) Meyer JL: Whole-lung irradiation for Kaposi's sarcoma. Am J Clin Oncol 1993; 16:372-376

(7.) DiMaio JM: The thoracic surgeon's role in the management of patients with HIV infection and AIDS. Chest Surg Clin North Am 1999; 9:97-111

(8.) Viallat JR, Rey F, Astoul P. et al: Thoracoscopic talc poudrage pleurodesis for malignant effusions. a review of 360 cases. Chest 1996; 110:1387-1393

RELATED ARTICLE: KEY POINTS

* Pleural effusions are a common problem with high morbidity and mortality in patients with the acquired immunodeficiency syndrome and Kaposi's sarcoma.

* Treatment of these effusions improves quality of life but often fails or requires repeat interventions.

* Medical thoracoscopy with talc pleurodesis can allow for simultaneous etiologic diagnosis and palliative treatment of symptomatic pleural effusions in these patients.

From the Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, La.

Reprint requests to Kevin L. Kovitz, MD, 1430 Tulane Aye, SL-9, New Orleans LA 70112.