Dislocation or wrong placement of central venous catheters into the pleural cavity is rare, but if undiagnosed, may cause major, sometimes life-threatening, complications (pneumothorax, hemothorax, infection, and migration) and accidental pleural effusion due to intravenous injection of fluids containing drugs (i.e. chemotherapy, antibiotics, parenteral nutrition, other). We report a rare case of pleural effusion consisting of chemotherapy (chemothorax) directly injected into the pleural cavity due to the wrong placement of a central venous catheter (Porth-A-Cath) in a woman with breast cancer. A multidisciplinary management consisting of antidote administration, followed by removal of the venous device and washing of the pleural cavity through video-assisted thoracic surgery (VATS), avoided any major complication related to the adverse event

Angela De Palma

Anna Rita Gasbarro

Debora Brascia

Doroty Sampietro

Francesca Signore

Giulia De Iaco

Giuseppe Marulli

Maria Dell’Aera

Rosatea Quercia

Teodora Panza

Vito Lorusso

Frontiers in Surgery

PubMed

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TYPE Case ReportPUBLISHED 26 July 2022| DOI 10.3389/fsurg.2022.921968EDITED BYPaola Ciriaco,San Raffaele Scientific Institute (IRCCS), ItalyREVIEWED BYStefano Viscardi,San Raffaele Hospital (IRCCS), ItalyAlessandro Palleschi,IRCCS Ca ’Granda Foundation MaggiorePoliclinico Hospital, Italy*CORRESPONDENCEAngela De Palmaangela.depalma@uniba.it†These authors have contributed equally to thiswork and share senior authorshipSPECIALTY SECTIONThis article was submitted to Thoracic Surgery,a section of the journal Frontiers in SurgeryRECEIVED 17 April 2022ACCEPTED 29 June 2022PUBLISHED 26 July 2022CITATIONPanza T, Quercia R, Signore F, De Iaco G,Brascia D, Sampietro D, GasbarroAnna Rita, Dell’Aera M, Lorusso V, Marulli G andDe Palma A (2022) Case report: Successfulmultimodal assessment and management ofchemothorax.Front. Surg. 9:921968.doi: 10.3389/fsurg.2022.921968COPYRIGHT© 2022 Panza, Quercia, Signore, De Iaco,Brascia, Sampietro, Gasbarro, Dell’Aera,Lorusso, Marulli and De Palma. This is an open-access article distributed under the terms of theCreative Commons Attribution License (CC BY).The use, distribution or reproduction in otherforums is permitted, provided the originalauthor(s) and the copyright owner(s) arecredited and that the original publication in thisjournal is cited, in accordance with acceptedacademic practice. No use, distribution orreproduction is permitted which does notcomply with these terms.Frontiers in SurgeryCase report: Successfulmultimodal assessment andmanagement of chemothoraxTeodora Panza1, Rosatea Quercia1, Francesca Signore1,Giulia De Iaco1, Debora Brascia1, Doroty Sampietro1,Anna Rita Gasbarro2, Maria Dell’Aera2, Vito Lorusso3,Giuseppe Marulli1† and Angela De Palma1*†1Unit of Thoracic Surgery, Department of Emergency and Organ Transplantation, University of Bari“Aldo Moro,” Bari, Italy, 2Pharmacy Unit, University Hospital Polyclinic of Bari, Bari, Italy, 3MedicalOncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II,” Bari, ItalyDislocation or wrong placement of central venous catheters into the pleuralcavity is rare, but if undiagnosed, may cause major, sometimes life-threatening, complications (pneumothorax, hemothorax, infection, andmigration) and accidental pleural effusion due to intravenous injection offluids containing drugs (i.e. chemotherapy, antibiotics, parenteral nutrition,other). We report a rare case of pleural effusion consisting of chemotherapy(chemothorax) directly injected into the pleural cavity due to the wrongplacement of a central venous catheter (Porth-A-Cath) in a woman withbreast cancer. A multidisciplinary management consisting of antidoteadministration, followed by removal of the venous device and washing of thepleural cavity through video-assisted thoracic surgery (VATS), avoided anymajor complication related to the adverse event.KEYWORDSPort-A-Cath, pleural effusion, chemothorax, chemotherapy, dislocation, thoracoscopy,video-assisted thoracic surgery, multidisciplinary managementIntroductionPleural effusion is a common entity in clinical practice with varying etiologicalorigin. Therefore, treatment and prognosis largely depend on its cause. Thoracoscopicapproach by video-assisted thoracic surgery (VATS) has been established to be themost sensitive and accurate method in the diagnosis and treatment of pleural effusionover the years (1–3).Dislocation or wrong placement of central venous catheters into the pleural cavity israre, but if undiagnosed, may cause major, sometimes life-threatening, complications(pneumothorax, bleeding, infection, migration, and venous air embolism) andaccidental pleural effusion due to intravenous injection of fluids containing drugs(i.e. chemotherapy, antibiotics, parenteral nutrition, other) (4).We report a rare case of pleural effusion consisting of chemotherapy (chemothorax)directly injected into the pleural cavity due to the wrong placement of a central venouscatheter (Porth-A-Cath) in a woman with breast cancer, successfully managed by amultidisciplinary approach, consisting of antidote administration, followed by removalof the venous device, and washing of the pleural cavity through VATS.01 frontiersin.orgFIGURE 1Chest x-ray showing a large right pleural effusion with abnormalposition of the distal tip of the Port-a-Cath.Panza et al. 10.3389/fsurg.2022.921968Case descriptionA 54-year-old Caucasian woman affected by breastcarcinoma underwent insertion of a central venous catheter(Port-a-Cath) in the right subclavian vein to receive inductionchemotherapy at another hospital. The patient had received abiopsy diagnosis of breast carcinoma 3 weeks earlier,requiring, for tumor stage, neo-adjuvant chemotherapy beforeundergoing demolitive breast surgery. The venous catheterwas placed without complications, so no post-procedure chestx-ray was performed to check its correct position. Previouschest x-ray at the time of breast biopsy did not show anypleural effusion.The patient received first chemotherapy infusion withCyclophosphamide and Epirubicin hydrochloride, 2 weeksafter catheter placement. A few hours later, she presented tothe emergency room of our hospital for right chest painradiating to the right hypochondrium.The patient had no fever, a pulse rate of 94 beats perminute, a blood pressure of 150/90 mmHg, a respiratory rateof 22 breaths per minute, and an oxygen saturation of 97%on room air; auscultation of the chest revealed the absence ofbreath sounds in the right basal hemithorax.Chest x-ray showed a right pleural effusion with suspectedabnormal position of the distal tip of the Port-a-Cath(Figure 1). Thus, we performed chest CT, which allowed todemonstrate the wrong placement of the proximal tip of thecatheter, placed tangentially to the right subclavian vein, whilethe catheter was located outside the superior vena cava,reaching with the distal tip the middle mediastinum at thelevel of the body of D6; a large right pleural effusion andcomplete atelectasis of the lower lobe of the right lung werealso present (Figure 2).The patient underwent placement of a right pleural drainage(16 Ch) with removal of serous and blood-tinged pleuraleffusion, a part of which was sent to the laboratory forcytological and toxicological examination. For the latter, thefluid was analyzed with the gas chromatography–massspectrometry (GC/MS) recording the presence ofCyclophosphamide and Lidocaine (this last one used duringlocal anesthesia for the placement of the chest tube). Thepresence of Epirubicin in the pleural fluid could not bedemonstrated due to the unavailability of the reactive agentfor its detection in our laboratory. Cytological examination ofthe fluid resulted negative.Following the placement of the drainage and the totalevacuation of the pleural fluid, an antidote (dexrazoxane atthe dose of 1,500 mg in 500 ml dilution on the first andsecond days and 750 mg in 500 ml dilution on the third day)was intravenously administered to the patient.After the first administration of the antidote, the patientunderwent surgical removal of the Port-a-Cath by triportalFrontiers in Surgery 02VATS under general anesthesia: this procedure enabled thevisualization of a diffuse parietal pleura hyperemia and of thecentral venous catheter located in the pleural cavity, anteriorlyto the right subclavian vessels, and which ran along thesuperior vena cava (Figure 3). Subsequently, the subcutaneousreservoir was surgically retrieved at the level of the rightpectoral region and the central venous catheter of the Port-a-Cath was slowly removed, without bleeding, under safeguidance of the thoracoscopic view (Figure 4). Then, wewashed the pleural cavity with 6,000 ml of heated salinesolution in order to remove any residual drugs. Finally, a28 Ch chest tube was placed to drain any post-operative fluids.On the first post-operative day, a serum increase ofpancreatic enzymes (amylase 263 U/L, lipase 3,374 U/L)without symptoms and with ultrasound evidence of slightpancreatic inflammation and leucopenia (1.11 × 103/µl) wasdetected, probably due to anesthetic drugs; thus, the patientunderwent specific medical therapy with gabexate mesilate.A further pleural fluid sample was analyzed twice (on thesecond and fifth post-operative day) recording the absence ofCyclophosphamide in both samples.The daily fluid output from the chest tube was as follows:350, 720, 360, 150, 300, 220, 100, and 80 ml, thus with atotal fluid output of 2,280 ml. On the eighth post-operativeday, the chest tube was removed, and the patient wasdischarged the day after, with normalization of the serumvalues of leukocytes and of pancreatic enzymes. Chest x-rayperformed 2 weeks after discharge showed the recurrenceof moderate pleural effusion, which was treated with afrontiersin.orgFIGURE 2Axial (A), coronal (B), and sagittal (C) chest CT scans showing a large right pleural effusion, complete atelectasis of the lower lobe of the right lung, theproximal tip of the central venous catheter placed tangentially to the right subclavian vein, and the catheter (white arrows) located outside thesuperior vena cava, reaching with the distal tip the middle mediastinum at the level of the body of D6.FIGURE 3Surgical removal of the Port-a-Cath by triportal video-assistedthoracic surgery (VATS): visualization of the central venouscatheter located in the pleural cavity, anteriorly to the rightsubclavian vessels, and running along the superior vena cava.FIGURE 4Surgical removal of the Port-a-Cath by triportal VATS: the centralvenous catheter of the Port-a-Cath is slowly removed, withoutbleeding, under safe guidance of the thoracoscopic view.Panza et al. 10.3389/fsurg.2022.921968small-bore pleural drainage (Drentech UNICO™), with a totalfluid output of 1,150 ml. No further relapse was then observedin the following controls.DiscussionPleural effusion is commonly associated with congestiveheart failure, cancer, pneumonia, and pulmonary embolism.Cases of pleural effusion caused by the infusion ofchemotherapy into the pleural cavity due to dislocation/misplacement of central venous catheter are exceptional andrarely reported in the literature (4).Central venous accesses are widely used in hematological/oncological patients for the management of total parenteralnutrition, chemotherapy, or for obtaining blood samples,Frontiers in Surgery 03significantly improving the patient’s quality of life. Inparticular, the Port-A-Cath is a small reservoir connected to acentral venous catheter and located in the subcutaneoustissue. Usually, post-implantation chest x-ray is recommendedto check the correct position of the venous catheter; howeverthis was not performed in the described patient, likely due tothe absence of complications during the procedure.Most common problems related to Port-A-Cath insertion/placement include thrombotic and infectious complications(5). Catheter migration, dislocation, or misplacement arerelatively rare but life-threatening complications with areported incidence of approximately 0.9%–2% (6). Particularly,the extravasation of cancer drugs (DNA-binding vesicantdrugs such as anthracyclines, e.g. Epirubicin) may lead to scardamage at injury sites with immediate symptoms (7, 8).Sometimes, symptoms can appear after several days or weeks (8).Therefore, in our case, the first priority was to secure thepatient, removing the chemotherapeutic agent by placing afrontiersin.orgPanza et al. 10.3389/fsurg.2022.921968pleural drainage. Moreover, after a multidisciplinary discussionwith the oncologists who were treating the patient, in order toplan the therapeutic strategy, we immediately began therapywith the antidote to reduce the complications of drugintoxication (7, 9, 10). Indeed, dexrazoxane prevents thepotential effects of anthracycline extravasation and is welltolerated by patients (11).Pronchik and Sexton described a similar case of accidentalinjection of chemotherapy into the chest treated merely withevacuative thoracentesis; in addition, the Port-a-Cath was notremoved after assessing its integrity and patency with a dyestudy (12). Likewise, Kelly et al. described the case of a patientcarrying a Port-a-Cath in an extravascular position resulting inaccidental injection of chemotherapy in the pleural cavity,treated with thoracentesis and subsequently with the placementof a pig-tail catheter (4); the Port-a-Cath was removed andrepositioned in order to perform the oncologic treatment. Inboth cases, no multidisciplinary approach was carried out bymedical therapy including the antidote. Furthermore, in thecase described by Pronchik and Sexton, the lack of removal ofthe Port-a-Cath could explain the subsequent hospitalization ofthe patient for fever and neutropenia and the microbiologicalpositivity on blood cultures (12).In our case, the thoracoscopic approach allowed to confirmthe position of the tip of the catheter and its relationship withthe mediastinal vessels and to safely remove it. Moreover,VATS enabled us to perform lavage and irrigation of thepleural cavity with a huge amount of saline solution thatwould not be possible through pleural drainage. The amountof 6,000 ml of heated saline solution to wash the pleuralcavity was chosen considering the double of maximal volumeof fluid that could be on average contained in a woman’spleural cavity and also due to the fact that this is the maximalamount contained in a sterile saline solution bag available forintraoperative use at our hospital. The procedure wasperformed in the absence of complications.The patient presented a recurrence of moderate pleuraleffusion, treated with a small-bore pleural drainage. On theother hand, Uges et al. described a pleural effusion due tothe malposition of a Port-a-Cath treated merely by drainage; theauthors did not remove the device, thus probably promoting thedevelopment of an empyema, which required subsequentsurgical decortication of the lung (8): this complication mayalso have been favored by the visual limitation of insertion thatcharacterizes simple percutaneous pleural drainage. For thisreason, we preferred a VATS approach, which allowed saferemoval of the catheter and accurate lavage of the pleural cavityto reduce the toxicity of drugs, as reported by Aguirre et al. (13).In conclusion, our experience demonstrated the importanceof a multidisciplinary approach, combining early medical andsurgical treatment in case of accidental pleural extravasationof chemotherapy drugs: in such emergency condition, theVATS approach allows not only to safely remove theFrontiers in Surgery 04malpositioned central venous catheter, but also to assesseventual tissue damage and adequately perform drainage,lavage, and irrigation of the pleural cavity. Moreover, theassociation of medical therapy with the well-toleratedantidote, dexrazoxane, is recommended to prevent short- andlong-term complications due to the toxicity of chemotherapy.Data availability statementThe raw data supporting the conclusions of this article willbe made available by the authors, without undue reservation.Ethics statementEthical review and approval was not required for the studyon human participants in accordance with the local legislationand institutional requirements. The patients/participantsprovided their written informed consent to participate in thisstudy. Written informed consent was obtained from theindividual(s) for the publication of any potentially identifiableimages or data included in this article.Author contributionsTP provided the introduction, case description, anddiscussion and wrote the entire article; RQ, FS, GD, DB, DS,FD, MV, MGC, GC, and ARG all provided the casedescription and discussion; MD and VL performed a criticalreview and gave the final approval of the manuscript; GM andAP provided the introduction, discussion, writing, andliterature, evaluated the results, performed the critical review,and gave the final approval of the manuscript. All authorscontributed to the article and approved the submitted version.Conflict of interestThe authors declare that the research was conducted in theabsence of any commercial or financial relationships that couldbe construed as a potential conflict of interest.Publisher’s noteAll claims expressed in this article are solely those of theauthors and do not necessarily represent those of theiraffiliated organizations, or those of the publisher, the editorsand the reviewers. Any product that may be evaluated in thisarticle, or claim that may be made by its manufacturer, is notguaranteed or endorsed by the publisher.frontiersin.orgPanza et al. 10.3389/fsurg.2022.921968References1. Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in malignantpleural effusions. Am Rev Respir Dis. (1981) 124:588–92. doi: 10.1164/arrd.1981.124.5.5882. Medford ARL, Awan YM, Marchbank A, Rahamim J, Unsworth-White J,Pearson PJK. 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Case report: Successful multimodal assessment and management of chemothorax

Panza, Teodora

Quercia, Rosatea

Signore, Francesca

De Iaco, Giulia

Brascia, Debora

Sampietro, Doroty

Gasbarro, Anna Rita

Dell’Aera, Maria

Lorusso, Vito

Marulli, Giuseppe

De Palma, Angela

PubMed Central

Dell'Aera, Maria

Archivio istituzionale della ricerca - Università di Bari

http://dx.doi.org/10.3389/fsurg.2022.921968

Case report: Successful multimodal assessment and management of chemothorax

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