Pulmonary Infarction with Pleural Effusion - Pathologic Surprise in the Oncological Patient

We present the case of a 49 years-old female treated 10 years ago for a breast cancer (mastectomy followed by radio- and chemotherapy), referred to our unit for a recurrent pleural effusion with no response to medical treatment (pleural liquid - total proteins 4,1 g%, glucose 100 mg%, LDH 493 U/l, abundant cellularity with 30% eosinophils but no obvious neoplastic cells). The CT examination showed a loculated pleural effusion and a thickened irregular pleura, raising the suspicion of malignancy. Intraoperatively we found a loculated effusion - Fraser Gourd decortication and 7 subpleural pulmonary tumors with a diameter between 0,5 and 5 cm which we considered to be pulmonary metastases and performed non-anatomical resections with pulmonary reconstruction. The postoperative course was favourable, with discharge on postoperative day 16.The pathologic examination showed an inflammatory infiltrated pleura with no atypia and pulmonary infarction in all the 7 pulmonary resection specimens. Standard coagulation tests were normal but a detailed analysis of the coagulation status was not available, while postoperative cardiac and peripheric venous ultrasound did not show any abnormality explaining the pulmonary infarction. After the definitive diagnosis, the patient was treated with antiaggregants and dicumarinic oral anticoagulation, the later being abandoned due to poor compliance. At the 26 months follow-up the patient showed no signs of recurrence but she died at 32 months after surgery due to a stroke. The case is interesting due to the illustration of the diagnostic difficulties encountered in the oncological patients with pleural effusions; considering this case as "inoperable" would have resulted in anuseless chemotherapy and progression towards a more severe pleuro-pulmonary suppuration.