Low-dose intrapleural therapy relieved a complex malignant pleural effusion

What happened, in summary

A 32-year-old woman had previously undergone oophorectomy for ovarian carcinoma. Ten years later, surveillance imaging found a lung nodule that was initially suspected to be an ovarian-cancer metastasis. Needle biopsy instead showed a new primary lung adenocarcinoma. Testing found no EGFR mutation, ALK alteration, or ROS1 alteration. CT staging was T3N3M1c, with spread to the pleura, adrenal gland, and bone.

She received six cycles of carboplatin and paclitaxel, but the disease progressed. Palliative pemetrexed and cisplatin were then started. During treatment, she developed a left malignant pleural effusion confirmed by malignant cells in the fluid. A small-bore chest tube was placed, but one month later the effusion returned with fever. A second 8-Fr tube was inserted, and Enterococcus faecalis infection was treated with amoxicillin-clavulanic acid. Despite drainage exceeding 200 mL daily for a week, imaging still showed a multiloculated effusion, thickened pleura, pleural nodules, and a lung mass. Her performance status was too poor for surgical decortication.

After a red-cell transfusion, she received a modified single low-dose intrapleural treatment: alteplase 5 mg followed by dornase alfa 5 mg. Over the next 24 hours, 2,000 mL of blood-tinged fluid drained without major bleeding. Imaging showed complete resolution of the loculated collection. Her breathlessness and fever improved, and her oxygen requirement fell from 5 L/min to 3 L/min. The intervention relieved a serious complication even though her metastatic lung cancer had already progressed through initial chemotherapy.