Stage IV lung adenocarcinoma with gelatinous malignant pleural effusion managed with PleurX catheter and hyaluronidase

What happened, in summary

This 46-year-old African American woman, a non-smoker with no family history of lung cancer, was diagnosed in August 2024 with Stage IV adenocarcinoma of the right lung. She first developed worsening shortness of breath, pleuritic chest pain that intensified with deep breathing, and difficulty lying flat. Imaging showed a large right hilar mass extending into the mediastinum, compressive atelectasis, and a large right pleural effusion. Same-day thoracentesis removed 1.5 L of cloudy, serosanguineous fluid, and cytology confirmed malignant cells. Bronchoscopy with endobronchial ultrasound showed near-complete occlusion of the right bronchus intermedius. Fine-needle aspiration of subcarinal and right paratracheal lymph nodes confirmed non-small-cell carcinoma consistent with adenocarcinoma, with TTF-1 and Napsin A positivity supporting a lung primary. Her cancer was staged T4N3M1a because of the large obstructing primary tumor, mediastinal nodal involvement, and malignant pleural effusion. Symptoms returned within days as the fluid re-accumulated. A PleurX catheter was placed for continuous drainage, but the effusion was unusually gelatinous and thick, resisting standard drainage. About 250 mL was removed initially, followed by another 1.2 L after intrapleural hyaluronidase was used to break down the viscous fluid. Imaging later showed trapped lung, meaning the lung could not fully re-expand. She continued oncology care with plans for definitive chemoradiation and possible immunotherapy or targeted therapy, including osimertinib if next-generation sequencing supported it. The episode showed that, in advanced lung adenocarcinoma, symptom control sometimes depends on both cancer diagnosis and specialized pleural-fluid management when ordinary drainage cannot evacuate thick malignant pleural fluid safely.