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J Thorac Cardiovasc Surg 2001;121:813
© 2001 The American Association for Thoracic Surgery

Brief Communications

Pleuroperitoneal shunts and tumor seeding

From the Department of Thoracic Surgery, Royal Devon and Exeter Hospital, Exeter, United Kingdom.

Received for publication Aug 2, 2000. Accepted for publication Aug 31, 2000. Address for reprints: R. G. Berrisford, ChM, FRCS(CTh), Department of Thoracic Surgery, Royal Devon and Exeter Hospital, Exeter EX2 5DW, United Kingdom (E-mail: richard{at}berrisford.u-net.com).

The Denver pleuroperitoneal shunt (Denver Biomedical, Golden, Colo) has been advocated as an effective and low-morbidity treatment for recurrent malignant pleural effusions. ^1,2 Respiratory symptoms are effectively palliated in most patients, without any further treatment for their effusion required. Tumor seeding in malignant pleural mesothelioma has been reported for invasive procedures, such as needle thoracocentesis, thoracoscopy, and use of chest tubes. ^3,4 To our knowledge, malignant seeding along the tract of a pleuroperitoneal shunt has not yet been described. The purpose of this case report is to highlight this complication and propose prophylactic irradiation to prevent its occurrence.

Clinical summary
A 76-year-old man with malignant mesothelioma of the left pleura was referred for surgical palliation. He was dyspneic at rest and had anterior chest pain and a persistent cough. Chest x-ray film revealed an extensive left pleural effusion.

A thoracoscopy was performed, and 3 L of pleural fluid was drained. Both the pleural surfaces and the diaphragm were studded with tumors. On maximal inflation of the lung, the parietal and visceral pleura did not oppose, and therefore a Denver shunt was inserted. At 6 weeks' follow-up, the shunt was performing satisfactorily. At follow-up 9 weeks postoperatively, the subcutaneous tunnel was infiltrated by mesothelioma over a distance of some 15 cm.

Discussion
Tumor growth along the track of a shunt was first reported by van Ooijen and associates. ⁵ They presented a case of seeding alongside a peritoneovenous shunt in abdominal malignant mesothelioma and a case of seeding along the track of a Port-A-Cath System (SIMS Deltec, Inc, St Paul, Minn) in pleural malignant mesothelioma. Lee and colleagues ¹ reported the case of a patient with seeding of the track of a pleuroperitoneal shunt in a series of 20 shunts for malignant effusions, but none of these effusions was related to malignant mesothelioma.

Local radiotherapy has been shown to be effective in preventing tumor seeding in malignant mesothelioma. ^3,4

We describe mesothelioma tracking alongside a pleuroperitoneal shunt, resulting in difficulty locating the chamber and ultimately shunt blockage. This patient had not received prophylactic radiotherapy, although it was our usual policy to irradiate the thoracoscopy port. We now perform early, postoperative, low-dose, local radiotherapy to the site of shunt insertion, which can be different from the site of thoracoscopy ports.

References

1. Lee KA, Harvey JC, Reich H. Management of malignant pleural effusions with pleuroperitoneal shunting. J Am Coll Surg 1994;178:586-8.[Medline]
   
2. Petrou BS, Kaplan D, Goldstraw P. Management of recurrent malignant pleural effusions: the complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 1995;75:801-5.[Medline]
   
3. Low EM, Khoury GG, Matthews AW, Neville E. Prevention of tumour seeding following thoracoscopy in mesothelioma by prophylactic radiotherapy. Clin Oncol 1995;7:317-8.
   
4. Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma: a randomized trial of local radiotherapy. Chest 1995;108:754-8.[Abstract/Free Full Text]
   
5. van Ooijen B, Eggermont AM, Wiggers T. Subcutaneous tumor growth complicating the positioning of Denver shunt and intrapleural port-a-cath in mesothelioma patients. Eur J Surg Oncol 1992;18:638-40.[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard G. Berrisford Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baeyens, I. Articles by Berrisford, R. G. Search for Related Content PubMed PubMed Citation Articles by Baeyens, I. Articles by Berrisford, R. G. Related Collections Pleura