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Simultaneous chylothorax and chylous ascites in a patient with castration‐resistant prostate cancer after docetaxel chemotherapy: An unusual manifestation

A 72-year-old man presented with a prostate-specific antigen (PSA) level of 920.0 ng/mL in February 2008. After biopsy, computed tomography and bone scan, prostate adenocarcinoma Gleason score 5 + 5 with vertebral metastasis at L1 (cT3bN0M1b) was diagnosed. Following surgical castration, PSA reached a nadir of 3.98 ng/mL in June 2009. In March 2012, PSA rose to 87.0 ng/mL and radiological studies showed vertebral metastases at Th7-L3; the patient was then started on docetaxel (36mg/m q2w). After 14 cycles of docetaxel, PSA reached a nadir of 0.96 ng/mL in April 2013. However, he presented with abdominal distention and dyspnea. Radiological studies showed massive pleural effusion and ascites with vertebral metastases that did not respond to docetaxel. The patient weighed 67 kg (baseline 59 kg). His albumin was 3.2 g/dL, with total protein of 5.4 g/dL. Straw-colored fluid was obtained by needle aspiration, and analysis showed exudative effusion without malignant cells, which was diagnosed as docetaxel-induced fluid retention syndrome. Symptoms improved after a month’s treatment with diuretics. After discontinuing docetaxel, PSA rose to 38.8 ng/mL and he presented with dyspnea in August 2013. Radiological studies showed massive pleural effusion and ascites, again (Fig. 1a,b) with a new metastatic lesion on the left thigh bone. He weighed 62 kg and his albumin was 2.5 g/dL, with total protein of 5.6 g/dL. Initially, we thought fluid retention syndrome recurred and diuretics were readministered; however, the symptoms did not resolve. Fluid aspiration was carried out. Surprisingly, pleural effusion and ascites appeared milky, and analysis showed triglyceride 1180mg/dL and 1289mg/dL, respectively (normal <110), which confirmed chylothorax and chylous ascites. No malignant cells were identified. Cultures for microorganisms, Mycobacterium tuberculosis and fungi were negative. A thoracic tube was placed in the patient’s left hemithorax. He was put on a low-fat diet and received octreotide intravenously. Symptoms improved for a month. Enzalutamide and abiraterone were not approved in 2013 by the Japanese Ministry of Health, so he received docetaxel again, but PSA continued to rise. The patient died in March 2014. No autopsy was carried out. Chylothorax and chylous ascites are rare findings, caused by obstruction of lymphatic channels by tumor, trauma, surgery or inflammation. The most common malignancies are lymphomas. Their association with prostate cancer (PCa) is rare. Just four cases of chylothorax and two cases of chylous ascites have been reported. To our knowledge, this is the first report of PCa with simultaneous chylothorax and chylous ascites. Though computed tomography did not show significant metastasis in lymphatic tissue, chylothorax and chylous ascites were thought to be caused by PCa progression, because PSA rose constantly and other etiologies were excluded. A large number of cancer cells can cause sludging in the lymphatic system, which might result in lymphatic obstruction, and subsequently chylothorax and chylous ascites. Conservative treatment or treatment of the underling disease should be considered. Fortunately, conservative management was efficacious in the present case, but he eventually died of PCa. Chylothorax and chylous ascites suggest poor prognosis, as reported in other malignancies. In conclusion, clinicians should keep this rare scenario in mind.