Title: Exudative pleural effusion in a woman with granulosa cell tumorAuthors: Muhammad Anees, MBBS1, Kevin Chiu, MD2, Stephen Goertzen, DO3, Carlos Jimenez3, MD, Saadia Faiz, MD3Institutional Affiliations: 1Division of Pulmonary, Critical Care, and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, United States, 2Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX, United States, 3Department of Pulmonary Medicine, The University of Texas at MD Anderson Cancer Center, Houston, TX, United States.Corresponding Author: Saadia A. Faiz, MD, Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX 77030-1402; Tel: (713)792-6238; Fax: (713) 794-4922; email: safaiz@mdanderson.orgConflicts of Interest: The author declares that no conflicts of interest existAuthor Contributions: MA, KC, SG, CJ, SF: conception and design, drafting the article, critical revision of intellectual content, final approval of the version to be publishedKey words: exudate, malignant pleural effusion, serositis, docetaxelPatient consent: The authors should confirm that written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.Word count: 939; Figures: 2; Tables: 1;Abstract word count: 183Abstract: Pleural effusions are common in cancer patients, and their development may signal progressive malignant disease. Drug-induced effusions are rare and often overlooked cause of exudative pleural effusions. We describe a 50-year-old woman with recurrent granulosa cell tumor of the ovary who developed bilateral pleural and pericardial effusions after 10 cycles of docetaxel and bevacizumab. Imaging showed stable pelvic disease without thoracic metastases. Pleural fluid analysis revealed exudates with negative cytology and cultures. Pleuroscopy demonstrated normal pleura, and biopsies confirmed reactive mesothelial hyperplasia without malignancy. Bilateral indwelling pleural catheters were placed. After discontinuation of docetaxel, effusions resolved, and indwelling pleural catheters were removed. Docetaxel causes fluid retention, typically generalized, but isolated serositis is uncommon. In our case, the temporal association with docetaxel, absence of malignant pleural involvement, and resolution after drug cessation support a diagnosis of docetaxel-induced serositis. This highlights the importance of considering non-malignant etiologies in patients with cancer with new effusions. Further multidisciplinary evaluation in these cases is paramount. Drug-induced serositis should be considered in patients receiving docetaxel who develop pleural effusions, particularly when imaging shows stable disease and cytology is negative.Key clinical message: Pleural effusions in cancer patients may signal progressive malignant disease, but therapy-related effusion may also occur. In cases of exudative effusion of unclear etiology, diagnostic intervention may be needed. Drug-induced serositis may occur in patients receiving docetaxel, particularly when imaging shows stable disease and cytology is negative.Introduction: Pleural effusions commonly occur in patients with cancer, and they may emerge due to a myriad of etiologies. Pleural fluid analysis is central to diagnostic evaluation(1). Although most malignant pleural effusions are exudates by Light’s criteria, transudates may also occur. Diagnostic sensitivity of pleural fluid cytology may vary based on tumor type(2). We describe a challenging case of bilateral effusions in a woman with granulosa cell tumor of the ovary.Case History/Examination: A 50-year-old woman with granulosa cell tumor of the ovary underwent a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Three years later, she developed recurrent disease with both perirectal and peritoneal metastases. She underwent laparotomy with debulking and subsequently received carboplatin/paclitaxel. Repeat imaging showed persistent pelvic disease without chest metastases, along with subcutaneous metastases, and she was then started on docetaxel and bevacizumab. After 10 cycles of docetaxel and bevacizumab, she presented with dyspnea with exertion and orthopnea. On physical exam, vital signs were as follows: blood pressure 134/96 mmHg, heart rate 107 beats per minute, temperature 98.1 F, respiratory rate 21 times per minute, body mass index 46.3 kg/m2. She had decreased bibasilar breath sounds, mild peripheral edema, but could not appreciate jugular venous distention or ascites given body habitus. Laboratory data was normal including N-terminal pro-B-type natriuretic peptide 74 pg/ml (<= 125 pg/ml), creatinine 0.59 mg/dl (0.51-0.95 mg/dl), serum albumin 3.5 gm/dl (3.5-5.2 gm/dl). Imaging demonstrated improving response in the measurable malignant disease but increased pericardial and bilateral pleural effusions had developed (Figure 1). The echocardiogram revealed normal left and right ventricular function and a small to moderate pericardial effusion, without signs of tamponade. Abdominal ultrasound did not show ascites. Bilateral thoracenteses improved her symptoms, and pleural fluid analysis (Table 1) revealed exudates. Cytology was negative. Two weeks later, she had recurrent symptoms with reaccumulation of bilateral pleural and stable pericardial effusions on imaging. Given unclear etiology of pleural effusions, pleuoroscopy with pleural catheter placement on her left hemithorax and placement of indwelling pleural catheter (IPC) on the right hemithorax was performed. Pleuroscopy reviewed no discrete lesions on the parietal pleura, and biopsies revealed reactive mesothelial hyperplasia without malignancy (Figure 2). Serum tumor markers were stable. After multidisciplinary discussion, docetaxel was held with subsequent cycles of chemotherapy.
