Lymphangioleiomyomatosis, chylous ascites, and diet

Perioperative management of thoracic surgery in patients with lymphangioleiomyomatosis

Background

General surgery for patients with lymphangioleiomyomatosis (LAM) is infrequent, however, general surgeons also occasionally experience it. Only a few reports have described the specific perioperative management appropriate for patients with LAM. Hence, in this case series, we aimed to investigate the surgical outcomes of LAM patients and their characteristics.

Case presentation

Medical records of 4482 patients who underwent thoracic surgery between 2009 and 2017 at our institution were assessed. Twelve patients were diagnosed with LAM. Details of the postoperative courses and surgical outcomes of LAM patients were retrospectively examined.

All LAM patients were female (age 41.3 ± 10.6 years). Surgeries were performed for patients undergoing biopsy (n = 4) and those with pneumothorax (n = 3), lung cancer (n = 2), and other conditions (n = 3). The mortality rate was 0% and the length of hospital stay was 27.4 ± 8.9 days. Ten postoperative complications occurred in six patients (50%): hypoxemia (n = 5), chylothorax (n = 2), and prolonged air leakage (n = 3).

Conclusions

Thoracic surgery may pose a risk of postoperative complications and long hospitalization for patients with LAM, although it lowers the risk of fatality. Management of perioperative air and chyle leakages and lymphatic stasis in the lungs is important for preventing morbidities.

Primary abdominal lymphangioleiomyomatosis: report of a case

Lymphangioleiomyomatosis is an uncommon progressive disease characterized by hamartomatous smooth muscle proliferation of the airways within the lungs as well as the lymph nodes, lymphatics, and blood vessels of the lungs, mediastinum, and abdomen. The most common manifestations of lymphangioleiomyomatosis are pulmonary symptoms. Primary abdominal lymphangioleiomyomatosis without any pathological changes in the respiratory system is extremely unusual. We report a case of primary abdominal lymphangioleiomyomatosis located between the left hepatic and gastric antrum of a 29-year-old woman. The patient had no typical symptoms of lymphangioleiomyomatosis (dyspnea, pneumothorax) or abdominal pain. All physical examination findings were normal. Laboratory test results, including routine blood examination, liver and kidney function, tumor markers, blood coagulation function, and urine and stool examinations, were all normal. She found abdominal cyst in an annual medical examination by ultrasonography and confirmed by computed tomography. For a clear diagnosis, a laparoscopic abdominal mass resection was performed. The postoperative pathohistological examination findings allowed for the definitive diagnosis. This case report may advance the understanding of primary peritoneal lymphatic leiomyoma and reduce the number of mistakenly diagnosed patients.

Peritoneovenous shunting for intractable chylous ascites complicated with lymphangioleiomyomatosis

A 38-year-old woman was admitted due to lymphangioleiomyomatosis (LAM)-associated massive chylous ascites and progressive cachexia. She was incidentally diagnosed to have ascites during her regular physical check-up two years previously and LAM was revealed as its underlying cause. Periodic paracentesis was required to ameliorate ascites-associated symptoms, but resulted in lymphocytopenia, malnutrition, and deterioration of general status. Ascites was refractory to diuretics and fat-restricted diet. Peritoneovenous shunt (Denver shunt) was placed and thereafter ascites has been managed successfully without any complications for one year after the placement. Peritoneovenous shunt should be considered in LAM patients whose chylous ascites can not be managed with conservative treatments.

Clinical experience of lymphangioleiomyomatosis in the UK

BACKGROUND

Lymphangioleiomyomatosis is a rare lung disease that affects only women. No controlled trials of management have been performed and, until such data are available, management must be based on clinical experience. This study provides data on the natural history of lymphangioleiomyomatosis in the UK and compares this with experience from other centres.

METHODS

We tried to identify all cases of lymphangioleiomyomatosis in the UK over a five year period by contacting all chest physicians. Cases were confirmed by lung biopsy or history and high resolution computed tomographic (CT) scanning. Details of disease and management were obtained from hospital notes.

RESULTS

The 50 patients who fitted the diagnostic criteria for lymphangioleiomyomatosis had a median age at onset of 35 years (range 22-50). Five presented when postmenopausal (four taking hormone replacement therapy). Pneumothorax and dyspnoea were the most common presenting features. Extrapulmonary presentations included renal angiomyolipomas (3) and lymphangiomyomas (2). Only half the patients were assessed for renal angiomyolipoma and six were identified. Thirty patients had had one or more pneumothoraces, of which two thirds recurred if treated conservatively. Chylous effusions occurred in 11 patients, five requiring surgery. Pregnancy was uncommon once the diagnosis was made (n=7), but was associated with an increase in complications. Half the patients were taking a beta agonist and many showed a bronchodilator response in the laboratory. Thirty six patients had received hormone treatment.

CONCLUSIONS

Our UK five year period prevalence was one per 1.1 million population. Since prophylactic interventions are sometimes indicated for renal angiomyolipoma, these data suggest that screening for angiomyolipoma, ideally by CT scanning, may be underused. Patients need to be aware of the increase in complications associated with pregnancy. Recurrence rate of pneumothorax was high in those not treated surgically. Hormone treatment was used variably and controlled trials are needed to determine their role and the optimum duration and dose.

[Lymphangioleiomyomatosis: study of 15 patients]

BACKGROUND

Lymphangioleiomyomatosis (LAM) is an uncommon disease of not well-known evolution. We describe the clinical features and follow-up of a group of patients diagnosed of LAM in a hospital pulmonary transplantation programme.

PATIENTS AND METHODS

15 women (mean age: 43, range: 36-52) diagnosed of LAM, 9 at the Hospital Vall d'Hebron and 6 referred from other hospitals, for preoperative evolution of lung transplantation, were retrospectively studied.

RESULTS

Dyspnea appeared in all cases and it was the main symptom. Pleural problems in the early evolution of the disease were also very frequent (12 out of 15 patients). For this reason, pleurodesis was performed in 7 patients and pleurectomy in 2 (one of them bilateral). Thoracic CT scan showed very characteristic cystic images and abdominal CT proved the presence of extrathoracic associated angiomyolipomas in one case. In two patients, LAM was diagnosed after studying the explanted lung. These two patients had been previously misdiagnosed of emphysema and pulmonary haemosiderosis. Survival since the beginning of symptoms was 82 and 49%, 5 and 10 years later, respectively. Six out of eight patients who underwent lung transplantation had a long postoperative survival.

CONCLUSIONS

LAM seems to be as infrequent in Catalunya as in other countries, even if some cases could be misdiagnosed. Lung transplantation is useful in the advanced stages of the disease and, in our experience, it has improved respiratory insufficiency in half of the patients.