A 50-year-old man presented with a left pleural effusion. Three months before, the patient underwent CABG using the left internal mammary artery. Postoperative course was unremarkable. He complained of dyspnea and decreasing exercise tolerance. Two thoracenteses drained 4 L of hemorrhagic fluid. Fluid analysis, including white and red blood cell counts, lactate dehydrogenase (LDH) and protein values, cytology, bacterial culture, and acid-fast bacilli smear failed to reveal a definitive diagnosis. He was admitted for chest tube drainage and pleural biopsy. Past medical history included diabetes, hyperlipidemia, and cigarette smoking.
Physical examination revealed a chronically ill–appearing white man. Breath sounds were diminished on the left. There was a 3-cm fixed nodule on the right arm. Laboratory data (serum) were white blood cell count, 9000/μL (80% segmented neutrophils); hemoglobin, 11.2 g/dL; sedimentation rate, 30 mm/h; complete metabolic profile, within normal limits; total protein, 7.0 g/dL; LDH, 170 U/L; and urinalysis, moderate blood.
Pleural fluid analysis results were red blood cell count, 130,000/μL; white blood cell count, 2000/μL (70% lymphocytes); pH, 8.0; total protein, 5.1 g/dL; LDH, 254 U/L; glucose, 264 mg/dL; amylase, 18 U/L; carcinoembryonic antigen, <0.5 ng/mL; and cytology, negative for malignancy.
Cope needle pleural biopsy showed chronic fibrinous pleuritis with atypical cells suspicious for malignancy. Bronchoscopy localized a fungating lesion in the lingula. Pathology confirmed poorly differentiated non–small cell carcinoma with spindle cell features. Computed tomography of the chest showed irregular nodules of the left pleura and right-sided pulmonary nodules. An abdominal computed tomographic scan revealed an irregular mass arising from the lower pole of the left kidney. The nodule on the right arm was metastatic renal cell carcinoma. The diagnosis was primary renal cell carcinoma with metastases to lung, pleura, and skin.