Skip to main content

Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report



Chylothorax is a rare condition due to leakage of chyle in the thoracic cavity. When large amounts of chyle leak into the thoracic cavity, it can lead to severe respiratory, immune, and metabolic complications. Chylothorax has many potential underlying etiologies, and the most common causes are traumatic chylothorax and lymphoma. Venous thrombosis of the upper extremities is a rare cause of a chylothorax.

Case presentation

A 62-year-old Dutch man with a medical history of gastric cancer, treated with neoadjuvant chemotherapy and surgery 13 months prior, presented with dyspnea and a swollen left arm. Computed tomography thorax showed bilateral pleural effusion that was more prominent on the left side. The computed tomography scan further revealed thrombosis of the left jugular and subclavian veins and osseal masses suggesting cancer metastasis. Thoracentesis was performed to confirm the suspicion of gastric cancer metastasis. The obtained fluid was milky with a high level of triglycerides, but contained no malignant cells; hence, the diagnosis of the pleural effusion was chylothorax. Treatment with anticoagulation and a medium-chain-triglycerides diet was started. Furthermore, bone metastasis was confirmed with a bone biopsy.


Our case report demonstrates chylothorax as a rare cause of dyspnea in a patient with pleural effusion and a history of cancer. Therefore, this diagnosis should be considered in all patients with a history of cancer with new-onset pleural effusion and thrombosis of the upper extremities or clavicular/mediastinal lymphadenopathy.

Peer Review reports


Chylothorax is a rare condition characterized by leakage of chyle in the thoracic cavity. Lymph fluid or chyle is produced in the intestinal wall, and mainly consists of long-chain triglycerides derived from nutrients in the form of chylomicrons. Chyle consists of T-lymphocytes, electrolytes, fat-soluble vitamins, and proteins. Depending on the amount of fat in the diet, the transport of lymph fluid can differ between 1.5 and 2.5 L a day. Lymph fluid flows through the cisterna chyli and the thoracic duct, and ultimately empties in the venous system at the junction of the left internal jugular and subclavian veins [1,2,3]. The left upper lung lobe drains lymph fluid to the thoracic duct. The drainage of lymph fluid of the right lung and the left lower lobe is predominantly through the bronchomediastinal trunk to the right subclavian vein [2, 3].

There are various causes of chylothorax. The most common cause is dysfunction of the thoracic duct or its suppliers, which could be caused by obstruction (for example, lymphomas) or trauma (for example, surgery). Other causes are nonsurgical trauma (for example, whiplash and seizures), malignancies (other than lymphoma), lupus, tuberculosis, sarcoidosis, and amyloidosis [1, 2].

A rare cause of chylothorax is (bilateral) thrombosis of the upper extremities or central venous thrombosis, occasionally provoked by central venous catheters [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22].

The signs and symptoms of a chylothorax differ depending on the amount of chyle leakage and the underlying cause. If a large amount of chyle leaks in the pleural space, immunological weakness, hypoalbuminemia, and lymphopenia can occur. Diagnosis is confirmed with thoracentesis showing milky fluid, triglycerides > 1.24 mmol/L, or triglycerides between 0.56 and 1.24 mmol/L, with chylomicrons present in the pleural fluid. The treatment of chylothorax includes drainage and a low-fat diet with medium-chain triglycerides (MCT diet), which means exclusion of long-chain triglycerides (LCTs), preventing malnutrition, and treating the underlying cause [23].

Diagnosing chylothorax, by assessing the aspect of the pleural fluid, measuring triglycerides and chylomicrons in pleural effusion, and timely starting of treatment, can help respiratory distress, immunosuppression, and malnutrition.

Case presentation

A 62-year-old Dutch male was diagnosed with a T3N2M0 diffuse type gastric cancer in 2017. His initial symptoms were weight loss and dysphagia. Imaging and gastroscopy showed an ulcer in the gastric antrum and positron emission tomography–computed tomography (PET–CT) showed negative lymph nodes in the omentum. The histological diagnosis was diffuse type adenocarcinoma. The patient was treated in a curative setting with neoadjuvant chemotherapy (epirubicin, oxaliplatin, and capecitabine) followed by laparoscopic gastrectomy. Postsurgery staging showed ypT2N3M0R0. Adjuvant chemotherapy was not administered after very careful consideration because of persistent nausea and poor intake postsurgery including antiemetics, antidiarrheals, and additional nutrition. He did not have the right physical condition to endure adjuvant chemotherapy and its possible side effects. Therefore, the oncologist decided not to pursue adjuvant chemotherapy.

During follow-up at 11 months, a CT-thorax-abdomen was performed due to weight loss. The CT showed multiple mesenterial (maximum 11 mm), multiple retroperitoneal (maximum 14 mm), a few mediastinal (maximum 11 mm), and one left retroclavicular (11 mm) lymphadenopathy. No mass was identifiable as recurrence in the gastric region and no distant metastasis were seen. None of the masses were technically suitable for biopsy (to obtain histology). The recurrence of cancer could therefore not be established but was still suspected, and follow-up was planned after 2 months.

After 2 months, the patient slowly developed abdominal pain, edema of the legs, and dyspnea. CT scan showed pleural effusion but insufficient amount for thoracentesis.

A few months later the patient developed progressive weakening and edema of the left arm with shoulder pain. Table 1 presents the laboratory findings. Another CT scan was performed showing bilateral pleural effusion (Fig. 1A, B), with more pronounced pleural effusion on the left side, thrombosis of the jugular vein up to the subclavian vein (see Fig. 2A, B), and diffuse osseal masses in the vertebral column and pelvis (see Fig. 3). Pleuritic carcinomatosis was suspected, and therefore thoracentesis was planned before starting anticoagulation.

Table 1 Laboratory assessments
Fig. 1
figure 1

A, B CT chest–abdomen showing bilateral pleural effusion (indicated by arrows)

Fig. 2
figure 2

A, B Thrombosis in the left internal jugular vein and Thrombosis in the left brachiocephalic-subclavian vein (indicated by arrows)

Fig. 3
figure 3

Multiple bone metastasis in spine and pelvis

An uncomplicated thoracentesis was conducted on the left side, removing 20 mL milky fluid. Analysis of the fluid revealed elevated levels of triglycerides (3.3 mmol/L) without malignant cells (Table 2). The milky/yellow aspect of the fluid, in combination with the increased level of triglycerides, confirmed the diagnosis of a chylothorax. Anticoagulation was started along with a MCT diet. A biopsy of one of the osseal masses was planned.

Table 2 Laboratory data—pleural fluid examination

Histology of one osseal mass confirmed the recurrence of gastric cancer, showing a poorly differentiated carcinoma. After considering the possible benefits and side effects of palliative chemotherapy, and taking the clinical condition of the patient into consideration, chemotherapy was not considered feasible and the patient was referred back to the general practitioner with best supportive care. The patient passed away a few months later.


In the current case report we illustrate a rare cause of pleural effusion. We recommend that chyle leakage should be considered in patients with gastric cancer, thrombosis of the upper extremities, and new-onset pleural effusion. The thoracentesis led to the diagnosis of chyle leakage in the thorax caused by thrombosis of the subclavian and jugular veins in a prothrombotic state of a patient with metastatic cancer. The thrombosis of the subclavian and jugular veins subsequently led to a dysfunctional thoracic duct, due to obstruction and high pressure in the thoracic duct, leading to the formation of collateral ducts. The thoracic duct is able to resist high pressure and is not easily ruptured. However, high pressure in the collaterals can lead to backflow of chyle into the lymphatic ducts of the parietal pleura, which subsequently causes chyle leakage in the thoracic cavity through fissures and ruptures.

Theoretically, our patient should have developed isolated left-sided pleural effusion caused by chyle leakage in the left lung as the drainage system of the right lung mostly does not involve the thoracic duct and the subclavian and jugular veins. However, other case reports have also described bilateral chylothorax with one-sided thrombosis in the upper extremities without thrombosis in the lower part of the central venous system (for example vena cava inferior) [7, 10, 13, 17]. Another possible explanations of the right-sided pleural effusion in our patient could be the rapid decrease in albumin. In addition, our patient suffered from edema in the extremities (that is, scrotal and legs), without any other explanation besides the hypoalbuminemia. Hypoalbuminemia is also one of the complications of a chylothorax (leakage of proteins).

In patients undergoing chemotherapy, central venous catheters may cause thrombosis in the upper extremities, or may lead to direct trauma to the thoracic duct or nearby structures, which can lead to a chylothorax [1, 6, 15, 20, 24]. Our patient had a peripherally inserted central catheter (PICC) on the right arm during treatment with chemotherapy in 2017. The chylothorax occurred 1 year after the placement of the PICC. Moreover, the PICC was placed at the right arm whereas the thrombosis occurred in the left subclavian vein and jugular vein, making it unlikely that the thrombosis is a direct result of the peripherally inserted central catheter placement.

Lymphomas can cause direct trauma to the thoracic duct and chylous leakage. In our case, only one retroclavicular lymph node and a few small mediastinal ones (all < 11 mm) were seen. The extent of the thrombosis in contrast to a few small lymph nodes makes the thrombosis certainly more likely to be the cause the chylous pleural effusion in our case.

With increasing indications for PICC, other central venous catheters, and prolonged treatments of cancer patients, more direct trauma and thrombosis in the upper extremities could be expected, which could potentially lead to chylothorax. Some other risk factors for thrombosis in the upper extremities are oral anticonception, nephrotic syndrome, and coagulation disorders. Multiple case reports have already described thrombosis of the upper extremities as a cause of chylothorax. This group of patients is diverse, describing children, infants, catheter-associated thrombosis, spontaneous one-sided chylothorax, and bilateral chylothorax [4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22].

Gastric cancer is described to be associated with chylothorax on its own [25,26,27,28,29,30,31,32]. Devaraj et al. [25] described a case report and reviewed six other patients with chylothorax with initial presentation of gastric cancer, or developing chylothorax as a complication of therapy. In addition, three other case reports also described chylothorax due to upper extremity thrombosis in patients with gastric cancer [8, 16, 17]. The etiology of the chylothorax is not always clear. However, in most patients, as in our patient, it is often a late manifestation of occult gastric adenocarcinoma, followed by a fulminant course and death within months after diagnosis.


Thrombosis of the upper extremities is a rare cause of chylothorax, in which leakage of chyle in the thoracic cavity can potentially lead to severe complications. In most cancer patients, dyspnea is caused by the primary tumor, pulmonary metastasis, lung embolism, or pleural effusion caused by pleuritis carcinomatosa. Our case demonstrates another rare cause of dyspnea with pleural effusion in a patient with cancer. We recommend that chylothorax should be considered as a cause for dyspnea when pleural effusion and thrombosis of the upper extremities are present.

Availability of data and materials

Not applicable.


  1. Uptodate: Etiology, clinical presentation, and diagnosis of chylothorax.,%20clinical%20presentation,%20and%20diagnosis%20of%20chylothorax&source=search_result&selectedTitle=1~76&usage_type=default&display_rank=1. Accessed 13 July 2022.

  2. Smeets RE, van Jaarsveld BC, Gooszen HC, Schipper RM. Chylothorax en chylopericard [Chylothorax and chylopericardium]. Ned Tijdschr Geneeskd. 1988;132(34):1584–7 (Dutch).

    CAS  PubMed  Google Scholar 

  3. Okada Y, Ito M, Nagaishi Ch. Anatomical study of the pulmonary lymphatics. Lymphology. 1979;12(3):118–24.

    CAS  PubMed  Google Scholar 

  4. Kho SS, Tie ST, Chan SK, Yong MC, Chai SL, Voon PJ. Chylothorax and central vein thrombosis, an under-recognized association: a case series. Respirol Case Rep. 2017;5(3): e00221.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Tacoronte Pérez S, Cerón Navarro J, Pastor Colom A, Morcillo Aixelá A. Chylothorax due to venous thrombosis in a double-lung transplant patient. Arch Bronconeumol (Engl Ed). 2019;55(7):381–2. (English, Spanish).

    Article  PubMed  Google Scholar 

  6. Álvarez Vega P, Cadenas Menéndez S, Sánchez Serrano A, Fernández Sánchez JL, Martín Sánchez MJ, López Zubizarreta M. Chylothorax due to upper-extremity deep vein thrombosis. Arch Bronconeumol. 2017;53(2):83–4. (English, Spanish).

    Article  PubMed  Google Scholar 

  7. Diaconis JN, Weiner CI, White DW. Primary subclavian vein thrombosis and bilateral chylothorax documented by lymphography and venography. Radiology. 1976;119(3):557–8.

    Article  CAS  PubMed  Google Scholar 

  8. Kayacan O, Karnak D, Ayşe Can B, Dizbay Sak S, Beder S. Gastric signet-ring cell adenocarcinoma presenting with left arm deep-vein thrombosis and bilateral chylothorax. Clin Appl Thromb Hemost. 2008;14(4):476–80.

    Article  PubMed  Google Scholar 

  9. Hanina S, Vivekananthan C, Randhawa R, Bhattacharya M, Thomas P, Kavidasan A. Spontaneous chylothorax complicating small cell lung cancer—review of aetiology and diagnosis. Respir Med Case Rep. 2015;8(15):51–3.

    Article  Google Scholar 

  10. Poswal L, Dhyani A, Malik P, Ameta P. Bilateral chylothorax due to brachiocephalic vein thrombosis in relapsing nephrotic syndrome. Indian J Pediatr. 2015;82(12):1181–2.

    Article  PubMed  Google Scholar 

  11. Berkenbosch JW, Monteleone PM, Tobias JD. Chylothorax following apparently spontaneous central venous thrombosis in a patient with septic shock. Pediatr Pulmonol. 2003;35(3):230–3.

    Article  PubMed  Google Scholar 

  12. Van Veldhuizen PJ, Taylor S. Chylothorax: a complication of a left subclavian vein thrombosis. Am J Clin Oncol. 1996;19(2):99–101.

    Article  PubMed  Google Scholar 

  13. Merza N, Lung J, Saadaldin M, Naguib T. Bilateral chylothorax as a unique presentation of pancreaticobiliary or upper gastrointestinal cancer. Case Rep Pulmonol. 2019;2(2019):9387021.

    Article  Google Scholar 

  14. Novikov VA, Galstian GM, Shavlokhov VS, Shevelev AA, Gorodetskiĭ VM. A case of spontaneous chylothorax complicating pregnancy. Ter Arkh. 2012;84(7):84–8 (Russian).

    CAS  PubMed  Google Scholar 

  15. Schiller G. Chylothorax as a complication of central venous catheter-induced superior vena cava thrombosis. Bone Marrow Transplant. 1992;9(4):302.

    CAS  PubMed  Google Scholar 

  16. Rieche K. Chylothorax und Chyloabdomen bei einem Patienten mit Magenkarzinom infolge neoplastisch-thrombotischer Verlegung der Einmündung des Ductus thoracicus [Chylothorax and chyloabdomen in a patient with gastric carcinoma caused by neoplastic-thrombotic obstruction of the thoracic duct junction]. Z Gesamte Inn Med. 1965;20(14):450–4 (German).

    CAS  PubMed  Google Scholar 

  17. Yamada M, Kudoh S, Hirata K, Yoshikawa J. Bilateral chylothorax as initial manifestation of gastric cancer. Nihon Kokyuki Gakkai Zasshi. 2001;39(5):343–6 (Japanese).

    CAS  PubMed  Google Scholar 

  18. de Saint-Julien J, Périchaud J, Gisserot D, Cazenave A, Camus P. Chylothorax par thrombose de la veine sous-clavière gauche [Chylothorax caused by a thrombosis of the left subclavian vein]. Chirurgie. 1984;110(6–7):643–9 (French).

    PubMed  Google Scholar 

  19. Kawada T, Yokote K, Mieda T, Endo S, Osada H, Hiekata T, Noguchi T, Ishizuka S. A case report of chylothorax caused by thrombotic obstruction of jugulo-subclavian veins. Kyobu Geka. 1987;40(12):1012–6 (Japanese).

    CAS  PubMed  Google Scholar 

  20. Warren WH, Altman JS, Gregory SA. Chylothorax secondary to obstruction of the superior vena cava: a complication of the LeVeen shunt. Thorax. 1990;45(12):978–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Bouslama A, Aouina H, Mustapha R, Chaabane M, Ladeb MF, Gannouni A. Chylothorax par thrombose de la veine cave supérieure au cours d’une maladie de Behçet [Chylothorax caused by thrombosis of the superior vena cava in Behçet’s disease]. Rev Mal Respir. 1987;4(4):177–9 (French).

    CAS  PubMed  Google Scholar 

  22. Wu ET, Takeuchi M, Imanaka H, Higuchi T, Kagisaki K. Chylothorax as a complication of innominate vein thrombosis induced by a peripherally inserted central catheter. Anaesthesia. 2006;61(6):584–6.

    Article  CAS  PubMed  Google Scholar 

  23. UpToDate: Management of chylothorax. Accessed 13 July 2022.

  24. Saxena P, Shankar S, Kumar V, Naithani N. Bilateral chylothorax as a complication of internal jugular vein cannulation. Lung India. 2015;32(4):370–4.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Devaraj U, Ramachandran P, Correa M, D’souza GA. Chylothorax in gastric adenocarcinoma: a case report and systematic review of the English literature. Lung India. 2014;31(1):47–52.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Miwa M, Kasamatsu N, Shibata M, Ogasawara T, Kobayashi T, Haga T, Hashizume I. A case of gastric cancer with bilateral chylothorax. Nihon Kokyuki Gakkai Zasshi. 2009;47(12):1115–9 (Japanese).

    PubMed  Google Scholar 

  27. Watanabe K, Yamauchi K, Kobayashi K, Takeda H. A case of gastric cancer initially presented by bilateral chylothorax. Nihon Kokyuki Gakkai Zasshi. 2004;42(5):415–8 (Japanese).

    PubMed  Google Scholar 

  28. Miyazaki S, Noda H, Morita T, Joman M, Okada M, Moriyama Y, Suzuki K, Takeuchi T. A case of gastric cancer detected incidentally following to chylothorax, followed by change in the appearance of pleural effusion with cancer progression. Nihon Shokakibyo Gakkai Zasshi. 2007;104(9):1359–64.

    PubMed  Google Scholar 

  29. Martín-Joven A, Fernández Ballesteros A, Cervero M, Marco J, Solís J. Quilotórax como forma de presentación de un adenocarcinoma gástrico [Chylothorax as presenting form of a gastric adenocarcinoma]. Rev Esp Enferm Dig. 1996;88(12):880–1 (Spanish).

    PubMed  Google Scholar 

  30. Tsuji H, Hara S, Urano J, Samukawa T, Makio T, Sugiyama Y, Hosoi K, Ogiyama H, Murayama Y, Min KY. Good controlled chylothorax in gastric carcinoma. Gan To Kagaku Ryoho. 2018;45(10):1449–51 (Japanese).

    PubMed  Google Scholar 

  31. Nagano N, Suzuki M, Tamura K, Kobayashi S, Kojima Y, Naka G, Iikura M, Izumi S, Takeda Y, Sugiyama H. Refractory chylothorax and lymphedema caused by advanced gastric cancer. Intern Med. 2019;58(21):3143–8.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Wu J, Lv L, Zhou K, Huo J. Chylothorax and lymphedema as the initial manifestations of gastric carcinoma: a case report and review of the literature. Oncol Lett. 2016;11(4):2835–8.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


Not applicable



Author information

Authors and Affiliations



MU, EU, and ALTI contributed to writing the case report and approved the final manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to M. Ünal.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Written informed consent was obtained from the patient’s next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ünal, M., Ünal, E. & Imholz, A.L.T. Chylothorax due to thrombosis of the jugular and subclavian veins in a patient with gastric cancer: a case report. J Med Case Reports 17, 75 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Chylothorax
  • Thrombosis
  • Gastric cancer