What is the most likely cause of persistent sub-breast pain in a lymphoma patient after bilateral pigtail catheter placement for pleural effusions?

Persistent Sub-Breast Pain After Pigtail Catheter Placement in Lymphoma Patients

The most likely cause of persistent sub-breast pain following bilateral pigtail catheter insertion for lymphoma-related pleural effusions is intercostal nerve injury (neuroma formation or neuropathy) from the catheter insertion procedure itself. 1

Primary Mechanism of Pain

Intercostal nerve trauma during pigtail catheter insertion is the predominant cause of persistent localized chest wall pain in this clinical scenario. The lateral chest wall zone—where pigtail catheters are typically inserted—is the most commonly injured area, accounting for 79% of nerve injuries in thoracic procedures. 2

Types of Nerve Injury from Catheter Placement:

• Mechanical nerve trauma/entrapment occurs at the insertion site or along the catheter tract, creating intercostal neuromas that produce sharp, localized pain at or near the surgical scar. 2

• Traction-stretch neuropathy can develop from the catheter placement technique, particularly if there was difficulty with insertion or repositioning. 2

• Direct nerve injury may occur during the percutaneous insertion process, especially in bilateral procedures where multiple insertion attempts increase cumulative nerve trauma risk. 3

Distinguishing Features to Confirm Nerve Injury

• Elicit a Tinel's sign along the lateral chest wall at the catheter insertion sites—tapping over the affected intercostal nerve will reproduce or intensify the pain if neuroma is present. 4

• Perform a diagnostic intercostal nerve block with local anesthetic at the painful site; temporary complete pain relief confirms neurogenic etiology. 4

• Pain characteristics are typically sharp, burning, or electric-shock-like, following a dermatomal distribution along the intercostal nerve pathway rather than diffuse breast pain. 5

Alternative Diagnoses to Exclude

Malignant Pleural Involvement

• Parietal pleural invasion by lymphoma causes chest pain through direct involvement of intercostal structures, but this pain typically predates catheter insertion and is associated with ongoing pleural fluid reaccumulation. 1

• Lymphatic obstruction from tumor infiltration or enlarged mediastinal lymph nodes can cause persistent effusions but does not directly explain localized insertion-site pain. 6

Catheter-Related Complications

• Malpositioned catheter tracking through lung parenchyma can cause pain and subcutaneous emphysema, identifiable on chest imaging. 3

• Residual pleural irritation from incomplete drainage or loculation may cause diffuse chest discomfort rather than focal sub-breast pain. 7

Pre-Eruptive Herpes Zoster

• Consider herpes zoster if pain is severe, burning in quality, follows a dermatomal pattern (T4-T6), and preceded any visible skin changes—though this would be coincidental timing rather than procedure-related. 5

• Examine skin carefully for subtle erythema, edema, or early vesicle formation in the painful dermatome. 5

Diagnostic Algorithm

1. Examine the catheter insertion sites for tenderness, Tinel's sign, and any signs of infection or skin changes. 4, 2

2. Obtain chest imaging (chest X-ray or CT) to exclude catheter malposition, residual pleural fluid, pneumothorax, or subcutaneous emphysema. 3

3. Perform diagnostic intercostal nerve block at the painful site(s) with 1% lidocaine; complete temporary relief confirms intercostal neuroma/neuropathy. 4

4. Assess for disease progression with pleural fluid cytology if effusions have reaccumulated, as lymphomatous pleural involvement can cause pain through parietal pleural invasion. 8

5. Examine for herpes zoster if pain is dermatomal and severe, looking for any subtle skin changes that may indicate pre-eruptive phase. 5

Management Approach

For Confirmed Intercostal Nerve Injury:

• Initial conservative management includes NSAIDs (ibuprofen or naproxen) for pain control and observation for spontaneous resolution over 4-6 weeks. 5

• Neuropathic pain medications such as gabapentin or pregabalin should be initiated if pain persists beyond 2 weeks despite NSAIDs. 2

• Surgical intervention with identification, clipping, and burying of the intercostal neuroma into underlying muscle provides definitive treatment for refractory cases with confirmed neuroma on nerve block. 4

For Lymphoma-Related Pleural Pain:

• Systemic chemotherapy is the primary treatment for lymphoma-related pleural effusions, as lymphomas are chemotherapy-responsive tumors where local interventions should not delay systemic therapy. 7, 6

• Therapeutic thoracentesis provides temporary symptomatic relief while chemotherapy takes effect, removing no more than 1.5L per procedure to prevent re-expansion pulmonary edema. 7, 6

• Avoid pleurodesis until systemic chemotherapy has been attempted, as effusions may resolve with tumor response, making invasive pleural procedures unnecessary. 7

Critical Pitfalls to Avoid

• Do not assume pain is solely from disease progression without evaluating for procedure-related nerve injury, as intercostal neuromas are a treatable cause of persistent pain. 4, 2

• Do not delay systemic chemotherapy in favor of repeated local pleural interventions, as lymphoma effusions respond better to systemic treatment than mechanical drainage alone. 7, 6

• Do not perform pleurodesis in lymphoma patients with chemotherapy-responsive disease until systemic therapy has been attempted and failed. 7

• Recognize that bilateral procedures double the risk of intercostal nerve injury, making nerve-related pain more likely than in unilateral catheter placement. 2