Beware the malignant jellyfish

Small pleural effusions that cannot be assessed by thoracentesis prior to surgery may represent a diagnostic challenge in the patient with a resectable, non–small cell cancer of the lung. Even if the effusion is drained preoperatively and analyzed, the cytology may be falsely negative. We have found that careful inspection of pleural effusions using a single small 2-cm incision and video-assisted thorascopy may reveal a gelatinous piece of clotlike material that resembles a jellyfish. This cohesive particulate piece of material lies in the effusion. This material can be sent for frozen section (unlike cytologic exams in most hospitals), and an immediate answer can be obtained. Cytology results of the surrounding effusion that return 24 hours later confirm the frozen section findings. If malignant, this avoids thoracotomy and pulmonary resection in a patient with unsuspected T4, stage IIIB lung cancer. It also avoids closing a patient with an unsuspected effusion and having to wait 24 hours for the cytology results. We review our experience with this jellyfish-like material.