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Malignant Pleural Effusions
Malignant Pleural Effusions
Malignant Pleural Effusions
Effusion (MPE)
- Investigations
- Managements
Pathophysiology:
tumour cell metastasize to the pleura via blood stream and invade the visceral pleura. (Lung ca
spreads via pulmonary vessels to ipsilateral visceral pleural).
Secondary dissemination to parietal pleura by tumour seeding along adhesions or exfoliated
tumour cells floating in the effusion.
Pleura may also be invaded through lymphagitis spread or direct extension of tumours infiltrating
adjacent structures.
Investigations for
malignant pleural effusion
Adapted from BTS guideline: Investigation of unilateral pleural effusion
Copyright BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
Clare Hooper et al. Thorax 2010;65:ii4-ii17
MRI
MRI distinguishes accurately between benign and malignant pleural
effusions via differences in signal intensity on T2-weighted images.
Assessment of diaphragmatic and chest wall involvement is superior to CT
Not easily available, but maybe used to accurately assess pleural disease
in patients for whom contrast is contraindicated.
PET SCAN:
Limited by false positives in patients with pleural inflammation including pleural
infection and following talc pleurodesis
Potential role in monitoring treatment of pleural mesothelioma
Percutaneous pleural biopsy
When investigating an undiagnosed effusion where malignancy is suspected
and areas of pleural nodularity are shown on contrast-enhanced CT, an
image-guided cutting needle is the percutaneous pleural biopsy method of
choice. (A)
Pleural malignant deposits tend to predominate close to the midline and
diaphragm, which are areas best avoided when performing an Abrams biopsy.
Blind biopsy : 57% diagnostic rate
Pleural malignant deposits tend to predominate close to the midline and
diaphragm, which are areas best avoided when performing an Abrams biopsy.
Percutaneous image-guided pleural biospy (CECT)
Thoracoscopy (LA) / VATS (GA)
Thoracoscopy is the investigation of choice in exudative pleural
effusions where a diagnostic pleural aspiration is inconclusive and
malignancy is suspected. (C)
diagnostic sensitivity for malignant pleural disease of 92.6%
Talc poudrage can be administered at the end of the procedure which
achieves a successful pleurodesis in 8090%.
VATS: require GA, not suitable for frail individuals
Surgeons able to proceed to thoracic surgical options
Place indwelling cathether during VATS (trapped lung syndrome, pleurodesis
likely to be ineffective)
Pleural fluid ANA: Should not be
routinely measured
Pleural fluid antinuclear antibodies should not be measured
routinely as it reflects the serum level and is therefore usually
unhelpful. (C)
Elevated pleural fluid antinuclear antibodies (ANA) and an increased
pleural fluid to serum ANA ratio is suggestive of SLE pleuritis, but
elevation is also sometimes seen in malignant effusions.
Chylothorax and pseudochylothorax
If a chylothorax or pseudochylothorax is suspected, pleural fluid
should be tested for cholesterol crystals and chylomicrons and the
pleural fluid triglyceride and cholesterol levels measured. (C)
Appearance: milky. May be confused with turbid empyema
In starved patients, may not be milky.
Due to disruption of thoracic ducts, trauma, surgery, lymphoma, TB,
lymphatic malformations
Chylothorax can be a result of transdiaphragmatic migration of
chylous ascites, which can be secondary to hepatic cirrhosis. In these
cases, the pleural effusion is often a transudate.
Lymphoma related pleural effusion
Effusion may be associated with mediastinal lymphadenopathy on CT
but often there are no clinical features to distinguish from other
causes of pleural effusion.
Exudate. Lymphocytic. Positive cytology in around 40%. Chylothorax in
around 15%.
Pleural fluid flow cytometry and cytogenetics may be useful.
Thoracoscopic pleural biopsies are often negative but required to
exclude other causes if diagnosis unclear
Management of
Malignant Pleural
Effusion
Adapted from the BTS guidelines 2010
Intrapleural fibrinolytics
Intrapleural instillation of fibrinolytic drugs is recommended for the
relief of distressing dyspnoea due to multiloculated malignant
effusion resistant to simple drainage. (C)
Thoracoscopy
In patients with good performance status, thoracoscopy is
recommended for diagnosis of suspected malignant pleural effusion
and for drainage and pleurodesis of a known malignant pleural
effusion. (B)
Yield : > 90%
Thoracoscopic talc poudrage should be considered for the control of
recurrent malignant pleural effusion. (B)
Talc pleurodesis success rate: 77 100%
Thoracoscopy is a safe procedure with low complication rates. (B)
Long-term ambulatory indwelling pleural catheter drainage