Malignant pleural effusion

May be the initial presentation of cancer, as a delayed finding in a known neoplasm or as a manifestation of recurrent cancer.

Defined by the presence of malignant cells in the pleural space.

Causes dyspnea in more than 1 million people worlwide annualy and prevalence increasing.

Affects more than 150,000 patients per year in US.

Prevalence is increasing.

Can arise from primary malignancy of the pleura or from intra or extra thoracic cancers.

Cancer cells reach the pleural fluid by contiguous spread, the blood or lymphatics.

More than 75% of cases related to lung, breast, ovary or lymphoma malignancies.

Metastatic adenocarcinoma the most common tissue type.

Can be due to mesotheliomas.

Median survival from findings of a malignant pleural effusion is 4 months.

Usually suggests advanced metastatic disease associated with poor prognosis.

When established tumors spread in the pleural space along parietal pleural membranes obstructing lymphatic vessels that drain the intrapleural fluid.

Pleural involvement by tumors stimulate release of chemokines that increase pleural and vascular membrane permeability resulting in further accumulation of pleural fluid.

Lung cancer accounts for more than one third of cases and is associated with a life expectancy of less than four months.

Patients typically present with low glucose (<60mg/dL), cell counts less than 5000/µL, and positive cytology.

Grossly bloody fluid and eosinophilia are common.

Symptomatic disease common cause of hospitalization, usually due to disabling shortness of breath.

Aim of treatent is palliation.

Treatment recommendation is chest tube insertion and pleurodesis as first line treatment.

Talc most effective pleurodesis agent.

Small talc particles may cause talc-associated acute respiratory distress syndrome therefore only large talc particles should be used.

Use of talc poudrage vs talc slurry are of equal efficacy, with the rate of successful pleurodesis 70% (Dressler CM et al).

Median hospitalization 7 days for talc pleurodesis is 7 days.

Difficulties with pleurodesis and talc therapy include: dislodgment of pleural tube in 7% (Hooper C, Maskell N), and presence of trapped lung, impairing the process, and a 1% pleural infection rate (Roberts ME et al).

95% of patients treated with Indwelling pleural catheter management have symptomatic improvement, with 46% having spontaneous pleurodesis, 2,8% developing empyema, 5,9% developing pneumothorax, and 3.7% catheter blockage (Van Meyer ME et all).,

30 day failure rate for talc pleurodesis with recurrent pleural fluid requiring further management is approximately 30%.

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