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Malignant pleural effusion
Malignant pleural effusion
Specialty	Oncology

Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity.^[1] Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions.^[2]^[3] Other common causes include pleural mesothelioma and lymphoma.

Diagnosis

Clinical evaluation

Clinical factors predicting the diagnosis of malignant pleural effusions are symptoms lasting more than 1 month and the absence of fever.^[4]

Imaging

Imaging is needed to confirm the presence of a pleural effusion. A Chest radiograph is usually performed first and may demonstrate an underlying lung cancer as well as the pleural effusion. Ultrasound has a sensitivity of 73% and specificity of 100% at distinguishing malignant pleural effusions from other causes of pleural effusion, based on the presence of visible pleural metastases, pleural thickening greater than 1 cm, pleural nodularity, diaphragmatic thickening measuring greater than 7mm and an echogenic swirling pattern visible in the pleural fluid.^[5]^[6]

Biochemical analysis

Malignant pleural effusions are exudates. A low pleural fluid pH is associated with poorer survival and reduced pleurodesis efficacy.^[7]^[8]

Histopathology

Pleural fluid cytology is positive in 60% of cases. However, in the remaining cases, pleural biopsy is required. Image guided biopsy and thoracoscopy have largely replaced blind biopsy due to their greater sensitivity and safety profile. CT guided biopsy has a sensitivity of 87% compared to Abrams' needle biopsy, which has a sensitivity of 47%.^[9]

Biomarkers

Identification of pleural fluid biomarkers to distinguish malignant pleural effusions from other causes of exudative effusions would help diagnosis. Biomarkers that have been shown to be raised in malignant pleural effusions compared to benign disease include vascular endothelial growth factor (VEGF), endostatin, matrix metalloproteinases and tumour markers such as carcinoembryonic antigen.^[10]^[11]^[12]^[13] Pleural fluid mesothelin has a sensitivity of 71%, greater than that of cytology, and a specificity of 89% for the diagnosis of malignant mesothelioma.^[14]

Treatment

The goal of treatment of malignant pleural effusions is relief of shortness of breath.^[15] Occasionally, treatment of the underlying cancer can cause resolution of the effusion. This may be the case with types of cancer that respond well to chemotherapy, such as small cell carcinoma or lymphoma. Simple aspiration of pleural fluid can relieve shortness of breath rapidly but fluid and symptoms will usually recur within a couple of weeks. Drainage should generally be done under ultrasound guidance.^[16]

For this reason, more permanent treatments are usually used to prevent fluid recurrence. Standard treatment involves inserting an indwelling pleural catheter and pleurodesis.^[16] However, this treatment requires an inpatient stay of approximately 2–7 days, can be painful and has a significant failure rate. This has led to the development of tunneled pleural catheters (e.g., Pleurx Catheters), which allow outpatient treatment of effusions. If an infection due to the catheter occurs, antibiotics are given and the catheter is generally left in.^[16]

A Cochrane review concluded tentatively in favour of thoracoscopy to remove the fluid and blow talc into the pleural cavity (talc poudrage) compared to other commonly used methods. ^[17]

References

^ "NCI Dictionary of Cancer Terms". NCI. 2011-02-02. Retrieved 21 December 2018.
^ Hausheer FH, Yarbro JW (March 1985). "Diagnosis and Management of Malignant Pleural Effusion". Seminars in Oncology. 12 (1): 54–75. PMID 2579439.
^ Antony VB, Loddenkemper R, Astoul P, et al. (August 2001). "Management of malignant pleural effusions". Eur. Respir. J. 18 (2): 402–19. doi:10.1183/09031936.01.00225601. PMID 11529302.
^ Ferrer J, Roldán J, Teixidor J, Pallisa E, Gich I, Morell F (March 2005). "Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy". Chest. 127 (3): 1017–22. doi:10.1378/chest.127.3.1017. PMID 15764788.
^ Qureshi NR, Rahman NM, Gleeson FV (February 2009). "Thoracic ultrasound in the diagnosis of malignant pleural effusion". Thorax. 64 (2): 139–43. doi:10.1136/thx.2008.100545. PMID 18852159.
^ Chian CF, Su WL, Soh LH, Yan HC, Perng WC, Wu CP (July 2004). "Echogenic swirling pattern as a predictor of malignant pleural effusions in patients with malignancies". Chest. 126 (1): 129–34. doi:10.1378/chest.126.1.129. PMID 15249453.
^ Sahn SA, Good JT (March 1988). "Pleural fluid pH in malignant effusions. Diagnostic, prognostic, and therapeutic implications". Ann. Intern. Med. 108 (3): 345–9. doi:10.7326/0003-4819-108-3-345. PMID 3341671.
^ Rodríguez-Panadero F, López Mejías J (March 1989). "Low glucose and pH levels in malignant pleural effusions. Diagnostic significance and prognostic value in respect to pleurodesis". Am. Rev. Respir. Dis. 139 (3): 663–7. doi:10.1164/ajrccm/139.3.663. PMID 2923367.
^ Maskell NA, Gleeson FV, Davies RJ (April 2003). "Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial". Lancet. 361 (9366): 1326–30. doi:10.1016/S0140-6736(03)13079-6. PMID 12711467. S2CID 22606449.
^ Sack U, Hoffmann M, Zhao XJ, et al. (April 2005). "Vascular endothelial growth factor in pleural effusions of different origin". Eur. Respir. J. 25 (4): 600–4. doi:10.1183/09031936.05.00037004. PMID 15802331.
^ Sumi M, Kagohashi K, Satoh H, Ishikawa H, Funayama Y, Sekizawa K (2003). "Endostatin levels in exudative pleural effusions". Lung. 181 (6): 329–34. doi:10.1007/s00408-003-1035-9. PMID 14749937. S2CID 10290685.
^ Gaspar MJ, De Miguel J, García Díaz JD, Díez M (2008). "Clinical utility of a combination of tumour markers in the diagnosis of malignant pleural effusions". Anticancer Res. 28 (5B): 2947–52. PMID 19031938.
^ Vatansever S, Gelisgen R, Uzun H, Yurt S, Kosar F (2009). "Potential role of matrix metalloproteinase-2,-9 and tissue inhibitors of metalloproteinase-1,-2 in exudative pleural effusions". Clin Invest Med. 32 (4): E293–300. doi:10.25011/cim.v32i4.6621. PMID 19640333.
^ Davies HE, Sadler RS, Bielsa S, et al. (September 2009). "Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions". Am. J. Respir. Crit. Care Med. 180 (5): 437–44. doi:10.1164/rccm.200811-1729OC. PMID 19299498.
^ Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ (August 2010). "Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010". Thorax. 65 (Suppl 2): ii32–40. doi:10.1136/thx.2010.136994. PMID 20696691.
^ ^a ^b ^c Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, et al. (October 2018). "Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline". American Journal of Respiratory and Critical Care Medicine. 198 (7): 839–849. doi:10.1164/rccm.201807-1415ST. PMID 30272503. S2CID 52894157.
^ Dipper, Alexandra; Jones, Hayley E.; Bhatnagar, Rahul; Preston, Nancy J.; Maskell, Nick; Clive, Amelia O. (21 April 2020). "Interventions for the management of malignant pleural effusions: a network meta-analysis". The Cochrane Database of Systematic Reviews. 2020 (4): CD010529. doi:10.1002/14651858.CD010529.pub3. ISSN 1469-493X. PMC 7173736. PMID 32315458.