Diagnosis and Management of Malignant Pleural Effusion

1
Diagnosis and Management of Malignant Pleural
Effusion

• ???????????????
• ?????
• 2006?7?20?

2
Etiology of Malignant Effusion

• Lung cancer 37.5, especially adenocarcinoma
• Breast cancer 16.8
• Lymphoma 11.5, most common in young adult

3
Etiology of Malignant Effusion

• Increasing production of effusion
• Increasing vascular permeability invasion of
  pleural vessels by tumor, cytokines, injury,
  infection etc.
• Increasing vascular hydrostatic gradient
  decreased pleural pressure by atelectasis,
  increased venous pressure by SVC syndrome,
  decreased plasma osmotic pressure by
  hypoalbuminemia
• Nonvascular entry by thoracic duct chylothorax

4
Etiology of Malignant Effusion

• Decreasing exit of effusion
• Increasing resistance to lymphatic flow
  infiltration of parietal pleura or mediastinal
  lymph nodes by tumor seeding
• Increasing gradient opposing lymphatic flow
  decreased pleural pressure by atelectasis,
  increased venous pressure by SVC syndrome

5
Clinical Presentation

• Dyspnea
• Cough
• Chest pain

6
Radiographic Evaluation

• Chest X-ray

7
(No Transcript)
8
Chest X-ray

• Amount of pleural effusion
• More than 2/3 hemithorax or even entire
  hemithorax
• 55 of large and massive effusions
• Other causes empyema and TB effusions
• Cytology diagnosis of large and small effusions
  no significant difference (63 vs. 53)

9
(No Transcript)
10
Chest X-ray

• Mediastinum position
• Shift away from a large effusion
• Midline mediastinum in large effusion
  significant lung collapse, fixed mediastinum LAP
• Shift toward a large effsuion trapped lung due
  to main-stem bronchial obstruction

11
(No Transcript)
12
Radiographic Evaluation

• Chest X-ray
• Chest CT

13
Chest CT

• Pleural surfaces, lung parenchyma, chest wall and
  mediastinum
• Malignant pleural disease pleural thickening (gt1
  cm), irregularity, nodules
• Pleural thickening also seen in empyema
• Pleural nodules only 17 in malignant effusions
• Other features lung mass, chest wall
  involvement, mediastinal LAP, hepatic metastases

14
(No Transcript)
15
(No Transcript)
16
Radiographic Evaluation

• Chest X-ray
• Chest CT
• Chest echo

17
Chest Echo

• Pleural surfaces, lung parenchyma, chest wall and
  pleural effusion
• Pleural effusion echo-free
• Pleural thickening and nodules
• Echo-guide thoracocentesis
• Echo-guide pleural biopsy

18
Diagnosis

• Pleural effusion
• Cytology
• Pathology

19
Pleural effusion

• Grossly bloody most common cause of bloody
  effusion
• Serosanguineous effusion
• Cell differentiation lymphocytes predominant
• Eosinophilia can not exclude malignant effusion

20
Pleural effusion

• Almost always exudate
• Lactate dehydrogenase (LDH) increased cell
  turnover and lysis
• Low glucose concentration and low pH level
  possible shorter survival
• pH lt 7.20 easily failure of pleurodesis

21
Cytology

• Adenocarcinoma most likely to be positive
• Low pH greater tumor burden
• Cytology diagnosis of large and small effusions
  no significant difference (63 vs. 53)
• Body fluid cell block

22
Pathology

• Pleural biopsy
• Closed needle biopsy
• Cope needle
• Abrams needle
• Urocut needle

23
Cope Needle
24
Abrams Needle
25
Urocut Needle
26
Diagnostic Procedures

• Diagnostic thoracocentesis under echo-guide
• Send pleural effusion for routine, BCS (LDH,
  protein, glucose), Gram/AFB stain, cytology, B/C,
  plus ABG (for pH)
• Pleural biopsy under echo-guide
• Send pleura for pathology and TB tissue/C
• Therapeutic thoracocentesis under echo-guide
• Send pleural effusion for body fluid cell block

27
Primary Tumor (T)

• T4
• A tumor of any size with invasion of the
  mediastinum, or involving heart, great vessels,
  trachea, esophagus, vertebral bodies, carina,
• or with the presence of malignant
  pleural/pericardial effusion,
• or exudative pleural effusion without evidence of
  obstructive pneumonitis,
• or with satellite tumor within the lobe of
  primary tumor at chest CT

28
Management

• Symptom-oriented management
• Less than 1/3 hemithorax, C/T sensitive tumor
• C/T at first, F/U regularly
• Slowly recurring effusion, short life span
• Repeated therapeutic thoracocentesis
• More than 2/3 hemithorax, no airway obstruction
• Pigtail insertion for pleurodesis within 24 hours

29
(No Transcript)
30
Management

• Before pleurodesis
• Daily drainage amount lt 100-150 ml
• Confirm with chest echo
• Ability of lung re-expansion
• Chemical pleurodesis
• Mnocycline injection
• Beta-iodine injection
• OK-432 injection

31
Management

• Pre-medication
• 2 xylocaine 10ml in 50ml normal saline
• Minocycline injection
• After 15 minutes, 300mg Minocycline in 50ml
  normal saline
• Clamp catheter/tube, change position 2-6 hours
• Unclamp catheter/tube, low pressure suction

32
Management

• Pre-medication
• 2 xylocaine 10ml in 50ml normal saline
• Beta-iodine injection
• After 15 minutes, 10 ml beta-iodine in 40ml
  normal saline
• Clamp catheter/tube, change position 2-6 hours
• Unclamp catheter/tube, low pressure suction

33
Management

• Indwelling catheter
• Good outpatient situation
• Good for trapped lung
• Pigtail catheter with drainage bag
• Chest tube with Heimlich valve

34
Management
35
Complication

• Re-expansion lung edema
• Empyema
• Restricted lung disease
• Trapped lung

36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
Prognosis

• Medium survival
• Lung cancer with malignant effusion 3 months
• Breast cancer with malignant effusion 5 months
• Mesothelioma with malignant effusion 6 months
• Lymphoma with malignant effusion 9 months

40
Thank You for Attention

• Reference
• Murray and Nadels Textbook of Respiratory
  Medicine, 4th edition, 2005
• Light and Lees Textbook of Pleural Disease, 1st
  edition, 2003
• Mathis and Lessnaus Atlas of Chest Sonography,
  1st edition, 2003