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Background: Finding malignant cells in pleural fluid and/or parietal pleura indicates a disseminated or advanced disease and reduced life expectancy in patients who have cancer. The management of malignant pleural effusion was outlined. Clinical Presentation: Most malignant effusions produce symptoms. If the pleural effusions are massive, with complete or almost complete opacification of a hemithorax on the chest x-ray, malignancy is the most common cause. Management: Asymptomatic patients who have a known tumor type can be observed. Symptomatic malignant effusions prompt consultation with the respiratory team and/or respiratory multidisciplinary team. If pleural effusions are treated by aspiration alone, recurrence of effusion within 1month is likely. If the patient's life expectancy exceeds 1month, aspiration is not recommended. Caution is needed if more than 1.5L is removed in a single episode. Except in patients with short life expectancies, small-bore chest tubes and pleurodesis are preferred to repeat aspiration. Pleurodesis after intercostal drainage prevents recurrence except with significant trapped lung. For effusion drainage plus pleurodesis, small-bore (10 to 14F) intercostal catheters are chosen initially. For large pleural effusions, controlled drainage will reduce the risk of re-expansion pulmonary edema. If only partial pleural apposition can be done, chemical pleurodesis may provide relief of symptoms. If pleural apposition is not possible in a patient with symptoms, an indwelling pleural catheter is more efficacious than repeat aspiration. Radiographic confirmation of effusion drainage and lung re-expansion should be immediately followed by pleurodesis. Usually suction to help pleural drainage is unnecessary, but if used, a high-volume low-pressure system is needed. Because intrapleural administration of sclerosing agents can be painful, 3mg/kg of lidocaine (maximum 250mg) is given intrapleurally just before the sclerosant is given. The use of premedication can alleviate both anxiety and pain associated with pleurodesis. The most effective sclerosant available is talc. Graded talc is preferred to ungraded talc because of the lower risk of arterial hypoxemia. Either a slurry or insufflation can be used. An alternative to talc is bleomycin, which has modest efficacy. Sclerosant administration can be complicated by pleuritic chest pain and fever. After intrapleural instillation of sclerosant, it is not necessary to rotate the patient. The intercostal tube is clamped for 1 hour after administering the sclerosant. The tube is removed within 24 to 48 hours if fluid drainage is not excessive (less than 250mg/day). In patients with proven or suspected mesothelioma, prophylactic radiotherapy may be used at the site of thoracoscopy, surgery, or insertion of a large-bore chest tube. However, for pleural aspiration or biopsy, such prophylaxis is not needed. For the relief of distressing dyspnea caused by multiloculated malignant effusion resistant to simple drainage, fibrinolytic drugs can be instilled intrapleurally. Thoracoscopy is recommended to diagnose suspected malignant pleural effusion and for drainage and pleurodesis of known malignant pleural effusion in patients with good performance status. To control recurrent malignant pleural effusion, thoracoscopic talc poudrage may be helpful. Thorascopy is safe and has low complication rates. To control recurrent and symptomatic malignant effusions, ambulatory indwelling pleural catheters may be useful. Pleurectomy cannot be recommended as an alternative to pleurodesis or an indwelling pleural catheter in patients with recurrent effusions or trapped lung. Conclusions: Lung cancer is the most common metastatic tumor (50% to 65% of cases) to the pleura in men and breast tissue in women, followed by lymphomas and tumors of the genitourinary tract and gastrointestinal tract (25% of cases). The primary is unknown in 7% to 15% of malignant pleural effusions. The clinical characteristics of pleural fluid have not yet been shown to correlate with survival. Guidelines for the management of malignant pleural effusions were offered |
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