Diagnosis and Management of Malignant Pleural Effusion[1]

Diagnosis and Management of Malignant Pleural Effusion 衛生署桃園醫院內科加護病房主任 莊子儀醫師 2006年7月20日 Etiology of Malignant Effusion    Lung cancer: 37.5%, especially adenocarcinoma Breast cancer: 16.8% Lymphoma: 11.5%, most common in young adult 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  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  Clinical Presentation    Dyspnea Cough Chest pain Radiographic Evaluation  Chest X-ray 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%) 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 Radiographic Evaluation   Chest X-ray Chest CT Chest CT      Pleural surfaces, lung parenchyma, chest wall and mediastinum Malignant pleural disease: pleural thickening (>1 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 Radiographic Evaluation    Chest X-ray Chest CT Chest echo 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 Diagnosis    Pleural effusion Cytology Pathology Pleural effusion     Grossly bloody: most common cause of bloody effusion Serosanguineous effusion Cell differentiation: lymphocytes predominant Eosinophilia: can not exclude malignant effusion Pleural effusion     Almost always exudate Lactate dehydrogenase (LDH): increased cell turnover and lysis Low glucose concentration and low pH level: possible shorter survival pH < 7.20: easily failure of pleurodesis 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 Pathology      Pleural biopsy Closed needle biopsy Cope needle Abrams needle Urocut needle Cope Needle Abrams Needle Urocut Needle 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) Send pleura for pathology and TB tissue/C  Pleural biopsy under echo-guide   Therapeutic thoracocentesis under echo-guide  Send pleural effusion for body fluid + cell block 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  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 Management  Before pleurodesis Daily drainage amount < 100-150 ml  Confirm with chest echo  Ability of lung re-expansion   Chemical pleurodesis Mnocycline injection  Beta-iodine injection  OK-432 injection  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  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  Management  Indwelling catheter Good outpatient situation  Good for trapped lung    Pigtail catheter with drainage bag Chest tube with Heimlich valve Management Complication     Re-expansion lung edema Empyema Restricted lung disease Trapped lung 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  Thank You for Attention     Reference: Murray and Nadel’s Textbook of Respiratory Medicine, 4th edition, 2005 Light and Lee’s Textbook of Pleural Disease, 1st edition, 2003 Mathis and Lessnau’s Atlas of Chest Sonography, 1st edition, 2003