1. Malignant Pleural Effusion
Department Of Pulmonary & Critical Care Medicine,
KyungHee Medical Center
R3 Yang Byung Hyuk

2. Introduction Malignant cells in pleural fluid Advanced disease
Reduced life expectancy
Median survival following diagnosis : 3 ~12 months
Lung cancer < unknown primary cancer < ovarian cancer

3. Pathophysiology Anatomical compartments Parietal systemic circulation
Parietal interstitial space
Pleural space
Pulmonary interstitium
Visceral circulation
Any disruption or obstruction by tumor cells along lymphatic network
Tumor emboli to visceral pleura with 2’ seeding to the parietal pleura
Direct tumor invasion
Hematogenous spread
Lymphatic involvement

5. Clinical manifestrations
Up to 25 % of patients are asymptomatic at presentation.
Dyspnoea : m/c presenting symptom
Reduced compliance of the chest wall
Depression of the ipsilateral diaphragm
Mediastinal shift
Reduction in lung volume
Stimulating neurogenic reflexes
Chest pain
-Involvement of the parietal pleura, ribs, and other intercostal structure
Constitutional symptoms : weight loss, malaise, anorexia

6. Imaging techniques Chest radiography : 500~2000 ml in volume
10 % massive pleural effusion
15 % < 500 ml in volume
Computerized tomography scan
Unrecognized small effusion
Mediastinal lymph node involvement
Underlying parenchymal disease
Pleural, pulmonary, distant metastases
Pleural plaque suggesting asbetos exposure
Ultrasonography
Identifying pleural lesion
Guided thoracentesis
MRI, PET scan : limited role

7. Diagnostic thoracentesis
Unilateral effusion or bilateral effusion with normal heart size on CXR
→ Malignancy should be considered. → diagnostic thoracentesis
Pleural fluid tests : exudate>transudate, bloody effusion
Nucleated cell count & differential : lymphocyte, mononuclear cell
Total protein, LDH
Glucose, pH
1/3 < pH 7.3
Low glucose and pH
Highter initial diagnostic yield on cytologic exam.
Worse survival
Better response to pleurodesis
Amylase : ↑→ adenocarcinoma of the lung
Cytology : 62~90 % diagnostic yeild
Tumor markers : CEA, Leu-1, mucin

8. Other diagnostic approaches
Closed pleural biopsy
40~75 % diagnostic yield
C/Ix. : bleeding diathesis, anticoagulation, chest wall inf., lack of patient cooperation
Medical throracoscopy
-less invasive and less expensive than VATS
Bronchoscopy
Hemoptysis
Atelectasis
Large effusions w/o contralateral mediastinal shift
Before attempting pleurodesis
Surgical biopsy

9. Malignant pleural effusions: Sensitivity of different biopsy methods
Malignant pleural effusions: Sensitivity of different biopsy methods. Presented is a prospective simultaneous comparison (n 5 206)

14. Other management options
Long term indwelling pleural catheter drainage
Long term indwelling pleural catheter V.S. doxycycline pleurodesis
Shorter length of hospitalization : 1 day V.S. 6 days
Spontaneous pleurodesis in 42 of the 91 patients
Lower late failure rate : 13 % V.S. 21 %
Highter complication rate : local cellulitis, tumor seeding
-Putman, et al.
Minimal length of hospitalization and outpatient
Pleuroperitoneal shunting
Pleurectomy

15. Malignant pleural effusion in specific disease
Lung cancer
7~15 % of all bronchogenic ca.
Most frequently with adenoca.
Poor prognosis
In NSCLC at advanced, inoperable stage : talc pleurodesis
In SCLC : systemic chemotherapy
Breast ca.
In 43 % of the patients, the effusion is the first symptom of metastatic disease.
The time from initial diagnosis until the development of effusions
mo. (range 0~246 mo.)
50 % : 40 % : 10 % = ipsilateral : contralateral : bilateral – Fentiman et al.
Chemotherapy with cytotoxic agents and/or hormones
Median survival : 13 mo.(range 0~72 mo.)