1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3m Symptoms – Malignant Pleural Effusions Module 3m Symptoms – Malignant Pleural Effusions EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Malignant pleural effusions... l Definition: fluid accumulation in the potential space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall

4. ... Malignant pleural effusions Impact: l Dyspnea l Cough l Chest pain l Decreased mobility and fear Impact: l Dyspnea l Cough l Chest pain l Decreased mobility and fear

5. Overview l Scope of the problem l Causes l Pathophysiology l Diagnosis l Prognosis l Management options l Treatment strategies l Scope of the problem l Causes l Pathophysiology l Diagnosis l Prognosis l Management options l Treatment strategies

6. Impact l > 25 % of newly diagnosed pleural effusions are due to malignancy l 50 % of cancer patients will develop a pleural effusion l In US, approx. 100,000 malignant effusions / yr l Life expectancy 4 – 12 months l > 25 % of newly diagnosed pleural effusions are due to malignancy l 50 % of cancer patients will develop a pleural effusion l In US, approx. 100,000 malignant effusions / yr l Life expectancy 4 – 12 months

7. Causes l Breast and lung cancer 50 – 65 % l Lymphoma, GU, GI 25 % l Unknown primary7 – 15 % l Breast and lung cancer 50 – 65 % l Lymphoma, GU, GI 25 % l Unknown primary7 – 15 %

8. Prognosis l Mortality 54 % at 1 month, 84% at 6 months l Survival ~ 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared to positive cytology l Role of pH, Karnofsky Performance Scale? l Mortality 54 % at 1 month, 84% at 6 months l Survival ~ 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared to positive cytology l Role of pH, Karnofsky Performance Scale?

9. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

10. Pathophysiology l Fluid production = fluid resorption l Causes Tumor cells blocking lymphatic drainage Changes in colloid osmotic pressure due to hypoalbuminemia l Fluid production = fluid resorption l Causes Tumor cells blocking lymphatic drainage Changes in colloid osmotic pressure due to hypoalbuminemia

11. Assessment l History of dyspnea, chest pain, cough l Physical examination of decreased breath sounds, dullness to percussion l History of dyspnea, chest pain, cough l Physical examination of decreased breath sounds, dullness to percussion

12. ... Assessment l Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance l Exam: decreased breath sounds, dullness to auscultation and percussion l CXR PA, lateral and decubitus films l Chest CT or U / S if loculated l Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance l Exam: decreased breath sounds, dullness to auscultation and percussion l CXR PA, lateral and decubitus films l Chest CT or U / S if loculated

13. Differential diagnosis l Parapneumonic effusion l Empyema l Chylothorax l Transudate l Parapneumonic effusion l Empyema l Chylothorax l Transudate

14. Benign vs. malignant effusions... l Light’s criteria Pleural fluid LDH > 0.6 Serum LDH Pleural fluid protein > 0.5 Serum protein Pleural fluid LDH > 2 / 3 ULN serum LDH l Light’s criteria Pleural fluid LDH > 0.6 Serum LDH Pleural fluid protein > 0.5 Serum protein Pleural fluid LDH > 2 / 3 ULN serum LDH

15. ... Benign vs. malignant effusions... l Heffner meta-analysis: Pleural LDH > 0.45 ULN Pleural cholesterol > 45 mg / dl Pleural protein > 2.9 gm / dl l Heffner meta-analysis: Pleural LDH > 0.45 ULN Pleural cholesterol > 45 mg / dl Pleural protein > 2.9 gm / dl Heffner 1997.

16. ... Benign vs. malignant effusions l Cytology Positive in approximately 55 – 65 % initially Yield up to 77 % on three pleural fluid samples l Cytology Positive in approximately 55 – 65 % initially Yield up to 77 % on three pleural fluid samples

17. Management Intrapleural catheter Doxycycline pleurodesis Initial drainage 97%68% Pleurodesis46%54% Late recurrence 13%21% Complications 13% outpt 14% inpt Putnam 1999.

18. Management options l Thoracentesis l Tube thoracostomy l Small-bore chest tubes l Pleurodesis l Thoracoscopy l Intrapleural catheters l Pleuroperitoneal shunting l Subcutaneous access ports l Thoracentesis l Tube thoracostomy l Small-bore chest tubes l Pleurodesis l Thoracoscopy l Intrapleural catheters l Pleuroperitoneal shunting l Subcutaneous access ports

19. Thoracentesis l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks: Pneumothorax Reexpansion pulmonary edema (especially if > 1,500 cc removed) l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks: Pneumothorax Reexpansion pulmonary edema (especially if > 1,500 cc removed)

20. Treatment recommendations l Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy l Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia l Thoracoscopy: life expectancy > 3 mos, loculated effusions, biopsies l Intrapleural catheters: outpatient pleurodesis l Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy l Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia l Thoracoscopy: life expectancy > 3 mos, loculated effusions, biopsies l Intrapleural catheters: outpatient pleurodesis

21. Thoracoscopy benefits l Direct visualization of lung re-expansion l Identify loculated areas and drain l Administration of dry talc, chest tube placement l Confirm equal distribution of talc l Shorter hospital stay than tube thoracostomy l Diagnostic yield 90 %, pleurodesis success rate 90% l Direct visualization of lung re-expansion l Identify loculated areas and drain l Administration of dry talc, chest tube placement l Confirm equal distribution of talc l Shorter hospital stay than tube thoracostomy l Diagnostic yield 90 %, pleurodesis success rate 90%

22. Tube thoracostomy and pleurodesis... l More definitive than repeated thoracentesis for recurrent effusions l Chest tube 12 – 24 hr or until drainage < 250 ml / 24 hr l More definitive than repeated thoracentesis for recurrent effusions l Chest tube 12 – 24 hr or until drainage < 250 ml / 24 hr

23. ... Tube thoracostomy and pleurodesis l Sclerosing agent when dry Talc, bleomycin, doxycycline Tube clamping controversial Rotation vs. nonrotation l Failure rate 10 – 40 % l Most widely used and cost effective method l Sclerosing agent when dry Talc, bleomycin, doxycycline Tube clamping controversial Rotation vs. nonrotation l Failure rate 10 – 40 % l Most widely used and cost effective method

24. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience