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Malignant Pleural Effusion (M.P.E.)

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Presentation on theme: "Malignant Pleural Effusion (M.P.E.)"— Presentation transcript:

1 Malignant Pleural Effusion (M.P.E.)
“An M.P.E. is defined by the presence of cancer cells in the pleural space”

2 Underlying Primary Cancer
Malignant Pleural Effusion (M.P.E.) “An M.P.E. is defined by the presence of cancer cells in the pleural space” Underlying Primary Cancer Lung tumors (including malignant pleural mesothelioma)  NSCLC: 14% at the time of diagnosis, 50% with advanced disease Breast cancer Ovarian cancer, gastric cancer Hodgkin’s and non-Hodgkin’s lymphoma Lung cancer, including Malignant Mesothelioma, is the most common cause of MPE. In women it is followed by breast cancer.

3 Malignant Pleural Effusion (M.P.E.)
“An M.P.E. is defined by the presence of cancer cells in the pleural space” Cancer cells reach the visceral pleura (through the pulmonary vasculature)or the parietal pleura (through hematogenous spread) Cancer cells in the pleural space (tumor deposit along parietal pleura) Obstruct lymphatic stromata (which drain intrapleural fluid) Release chemockines ( increasing vascular permeability)

4 ≠ Malignant Pleural Effusion (M.P.E.) Paramalignant Effusion
1. Mediastinal lymph node tumor infiltration 2. Bronchial obstruction/Atelectasis 3. Pulmonary embolism 4. “Superior vena cava syndrome” 5. Decreased oncotic pressure (cachexia) 6. Radiotherapy/Chemotherapy Cancer cells are absent from the pleural space

5 Malignant Plural Effusion
And Diagnosis

6 M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE

7 M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE Diagnostic thoracentesis: Diagnostic yield of PF cytology ranging from 62 to 90% Positive results on cytology might not differentiate between adk subtypes or between pleural adk and mesothelioma Additional PF studies could complement standard cytology: Electrochetoluminescence for tumor markers, genetic analysis

8 M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE Diagnostic thoracentesis, if cytology not diagnostic:

9 M.P.E. and Diagnosis Cytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE Diagnostic thoracentesis, if cytology not diagnostic: Pleural Biopsy: Closed-needle pleural biopsy (sensitivity of 40-75%) Ultrasonography or chest CT-guided percutaneous pleural biopsy (higher sensitivities and specificities) Medical thoracoscopy, or Video Assisted Thoracoscopic Surgery (VATS)

10 M.P.E. and Diagnosis Is diagnosis with cytology or histology always requested (and useful) in our clinical practice?

11 M.P.E. and Diagnosis Does the presence of M.P.E. add prognostic and therapeutic informations?

12 Non Small Cell Lung Cancer
M.P.E. and Diagnosis Non Small Cell Lung Cancer Does the presence of M.P.E. add prognostic and therapeutic informations?

13 Non Small Cell Lung Cancer
M.P.E. and Diagnosis Non Small Cell Lung Cancer Poor PS Known advanced cancer DIAGNOSIS NOT NECESSARY

14 Non Small Cell Lung Cancer
M.P.E. and Diagnosis Non Small Cell Lung Cancer Good PS multimodality treatment Poor PS Known advanced cancer DIAGNOSIS IS CRITICAL FOR TREATMENT PLANNING DIAGNOSIS NOT NECESSARY

15 NSCLC with M.P.E: Prognosis
Patients with M.P.E. (without other metastatic disease) had a median OS of 8 months Versus 13 months of other cT4 M0 Versus 6 months of patients with distant metastases Postmus, JTO 2007

16 NSCLC with M.P.E: Prognosis
TNM staging Six Edition: T4 (Stage III B) TNM staging Seventh Edition: M1 a (Stage IV) Goldstraw, JTO 2007

17 NSCLC with M.P.E: Prognosis
TNM staging Six Edition: T4 (Stage III B) TNM staging Seventh Edition: M1 a (Stage IV) If P.E. is cytologically negative. and is evaluated as not related to the tumor by clinical judgment, patient should be classified as T1, T2, T3, T4. Goldstraw, JTO 2007

18 Malignant Pleural Effusion
And Treatment

19 M.P.E. and Treatment THERAPEUTIC THORACENTESIS PLEURODESIS

20 Management of MPE is palliative...
M.P.E. and Treatment THERAPEUTIC THORACENTESIS PLEURODESIS Management of MPE is palliative...

21 When to proceed with treatment of Pleural Effusion?
M.P.E. and Treatment When to proceed with treatment of Pleural Effusion?

22 When to proceed with treatment of Pleural Effusion?
M.P.E. and Treatment When to proceed with treatment of Pleural Effusion? Patient is symptomatic (for dyspnea or cough or chest pain), and symptoms are considered to be caused from pleural effusion. Patient is not suitable for specific cancer treatment (eg. chemotherapy), or Pleural Effusion is resistant to specific cancer treatment.

23 Is patient symptomatic?
M.P.E. and Treatment Is patient symptomatic? Is tumor likely to respond to chemotherapy?

24 Is patient symptomatic?
M.P.E. and Treatment No Is patient symptomatic? No intervention Is tumor likely to respond to chemotherapy?

25 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis Is tumor likely to respond to chemotherapy?

26 THERAPEUTIC THORACENTESIS
M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days

27 THERAPEUTIC THORACENTESIS
M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days Repeated THORACENTESES PLEURODESIS

28 THERAPEUTIC THORACENTESIS
M.P.E. and Treatment THERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days Repeated THORACENTESES PLEURODESIS

29 M.P.E. and Treatment PLEURODESIS
Selection of patients should be based on:. 1 Patient’s characteristics Tumor’s characteristics 2

30 M.P.E. and Treatment PLEURODESIS
Selection of patients should be based on:. 1 Patient characteristics Tumor characteristics “Does the patient’s life expectancy warrant pleurodesis?” * (PS has the most value) 2 * 32% of p. do not survive 30 days after pleurodesis

31 M.P.E. and Treatment PLEURODESIS
Selection of patients should be based on:. 1 Patient characteristics Tumor characteristics “Does the patient’s life expectancy warrant pleurodesis?” * (PS has the most value) 2 * 32% of p. do not survive 30 days after pleurodesis

32 Pleural Effusion is unlikely to respond to pleurodesis if:
M.P.E. and Treatment PLEURODESIS Pleural Effusion is unlikely to respond to pleurodesis if: There is an airway obstruction from an endobronchial tumor (the lung does not expand to the chest wall after therapeutic thoracentesis) Effusion is multiloculated There are large tumor masses along pleural surfaces

33 Chest-catheter Pleurodesis Thoracoscopic Pleurodesis
M.P.E. and Treatment PLEURODESIS Chest-catheter Pleurodesis Thoracoscopic Pleurodesis TALC is considered a superior pleurodesis agent when compared with other commonly used sclerosant (as Bleomycin or tetracycline) Cochrane Review, 2004

34 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis Is tumor likely to respond to chemotherapy?

35 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis Improvement in symptoms? Is tumor likely to respond to chemotherapy?

36 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy?

37 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes Adequate Re-expansion?

38 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes Adequate Re-expansion? Yes Good PS?

39 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes Adequate Re-expansion? Yes Yes Good PS? Pleurodesis

40 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes No Adequate Re-expansion? Yes Yes Good PS? Pleurodesis

41 Therapeutic Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes No Adequate Re-expansion? Yes No Yes Good PS? Pleurodesis

42 Therapeutic Thoracentesis Repeated Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes Repeated Thoracentesis No Adequate Re-expansion? Pleural Catheter Yes No Yes Good PS? Pleurodesis

43 M.P.E. and Treatment Repeated THORACENTESES
Should be reserved for patients who: (1) Appear unlikely to survive beyond 1 to 3 months (2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis. (3) Have a PE that does not respond to pleurodesis

44 M.P.E. and Treatment ...OR... Repeated THORACENTESES
Should be reserved for patients who: (1) Appear unlikely to survive beyond 1 to 3 months (2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis. (3) Have a PE that does not respond to pleurodesis (4) Have cancers that commonly respond to therapy with resolution of the associated effusions ...OR...

45 Therapeutic Thoracentesis Repeated Thoracentesis
M.P.E. and Treatment No Is patient symptomatic? No intervention Yes Therapeutic Thoracentesis No Improvement in symptoms? Is tumor likely to respond to chemotherapy? Yes Repeated Thoracentesis No Adequate Re-expansion? Pleural Catheter Yes No Yes Good PS? Pleurodesis


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