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

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

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

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

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

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

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

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)

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

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 - 41.5 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.)