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

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

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 Symptoms: l Dyspnea l Cough l Chest pain l Decreased mobility and fear Symptoms: 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 More than 25% of newly diagnosed pleural effusions are due to malignancy l 50% of cancer patients will develop a pleural effusion l In US, approximately 100,000 malignant effusions/year occur l Life expectancy 4-12 months l More than 25% of newly diagnosed pleural effusions are due to malignancy l 50% of cancer patients will develop a pleural effusion l In US, approximately 100,000 malignant effusions/year occur 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 about 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared with positive cytology l Role of pH, Karnofsky Performance Scale? l Mortality 54% at 1 month, 84% at 6 months l Survival about 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared with positive cytology l Role of pH, Karnofsky Performance Scale?

9. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

10. Pathophysiology l Normally pleural fluid production equals fluid resorption l Effusion: Imbalance between fluid production and resorption l Causes: o Tumor cells blocking lymphatic drainage o Changes in colloid osmotic pressure due to hypoalbuminemia l Normally pleural fluid production equals fluid resorption l Effusion: Imbalance between fluid production and resorption l Causes: o Tumor cells blocking lymphatic drainage o 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 Chest X-Ray PA, lateral, and decubitus films l Chest CT or Ultrasound 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 Chest X-Ray PA, lateral, and decubitus films l Chest CT or Ultrasound 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 for exudates (one or more of following): 1. Pleural fluid LDH divided by serum LDH is greater than 0.6 2. Pleural fluid protein divided by serum protein is greater than 0.5 3. Pleural fluid LDH is greater than two- thirds upper limit of normal (ULN) of serum LDH l Light’s criteria for exudates (one or more of following): 1. Pleural fluid LDH divided by serum LDH is greater than 0.6 2. Pleural fluid protein divided by serum protein is greater than 0.5 3. Pleural fluid LDH is greater than two- thirds upper limit of normal (ULN) of serum LDH

15. ... Benign vs. malignant effusions... l Heffner meta-analysis for exudates: 1. Pleural LDH is greater than 0.45 ULN 2. Pleural cholesterol is greater than 45 mg per dl 3. Pleural protein is greater than 2.9 g per dl Heffner 1997 l Heffner meta-analysis for exudates: 1. Pleural LDH is greater than 0.45 ULN 2. Pleural cholesterol is greater than 45 mg per dl 3. Pleural protein is greater than 2.9 g per dl Heffner 1997.

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

17. 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

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

19. Thoracentesis l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks:  Pneumothorax  Re-expansion pulmonary edema (especially if more than 1500 cc removed) l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks:  Pneumothorax  Re-expansion pulmonary edema (especially if more than 1500 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 greater than 3 months, 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 greater than 3 months, 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 to 24 hours or until drainage is less than 250 ml per 24 hr l More definitive than repeated thoracentesis for recurrent effusions l Chest tube 12 to 24 hours or until drainage is less than 250 ml per 24 hr

23. ... Tube thoracostomy and pleurodesis l Sclerosing agent: Use after fluid completely drained from pleural space o Talc, bleomycin, doxycycline o Tube clamping controversial o Rotation vs. nonrotation l Failure rate 10 to 40% l Most widely used and cost-effective method l Sclerosing agent: Use after fluid completely drained from pleural space o Talc, bleomycin, doxycycline o Tube clamping controversial o Rotation vs. nonrotation l Failure rate 10 to 40% l Most widely used and cost-effective method

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