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