Pleural effusion caused by malignancies has been described as malignant pleural effusion. Etiology,pathogenesis,diagnosis and management of malignant pleural effusion has been descibed in this powerpoint presentation.

1. Malignant Pleural effusion
Dr Dileep MD
Asst. Professor
Pulmonary Medicine
Mediciti Medical College
Hyderabad

2. • INTRODUCTION
• ETIOLOGY
• PATHOGENESIS
• CLINICAL PRESENTATION
• DIAGNOSIS
• MANAGEMENT

3. INTRODUCTION
• Malignant pleural effusion is 2nd leading cause of exudative pleural
effusions (after parapneumonic effusions)
• Diagnosis- detecting exfoliated malignant cells in pleural fluid or in
pleural tissue obtained by pleural biopsy, thoracoscopy, thoracotomy
• Pleural effusions associated with malignancy, with no direct pleural
involvement are categorized as paramalignant effusions

4. ETIOLOGY
• Carcinomas of lung, breast and lymphomas account for
approximately 75% of malignant pleural effusions
• Metastatic ovarian carcinoma is the 4th leading cause of malignant
pleural effusions
• Sarcomas, particularly melanoma, account for a small percentage of
malignant pleural effusions

5. MALIGNANCIES ASSOCIATED WITH
PLEURAL EFFUSIONS

6. Lung Cancer
• In patients of lung cancer, upto 15% have a pleural effusion
• During course of disease, at least 50% of patients with disseminated
lung cancer develop a pleural effusion
• Pleural effusions occur with all types of lung ca, but most frequent
with adenocarcinoma and least with Small Cell Ca.(15%)
• Presence of pleural effusion in a patient with lung cancer almost
always indicates that patient is not curable with surgery whether or
not the cytology is positive

7. Malignant Mesothelioma
• Malignant mesothelioma is a primary tumor of the pleura
• An early manifestation of tumor is a pleural effusion that is reabsorbed and
then replaced by tumor and fibrosis
• Lung is often encased in tumor that involves both visceral and parietal
pleural surfaces
• Tumor never penetrates deeply into the lung parenchyma; but extends into
interlobar fissures
• Hilar lymph nodes are involved by tumor in less than 50% of patients
• Distant hematogenous metastases are unusual but found in liver, bone,
adrenals, thyroid, and kidneys

8. Unknown Primary
• Patients with a malignant pleural effusion and an unknown primary
should have a CT scan of chest, abdomen, and pelvis
• If pulmonary parenchymal abnormalities are discovered, then a
bronchoscopy is indicated with special attention to area of abnormality
• Masses in the abdomen should be evaluated
• If the patient has symptoms referable to a specific organ, that organ
should be evaluated
• If patient is a woman, mammography and a careful pelvic examination
should be performed

9. PATHOGENESIS

10. CLINICAL PRESENTATION
• Dyspnea, cough and chest pain
• Degree of dyspnea depends on size of effusion and patient’s
underlying pulmonary function
• Most common symptom is dyspnea(>50%)
• Patients with malignant pleural effusions have dull chest pain,
whereas benign disease have pleuritic chest pain

11. DIAGNOSIS

12. CHEST RADIOGRAPHY
• Pleural effusion is usually ipsilateral to primary lesion in carcinoma of
lung
• When primary site of cancer is elsewhere, there is no ipsilateral
predilection and bilateral effusions are common (except breast
cancer)
• In 75% patients, pleural effusion is moderate to large, with volumes
ranging from 500 to 2000 mL of fluid
• Approximately 10% present with effusions of < 500 mL; another 10%
present with massive pleural effusions (complete opacification)

13. The massive left pleural effusion associated with a contralateral shift of the mediastinum

14. • If mediastinum does not shift contralaterally in the face of a large
pleural effusion (>1500 mL),malignancy is highly likely
The following diagnoses are then considered:
(1) Carcinoma of ipsilateral mainstem bronchus resulting in
atelectasis
(2) a fixed mediastinum due to malignant lymph nodes
(3) malignant mesothelioma
(4) extensive tumor infiltration of the ipsilateral lung,
radiographically mimicking a large effusion
• Interstitial infiltrates with effusions (lymphangitic carcinomatosis)
and multiple nodules with effusions also suggest malignant disease

15. CT -CHEST
• Findings on CT can help distinguish benign and malignant effusions
The following findings were suggestive of malignancy:
• pleural nodularity
• Pleural rind
• Mediastinal pleural involvement
• Pleural thickening greater than 1 cm

16. Ultrasound
Ultrasound can be used in several different situations, including the
following:
(a) Identification of location for thoracentesis, pleural biopsy, or chest
tube placement
(b) Identification of pleural fluid loculations
(c) Distinction of pleural fluid from pleural thickening
(d) Semiquantitation of the amount of pleural fluid
(e) Identify pleural nodules and focal pleural thickening

17. CHARACTERISTICS OF MALIGNANT EFFUSION
• Malignant pleural fluid may be serous, sero-sanguineous,or grossly bloody
• Malignant pleural effusion is typically an exudate with a protein
concentration of about 4 g/dL
• In about one-half of malignant pleural effusions, lymphocytes predominate
(50% –70% of nucleated cells)
• In about one-third of patients, the pleural fluid pH is low (<7.30), ranging
from 6.95 to 7.29
• In these low-pH effusions, glucose concentration is also low (<60 mg/dL),
the lactate concentration is high which frequently exceeds 600 IU/L

18. Cytologic Examination
• Cytology is a more sensitive than percutaneous pleural biopsy
• Cytologic study of the pleural fluid establishes the diagnosis of a
malignant pleural effusion ranging from 40% to 87%
• When 3 separate pleural fluid specimens are submitted to an
experienced cytologist, it is diagnostic in 80% of patients
• Most cases of metastatic adenocarcinoma can be diagnosed by
pleural fluid cytology
• With lymphoma, cytologic test is positive in approximately 25 % of
patients with Hodgkin's disease and in 50% to 60% of patients with
non-Hodgkin's lymphoma

19. Pleural Biopsy
• Needle biopsy of pleura can establish diagnosis of a malignant pleural
effusion
• Percentage of positive pleural biopsies ranges from 39% to 75%
• It has lower diagnostic yield than pleural fluid cytologic examination,
as in approximately 50% of patients, costal parietal pleura is not
involved
• An alternative - pleural biopsy can be obtained with CT-guided
cutting-needle biopsy, where the pleura is the most thickened

20. Thoracoscopy or an Open Thoracotomy
• Thoracoscopy will establish the diagnosis of malignancy in
approximately 90% of patients with malignancy
• If thoracoscopy is not available, an alternative approach is to
perform a thoracotomy with open biopsy of pleura
• Thoracoscopic biopsy has a high diagnostic yield for mesothelioma,
approaching 100% in some series

21. lmmunohistochemical Tests
• Monoclonal antibodies against various antigens - distinguishing
malignant from benign pleural effusions
• Metastatic adenocarcinomas stain positive with CEA, MOC-31, Ber-
EP4 and TTF- 1
• Mesothelial cells stain positive with calretinin, keratin5/6, and WT 1
• If cytology of pleural fluid is positive, but primary is unknown,
immunohistochemical tests can help identify the site of primary

22. Lipid Analysis
• The possibility of a chylothorax should be considered in every patient
with malignant disease and a pleural effusion
• If the supernatant is turbid, a chylothorax should be suspected, and
the triglyceride level in the pleural fluid should be determined
• If the pleural fluid triglyceride level > 110 mg/dL - chylothorax;
• If the level is < 50 mg/dL - not a chylothorax
• If the level is between 50 and 110 mg/dL -lipoprotein electrophoresis

23. MANAGEMENT

25. • Systemic Chemotherapy
• Mediastinal Radiation
• Indwelling Pleural Catheter (PleurX)
• Pleurodesis
• Pleuroperitoneal Shunt
• Pleurectomy
• Thoracentesis
• Symptomatic Treatment

26. Systemic Chemotherapy
• Patients with lymphoma, breast cancer, or small-cell carcinoma of
the lung manifest a good response to chemotherapy

27. Mediastinal Radiation
• Radiation of hemithorax is contraindicated in malignant effusions
from lung cancer, as adverse effects from radiation pneumonitis
outweigh benefits of therapy
• Helpful in patients with lymphoma and lymphomatous chylothorax
when involvement of mediastinal node predominates
• When a patient with a malignant pleural effusion has a chylothorax,
the thoracic duct is usually involved by the neoplastic process

28. Indwelling Pleural Catheter (PleurX)
• The use of indwelling catheters (PleurX) is an OP procedure, and
patient can manage pleural effusion in a timely fashion at home
• Can successfully palliate symptoms regardless of whether lung
entrapment is present or not
• The PleurX catheter is a 15.5 F silicone rubber catheter, 66 cm in
length, with fenestrations along the proximal 24 cm
• It is inserted into the pleural space using the Seldinger technique
under local anesthesia

29. • It has a special valve on its distal end. The valve prevents fluid or air
from passing in either direction through the catheter
• Approximately 50% of patients develop spontaneous pleurodesis by
2 months
• Patients who have weekly pleural fluid production of > 1000 mL fluid
for 7 to 14 days, pleurodesis should be performed through PleurX

32. Complications:
• The two most significant complications with the indwelling catheter
are empyema and obstruction of the catheter
• Fever, pneumothorax, misplacement of the catheter, reexpansion
pulmonary edema
• Local cellulitis around the catheter tract
• The indwelling catheter may also become fractured when attempts
are made to remove it
• Tumor metastasis along the tract between the pleura and skin
surface

33. Pleurodesis
• Pleurodesis should be considered in patients with malignant pleural
effusions who are not candidates for pleurex catheter or systemic
chemotherapy or chylothorax
• Pleurodesis success -degree of visceral and parietal pleural apposition
• Prerequisites-
 Patient should be symptomatic from effusion
 Expected survival need to be at least several weeks
 patient should not be debilitated
 pleural fluid pH is above 7.30

34. Failure of pleurodesis is high-
 If lung cannot be expanded fully - bronchial occlusion or lung entrapment
 A large tumor bulk involving the pleural surfaces
 Low-pH
 Low-glucose
 High LDH

35. Agents –
 Talc (either insuffiated or as a slurry)
 Tetracycline derivatives (minocycline or doxycycline)
 Antineoplastic agents (bleomycin or mitoxantrone)
 Silver nitrate
 Iodopovidone
Complications of talc –
 Fever
 Empyema
 Arrhythmia
 ARDS
 Pneumonitis

36. Pleuroperitoneal Shunt
• With experienced operators, palliation is obtained in 80% to 90% of
properly selected patients
• Indications:
 Patients who cannot undergo pleurodesis
 Refractory chylothorax, as it allows recirculation of chyle
 Trapped lung
 Poor surgical candidates

39. • The advantages of the shunt include the following:
(a) hospitalization time is less
(b) pain is less than with pleurodesis
(c) can be performed on an outpatient basis
(d) patient may benefit psychologically using the pump when he or
she is dyspneic
• The disadvantages of the shunt include the following:
(a) shunt becomes obstructed in some cases
(b) insertion requires general anesthesia
(c) must be inserted by a surgeon
(d) patient must use the pump daily

40. Pleurectomy
• Pleurectomy may be attempted in two different situations
• First -In patient who undergoes a diagnostic thoracotomy for an
undiagnosed pleural effusion
• If malignancy is found, an immediate parietal pleurectomy is done
• Parietal pleurectomy - stripping all of parietal pleura from rib cage
and mediastinum
• Second -In patient with a persistent pleural effusion and trapped lung
• Surgical procedure -decortication of trapped lung along with parietal
pleurectomy
• Pleurectomy controls the pleural effusion in more than 90% of cases

41. Thoracentesis
• In the past, malignant pleural effusion were managed with repeated
therapeutic thoracenteses for symptomatic relief
Drawbacks-
 Reaccumulate rapidly in 1 to 3 days
 Frequent physician visits
 Loculation of the pleural fluid making pleurodesis difficult
• Hence serial therapeutic thoracentesis should be performed only in
moribund patients in whom procedure offers symptomatic relief

42. Symptomatic Treatment
• Two primary symptoms - chest pain & SOB
• If patient has chest pain, sufficient analgesics should be given
• If primary symptom is dyspnea, the patient should be given opiates
or oxygen, or both
• Both opiates and oxygen relieve the dyspnea
• Disadvantage of opiates -an increase in the Paco2, which in turn will
lead to decrease in Pao2"
• Disadvantage of oxygen - very expensive and is not portable

44. Thank You