Malignant Pleural Effusion

2.  Classification of pleural effusions.
 Causes of pleural effusions.
 Clinical presentation.
 Management options.
 Pleurx drain.
 Complications of Pleurx drain.

3.  A pleural effusion is an abnormal build-up of fluid in the pleural space.
 Pleural effusions may be classified as being either a transudate or exudate
according to the protein concentration.
Transudate (< 30g/L protein) Exudate (> 30g/L protein)
• heart failure (most common transudate cause)
• hypoalbuminaemia (liver disease, nephrotic
syndrome, malabsorption)
• hypothyroidism
• infection: pneumonia (most common exudate
cause), TB, subphrenic abscess
• connective tissue disease: RA, SLE
• neoplasia: lung cancer,
mesothelioma, metastases
• pancreatitis
• pulmonary embolism
• yellow nail syndrome

4. If the protein level is between 25-35 g/L, Light's criteria should be applied.
An exudate is likely if at least one of the following criteria are met:
 pleural fluid protein divided by serum protein >0.5
 pleural fluid LDH divided by serum LDH >0.6
 pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

5.  Occurs when either a lung cancer or another type of cancer spread to the pleural space.
 These cancer cells;
 increase the production of pleural fluid
 cause decreased absorption of the fluid
 Who gets malignant pleural effusions?
 carcinomas of the lung & mesothelioma (36%)
 breast (25%)
 lymphoma (10%)
 ovary (5%)

6.  Median survival following diagnosis ranges from 3 to 12 months.
 Dependent on the stage and type of the underlying malignancy.
 The shortest survival time is observed in malignant effusions secondary to lung
cancer, and the longest in ovarian cancer.

7. The majority of malignant effusions are symptomatic.
 Dyspnoea is the most common presenting symptom.
 Chest pain/ pressure.
 Cough.
 Constitutional symptoms including weight loss, malaise and anorexia generally
accompany respiratory symptoms.
Confirmation by:
 CXR
 CT
 Ultrasound

9. Observation:
 Observation is recommended if the patient is asymptomatic and the tumour type is known.
 Advice should be sought from the respiratory team for symptomatic malignant effusions.
Therapeutic pleural aspiration:
 Pleural effusions treated by aspiration alone are associated with a high rate of recurrence of
effusion at 1 month, so aspiration is NOT recommended if life expectancy is >1 month.
 Caution should be taken if removing >1.5 L on a single occasion.

10. Intercostal tube drainage and intrapleural instillation of sclerosant:
 Other than in patients with a very short life expectancy, small-bore chest tubes
followed by pleurodesis are preferable to recurrent aspiration.
 Talc is the most effective sclerosant available for pleurodesis.
 Large pleural effusions should be drained in a controlled fashion to reduce the
risk of re-expansion pulmonary oedema.

12.  IPC-related pleural infection – Antibiotics, MIST2 trial.
 Catheter tract metastasis - Simple analgesia and external beam radiotherapy.
 Symptomatic loculations - Pleural aspiration, removal of the ineffective IPC and
insertion of a second catheter targeting the residual locules, intrapleural
fibrinolysis.
 Catheter blockage - Saline flush and manipulation along the catheter.

13. https://thorax.bmj.com/content/65/Suppl_2/ii32