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Diagnosis and Management of Malignant Pleural Effusion

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Title: Diagnosis and Management of Malignant Pleural Effusion


1
Diagnosis and Management of Malignant Pleural
Effusion
  • ???????????????
  • ?????
  • 2006?7?20?

2
Etiology of Malignant Effusion
  • Lung cancer 37.5, especially adenocarcinoma
  • Breast cancer 16.8
  • Lymphoma 11.5, most common in young adult

3
Etiology of Malignant Effusion
  • Increasing production of effusion
  • Increasing vascular permeability invasion of
    pleural vessels by tumor, cytokines, injury,
    infection etc.
  • Increasing vascular hydrostatic gradient
    decreased pleural pressure by atelectasis,
    increased venous pressure by SVC syndrome,
    decreased plasma osmotic pressure by
    hypoalbuminemia
  • Nonvascular entry by thoracic duct chylothorax

4
Etiology of Malignant Effusion
  • Decreasing exit of effusion
  • Increasing resistance to lymphatic flow
    infiltration of parietal pleura or mediastinal
    lymph nodes by tumor seeding
  • Increasing gradient opposing lymphatic flow
    decreased pleural pressure by atelectasis,
    increased venous pressure by SVC syndrome

5
Clinical Presentation
  • Dyspnea
  • Cough
  • Chest pain

6
Radiographic Evaluation
  • Chest X-ray

7
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8
Chest X-ray
  • Amount of pleural effusion
  • More than 2/3 hemithorax or even entire
    hemithorax
  • 55 of large and massive effusions
  • Other causes empyema and TB effusions
  • Cytology diagnosis of large and small effusions
    no significant difference (63 vs. 53)

9
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10
Chest X-ray
  • Mediastinum position
  • Shift away from a large effusion
  • Midline mediastinum in large effusion
    significant lung collapse, fixed mediastinum LAP
  • Shift toward a large effsuion trapped lung due
    to main-stem bronchial obstruction

11
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12
Radiographic Evaluation
  • Chest X-ray
  • Chest CT

13
Chest CT
  • Pleural surfaces, lung parenchyma, chest wall and
    mediastinum
  • Malignant pleural disease pleural thickening (gt1
    cm), irregularity, nodules
  • Pleural thickening also seen in empyema
  • Pleural nodules only 17 in malignant effusions
  • Other features lung mass, chest wall
    involvement, mediastinal LAP, hepatic metastases

14
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16
Radiographic Evaluation
  • Chest X-ray
  • Chest CT
  • Chest echo

17
Chest Echo
  • Pleural surfaces, lung parenchyma, chest wall and
    pleural effusion
  • Pleural effusion echo-free
  • Pleural thickening and nodules
  • Echo-guide thoracocentesis
  • Echo-guide pleural biopsy

18
Diagnosis
  • Pleural effusion
  • Cytology
  • Pathology

19
Pleural effusion
  • Grossly bloody most common cause of bloody
    effusion
  • Serosanguineous effusion
  • Cell differentiation lymphocytes predominant
  • Eosinophilia can not exclude malignant effusion

20
Pleural effusion
  • Almost always exudate
  • Lactate dehydrogenase (LDH) increased cell
    turnover and lysis
  • Low glucose concentration and low pH level
    possible shorter survival
  • pH lt 7.20 easily failure of pleurodesis

21
Cytology
  • Adenocarcinoma most likely to be positive
  • Low pH greater tumor burden
  • Cytology diagnosis of large and small effusions
    no significant difference (63 vs. 53)
  • Body fluid cell block

22
Pathology
  • Pleural biopsy
  • Closed needle biopsy
  • Cope needle
  • Abrams needle
  • Urocut needle

23
Cope Needle
24
Abrams Needle
25
Urocut Needle
26
Diagnostic Procedures
  • Diagnostic thoracocentesis under echo-guide
  • Send pleural effusion for routine, BCS (LDH,
    protein, glucose), Gram/AFB stain, cytology, B/C,
    plus ABG (for pH)
  • Pleural biopsy under echo-guide
  • Send pleura for pathology and TB tissue/C
  • Therapeutic thoracocentesis under echo-guide
  • Send pleural effusion for body fluid cell block

27
Primary Tumor (T)
  • T4
  • A tumor of any size with invasion of the
    mediastinum, or involving heart, great vessels,
    trachea, esophagus, vertebral bodies, carina,
  • or with the presence of malignant
    pleural/pericardial effusion,
  • or exudative pleural effusion without evidence of
    obstructive pneumonitis,
  • or with satellite tumor within the lobe of
    primary tumor at chest CT

28
Management
  • Symptom-oriented management
  • Less than 1/3 hemithorax, C/T sensitive tumor
  • C/T at first, F/U regularly
  • Slowly recurring effusion, short life span
  • Repeated therapeutic thoracocentesis
  • More than 2/3 hemithorax, no airway obstruction
  • Pigtail insertion for pleurodesis within 24 hours

29
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30
Management
  • Before pleurodesis
  • Daily drainage amount lt 100-150 ml
  • Confirm with chest echo
  • Ability of lung re-expansion
  • Chemical pleurodesis
  • Mnocycline injection
  • Beta-iodine injection
  • OK-432 injection

31
Management
  • Pre-medication
  • 2 xylocaine 10ml in 50ml normal saline
  • Minocycline injection
  • After 15 minutes, 300mg Minocycline in 50ml
    normal saline
  • Clamp catheter/tube, change position 2-6 hours
  • Unclamp catheter/tube, low pressure suction

32
Management
  • Pre-medication
  • 2 xylocaine 10ml in 50ml normal saline
  • Beta-iodine injection
  • After 15 minutes, 10 ml beta-iodine in 40ml
    normal saline
  • Clamp catheter/tube, change position 2-6 hours
  • Unclamp catheter/tube, low pressure suction

33
Management
  • Indwelling catheter
  • Good outpatient situation
  • Good for trapped lung
  • Pigtail catheter with drainage bag
  • Chest tube with Heimlich valve

34
Management
35
Complication
  • Re-expansion lung edema
  • Empyema
  • Restricted lung disease
  • Trapped lung

36
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39
Prognosis
  • Medium survival
  • Lung cancer with malignant effusion 3 months
  • Breast cancer with malignant effusion 5 months
  • Mesothelioma with malignant effusion 6 months
  • Lymphoma with malignant effusion 9 months

40
Thank You for Attention
  • Reference
  • Murray and Nadels Textbook of Respiratory
    Medicine, 4th edition, 2005
  • Light and Lees Textbook of Pleural Disease, 1st
    edition, 2003
  • Mathis and Lessnaus Atlas of Chest Sonography,
    1st edition, 2003
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