Pleural Effusion-Malignant

Epidemiology

Acute Lymphocytic Leukemia (ALL) (see Acute Lymphocytic Leukemia, [[Acute Lymphocytic Leukemia]])
Acute Myeloid Leukemia (AML) (see Acute Myeloid Leukemia, [[Acute Myeloid Leukemia]])
Breast Cancer (see Breast Cancer, [[Breast Cancer]]): 25% of all cases
Chronic Lymphocytic Leukemia (CLL) (see Chronic Lymphocytic Leukemia, [[Chronic Lymphocytic Leukemia]]))
Chronic Myeloid Leukemia (CML) (see Chronic Myeloid Leukemia, [[Chronic Myeloid Leukemia]])
Lung Cancer (see Lung Cancer, [[Lung Cancer]]): 30% of all cases
Lymphoma (see Lymphoma, [[Lymphoma]]): 20% of all cases
Multiple Myeloma (see Multiple Myeloma, [[Multiple Myeloma]])
Ovarian Cancer (see Ovarian Cancer, [[Ovarian Cancer]]): 6% of all cases
Sarcomas and Melanoma: 3% of all cases
- Kaposi Sarcoma (see Kaposi Sarcoma, [[Kaposi Sarcoma]])
Unknown Primary Malignancy: 6% of all pleural metastatic cases
Waldenstrom’s Macroglobulinemia (see Waldenstrom’s Macroglobulinemia, [[Waldenstroms Macroglobulinemia]])

Acute Pulmonary Embolism (PE) (see Acute Pulmonary Embolism, [[Acute Pulmonary Embolism]]): if present
Bronchial Obstruction with Decreased Pleural Pressure: if present
Hypoproteinemia: if present
Mediastinal Adenopathy with Decreased Pleural Lymphatic Drainage: if present
Pericardial Involvement: if present
Pleural Metastases with Increased Pleural Permeability: not the predominant mechanism in malignant effusion (since amount of protein entering pleural space is similar to that seen in CHF)
Pleural Metastases with Lymphatic Obstruction: predominant mechanism in malignant pleural effusion (since volume of lymph flow is decreased compared to TB, PE, and CHF effusions)
Post-Obstructive Pneumonia: if present
Radiation Pleuritis (see Radiation Pleuritis, [[Radiation Pleuritis]]): if present
Thoracic Duct Interruption (with Chylothorax) (see Pleural Effusion-Chylothorax, [[Pleural Effusion-Chylothorax]])

Exudate
Appearance: may be bloody (but 50% have RBC counts <10,000/mm3)
pH: usually changes with glucose
LDH ratio: increased (most effusions that are exudates by LDH criteria but not by the protein criteria are malignant)
Total protein ratio: increased
Glucose: <60 mg/dL in 20% of cases (those with low glucose usually have low pH)
Cell count/ diff: eosinophilia is uncommon
Cytology: overall 40-87% sensitivity
- Cytology is less frequently positive in cases due to squamous cell lung cancer (since main mechanisms of effusion formation are bronchial and lymphatic obstruction)
- Cytology is less frequently positive in cases due to complicating PE, CHF, etc.
- 75% sensitivity in cases due to NHL but only 25% sensitivity in cases due to Hodgkin’s
- Cytology is more frequently positive in adenocarcinomas than in sarcomas
Cholesterol: elevated >55-60 mg/dL (seen in all exudates)
Pleural: serum cholesterol ratio: elevated (seen in all exudates)
Pleural fluid amylase: elevated in 10% of cases (source of malignancy is usually not the pancreas in these cases/ amylase in malignancy is usually of salivary type)
Tumor Markers: 30-40% of mailgnant effusions have CEA that is >10 ng/mL (while benign effusions rarely exceed this level)
- However, most malignant effusions have positive cytology (making CEA measurement unnecessary)

Sensitivity: 40-75%
- Cytology may be more sensitive than pleural biopsy for malignant effusions (but this is controversial)

Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
- Dyspnea (see Dyspnea, [[Dyspnea]])

Clinical Efficacy
- UK-Based TIME1 Trial Comparing Small-Bore Chest Tube vs Large-Bore Chest for Pleurodesis in Malignant Pleural Effusion (JAMA, 2015) [MEDLINE]: 2×2 factorial phase 3 randomized trial
  - NSAID’s and Opiates Demonstrated No Difference in Pain Scores: however, NSAID’s demonstrated a higher need for rescue medication
  - NSAID’s Did Not Impact the Efficacy of Pleurodesis at 3 mo
  - Placement of 12F Chest Tube vs 24F Chest Tube was Associated with a Modest Reduction in Pain
  - Placement of a 24 Chest Tube was Superior to a 12F Chest Tube in Terms of Pleurodesis Efficacy

Pre-Pleurodesis Anesthesia: lidocaine 4 mg/kg (?) in 50 mL NS injected into pleural space, then x min of waiting with repositioning
Pleurodesis Agents
(chemical agent followed by 50 mL NS flush, clamp x 2 hrs, then suction)
Doxycycline: 500 mg in 50 ml saline, flush with 50 ml saline
- May be preferred agent for treatment of PTX
Talc Slurry: 6-10 g instillation
- Risk of ARDS may be related to particle size <30 um (check talc)
Bleomycin:
Thoracoscopic Talc Insufflation:
- Risk of ARDS may be related to particle size <30 um (check talc)
Pleural Abrasion
Silver Nitrate

Malignant Pleural Effusion without Trapped Lung
Malignant Pleural Effusion with Trapped Lung
- Placement in Patients with Trapped Lung is Associated with Moderate Improvement in Quality of Life Indices [MEDLINE]

Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters. Interact Cardiovasc Thorac Surg. 2009 Dec;9(6):961-4. doi: 10.1510/icvts.2009.211516. Epub 2009 Jul 28 [MEDLINE]
Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA. 2015 Dec;314(24):2641-53 [MEDLINE]