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Diagnosis and Management of Malignant Pleural Effusion. 衛生署桃園醫院內科加護病房主任 莊子儀醫師 2006 年 7 月 20 日. Etiology of Malignant Effusion. Lung cancer: 37.5%, especially adenocarcinoma Breast cancer: 16.8% Lymphoma: 11.5%, most common in young adult. Etiology of Malignant Effusion.

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diagnosis and management of malignant pleural effusion

Diagnosis and Management of Malignant Pleural Effusion

衛生署桃園醫院內科加護病房主任

莊子儀醫師

2006年7月20日

etiology of malignant effusion
Etiology of Malignant Effusion
  • Lung cancer: 37.5%, especially adenocarcinoma
  • Breast cancer: 16.8%
  • Lymphoma: 11.5%, most common in young adult
etiology of malignant effusion1
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
etiology of malignant effusion2
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
clinical presentation
Clinical Presentation
  • Dyspnea
  • Cough
  • Chest pain
chest x ray
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%)
chest x ray1
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
radiographic evaluation1
Radiographic Evaluation
  • Chest X-ray
  • Chest CT
chest ct
Chest CT
  • Pleural surfaces, lung parenchyma, chest wall and mediastinum
  • Malignant pleural disease: pleural thickening (>1 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
radiographic evaluation2
Radiographic Evaluation
  • Chest X-ray
  • Chest CT
  • Chest echo
chest echo
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
diagnosis
Diagnosis
  • Pleural effusion
  • Cytology
  • Pathology
pleural effusion
Pleural effusion
  • Grossly bloody: most common cause of bloody effusion
  • Serosanguineous effusion
  • Cell differentiation: lymphocytes predominant
  • Eosinophilia: can not exclude malignant effusion
pleural effusion1
Pleural effusion
  • Almost always exudate
  • Lactate dehydrogenase (LDH): increased cell turnover and lysis
  • Low glucose concentration and low pH level: possible shorter survival
  • pH < 7.20: easily failure of pleurodesis
cytology
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
pathology
Pathology
  • Pleural biopsy
  • Closed needle biopsy
  • Cope needle
  • Abrams needle
  • Urocut needle
diagnostic procedures
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
primary tumor t
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
management
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
management1
Management
  • Before pleurodesis
    • Daily drainage amount < 100-150 ml
    • Confirm with chest echo
    • Ability of lung re-expansion
  • Chemical pleurodesis
    • Mnocycline injection
    • Beta-iodine injection
    • OK-432 injection
management2
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
management3
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
management4
Management
  • Indwelling catheter
    • Good outpatient situation
    • Good for trapped lung
  • Pigtail catheter with drainage bag
  • Chest tube with Heimlich valve
complication
Complication
  • Re-expansion lung edema
  • Empyema
  • Restricted lung disease
  • Trapped lung
prognosis
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
thank you for attention
Thank You for Attention
  • Reference:
  • Murray and Nadel’s Textbook of Respiratory Medicine, 4th edition, 2005
  • Light and Lee’s Textbook of Pleural Disease, 1st edition, 2003
  • Mathis and Lessnau’s Atlas of Chest Sonography, 1st edition, 2003