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Malignant Pleural Effusion (M.P.E.)Malignant Pleural Effusion (M.P.E.)
““An M.P.E. is defined by the An M.P.E. is defined by the presence of presence of cancer cellscancer cells in the in the
pleural spacepleural space””
Malignant Pleural Effusion (M.P.E.)Malignant Pleural Effusion (M.P.E.)
““An M.P.E. is defined by the An M.P.E. is defined by the presence of presence of cancer cellscancer cells in the in the
pleural spacepleural space””Underlying Primary CancerUnderlying Primary Cancer
1.1.Lung tumors Lung tumors (including malignant (including malignant
pleural mesothelioma) pleural mesothelioma) NSCLC:NSCLC: 14% at 14% at
the time of diagnosis, 50% with advanced the time of diagnosis, 50% with advanced
diseasedisease
2.2. Breast cancerBreast cancer
3.3. Ovarian cancer, gastric cancerOvarian cancer, gastric cancer
4.4. Hodgkin’s and non-Hodgkin’s lymphomaHodgkin’s and non-Hodgkin’s lymphoma
Malignant Pleural Effusion (M.P.E.)Malignant Pleural Effusion (M.P.E.)
““An M.P.E. is defined by the An M.P.E. is defined by the presence of presence of cancer cellscancer cells in the in the
pleural spacepleural space””
Cancer cells reach theCancer cells reach the visceral pleuravisceral pleura (through(through the the
pulmonary vasculature)or thepulmonary vasculature)or the parietal pleuraparietal pleura (through (through
hematogenous spreadhematogenous spread)
Cancer cells in the pleural spaceCancer cells in the pleural space
(tumor deposit along parietal pleura)(tumor deposit along parietal pleura)
A.A. Obstruct lymphatic stromata (which drain intrapleural Obstruct lymphatic stromata (which drain intrapleural
fluid)fluid)
B.B. Release chemockines ( increasing vascular permeability)Release chemockines ( increasing vascular permeability)
Malignant Pleural Effusion (M.P.E.)Malignant Pleural Effusion (M.P.E.)
≠≠ Paramalignant EffusionParamalignant Effusion1.1. Mediastinal lymph node tumor infiltration Mediastinal lymph node tumor infiltration
2. 2. Bronchial obstruction/AtelectasisBronchial obstruction/Atelectasis
3. 3. Pulmonary embolismPulmonary embolism
4.4. “Superior vena cava syndrome” “Superior vena cava syndrome”
5. 5. Decreased oncotic pressure (cachexia)Decreased oncotic pressure (cachexia)
6.6. Radiotherapy/Chemotherapy Radiotherapy/Chemotherapy
Malignant Plural EffusionMalignant Plural EffusionAndAnd
DiagnosisDiagnosis
M.P.E. and DiagnosisM.P.E. and Diagnosis
CytologicCytologic or or tissue biopsytissue biopsy confirmation is required to confirmation is required to
establish a diagnosis of MPEestablish a diagnosis of MPE
M.P.E. and DiagnosisM.P.E. and Diagnosis
CytologicCytologic or or tissue biopsytissue biopsy confirmation is required to confirmation is required to
establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis:Diagnostic thoracentesis:
• Diagnostic yield ofDiagnostic yield of PF cytologyPF cytology ranging from ranging from 62 to 62 to
90%90%
• Positive results on cytology Positive results on cytology might not differentiate might not differentiate
betweenbetween adk subtypes or between pleural adk and adk subtypes or between pleural adk and
mesotheliomamesothelioma
• Additional PF studiesAdditional PF studies could complement standard could complement standard
cytology: Electrochetoluminescence forcytology: Electrochetoluminescence for tumor tumor
markersmarkers, ,
genetic analysisgenetic analysis
M.P.E. and DiagnosisM.P.E. and Diagnosis
CytologicCytologic or or tissue biopsytissue biopsy confirmation is required to confirmation is required to
establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis, Diagnostic thoracentesis, if cytology not if cytology not diagnostic:diagnostic:
M.P.E. and DiagnosisM.P.E. and Diagnosis
CytologicCytologic or or tissue biopsytissue biopsy confirmation is required to confirmation is required to
establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis, Diagnostic thoracentesis, if cytology not if cytology not diagnostic:diagnostic:
Pleural Biopsy:Pleural Biopsy: Closed-needle pleural biopsy Closed-needle pleural biopsy (sensitivity of 40-(sensitivity of 40-75%)75%) Ultrasonography Ultrasonography or or chest CT-guided percutaneous chest CT-guided percutaneous pleural biopsy pleural biopsy (higher sensitivities and (higher sensitivities and specificities)specificities)
Medical thoracoscopy, orMedical thoracoscopy, orVideo Assisted Thoracoscopic Surgery (VATS)Video Assisted Thoracoscopic Surgery (VATS)
M.P.E. and DiagnosisM.P.E. and Diagnosis
Is diagnosis with Is diagnosis with cytologycytology or or
histologyhistology always requested (and always requested (and
useful) in our clinical practice?useful) in our clinical practice?
M.P.E. and DiagnosisM.P.E. and Diagnosis
Does the presence of M.P.E. add Does the presence of M.P.E. add prognosticprognostic and and therapeutictherapeutic
informations?informations?
M.P.E. and DiagnosisM.P.E. and Diagnosis
Non Small Cell Lung CancerNon Small Cell Lung Cancer
Does the presence of M.P.E. add Does the presence of M.P.E. add prognosticprognostic and and therapeutictherapeutic
informations?informations?
M.P.E. and DiagnosisM.P.E. and Diagnosis
Non Small Cell Lung CancerNon Small Cell Lung Cancer
• Poor PSPoor PS• Known advanced cancerKnown advanced cancer
DIAGNOSIS NOT NECESSARYDIAGNOSIS NOT NECESSARY
M.P.E. and DiagnosisM.P.E. and Diagnosis
Non Small Cell Lung CancerNon Small Cell Lung Cancer
• Poor PSPoor PS• Known advanced cancerKnown advanced cancer
DIAGNOSIS NOT NECESSARYDIAGNOSIS NOT NECESSARY
• Good PSGood PS• multimodality treatmentmultimodality treatment
DIAGNOSIS IS CRITICAL DIAGNOSIS IS CRITICAL FOR TREATMENT FOR TREATMENT
PLANNINGPLANNING
NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis• Patients with M.P.E. (without other metastatic disease) Patients with M.P.E. (without other metastatic disease) had a had a median OS of 8 monthsmedian OS of 8 months
• Versus Versus 13 months13 months of other cT4 M0 of other cT4 M0
• Versus Versus 6 months6 months of patients with distant metastases of patients with distant metastases
Postmus, JTO 2007Postmus, JTO 2007
NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis
Goldstraw, JTO 2007Goldstraw, JTO 2007
TNM stagingTNM stagingSix Edition:Six Edition:
T4T4(Stage III B)(Stage III B)
TNM stagingTNM stagingSeventh Edition:Seventh Edition:
M1 aM1 a(Stage IV)(Stage IV)
NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis
Goldstraw, JTO 2007Goldstraw, JTO 2007
TNM stagingTNM stagingSix Edition:Six Edition:
T4T4(Stage III B)(Stage III B)
TNM stagingTNM stagingSeventh Edition:Seventh Edition:
M1 aM1 a(Stage IV)(Stage IV)If P.E. is If P.E. is cytologically negativecytologically negative. .
and is evaluated as not related and is evaluated as not related to the tumor by clinical to the tumor by clinical
judgment, judgment, patient should be patient should be classified as T1, T2, T3, T4.classified as T1, T2, T3, T4.
Malignant Pleural EffusionMalignant Pleural EffusionAndAnd
TreatmentTreatment
M.P.E. and TreatmentM.P.E. and Treatment
1)1) THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS
2)2) PLEURODESISPLEURODESIS
M.P.E. and TreatmentM.P.E. and Treatment
Management of MPE is Management of MPE is palliative...palliative...
1)1) THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS
2)2) PLEURODESISPLEURODESIS
M.P.E. and TreatmentM.P.E. and Treatment
When to proceed with treatment When to proceed with treatment of Pleural Effusion?of Pleural Effusion?
M.P.E. and TreatmentM.P.E. and Treatment
When to proceed with treatment When to proceed with treatment of Pleural Effusion?of Pleural Effusion?
Patient is symptomaticPatient is symptomatic (for dyspnea or cough or chest pain), (for dyspnea or cough or chest pain), and and symptoms are considered to be caused from symptoms are considered to be caused from pleural effusion.pleural effusion. Patient is not suitable forPatient is not suitable for specific cancer specific cancer treatment (eg. chemotherapy), treatment (eg. chemotherapy), or Pleural or Pleural Effusion is resistant to specific cancer Effusion is resistant to specific cancer treatment.treatment.
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic?
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo interventionNoNo
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
M.P.E. and TreatmentM.P.E. and Treatment
THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS Symptoms can improve after Symptoms can improve after
thoracentesisthoracentesis But But 98% to 100%98% to 100% of patients experience of patients experience
reaccumulation of fluidreaccumulation of fluid and and recurrence recurrence
of of
symptomssymptoms within 30 days within 30 days
M.P.E. and TreatmentM.P.E. and Treatment
THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS Symptoms can improve after Symptoms can improve after
thoracentesisthoracentesis But But 98% to 100%98% to 100% of patients experience of patients experience
reaccumulation of fluidreaccumulation of fluid and and recurrence recurrence
of of
symptomssymptoms within 30 days within 30 days
RepeatedRepeated THORACENTESESTHORACENTESES PLEURODESISPLEURODESIS
M.P.E. and TreatmentM.P.E. and Treatment
THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS Symptoms can improve after Symptoms can improve after
thoracentesisthoracentesis But But 98% to 100%98% to 100% of patients experience of patients experience
reaccumulation of fluidreaccumulation of fluid and and recurrence recurrence
of of
symptomssymptoms within 30 days within 30 days
RepeatedRepeated THORACENTESESTHORACENTESES PLEURODESISPLEURODESIS
M.P.E. and TreatmentM.P.E. and Treatment
PLEURODESISPLEURODESIS
Selection of patients should be based Selection of patients should be based on:on:..
Patient’s characteristicsPatient’s characteristics
Tumor’s characteristicsTumor’s characteristics
11
22
M.P.E. and TreatmentM.P.E. and Treatment
PLEURODESISPLEURODESIS
Selection of patients should be based Selection of patients should be based on:on:..
Patient characteristicsPatient characteristics
Tumor characteristicsTumor characteristics
11
22
““Does the patient’s life Does the patient’s life expectancy warrant expectancy warrant pleurodesis?” pleurodesis?” **((PSPS has the most value) has the most value)
** 32% of p. do not survive 30 days after pleurodesis32% of p. do not survive 30 days after pleurodesis
M.P.E. and TreatmentM.P.E. and Treatment
PLEURODESISPLEURODESIS
Selection of patients should be based Selection of patients should be based on:on:..
Patient characteristicsPatient characteristics
Tumor characteristicsTumor characteristics
11
22
““Does the patient’s life Does the patient’s life expectancy warrant expectancy warrant pleurodesis?” pleurodesis?” **((PSPS has the most value) has the most value)
** 32% of p. do not survive 30 days after pleurodesis32% of p. do not survive 30 days after pleurodesis
M.P.E. and TreatmentM.P.E. and Treatment
PLEURODESISPLEURODESIS
Pleural Effusion is unlikely to Pleural Effusion is unlikely to respond to pleurodesis if:respond to pleurodesis if:
There is an airway obstruction from an There is an airway obstruction from an
endobronchial tumor (the lung does not expand endobronchial tumor (the lung does not expand
to the chest wall after therapeutic to the chest wall after therapeutic
thoracentesis)thoracentesis)
Effusion is multiloculated Effusion is multiloculated
There are large tumor masses along pleural There are large tumor masses along pleural
surfacessurfaces
M.P.E. and TreatmentM.P.E. and Treatment
PLEURODESISPLEURODESIS
Chest-catheter PleurodesisChest-catheter Pleurodesis
Thoracoscopic PleurodesisThoracoscopic Pleurodesis
TALC TALC is considered a superior pleurodesis agentis considered a superior pleurodesis agent
when compared with other commonly used sclerosantwhen compared with other commonly used sclerosant
(as Bleomycin or tetracycline)(as Bleomycin or tetracycline)
Cochrane Review, 2004Cochrane Review, 2004
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
YesYes
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
PleurodesisPleurodesisYesYes
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
PleurodesisPleurodesis
NoNo
YesYes
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
PleurodesisPleurodesis
NoNo
NoNoYesYes
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
Repeated ThoracentesisRepeated Thoracentesis
Pleural CatheterPleural Catheter
PleurodesisPleurodesis
NoNo
NoNoYesYes
M.P.E. and TreatmentM.P.E. and Treatment
RepeatedRepeated THORACENTESESTHORACENTESES
Should be reserved for patients who:Should be reserved for patients who:
(1)(1) Appear unlikely to survive Appear unlikely to survive beyond 1 to 3 monthsbeyond 1 to 3 months(2)(2) Cannot tolerateCannot tolerate other more interventional other more interventional procedures to control pleural fluid, such as procedures to control pleural fluid, such as
pleurodesispleurodesis..(3)(3) Have a PE Have a PE that does not respondthat does not respond to pleurodesis to pleurodesis
M.P.E. and TreatmentM.P.E. and Treatment
RepeatedRepeated THORACENTESESTHORACENTESES
Should be reserved for patients who:Should be reserved for patients who:
(1)(1) Appear unlikely to survive Appear unlikely to survive beyond 1 to 3 monthsbeyond 1 to 3 months(2)(2) Cannot tolerateCannot tolerate other more interventional other more interventional procedures to control pleural fluid, such as procedures to control pleural fluid, such as
pleurodesispleurodesis..(3)(3) Have a PE Have a PE that does not respondthat does not respond to pleurodesis to pleurodesis
(4)(4) Have cancers that commonly Have cancers that commonly respond to therapyrespond to therapy with resolution of the associated effusionswith resolution of the associated effusions
...OR......OR...
M.P.E. and TreatmentM.P.E. and Treatment
Is patient symptomatic?Is patient symptomatic? No interventionNo intervention
YesYes
NoNo
Therapeutic ThoracentesisTherapeutic Thoracentesis
Improvement in symptoms?Improvement in symptoms?NoNo
Adequate Re-expansion?Adequate Re-expansion?
Good PS?Good PS?
YesYes
YesYes
Repeated ThoracentesisRepeated Thoracentesis
Pleural CatheterPleural Catheter
PleurodesisPleurodesis
NoNo
NoNoYesYes