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Given the many management options for malignant pleural effusions, several different algorithms have been suggested.
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Although pleurodesis may provide permanent relief of symptoms, it also leads to more hospital days and is more costly than tunneled pleural catheters (TPCs).
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TPCs also have the benefit of providing a means to manage trapped lung, a condition not amenable to pleurodesis.
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It is important to consider the patient’s overall prognosis, symptoms, functional status, and social and financial
Malignant Pleural Effusions: A Review
Section snippets
Key points
Incidence
The annual incidence of MPEs is estimated to be 150,000 to 175,000 in the United States2, 3 and they are believed to be present in up to 15% of patients who die with malignancies, based on 1 postmortem series.4 In addition, exudative effusions are more often (44%–77%) associated with malignancies than any other disease process.5, 6 The most common causes of MPEs in order of most common to least common are lung cancer (most commonly adenocarcinoma), breast cancer, lymphoma, unknown primary,
Pathophysiology
Fluid collects in the pleural space (a potential space between the visceral and parietal pleural layers that normally contains only a small amount, typically 10–20 mL, of pleural fluid) when there is an abnormality of oncotic or hydrostatic pressures. For instance, in the setting of left-sided congestive heart failure, failure of the left heart to pump blood forward results in an increased pressure in the pulmonary venous system, which in turn leads to leakage of fluid from the intravascular
Mechanisms Involved in Pleurodesis
Pleurodesis is the process of obliterating the pleural space by causing extensive adhesion of the visceral and parietal pleural surfaces by means of either mechanical or chemical-induced inflammation of the pleura. Pleurodesis is used after evacuation of pleural fluid for treatment of MPEs or pneumothorax and, less commonly, some benign pleural effusions. Many different sclerosing agents are available, and they share similar mechanisms of inducing biological responses mediated by pleural
Therapeutic Thoracentesis
Large-volume thoracentesis is usually the first step to both diagnosing and treating MPEs. The patient’s symptomatic response to the large-volume pleural fluid removal determines whether it is prudent to proceed to more invasive techniques of either pleural drainage or pleurodesis. Up to 50% of patients with MPEs do not have symptomatic relief after thoracentesis, whether it is because of comorbid conditions, generalized deconditioning from their malignancy, or incomplete reexpansion of the
Summary
Given the many management options for MPEs, several different algorithms have been suggested.12 Fig. 3 is our preferred algorithm in management of MPEs.17 Although pleurodesis may provide permanent relief of symptoms, it also leads to more hospital days and is more costly than TPCs. TPCs also have the benefit of providing a means to manage trapped lung, a condition not amenable to pleurodesis. It is important to consider the patient’s overall prognosis, symptoms, functional status, and social
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Cited by (65)
Inertia-magnetic microfluidics for rapid and high-purity separation of malignant tumor cells
2023, Sensors and Actuators B: ChemicalUpdate on the diagnosis and management of malignant pleural effusions
2022, Respiratory MedicineCitation Excerpt :Increased pleural fluid formation related to tumor-induced inflammation with increases in capillary permeability and abnormal angiogenesis also plays a major role [12,14]. A number of cytokines and transcription factors including vascular endothelial growth factor (VEGF), tumor necrosis factor (TNF), interleukin 6, and osteopontin have been implicated in the formation of malignant effusions via the mechanisms above, but thus far no targeted therapy aimed at any of these has demonstrated therapeutic effectiveness for MPE although preclinical animal studies have shown promise [12,15–19]. Lung and breast cancer together account for over half of all malignant pleural effusions, with hematologic and other malignancies comprising a significant minority of cases (Fig. 1) [3,4,12].
Driverless artificial intelligence framework for the identification of malignant pleural effusion
2021, Translational OncologyCitation Excerpt :To sum up, we concluded that the driverless AI framework, including ML and DL, offered great improvement in separating MPE from BPE over the effusion CEA. MPE usually represents end-stage malignancy and is closely related to poor median survival [26,27]. The high morbidity of MPE continues to rise and therefore causes a heavy health care burden [28].
Management of Malignant Pleural Effusions
2020, Clinics in Chest MedicineCitation Excerpt :The presence of more than a small amount of pleural fluid implies either a major increase in pleural fluid production, a reduction in pleural fluid drainage, or a combination of both processes. Malignant pleural effusion (MPE) refers to accumulation of pleural fluid as a consequence of an underlying malignancy and is most commonly due to lung or breast cancer.1 A patient is diagnosed as having MPE using either pleural fluid cytology (that has a limited sensitivity of around 60%) or pleural biopsy, which, when performed thoracoscopically, has a sensitivity of around 95%.2–7
Disclosures: Ali I. Musani, MD has received honoraria as a consultant and a speaker, as well as a research grant from CareFusion.