Original article
Prognostic significance of pleural fluid data in patients with malignant effusion

https://doi.org/10.1016/j.ejim.2007.09.014Get rights and content

Abstract

Background

To determine the effects of the biochemical and cytological properties of the pleural fluid (PF) on the survival of patients with malignant pleural effusion (MPE).

Methods

A retrospective study of 284 patients with MPE was performed, which measured overall survival, survival of patients with different types of primary tumors, and survival as a function of PF biochemical variables transformed into quartiles.

Results

Median overall survival of MPE patients was 5.4 months following diagnosis. Survival varied significantly depending on the type of the primary tumor: 17.4 months for mesothelioma, 13.2 months for breast cancer, 7 months for lymphoma and 2.6 months for lung cancer. A multivariate analysis of PF biochemical parameters showed that survival was lower as the concentration of lactate dehydrogenase (LDH) increased (11.3 months if LDH was between 140 U/L and 358 U/L vs 2.8 months if LDH was between 1027 U/L and 10,110 U/L) or the concentration of pleural proteins decreased (9.4 months if proteins were between 4.92 g/dL and 7.94 g/dL vs 2.2 months if proteins were between 0.97 g/dL and 3.85 g/dL). We also found that when mesotheliomas were excluded from the analysis, survival was lower in patients with a PF pH lower than 7.3 (2.4 months vs 6.8 months, p = 0.03).

Conclusions

Tumor type as well as some biochemical features of the pleural fluid, such as pH and concentrations of proteins and LDH, influence survival in patients with MPE.

Introduction

Malignant pleural effusion (MPE) indicates advanced neoplastic disease (i.e. IIIB stage in lung cancer and IV stage in breast cancer) and implies lower survival and quality of life for the patient [1], [2]. The decision to employ a palliative treatment such as pleurodesis depends on the presence of dyspnea secondary to MPE, pulmonary re-expansion after pleural fluid (PF) evacuation and expected survival. Thus, it is important to consider the influence of those prognostic factors that may predict a short-term outcome [3].

It is known that survival in MPE is directly associated with the type of tumor and the patient's functional state (measured by the Karnofsky index) [4]. However, the effect of other factors, such as the biochemistry of the PF [5], [6] or the size of the pleural effusion (PE) [7], [8], is less clear. The present study was performed to determine whether patient survival is affected by the type of pleural cavity tumor, the biochemistry of the PF or the size of the MPE, and the relative contribution of each of these potential predictors of survival.

Section snippets

Methods

The Ethics Committee of the Arnau de Vilanova University Hospital in Lleida, Spain, approved this study in accordance with the recommendations found in the Helsinki declaration. Clinical, radiological and biochemical data on patients with MPE were collected from our pleural effusion database. Patients submitted to a diagnostic thoracentesis from June 1993 to August 2006 were included in this retrospective analysis. We collected information on patient age and sex; size and localization of the PE

Patients and tumor type

A total of 1431 patients with PE were identified, of which 284 had MPE confirmed by cytological studies of PF (262 patients) or pleural biopsy (22 patients). There were 150 males and 134 women with a mean age of 67 ± 13 years. The date of death of 206 patients was obtained, while in 66 patients the follow-up was lost a median of 4 months (range 1 day to 72 months) after MPE diagnosis. Moreover, 12 patients were still alive at the end of the study with a median survival of 11 months (range 5 days

Discussion

Part of the rationale for initiating certain palliative treatments such as pleurodesis is the prediction of a good prognosis in the short term [1]. The diagnosis of MPE implies a poor survival, which was shown in our study to be 5.4 months (median). In a previous meta-analysis of 417 patients with MPE, a median survival of 4 months was observed [9]. We hypothesize that such variation in the predicted duration of survival for MPE patients depends upon the type of primary tumor. When viewed as a

Learning points

  • Pleural fluid analysis has not only diagnostic but also prognostic significance in patients with malignant effusions.

  • The finding of high LDH or low protein concentrations in the pleural fluid anticipates a poor survival. Pleural acidosis is also a poor prognostic factor in metastatic malignant effusions.

References (23)

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