Management of symptomatic malignant pleural effusion

CT: computed tomography.

* Dyspnea is the most common symptom but some patients present with chest pain or cough.

¶ We generally remove as much fluid as is tolerated. We advise monitoring symptoms of chest discomfort and cough carefully during the procedure to guide the volume of fluid to be removed. Pleural manometry is not routinely performed during initial thoracentesis.

Δ In some tumor types, treating the underlying malignancy may be effective in preventing recurrence. Examples of antitumor-responsive malignancies include breast, ovarian, and prostate cancer, germ cell tumors, lymphoma, and small cell lung cancer. However, in many cases the cancer does not respond to, or recurs despite, antitumor therapy.

◊ Recurrence occurs in over 50% of patients with malignant pleural effusion. Two-thirds of recurrences develop within the first month following initial thoracentesis.

§ The distinction is important since patients with nonexpandable lung are not suitable for pleurodesis since pleural-pleural apposition is required for this procedure. The ability of the lung to re-expand is typically assessed on follow-up chest radiography and in some cases, chest CT. Expandable lung is that which completely expands radiologically after therapeutic thoracentesis while nonexpandable lung is that which incompletely expands or does not expand after thoracentesis. Nonexpandanble lung may be present in over half of patients with malignant pleural effusion and may be suggested when a therapeutic thoracentesis does not improve dyspnea and when fluid is replaced by air after thoracentesis on chest imaging. While expandable and nonexpandable lung can also be distinguished on pleural manometry, it is not always available.

¥ Considerable variation exists in practice with guideline groups and many other experts suggesting proceeding directly to IPC drainage or to pleurodesis, or even combining both IPC and pleurodesis. Our general preference is for IPC since it is a minimally invasive procedure that can result in spontaneous pleurodesis and can be performed as an outpatient procedure and combined with pleurodesis, if necessary.

‡ Estimating survival is challenging and physicians should use their best judgement in this regard.

† Palliation may involve oxygen, morphine, bronchodilators (please refer to the UTD topic on palliation of dyspnea).

** Limited pleurodesis may be an option in those who achieved partial pleural-pleural apposition after large-volume thoracentesis. While decortication and intrapleural fibrinolytics are feasible options in some patients with nonexpandable lung from benign disease, these options are less well supported and rarely performed but can be considered in patients with nonexpandanble lung due to malignancy.