Management of malignant and paramalignant pleural effusions

Option	Comment
Observation	For asymptomatic effusions; most will progress and require therapy
Therapeutic thoracentesis	Prompt relief of dyspnea; most effusions recur unless underlying tumor responds to chemo- or radiotherapy
Chest catheter drainage only	Most effusions will recur after catheter removal
Chest catheter drainage with chemical pleurodesis (eg, talc slurry)	Variable response rate with 60 to 90 percent of patients responding to talc pleurodesis
Thoracoscopy with talc insufflation	Control of effusion with similar frequency as chest catheter drainage with talc pleurodesis
Long-term indwelling pleural catheter	Control of effusion and improved symptoms in most patients. Some patients may experience pleurodesis after two weeks (median 11 weeks) of catheter drainage, which allows catheter removal.
Long-term indwelling pleural catheter with talc instillation	Control of effusion and symptoms with successful pleurodesis in 43 percent of patients without hospitalization
Pleural abrasion or pleurectomy	Requires thoracoscopy or thoracotomy. Effectively controls effusions in nearly all patients.
Pleuroperitoneal shunt	When other options have failed or are not indicated; may be useful for chylothorax
Chemotherapy	May be effective in some tumor types, such as breast cancer, lymphoma, and small cell lung cancer
Radiotherapy	Mediastinal radiation therapy may be effective in lymphoma and lymphomatous chylothorax

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