Download Pleural Malignancy_meds 2017

Pleural Malignancy
March 22nd/2017
Kayvan Amjadi MD, FRCPC
Interventional Pulmonology
Division of Respirology
Objectives

Develop an understanding of pleural malignancy

Explain the differences between primary and secondary malignancies of the pleura
and describe their symptomatology

List common sites of origin of malignant pleural effusions

Describe chest tube placement and thoracentesis
 Indications
 Contra-indications
 Complications

Describe management of malignant pleural effusion
Patient BB
•
•
•
•
58 y.o presents with SOBOE x 3/52
No fever, chills or sick contacts
No chest pain
Non-smoker
•
PHx
– Left mastectomy for breast cancer 4
years ago
– Melanoma removed from her back 6
years ago
•
No medications
Thoracentesis

A procedure that involves percutaneous drainage of pleural fluid by insertion of a
needle into the pleural space

Diagnostic Thoracentesis
 Refers to removal of small amount of fluid for analysis

Therapeutic thoracentesis
 Removal of large amount of pleural fluid for relief of symptoms

Indication
 Anyone with pleural effusion of unknown etiology
 Anyone with symptomatic pleural effusion
Thoracentesis

Thoracentesis is not required if
 There is small amount of pleural effusion and the diagnosis is secured clinically (e.g. Viral
pleurisy)
 There is obvious congestive heart failure without atypical features

Atypical features that should prompt consideration of diagnostic thoracentesis in a
patient with CHF include







A unilateral effusion (especially if it is left sided)
Bilateral effusions that are of disparate sizes
Pleuritic chest pain
Fever
Normal cardiac silhouette on CXR
Normal left ventricular function on echocardiogram
An effusion that fails to respond to heart failure therapy (> 48 hours)
Contra-indications

There are no absolute contra-indications

Increased caution is warranted if
 Anticoagulation or bleeding diathesis
o INR > 1.5
o Platelets < 25,000/mm3
o Uraemia
 Very small amount of effusion
o Risk outweighs benefit
 Mechanical ventilation
o Increased risk of developing tension pneumothorax or persistent air leak if pneumothorax occurs
 Active skin infection at the point of needle insertion
o Insertion of the needle at this site could result in pleural infection
Thoracentesis

Identify the site for thoracentesis
 Physical exam
o
o
o
o
o
o
Decreased breath sounds
Dullness to percussion
Decreased tactile fremitus
Egophony (E-to-A change)
Pleural friction rub
Mediastinal shift away from the effusion


Observed with large effusions (> 1000 ml)
Displacement of trachea toward the side of effusion is suggestive of endobronchial lesion causing collapsed
lung
 Ultrasound guidance
Ultrasonography in Pleural Effusion
Diagnostic Thoracentesis

With physical exam as our guide, in an upright seated patient, the puncture site is marked

Midway between the posterior axillary line and the spine
o 5 – 10 cm lateral to the spine

1 – 2 rib interspaces below the level of dullness to percussion, decreased breath sound, and loss of
fremitus
o Not below the 9th rib; to avoid sub-diaphragmatic puncture

Site is dis-infected with Chlorhexidine and/or 10% povidone-iodine solution

Sterile drapes are placed around the marked site

Anesthetize the skin, periosteum and parietal pleura with 1% or 2% lidocaine using a 25-guage
needle


Advance a 1.5 inch, 22-guage needle toward the rib, and then “walk” over its superior margin


Confirm the correct location for thoracentesis by aspirating pleural fluid through this needle
Decrease the risk of injury to the neurovascular bundle
Aspirate 50 mls of fluid for analysis
Diagnostic Thoracentesis
Therapeutic Thoracentesis

Same as diagnostic thoracentesis except
 Use an angio-catheter for drainage of large volumes to minimize risk of pneumothorax
 Three way stop-cock
o Attach a drainage line to a vacuum bottle
 Limit drainage to patient’s symptoms of
o Persistent cough
o Chest pain

Usually occurs after drainage of 1500 ml of fluid
 Administer Oxygen
o V/Q mis-match may cause a drop in oxygen saturation
Complications

Pain at puncture site

Cutaneous or internal bleeding

Empyema

Spleen / liver injury
 Minimized with the use of ultrasound

Re-expansion pulmonary edema

Pneumothorax (12 – 30%)
 Minimized with the use of ultrasound , large effusion, and experience of the operator
 < 5% require chest tube drainage
Patient BB
•
Pleural fluid analysis
–
–
–
–
–
–
–
–
1.5 L of dark brown fluid removed
LDH 560 (serum 147)
Protein 49 (serum 60)
Glucose 4
pH 7.3
70% lymphocytes
Cultures negative
Cytology negative
Investigations: When thoracentesis is non-diagnostic
• If clinical examination and pleural fluid analysis fail to result in
a diagnosis additional investigations include
– CT chest
– PET scan
– Pleural biopsies
• CT or U/S guided
• Pleuroscopy
• VATS
– Bronchoscopy
– Regular follow-up with repeat imaging and repeat fluid analysis
• Mainly to rule out malignancy as the cause.
CT Thorax
• Should be performed with contrast in all patients (if possible)
with undiagnosed pleural effusion
• CT may identify optimal sites for cutting needle biopsy
– Irregular or thickened pleura
– Signs of invasion of underlying or adjacent structures (suggest
malignant pleural disease)
• CT pulmonary angiography may be considered to rule out PE
CT Thorax
• Normal pleura
– 1 – 2 mm thick line of soft
tissue attenuation
– Seen at the point of
contact between the lung
and the chest wall
• Visceral and parietal
pleura
– Extra-pleural fat and endothoracic fascia, each 0.25
mm thick are visible
between the pleura and
intercostal muscles
CT Thorax
• CT findings that are worrisome
for malignancy
– Circumferential pleural
thickening (> 1cm)
– Diffuse nodularity
– Nodularity or thickening
involving the mediastinal
pleura
CT Thorax
• CT findings that are worrisome
for malignancy
– Involvement of the fissure
– Pleural thickening and
accompanying pleural effusion
– Contraction of a hemithorax
– Midline mediastinum
– Contralateral shift of the
mediastinum
– Rib destruction
Positron emission tomography (PET/CT)
• 18 – fluorodeoxyglucose (FDG) PET has an emerging role
• A negative PET/CT would favor a benign etiology
• Increased activity would suggest inflammation or malignancy
• Focal increased uptake of FDG in the pleura and the presence
of solid pleural abnormalities on CT are suggestive of
malignant pleural disease
Bronchoscopy
• Useful in one of the
following 4 conditions
– Pulmonary infiltrate present
– Hemoptysis (suggests
endobronchial lesion)
– Pleural effusion is massive
• > ¾ of hemithorax
– Mediastinal shift towards the
side of effusion
Patient BB
•
CT chest showed minimal pleural
nodularity that was circumferential
and 6mm thick
– Not amenable to percutaneous
biopsies
•
No evidence for chest wall invasion
•
No pericardial disease
•
No lung lesions
•
No pulmonary embolus
Malignant Pleural Effusion:
Sensitivity of Different Biopsy Methods (%)
Closed Pleural Biopsy
Fluid Cytology
44
Medical Thoracoscopy
62
74
95
96
97
Loddenkemper R. Eur Respir J 1998; 11:213 - 221
Pleural Tumors
• Majority of pleural tumors are malignant
• Most represent metastatic disease rather than primary pleural
malignancy
• The mechanisms by which pleural involvement occurs
includes
–
–
–
–
–
Primary tumors originating from the pleura
Extension of bronchogenic cancer to the pleura
Subpleural tumors (as in Lymphoma)
Hematogenous dissemination to the pleura
Direct focal pleural seeding (“drop metastases” as in thymoma
or bronchogenic carcinoma)
Primary Tumor Site in Patients with Malignant
Pleural Effusion
10 Tumor site
Salyer
(1975)
N=95
Chernow
(1977)
N=96
Johnston
(1985)
N=472
Sears
(1987)
N=592
Hsu
(1987)
N=785
Total (%)
Lung
42
32
168
112
410
764 (37.5)
Breast
11
20
70
141
101
343 (16.8)
Lymphoma
11
-
75
92
56
234 (11.5)
GI
-
13
28
32
68
141 (6.9)
GU
-
13
57
51
70
191 (9.4)
Other
14
5
26
88
15
148 (7.3)
Unknown
17
13
48
76
65
219 (10.7)
Malignant Mesothelioma
•
Annual incidence of 1 per 100,000
– ~ 2500 cases per year in US
•
Asbestos workers have 300 – fold higher incidence than the general population
– 6% of the asbestos workers eventually develop the disease
– Latency period of 20 to 30 years
•
Present frequently with dyspnea and non-pleuritic chest pain
•
Histology
– Epithelial
– Sarcomatoid
– Mixed
•
Median survival is 12 months
– 5 year survival is 3%
Malignant Mesothelioma
• Poor prognostic signs
–
–
–
–
–
–
Sarcomatous or mixed histology
Thrombocytosis, leukocytosis, or anemia
fever of unknown origin
Age > 65 years
Poor performance status
Male gender
• Good prognosis
–
–
–
–
–
–
Epithelial histology
Stage I disease
Age < 65
Performance status 0 – 1
Lack of chest pain
Presence of symptoms > 6 months prior to diagnosis
Other Pleural Tumors
• Lipomas
– Tend to occur in the upper chest
along the 2nd or 3rd rib
•
Neurogenic tumors
•
Solitary fibrous tumors
– Usually benign (90%) with good
prognosis
– 50% are asymptomatic
– 20% of patients have hypertrophic
pulmonary osteoarthropathy
– Malignant ones tend to recur despite
surgical resection
– May be a/w hypoglycemia
• Doege-Potter syndrome
Patient BB
•
Biopsies are consistent with
metastatic malignant melanoma
•
Patient reports significant benefit
from thoracentesis
– But has been getting progressively
more SOB (within 2-3 days)
•
Repeat CXR shows re-accumulation
of her pleural effusion
•
What are our options?
Management of Malignant Pleural Effusion
Primary Goals of Management
• Alleviate symptoms
– Therapeutic drainage of the effusion
• Prevent recurrence
– Chemo/Radiation
– Other
Treatment Options
• Symptomatic management
• Thoracentesis
• Chest tube drainage
• Chemical pleurodesis
• Chronic Indwelling Catheters
• Pleuroperitoneal shunt
• Pleurectomy
Chest tube insertion: Indications

Fluid analysis




pH < 7.2
LDH > 1000
Pus
Gram’s stain positive

Empyema and complicated parapneumonic pleural effusion

Pneumothorax



In ventilated patient
Tension pneumothorax (after initial needle relief)
Large secondary spontaneous pneumothorax in patients over 50 years

Malignant pleural effusion

Traumatic haemopneumothorax

Post-operative (post-thoracotomy, cardiac surgery, or esophagectomy)
Chest tube insertion
Chest tube insertion: Underwater seal
•
Used to allow air to escape through the
drain but not to re-enter the thoracic
cavity
•
The drainage system should always be
kept below the level of patient
–
•
Persistent bubbling of air through the
water indicates an air leak from the lung
–
•
Otherwise its contents will siphon back
into the chest cavity
Should never clamp a chest tube in this
scenario to avoid tension pneumothorax
The air outlet of the underwater seal may
be connected to moderate suction (-20 cm
water)
–
To assist lung re-expansion
Chest tube insertion: Complications

“There is no organ in the thoracic or abdominal cavity that has not been pierced by chest drain”


Acute complications








Avoid using steel trocars and excessive force
Hemothorax (laceration of intercostal vessel requiring thoracotomy)
Lung laceration (pleural adhesions not broken down) in 0.2 – 0.6%
Diaphragm / Abdominal cavity penetration (placed too low) in 0.4%
Stomach /colon injury (un-recognized diaphragmatic hernia)
Tube placed subcutaneously in 0.6%
Tube placed too far (pain)
Tube falls out (not secured)
Late complications




Blocked tube (clot, lung)
Retained hemothorax
Empyema (1- 3%)
Pneumothorax after removal (poor technique)
Pleurx®, Denver Biomedical/Cardinal Health; Golden, CO
Putnam et al. Cancer 1999; 86:1992 - 1999
Tremblay et al. Chest 2006; 129:362 - 368
Summary
•
Pleural fluid cytology may be negative in malignant pleural effusion meriting additional
investigations
–
–
–
Chest imaging
Thoracoscopy
Bronchoscopy
•
Majority of pleural tumors represent metastatic disease
•
Malignant pleural effusion portends a poor prognosis
•
Removal of malignant pleural effusion may be necessary for symptom relief
–
–
–
Thoracentesis
Chest tube
Chronic Indwelling Catheters