Download MPE and Treatment

Malignant Pleural Effusion (M.P.E.)
“An M.P.E. is defined by the presence
of cancer cells in the pleural space”
Malignant Pleural Effusion (M.P.E.)
“An M.P.E. is defined by the presence
of cancer cells in the pleural space”
Underlying Primary Cancer
1.Lung tumors (including malignant pleural
mesothelioma)  NSCLC: 14% at the time of
diagnosis, 50% with advanced disease
2. Breast cancer
3. Ovarian cancer, gastric cancer
4. Hodgkin’s and non-Hodgkin’s lymphoma
Malignant Pleural Effusion (M.P.E.)
“An M.P.E. is defined by the presence
of cancer cells in the pleural space”
Cancer cells reach the visceral pleura (through the pulmonary
vasculature)or the parietal pleura (through hematogenous spread)
Cancer cells in the pleural space
(tumor deposit along parietal pleura)
A. Obstruct lymphatic stromata (which drain intrapleural fluid)
B. Release chemockines ( increasing vascular permeability)
Malignant Pleural Effusion (M.P.E.)
≠
1.
2.
3.
4.
5.
6.
Paramalignant Effusion
Mediastinal lymph node tumor infiltration
Bronchial obstruction/Atelectasis
Pulmonary embolism
“Superior vena cava syndrome”
Decreased oncotic pressure (cachexia)
Radiotherapy/Chemotherapy
Malignant Plural Effusion
And
Diagnosis
M.P.E. and Diagnosis
Cytologic or tissue biopsy confirmation is
required to establish a diagnosis of MPE
M.P.E. and Diagnosis
Cytologic or tissue biopsy confirmation is
required to establish a diagnosis of MPE
Diagnostic thoracentesis:
• Diagnostic yield of PF cytology ranging from 62 to 90%
• Positive results on cytology might not differentiate
between adk subtypes or between pleural adk and
mesothelioma
• Additional PF studies could complement standard
cytology: Electrochetoluminescence for tumor markers,
genetic analysis
M.P.E. and Diagnosis
Cytologic or tissue biopsy confirmation is
required to establish a diagnosis of MPE
Diagnostic thoracentesis, if cytology not diagnostic:
M.P.E. and Diagnosis
Cytologic or tissue biopsy confirmation is
required to establish a diagnosis of MPE
Diagnostic thoracentesis, if cytology not diagnostic:
Pleural Biopsy:
 Closed-needle pleural biopsy (sensitivity of 40-75%)
 Ultrasonography or chest CT-guided percutaneous
pleural biopsy (higher sensitivities and specificities)
Medical thoracoscopy, or
Video Assisted Thoracoscopic Surgery (VATS)
M.P.E. and Diagnosis
Is diagnosis with cytology or histology
always requested (and useful) in our
clinical practice?
M.P.E. and Diagnosis
Does the presence of M.P.E. add
prognostic and therapeutic informations?
M.P.E. and Diagnosis
Non Small Cell Lung Cancer
Does the presence of M.P.E. add
prognostic and therapeutic informations?
M.P.E. and Diagnosis
Non Small Cell Lung Cancer
• Poor PS
• Known advanced cancer
DIAGNOSIS NOT NECESSARY
M.P.E. and Diagnosis
Non Small Cell Lung Cancer
• Poor PS
• Known advanced cancer
DIAGNOSIS NOT NECESSARY
• Good PS
• multimodality treatment
DIAGNOSIS IS CRITICAL
FOR TREATMENT
PLANNING
NSCLC with M.P.E: Prognosis
•
•
•
Patients with M.P.E. (without other metastatic disease) had a
median OS of 8 months
Versus 13 months of other cT4 M0
Versus 6 months of patients with distant metastases
Postmus, JTO 2007
NSCLC with M.P.E: Prognosis
TNM staging
Six Edition:
TNM staging
Seventh Edition:
T4
(Stage III B)
M1 a
(Stage IV)
Goldstraw, JTO 2007
NSCLC with M.P.E: Prognosis
TNM staging
Six Edition:
T4
If III
P.E. isB)cytologically negative.
(Stage
and is evaluated as not related to
the tumor by clinical judgment,
patient should be classified as
T1, T2, T3, T4.
TNM staging
Seventh Edition:
M1 a
(Stage IV)
Goldstraw, JTO 2007
Malignant Pleural Effusion
And
Treatment
M.P.E. and Treatment
1)
THERAPEUTIC THORACENTESIS
2)
PLEURODESIS
M.P.E. and Treatment
1)
THERAPEUTIC THORACENTESIS
2)
PLEURODESIS
Management of MPE is palliative...
M.P.E. and Treatment
When to proceed with treatment of
Pleural Effusion?
M.P.E. and Treatment
When to proceed with treatment of
Pleural Effusion?
Patient
is symptomatic
(for dyspnea or cough or chest pain), and
symptoms are considered to be caused from
pleural effusion.
Patient is not suitable for
specific cancer
treatment (eg. chemotherapy), or Pleural
Effusion is resistant to specific cancer treatment.
M.P.E. and Treatment
Is patient symptomatic?
M.P.E. and Treatment
Is patient symptomatic?
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
Yes
Therapeutic Thoracentesis
No
No intervention
M.P.E. and Treatment
THERAPEUTIC THORACENTESIS
 Symptoms can improve after thoracentesis
 But 98% to 100% of patients experience
reaccumulation of fluid and recurrence of
symptoms within 30 days
M.P.E. and Treatment
THERAPEUTIC THORACENTESIS
 Symptoms can improve after thoracentesis
 But 98% to 100% of patients experience
reaccumulation of fluid and recurrence of
symptoms within 30 days
Repeated
THORACENTESES
PLEURODESIS
M.P.E. and Treatment
THERAPEUTIC THORACENTESIS
 Symptoms can improve after thoracentesis
 But 98% to 100% of patients experience
reaccumulation of fluid and recurrence of
symptoms within 30 days
Repeated
THORACENTESES
PLEURODESIS
M.P.E. and Treatment
PLEURODESIS
Selection of patients should be based on:.
1 Patient’s characteristics
2 Tumor’s characteristics
M.P.E. and Treatment
PLEURODESIS
Selection of patients should be based on:.
1 Patient characteristics
“Does the patient’s life
expectancy warrant
pleurodesis?” *
(PS has the most value)
2 Tumor characteristics
* 32% of p. do not survive 30 days after pleurodesis
M.P.E. and Treatment
PLEURODESIS
Selection of patients should be based on:.
1 Patient characteristics
“Does the patient’s life
expectancy warrant
pleurodesis?” *
(PS has the most value)
2 Tumor characteristics
* 32% of p. do not survive 30 days after pleurodesis
M.P.E. and Treatment
PLEURODESIS
Pleural Effusion is unlikely to respond to
pleurodesis if:

There is an airway obstruction from an
endobronchial tumor (the lung does not expand
to the chest wall after therapeutic thoracentesis)
Effusion is multiloculated
 There are large tumor masses along pleural surfaces
M.P.E. and Treatment
PLEURODESIS
Chest-catheter Pleurodesis
Thoracoscopic Pleurodesis
TALC is considered a superior pleurodesis agent
when compared with other commonly used sclerosant
(as Bleomycin or tetracycline)
Cochrane Review, 2004
M.P.E. and Treatment
Is patient symptomatic?
Yes
Therapeutic Thoracentesis
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
No
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
No
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
Yes
Adequate Re-expansion?
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
No
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
Yes
Adequate Re-expansion?
Yes
Good PS?
No
No intervention
M.P.E. and Treatment
Is patient symptomatic?
No
No intervention
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
No
Yes
Adequate Re-expansion?
Yes
Good PS?
Yes
Pleurodesis
M.P.E. and Treatment
Is patient symptomatic?
No
No intervention
Yes
Therapeutic Thoracentesis
Improvement in symptoms?
No
Yes
Adequate Re-expansion?
No
Yes
Good PS?
Yes
Pleurodesis
M.P.E. and Treatment
No
Is patient symptomatic?
No intervention
Yes
Therapeutic Thoracentesis
No
Improvement in symptoms?
Yes
Adequate Re-expansion?
Yes
Good PS?
No
No
Yes
Pleurodesis
M.P.E. and Treatment
No
Is patient symptomatic?
No intervention
Yes
Therapeutic Thoracentesis
No
Improvement in symptoms?
Yes
Adequate Re-expansion?
Yes
Good PS?
Repeated Thoracentesis
No
No
Pleural Catheter
Yes
Pleurodesis
M.P.E. and Treatment
Repeated
THORACENTESES
Should be reserved for patients who:
(1) Appear unlikely to survive beyond 1 to 3 months
(2) Cannot tolerate other more interventional
procedures to control pleural fluid, such as pleurodesis.
(3) Have a PE that does not respond to pleurodesis
M.P.E. and Treatment
Repeated
THORACENTESES
Should be reserved for patients who:
(1) Appear unlikely to survive beyond 1 to 3 months
(2) Cannot tolerate other more interventional
procedures to control pleural fluid, such as pleurodesis.
(3) Have a PE that does not respond to pleurodesis
...OR...
(4) Have cancers that commonly respond to therapy
with resolution of the associated effusions
M.P.E. and Treatment
No
Is patient symptomatic?
No intervention
Yes
Therapeutic Thoracentesis
No
Improvement in symptoms?
Yes
Adequate Re-expansion?
Yes
Good PS?
Repeated Thoracentesis
No
No
Pleural Catheter
Yes
Pleurodesis