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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