Managing Malignant Pleural Effusion, with an Eye on the Future

By Mark Weir, MBChB, MRCP

Malignant pleural effusion (MPE) can be a debilitating manifestation of metastatic cancer—and with patients living longer than ever, treatment for pleural effusion must also be longer-term and thoughtful in its approach. MPE is most commonly seen in lung cancer, lymphoma, breast cancer and ovarian cancer. The most common symptom is breathlessness.

When choosing a therapeutic option, we should take into account patient preference, social support, co-morbidities, presence of trapped lung or septation, prognosis, tumor biology and response to possible future therapy. Effective management should endeavor to minimize hospitalization, interruption of daily life, exposure to complications, and chance of recurrence. Response to initial drainage will give us insight into how much the effusion contributes to the symptom of breathlessness, whether the lung is trapped, and the speed of recurrence.

Malignant pleural effusion can be managed with techniques including pleurodesis, repeat thoracentesis or insertion of a pleural catheter.

Individuals with advanced cancer and poor performance status, and who derive limited benefit from thoracentesis and have slow re-accumulation, should probably be managed conservatively, with palliative care and repeat thoracentesis if needed. Individuals with advanced cancer, reasonable performance status and intermediate prognosis (>1 month), especially those with trapped lung, are good candidates for indwelling pleural catheters (IPCs). Although not to every patient’s liking (and not always covered by insurance), IPCs provide good symptom control, can be inserted via an outpatient procedure and have a relatively low complication rate; the main risk is infection. A new silver nitrate-coated IPC, currently in clinical trials, may even induce rapid pleurodesis while maintaining symptom control. In individuals with good performance status, and for whom chemotherapy may be indicated, we should attempt to achieve pleurodesis and symptom control with minimal hospitalization through medical thoracoscopy under local anesthesia and sedation, combined with talc poudrage and IPC insertion. The IPC can usually be removed after 7–10 days, and 92 percent of patients achieve pleurodesis.1 If combining MPE management with lobectomy or tumor debulking, a video-assisted thoracoscopic surgery (VATS) approach is more appropriate. Tailoring our management techniques may help patients with metastatic cancer lead longer, more comfortable lives.


References

1 Reddy, C., et al. (2011). Rapid pleurodesis for malignant pleural effusions: a pilot study. Chest 139: 1419–1423. doi: 10.1378/chest.10-1868