Diagnosis and Diagnosis and Management of Management of

Malignant Pleural Malignant Pleural EffusionEffusion

衛生署桃園醫院內科加護病房主任衛生署桃園醫院內科加護病房主任莊子儀醫師莊子儀醫師

20062006 年年 77月月 2020 日日

Etiology of Malignant Etiology of Malignant EffusionEffusion

Lung cancer: 37.5%, especially adenocLung cancer: 37.5%, especially adenocarcinomaarcinoma

Breast cancer: 16.8%Breast cancer: 16.8% Lymphoma: 11.5%, most common in yLymphoma: 11.5%, most common in y

oung adultoung adult

Etiology of Malignant Etiology of Malignant EffusionEffusion

Increasing production of effusion:Increasing production of effusion: Increasing vascular permeability: invasion of pIncreasing vascular permeability: invasion of p

leural vessels by tumor, cytokines, injury, infeleural vessels by tumor, cytokines, injury, infection etc.ction etc.

Increasing vascular hydrostatic gradient: decreIncreasing vascular hydrostatic gradient: decreased pleural pressure by atelectasis, increased ased pleural pressure by atelectasis, increased venous pressure by SVC syndrome, decreased venous pressure by SVC syndrome, decreased plasma osmotic pressure by hypoalbuminemiaplasma osmotic pressure by hypoalbuminemia

Nonvascular entry by thoracic duct: chylothorNonvascular entry by thoracic duct: chylothoraxax

Etiology of Malignant Etiology of Malignant EffusionEffusion

Decreasing exit of effusion:Decreasing exit of effusion: Increasing resistance to lymphatic flow: iIncreasing resistance to lymphatic flow: i

nfiltration of parietal pleura or mediastinanfiltration of parietal pleura or mediastinal lymph nodes by tumor seedingl lymph nodes by tumor seeding

Increasing gradient opposing lymphatic flIncreasing gradient opposing lymphatic flow: decreased pleural pressure by atelectaow: decreased pleural pressure by atelectasis, increased venous pressure by SVC synsis, increased venous pressure by SVC syndromedrome

Clinical PresentationClinical Presentation

DyspneaDyspnea CoughCough Chest painChest pain

Radiographic EvaluationRadiographic Evaluation

Chest X-rayChest X-ray

Chest X-rayChest X-ray

Amount of pleural effusionAmount of pleural effusion More than 2/3 hemithorax or even entire More than 2/3 hemithorax or even entire

hemithoraxhemithorax 55% of large and massive effusions55% of large and massive effusions Other causes: empyema and TB effusionOther causes: empyema and TB effusion

ss Cytology diagnosis of large and small effCytology diagnosis of large and small eff

usions: no significant difference (63% vs.usions: no significant difference (63% vs. 53%) 53%)

Chest X-rayChest X-ray

Mediastinum positionMediastinum position Shift away from a large effusionShift away from a large effusion Midline mediastinum in large effusion:Midline mediastinum in large effusion:

significant lung collapse, fixed medias significant lung collapse, fixed mediastinum LAPtinum LAP

Shift toward a large effsuion: trapped lShift toward a large effsuion: trapped lung due to main-stem bronchial obstrung due to main-stem bronchial obstructionuction

Radiographic EvaluationRadiographic Evaluation

Chest X-rayChest X-ray Chest CTChest CT

Chest CTChest CT

Pleural surfaces, lung parenchyma, chest Pleural surfaces, lung parenchyma, chest wall and mediastinumwall and mediastinum

Malignant pleural disease: pleural thickenMalignant pleural disease: pleural thickening (>1 cm), irregularity, nodulesing (>1 cm), irregularity, nodules

Pleural thickening: also seen in empyemaPleural thickening: also seen in empyema Pleural nodules: only 17% in malignant efPleural nodules: only 17% in malignant ef

fusionsfusions Other features: lung mass, chest wall invoOther features: lung mass, chest wall invo

lvement, mediastinal LAP, hepatic metastlvement, mediastinal LAP, hepatic metastasesases

Radiographic EvaluationRadiographic Evaluation

Chest X-rayChest X-ray Chest CT Chest CT Chest echoChest echo

Chest EchoChest Echo

Pleural surfaces, lung parenchyma, chPleural surfaces, lung parenchyma, chest wall and pleural effusionest wall and pleural effusion

Pleural effusion: echo-freePleural effusion: echo-free Pleural thickening and nodulesPleural thickening and nodules Echo-guide thoracocentesisEcho-guide thoracocentesis Echo-guide pleural biopsyEcho-guide pleural biopsy

DiagnosisDiagnosis

Pleural effusionPleural effusion CytologyCytology PathologyPathology

Pleural effusionPleural effusion

Grossly bloody: most common cause oGrossly bloody: most common cause of bloody effusionf bloody effusion

Serosanguineous effusionSerosanguineous effusion Cell differentiation: lymphocytes predCell differentiation: lymphocytes pred

ominantominant Eosinophilia: can not exclude malignaEosinophilia: can not exclude maligna

nt effusionnt effusion

Pleural effusionPleural effusion

Almost always exudateAlmost always exudate Lactate dehydrogenase (LDH): increasLactate dehydrogenase (LDH): increas

ed cell turnover and lysised cell turnover and lysis Low glucose concentration and low pH Low glucose concentration and low pH

level: possible shorter survivallevel: possible shorter survival pH < 7.20: easily failure of pleurodesispH < 7.20: easily failure of pleurodesis

CytologyCytology

Adenocarcinoma: most likely to be posAdenocarcinoma: most likely to be positiveitive

Low pH: greater tumor burdenLow pH: greater tumor burden Cytology diagnosis of large and small eCytology diagnosis of large and small e

ffusions: no significant difference (63ffusions: no significant difference (63% vs. 53%)% vs. 53%)

Body fluid + cell blockBody fluid + cell block

PathologyPathology

Pleural biopsyPleural biopsy Closed needle biopsyClosed needle biopsy Cope needleCope needle Abrams needleAbrams needle Urocut needleUrocut needle

Cope NeedleCope Needle

Abrams NeedleAbrams Needle

Urocut NeedleUrocut Needle

Diagnostic ProceduresDiagnostic Procedures

Diagnostic thoracocentesis under echo-guiDiagnostic thoracocentesis under echo-guidede Send pleural effusion for routine, BCS (LDH, prSend pleural effusion for routine, BCS (LDH, pr

otein, glucose), Gram/AFB stain, cytology, B/C, otein, glucose), Gram/AFB stain, cytology, B/C, plus ABG (for pH)plus ABG (for pH)

Pleural biopsy under echo-guidePleural biopsy under echo-guide Send pleura for pathology and TB tissue/CSend pleura for pathology and TB tissue/C

Therapeutic thoracocentesis under echo-guTherapeutic thoracocentesis under echo-guideide Send pleural effusion for body fluid + cell blockSend pleural effusion for body fluid + cell block

Primary Tumor (T)Primary Tumor (T)

T4: T4: A tumor of any size with invasion of the A tumor of any size with invasion of the

mediastinum, or involving heart, great vemediastinum, or involving heart, great vessels, trachea, esophagus, vertebral bodissels, trachea, esophagus, vertebral bodies, carina, es, carina,

or with the presence of malignant pleuraor with the presence of malignant pleural/pericardial effusion, l/pericardial effusion,

or exudative pleural effusion without evior exudative pleural effusion without evidence of obstructive pneumonitis, dence of obstructive pneumonitis,

or with satellite tumor within the lobe of or with satellite tumor within the lobe of primary tumor at chest CTprimary tumor at chest CT

ManagementManagement

Symptom-oriented managementSymptom-oriented management Less than 1/3 hemithorax, C/T sensitive tumLess than 1/3 hemithorax, C/T sensitive tum

oror C/T at first, F/U regularlyC/T at first, F/U regularly

Slowly recurring effusion, short life spanSlowly recurring effusion, short life span Repeated therapeutic thoracocentesisRepeated therapeutic thoracocentesis

More than 2/3 hemithorax, no airway obstruMore than 2/3 hemithorax, no airway obstructionction Pigtail insertion for pleurodesis within 24 hoursPigtail insertion for pleurodesis within 24 hours

ManagementManagement

Before pleurodesisBefore pleurodesis Daily drainage amount < 100-150 mlDaily drainage amount < 100-150 ml Confirm with chest echoConfirm with chest echo Ability of lung re-expansionAbility of lung re-expansion

Chemical pleurodesisChemical pleurodesis Mnocycline injectionMnocycline injection Beta-iodine injectionBeta-iodine injection OK-432 injectionOK-432 injection

ManagementManagement

Pre-medicationPre-medication 2% xylocaine 10ml in 50ml normal saline2% xylocaine 10ml in 50ml normal saline

Minocycline injectionMinocycline injection After 15 minutes, 300mg Minocycline in 5After 15 minutes, 300mg Minocycline in 5

0ml normal saline 0ml normal saline Clamp catheter/tube, change position 2-6 Clamp catheter/tube, change position 2-6

hourshours Unclamp catheter/tube, low pressure suctUnclamp catheter/tube, low pressure suct

ionion

ManagementManagement

Pre-medicationPre-medication 2% xylocaine 10ml in 50ml normal saline2% xylocaine 10ml in 50ml normal saline

Beta-iodine injectionBeta-iodine injection After 15 minutes, 10 ml beta-iodine in 40mAfter 15 minutes, 10 ml beta-iodine in 40m

l normal saline l normal saline Clamp catheter/tube, change position 2-6 Clamp catheter/tube, change position 2-6

hourshours Unclamp catheter/tube, low pressure suctUnclamp catheter/tube, low pressure suct

ionion

ManagementManagement

Indwelling catheterIndwelling catheter Good outpatient situationGood outpatient situation Good for trapped lungGood for trapped lung

Pigtail catheter with drainage bagPigtail catheter with drainage bag Chest tube with Heimlich valveChest tube with Heimlich valve

ManagementManagement

ComplicationComplication

Re-expansion lung edemaRe-expansion lung edema EmpyemaEmpyema Restricted lung diseaseRestricted lung disease Trapped lungTrapped lung

PrognosisPrognosis

Medium survivalMedium survival Lung cancer with malignant effusion: 3 mLung cancer with malignant effusion: 3 m

onthsonths Breast cancer with malignant effusion: 5 Breast cancer with malignant effusion: 5

monthsmonths Mesothelioma with malignant effusion: 6 Mesothelioma with malignant effusion: 6

monthsmonths Lymphoma with malignant effusion: 9 moLymphoma with malignant effusion: 9 mo

nthsnths

Thank You for AttentionThank You for Attention

Reference:Reference: Murray and Nadel’s Textbook of RespMurray and Nadel’s Textbook of Resp

iratory Medicine, 4th edition, 2005iratory Medicine, 4th edition, 2005 Light and Lee’s Textbook of Pleural DLight and Lee’s Textbook of Pleural D

isease, 1st edition, 2003isease, 1st edition, 2003 Mathis and Lessnau’s Atlas of Chest SMathis and Lessnau’s Atlas of Chest S

onography, 1st edition, 2003onography, 1st edition, 2003