Semin Respir Crit Care Med 2008; 29(4): 405-413
DOI: 10.1055/s-2008-1081283
© Thieme Medical Publishers

Management of Malignant Pleural Effusions

Marcelo Spector1 , Jeffrey S. Pollak1
  • 1Section of Vascular and Interventional Radiology, Department of Radiology, Yale University School of Medicine, New Haven, Connecticut
Further Information

Publication History

Publication Date:
23 July 2008 (online)

ABSTRACT

Malignant pleural effusions (MPEs) are commonly seen as complications of advanced malignancy, especially in lung cancer and breast cancer. The management will depend on the performance status of the patient, severity of the symptoms, and the primary tumor's response to systemic therapy. Thoracentesis is usually the first step for both diagnostic and therapeutic reasons. Chest tube placement with sclerotherapy is successful in 60 to 90% of cases, but it requires hospitalization for ~1 week. Alternatively, long-term tunneled pleural drainage catheters can be performed on an outpatient basis and are effective in controlling symptoms in 80 to 100% of patients. Additional advantages are the ability to treat trapped lung, large loculated effusions, and bilateral effusions simultaneously, as well as lower charges. Spontaneous pleurodesis can occur in up to 50% of the patients. Tunneled catheters should be considered in all patients with MPE and particularly those who have a reasonable expectancy of being outpatient.

REFERENCES

  • 1 Neragi-Miandoab S. Malignant pleural effusion, current and evolving approaches for its diagnosis and management.  Lung Cancer. 2006;  54 1-9
  • 2 American Thoracic Society . Management of malignant pleural effusions.  Am J Respir Crit Care Med. 2000;  162 1987-2001
  • 3 Antunes G, Neville E, Duffy J, Ali N. BTS guidelines for the management of malignant pleural effusions.  Thorax. 2003;  58(Suppl II) ii29-ii38
  • 4 Grossi F, Pennucci M C, Tixi L, Cafferata M A, Ardizzoni A. Management of malignant pleural effusions.  Drugs. 1998;  55 47-58
  • 5 Tattersall M. Management of malignant pleural effusion.  Aust N Z J Med. 1998;  28 394-396
  • 6 Sears D, Hajdu S I. The cytologic diagnosis of malignant neoplasm in pleural and peritoneal effusions.  Acta Cytol. 1987;  31 85-97
  • 7 van de Molengraft F J, Voojis G P. Survival of patients with malignancy-associated effusions.  Acta Cytol. 1989;  33 911-916
  • 8 Heffner J E, Nietert P J, Barbieri C. Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions.  Chest. 2000;  117 79-86
  • 9 Judson M A, Sahn S A. Pulmonary physiologic abnormalities caused by pleural disease.  Semin Respir Crit Care Med. 1995;  16 346-353
  • 10 Sahn S A. State of the art: the pleura.  Am Rev Respir Dis. 1988;  138 184-234
  • 11 Lynch Jr T J. Management of malignant pleural effusions.  Chest. 1993;  103 (4 Suppl) 385S-389S
  • 12 Canto A, Ferrer G, Ramgosa V et al.. Lung cancer and pleural effusion: clinical significant and study of pleural metastatic locations.  Chest. 1985;  87 649-652
  • 13 Iranai D R, Underwood R D, Johnson E H, Greenberg S D. Malignant pleural effusions: a clinical cytopathologic study.  Arch Intern Med. 1987;  147 1133-1136
  • 14 Johnston W W. The malignant pleural effusion: a review of cytopathologic diagnosis of 584 specimens from 472 consecutive patients.  Cancer. 1985;  56 905-909
  • 15 Ruckdeschel J C. Management of malignant pleural effusion: an overview.  Semin Oncol. 1988;  15 24-28
  • 16 Tarver R D, Broderick L S, Conces D J. Reexpansion pulmonary edema.  J Thorac Imaging. 1996;  11 198-209
  • 17 Mahfood S, Hix W R, Aaron B L et al.. Reexpansion pulmonary edema.  Ann Thorac Surg. 1988;  45 340-345
  • 18 Stretton F, Edmonds P, Marrinan M. Malignant pleural effusions.  Eur J Palliative Care. 1999;  6 5-9
  • 19 Anderson C B, Philpott G W, Ferguson T B. The treatment of malignant effusions.  Cancer. 1974;  33 916-922
  • 20 Izbicki R, Weyhing B T, Baker L et al.. Pleural effusion in cancer patients: a prospective randomized study of pleural drainage with the addition of radioactive phosphorus to the pleural space versus pleural drainage alone.  Cancer. 1975;  36 1511-1518
  • 21 Groth G, Gatzemeier U, Haubingen K et al.. Intrapleural palliative treatment of malignant pleural effusions with mitoxantrone versus placebo (pleural tube alone).  Ann Oncol. 1991;  2 213-215
  • 22 Antony V B. Pathogenesis of malignant pleural effusions and talc pleurodesis.  Pneumologie. 1999;  53 493-498
  • 23 Hewitt J B, Janssen W R. A management strategy for malignancy-induced pleural effusion: long-term thoracostomy drainage.  Oncol Nurs Forum. 1987;  14 17-22
  • 24 Patz E F, McAdams H P, Goodman P C et al.. Ambulatory sclerotherapy for malignant pleural effusions.  Radiology. 1996;  199 133-135
  • 25 Parker L A, Charnock G C, Delany D J. Small bore catheter drainage and sclerotherapy for malignant pleural effusions.  Cancer. 1989;  64 1218-1221
  • 26 Morrison M C, Mueller P R, Lee M J et al.. Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters.  AJR Am J Roentgenol. 1992;  158 41-43
  • 27 Seaton K G, Patz Jr E F, Goodman P C. Palliative treatment of malignant pleural effusions: value of small-bore catheter thoracostomy and doxycycline sclerotherapy.  AJR Am J Roentgenol. 1995;  164 589-591
  • 28 Patz Jr E F, McAdams H P, Erasmus J J et al.. Sclerotherapy for malignant pleural effusions: a prospective randomized trial of bleomycin vs doxycycline with small-bore catheter drainage.  Chest. 1998;  113 1305-1311
  • 29 Clementsen P, Evald T, Grode G et al.. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study.  Respir Med. 1998;  92 593-596
  • 30 Adler R H, Sayek I. Treatment of malignant pleural effusion: a method using tube thoracostomy and talc.  Ann Thorac Surg. 1976;  22 8-15
  • 31 Villanueva A G, Gray Jr A W, Shahian D M et al.. Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.  Thorax. 1994;  49 23-25
  • 32 Tan C, Sedrakyan A, Browne J, Swift S, Treasure T. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review.  Eur J Cardiothorac Surg. 2006;  29 829-838
  • 33 Zimmer P W, Hill M, Casey K et al.. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions.  Chest. 1997;  112 430-434
  • 34 Lynch Jr T J, Kalish L, Mentzer S J et al.. Optimal therapy of malignant pleural effusions: report of a randomized trial of bleomycin, tetracycline and talc and a meta-analysis.  Int J Oncol. 1996;  8 183-190
  • 35 Sherman S, Grady K J, Seidman J C. Clinical experience with tetracycline pleurodesis of malignant pleural effusions.  South Med J. 1987;  80 716-719
  • 36 Bayly T C, Kisner D L, Sybert A et al.. Tetracycline and quinacrine in the control of malignant pleural effusions: a randomized trial.  Cancer. 1978;  41 1188-1192
  • 37 Martinez-Moragon E, Aparicio J, Rogado M C et al.. Pleurodesis in malignant pleural effusions: a randomized study of tetracycline versus bleomycin.  Eur Respir J. 1997;  10 2380-2383
  • 38 Kennedy L, Rusch V W, Strange C et al.. Pleurodesis using talc slurry.  Chest. 1994;  106 342-346
  • 39 Webb W R, Ozmen V, Moulder P V et al.. Iodized talc pleurodesis for the treatment of pleural effusions.  J Thorac Cardiovasc Surg. 1992;  103 881-885
  • 40 Weissberg D, Ben-Zeev I. Talc pleurodesis: experience with 360 patients.  J Thorac Cardiovasc Surg. 1993;  106 689-695
  • 41 Bitran J D, Brown C, Desser R K et al.. Intracavitary bleomycin for the control of malignant effusions.  J Surg Oncol. 1981;  16 273-277
  • 42 Ostrowski M J, Halsall G M. Intracavitary bleomycin in the management of malignant effusions: a multicenter study.  Cancer Treat Rep. 1982;  66 1903-1907
  • 43 Heffner J E, Standerfer R J, Torstveit J et al.. Clinical efficacy of doxycycline for pleurodesis.  Chest. 1994;  105 1743-1747
  • 44 Lorch D G, Gordon L, Wooten S et al.. Effect of patient positioning on distribution of tetracycline in the pleural space during pleurodesis.  Chest. 1988;  93 527-529
  • 45 Dryzer S R, Allen M L, Strange C, Sahn S H. A comparison of rotation and nonrotation in tetracycline pleurodesis.  Chest. 1993;  104 1763-1766
  • 46 Dresler C M, Olak J, Herndon II J E et al.. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.  Chest. 2005;  127 909-915
  • 47 Sahn S A. Pleural diseases related to metastatic malignancies.  Eur Respir J. 1997;  10 1907-1913
  • 48 Yim A P, Chan A T, Lee T W et al.. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion.  Ann Thorac Surg. 1996;  62 1655-1658
  • 49 Robinson L A, Fleming W H, Galbraith T A. Intrapleural doxycycline control of malignant pleural effusions.  Ann Thorac Surg. 1993;  55 1115-1121
  • 50 Pulsiripunya C, Youngchaiud P, Pushpakom R et al.. The efficacy of doxycycline as a pleural sclerosing agent in malignant pleural effusion: a prospective study.  Respirology. 1996;  1 69-72
  • 51 Janssen J P, Collier G, Astoul P et al.. Safety of pleurodesis with talc poudrage in malignant pleural effusion: a prospective cohort study.  Lancet. 2007;  369 1535-1539
  • 52 Hsu L H, Soong T C, Feng A C, Liu M C. Intrapleural urokinase for the treatment of loculated malignant pleural effusions and trapped lungs in medically inoperable cancer patients.  J Thorac Oncol. 2006;  1 460-467
  • 53 Jerjes-Sanchez C, Ramirez-Rivera A, Elizalde J J et al.. Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema.  Chest. 1996;  109 1514-1519
  • 54 Davies C WH, Traill Z C, Gleeson F V et al.. Intrapleural streptokinase in the management of malignant multiloculated pleural effusions.  Chest. 1999;  115 729-733
  • 55 Leff R S, Eisenberg B, Baisden C E, Mosley K R, Messerschmidt G L. Drainage of recurrent pleural effusion via an implanted port and intrapleural catheter.  Ann Intern Med. 1986;  104 208-209
  • 56 Zeldin D C, Rodriguez R M, Glassford D M, Cutrell G, Newman J H. Management of refractory MPEs with a chronic indwelling pleural catheter.  Chest. 1991;  100 87S
  • 57 Robinson R D, Fullerton D A, Albert J D, Sorensen J, Johnston M R. Use of pleural Tenckhoff catheter to palliate malignant pleural effusion.  Ann Thorac Surg. 1994;  57 286-288
  • 58 Putnam Jr J B, Light R W, Rodriguez R M et al.. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions.  Cancer. 1999;  86 1992-1999
  • 59 Putnam Jr J B, Walsh G L, Swisher S G et al.. Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter.  Ann Thorac Surg. 2000;  69 369-375
  • 60 Smart J M, Tung K T. Initial experiences with a long-term indwelling tunnelled pleural catheter for the management of malignant pleural effusion.  Clin Radiol. 2000;  55 882-884
  • 61 Pollak J S, Burdge C M, Rosenblatt M, Houston J P, Hwu W J, Murren J. Treatment of malignant pleural effusions with tunneled long-term drainage catheters.  J Vasc Interv Radiol. 2001;  12 201-208
  • 61a Musani A I, Haas A, Seijo L et al.. Outpatient management of malignant pleural effusions with a tunneled pleural catheter: pleurodesis without sclerosing agents.  Respiration. 2004;  71 559-566
  • 62 Pien G W, Gant M J, Washam C L, Sterman D H. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion.  Chest. 2001;  119 1641-1646
  • 63 Ohm C, Park D, Vogen M et al.. Use of an indwelling pleural catheter compared with thorascopic talc pleurodesis in the management of pleural effusions.  Am Surg. 2003;  69 198-202 discussion 202
  • 64 Tremblay A, Michaud G. Single-center experience with 250 tunneled pleural catheter insertions for malignant pleural effusion.  Chest. 2006;  129 362-368
  • 65 Reed Jr D N, Vyskocil J J, Rao V. Subcutaneous access ports with fenestrated catheters for improved management of recurrent pleural effusions.  Am J Surg. 1999;  177 145-146
  • 66 Daniel C, Kriegel I, Di Maria S et al.. Use of a pleural implantable access system for the management of malignant pleural effusion: the Institut Curie experience.  Ann Thorac Surg. 2007;  84 1367-1370

Marcelo SpectorM.D. 

Section of Vascular and Interventional Radiology, Department of Radiology, Yale University School of Medicine

P.O. Box 208042, New Haven, CT 06520-8042

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