Download PDF
Semin Respir Crit Care Med 2018; 39(06): 704-712
DOI: 10.1055/s-0038-1676572
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Malignant Pleural Effusions: Management Options

David J. McCracken
1   Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
2   Oxford Respiratory Trials Unit, Oxford, United Kingdom
,
Jose M. Porcel
3   Pleural Medicine Unit, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
,
Najib M. Rahman
1   Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
2   Oxford Respiratory Trials Unit, Oxford, United Kingdom
4   Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
› Author Affiliations
Further Information

Publication History

Publication Date:
14 January 2019 (online)

    Permissions and Reprints

Abstract

Malignant pleural effusion (MPE) represents advanced metastatic malignancy and is associated with poor median survival. Incidence remains high and continues to rise, in part due to changing population demographics. This therefore represents a significant health care burden. Management is predominantly palliative in nature and multiple interventions are available within conventional treatment paradigms, all of which are proven to result in statistically significant patient benefit. This article further explores the methods available in the management of MPE along with the pitfalls, complications, and alternatives. Recent advances within the field are discussed with an exploration of likely future directions, including the role of ultrasound as a prospective predictor and the role of intrapleural fibrinolytic therapy.

Keywords

malignant pleural effusion - talc pleurodesis - indwelling pleural catheter - palliative - care - unexpandable lung - autopleurodesis - thoracic ultrasound
 

  • References

  • 1 Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ. ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 02) ii32-ii40
    PubMedGoogle Scholar
  • 2 Clive AO, Kahan BC, Hooper CE. , et al. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax 2014; 69 (12) 1098-1104
    CrossrefPubMedGoogle Scholar
  • 3 Psallidas I, Kanellakis NI, Gerry S. , et al. Development and validation of response markers to predict survival and pleurodesis success in patients with malignant pleural effusion (PROMISE): a multicohort analysis. Lancet Oncol 2018; 19 (07) 930-939
    CrossrefPubMedGoogle Scholar
  • 4 Cancer Research UK. Worldwide Cancer Incidence Statistics. Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics/worldwide-cancer/incidence . Accessed August 2018
    PubMedGoogle Scholar
  • 5 Cancer Research UK. Cancer Incidence Statistics. Available at: http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence . Accessed May 2018
    PubMed
  • 6 Cancer Research UK. Mesothelioma Statistics. Available at: http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/mesothelioma . Accessed August 2018
    PubMed
  • 7 Corcoran JP, Hallifax RJ, Talwar A, Psallidas I, Sykes A, Rahman NM. Intercostal chest drain insertion by general physicians: attitudes, experience and implications for training, service and patient safety. Postgrad Med J 2015; 91 (1075): 244-250
    CrossrefPubMedGoogle Scholar
  • 8 Davies HE, Mishra EK, Kahan BC. , et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 2012; 307 (22) 2383-2389
    CrossrefPubMedGoogle Scholar
  • 9 Thomas R, Fysh ETH, Smith NA. , et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: the AMPLE randomized clinical trial. JAMA 2017; 318 (19) 1903-1912
    CrossrefPubMedGoogle Scholar
  • 10 Razazi K, Thille AW, Carteaux G. , et al. Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc 2014; 11 (07) 1018-1024
    CrossrefPubMedGoogle Scholar
  • 11 Goligher EC, Leis JA, Fowler RA, Pinto R, Adhikari NK, Ferguson ND. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2011; 15 (01) R46
    CrossrefPubMedGoogle Scholar
  • 12 Wang LM, Cherng JM, Wang JS. Improved lung function after thoracocentesis in patients with paradoxical movement of a hemidiaphragm secondary to a large pleural effusion. Respirology 2007; 12 (05) 719-723
    CrossrefPubMedGoogle Scholar
  • 13 Clive AO, Bhatnagar R, Psallidas I, Maskell NA. Individualised management of malignant pleural effusion. Lancet Respir Med 2015; 3 (07) 505-506
    CrossrefPubMedGoogle Scholar
  • 14 Havelock T, Teoh R, Laws D, Gleeson F. ; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 02) ii61-ii76
    PubMedGoogle Scholar
  • 15 Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007; 84 (05) 1656-1661
    CrossrefPubMedGoogle Scholar
  • 16 Josephson T, Nordenskjold CA, Larsson J, Rosenberg LU, Kaijser M. Amount drained at ultrasound-guided thoracentesis and risk of pneumothorax. Acta Radiol 2009; 50 (01) 42-47
    CrossrefPubMedGoogle Scholar
  • 17 Psallidas I, Yousuf A, Talwar A. , et al. Assessment of patient-reported outcome measures in pleural interventions. BMJ Open Respir Res 2017; 4 (01) e000171
    CrossrefPubMedGoogle Scholar
  • 18 Lee YC, Light RW. Management of malignant pleural effusions. Respirology 2004; 9 (02) 148-156
    CrossrefPubMedGoogle Scholar
  • 19 Rahman NM, Pepperell J, Rehal S. , et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion: the TIME1 randomized clinical trial. JAMA 2015; 314 (24) 2641-2653
    CrossrefPubMedGoogle Scholar
  • 20 Clive AO, Jones HE, Bhatnagar R, Preston NJ, Maskell N. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2016; (05) CD010529
    PubMedGoogle Scholar
  • 21 Anderson CB, Philpott GW, Ferguson TB. The treatment of malignant pleural effusions. Cancer 1974; 33 (04) 916-922
    CrossrefPubMedGoogle Scholar
  • 22 Bhatnagar R, Laskawiec-Szkonter M, Piotrowska HEG. , et al. Evaluating the efficacy of thoracoscopy and talc poudrage versus pleurodesis using talc slurry (TAPPS trial): protocol of an open-label randomised controlled trial. BMJ Open 2014; 4 (11) e007045
    CrossrefPubMedGoogle Scholar
  • 23 Psallidas I, Piotrowska HEG, Yousuf A. , et al. Efficacy of sonographic and biological pleurodesis indicators of malignant pleural effusion (SIMPLE): protocol of a randomised controlled trial. BMJ Open Respir Res 2017; 4 (01) e000225
    PubMedGoogle Scholar
  • 24 Zhu Z, Donnelly E, Dikensoy O. , et al. Efficacy of ultrasound in the diagnosis of pleurodesis in rabbits. Chest 2005; 128 (02) 934-939
    CrossrefPubMedGoogle Scholar
  • 25 Salamonsen MR, Lo AKC, Ng ACT, Bashirzadeh F, Wang WYS, Fielding DIK. Novel use of pleural ultrasound can identify malignant entrapped lung prior to effusion drainage. Chest 2014; 146 (05) 1286-1293
    CrossrefPubMedGoogle Scholar
  • 26 Corcoran JP, Talwar A, Hallifax RJ, Psallidas I, Wrightson JM, Rahman NM. P2 Incorporation of an in-depth thoracic ultrasound assessment into routine pre-procedural evaluation of patients with pleural effusions. Thorax 2016; 71 (Suppl. 03) A83-A4
    PubMedGoogle Scholar
  • 27 Wahidi MM, Reddy C, Yarmus L. , et al. Randomized trial of pleural fluid drainage frequency in patients with malignant pleural effusions. The ASAP trial. Am J Respir Crit Care Med 2017; 195 (08) 1050-1057
    CrossrefPubMedGoogle Scholar
  • 28 Bhatnagar R, Keenan EK, Morley AJ. , et al. Outpatient talc administration by indwelling pleural catheter for malignant effusion. N Engl J Med 2018; 378 (14) 1313-1322
    CrossrefPubMedGoogle Scholar
  • 29 Penz ED, Mishra EK, Davies HE, Manns BJ, Miller RF, Rahman NM. Comparing cost of indwelling pleural catheter vs talc pleurodesis for malignant pleural effusion. Chest 2014; 146 (04) 991-1000
    CrossrefPubMedGoogle Scholar
  • 30 Bhatnagar R, Corcoran JP, Maldonado F. , et al. Advanced medical interventions in pleural disease. Eur Respir Rev 2016; 25 (140) 199-213
    CrossrefPubMedGoogle Scholar
  • 31 Corcoran JP, Rahman NM. Picking the winners: outcome prediction in pleural disease. Respirology 2018; 23 (06) 558-559
    CrossrefPubMedGoogle Scholar
  • 32 Leemans J, Dooms C, Ninane V, Yserbyt J. Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: a single-centre experience. Respirology 2018; 23 (06) 613-617
    CrossrefPubMedGoogle Scholar
  • 33 Merrick C, Asciak R, Edey A, Maldonado F, Psallidas I. Pleural effusion. Eur Respir Monogr 2018; 79: 64-74
    PubMedGoogle Scholar
  • 34 McNicholl DM, Stevenson M, McGarvey LP, Heaney LG. The utility of fractional exhaled nitric oxide suppression in the identification of nonadherence in difficult asthma. Am J Respir Crit Care Med 2012; 186 (11) 1102-1108
    CrossrefPubMedGoogle Scholar
  • 35 Hollevoet K, Reitsma JB, Creaney J. , et al. Serum mesothelin for diagnosing malignant pleural mesothelioma: an individual patient data meta-analysis. J Clin Oncol 2012; 30 (13) 1541-1549
    CrossrefPubMedGoogle Scholar
  • 36 Mishra EK, Clive AO, Wills GH. , et al. Randomized controlled trial of urokinase versus placebo for nondraining malignant pleural effusion. Am J Respir Crit Care Med 2018; 197 (04) 502-508
    CrossrefPubMedGoogle Scholar
  • 37 Rahman NM, Maskell NA, West A. , et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365 (06) 518-526
    CrossrefPubMedGoogle Scholar
  • 38 Saydam O, Karapinar K, Gokce M. , et al. The palliative treatment with intrapleural streptokinase in patients with multiloculated malignant pleural effusion: a double-blind, placebo-controlled, randomized study. Med Oncol 2015; 32 (06) 612
    PubMedGoogle Scholar
  • 39 Okur E, Baysungur V, Tezel C, Ergene G, Okur HK, Halezeroglu S. Streptokinase for malignant pleural effusions: a randomized controlled study. Asian Cardiovasc Thorac Ann 2011; 19 (3-4): 238-243
    CrossrefPubMedGoogle Scholar
  • 40 Davies CW, Traill ZC, Gleeson FV, Davies RJ. Intrapleural streptokinase in the management of malignant multiloculated pleural effusions. Chest 1999; 115 (03) 729-733
    CrossrefPubMedGoogle Scholar
  • 41 Bibby AC, Dorn P, Psallidas I. , et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J 2018; 52 (01) 52
    CrossrefPubMedGoogle Scholar