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.)Malignant Pleural Effusion (M.P.E.)

““An M.P.E. is defined by the An M.P.E. is defined by the presence of presence of cancer cellscancer cells in the in the

pleural spacepleural space””



pleural spacepleural space””Underlying Primary CancerUnderlying Primary Cancer

1.1.Lung tumors Lung tumors (including malignant (including malignant

pleural mesothelioma) pleural mesothelioma) NSCLC:NSCLC: 14% at 14% at

the time of diagnosis, 50% with advanced the time of diagnosis, 50% with advanced

diseasedisease

2.2. Breast cancerBreast cancer

3.3. Ovarian cancer, gastric cancerOvarian cancer, gastric cancer

4.4. Hodgkin’s and non-Hodgkin’s lymphomaHodgkin’s and non-Hodgkin’s lymphoma



pleural spacepleural space””

Cancer cells reach theCancer cells reach the visceral pleuravisceral pleura (through(through the the

pulmonary vasculature)or thepulmonary vasculature)or the parietal pleuraparietal pleura (through (through

hematogenous spreadhematogenous spread)

Cancer cells in the pleural spaceCancer cells in the pleural space

(tumor deposit along parietal pleura)(tumor deposit along parietal pleura)

A.A. Obstruct lymphatic stromata (which drain intrapleural Obstruct lymphatic stromata (which drain intrapleural

fluid)fluid)

B.B. Release chemockines ( increasing vascular permeability)Release chemockines ( increasing vascular permeability)


≠≠ Paramalignant EffusionParamalignant Effusion1.1. Mediastinal lymph node tumor infiltration Mediastinal lymph node tumor infiltration

2. 2. Bronchial obstruction/AtelectasisBronchial obstruction/Atelectasis

3. 3. Pulmonary embolismPulmonary embolism

4.4. “Superior vena cava syndrome” “Superior vena cava syndrome”

5. 5. Decreased oncotic pressure (cachexia)Decreased oncotic pressure (cachexia)

6.6. Radiotherapy/Chemotherapy Radiotherapy/Chemotherapy

Malignant Plural EffusionMalignant Plural EffusionAndAnd

DiagnosisDiagnosis

M.P.E. and DiagnosisM.P.E. and Diagnosis

CytologicCytologic or or tissue biopsytissue biopsy confirmation is required to confirmation is required to

establish a diagnosis of MPEestablish a diagnosis of MPE



establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis:Diagnostic thoracentesis:

• Diagnostic yield ofDiagnostic yield of PF cytologyPF cytology ranging from ranging from 62 to 62 to

90%90%

• Positive results on cytology Positive results on cytology might not differentiate might not differentiate

betweenbetween adk subtypes or between pleural adk and adk subtypes or between pleural adk and

mesotheliomamesothelioma

• Additional PF studiesAdditional PF studies could complement standard could complement standard

cytology: Electrochetoluminescence forcytology: Electrochetoluminescence for tumor tumor

markersmarkers, ,

genetic analysisgenetic analysis



establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis, Diagnostic thoracentesis, if cytology not if cytology not diagnostic:diagnostic:



establish a diagnosis of MPEestablish a diagnosis of MPEDiagnostic thoracentesis, Diagnostic thoracentesis, if cytology not if cytology not diagnostic:diagnostic:

Pleural Biopsy:Pleural Biopsy: Closed-needle pleural biopsy Closed-needle pleural biopsy (sensitivity of 40-(sensitivity of 40-75%)75%) Ultrasonography Ultrasonography or or chest CT-guided percutaneous chest CT-guided percutaneous pleural biopsy pleural biopsy (higher sensitivities and (higher sensitivities and specificities)specificities)

Medical thoracoscopy, orMedical thoracoscopy, orVideo Assisted Thoracoscopic Surgery (VATS)Video Assisted Thoracoscopic Surgery (VATS)


Is diagnosis with Is diagnosis with cytologycytology or or

histologyhistology always requested (and always requested (and

useful) in our clinical practice?useful) in our clinical practice?


Does the presence of M.P.E. add Does the presence of M.P.E. add prognosticprognostic and and therapeutictherapeutic

informations?informations?


Non Small Cell Lung CancerNon Small Cell Lung Cancer

Does the presence of M.P.E. add Does the presence of M.P.E. add prognosticprognostic and and therapeutictherapeutic

informations?informations?



• Poor PSPoor PS• Known advanced cancerKnown advanced cancer

DIAGNOSIS NOT NECESSARYDIAGNOSIS NOT NECESSARY



• Poor PSPoor PS• Known advanced cancerKnown advanced cancer

DIAGNOSIS NOT NECESSARYDIAGNOSIS NOT NECESSARY

• Good PSGood PS• multimodality treatmentmultimodality treatment

DIAGNOSIS IS CRITICAL DIAGNOSIS IS CRITICAL FOR TREATMENT FOR TREATMENT

PLANNINGPLANNING

NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis• Patients with M.P.E. (without other metastatic disease) Patients with M.P.E. (without other metastatic disease) had a had a median OS of 8 monthsmedian OS of 8 months

• Versus Versus 13 months13 months of other cT4 M0 of other cT4 M0

• Versus Versus 6 months6 months of patients with distant metastases of patients with distant metastases

Postmus, JTO 2007Postmus, JTO 2007

NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis

Goldstraw, JTO 2007Goldstraw, JTO 2007

TNM stagingTNM stagingSix Edition:Six Edition:

T4T4(Stage III B)(Stage III B)

TNM stagingTNM stagingSeventh Edition:Seventh Edition:

M1 aM1 a(Stage IV)(Stage IV)

NSCLC with M.P.E:NSCLC with M.P.E: Prognosis Prognosis

Goldstraw, JTO 2007Goldstraw, JTO 2007

TNM stagingTNM stagingSix Edition:Six Edition:

T4T4(Stage III B)(Stage III B)

TNM stagingTNM stagingSeventh Edition:Seventh Edition:

M1 aM1 a(Stage IV)(Stage IV)If P.E. is If P.E. is cytologically negativecytologically negative. .

and is evaluated as not related and is evaluated as not related to the tumor by clinical to the tumor by clinical

judgment, judgment, patient should be patient should be classified as T1, T2, T3, T4.classified as T1, T2, T3, T4.

Malignant Pleural EffusionMalignant Pleural EffusionAndAnd

TreatmentTreatment

M.P.E. and TreatmentM.P.E. and Treatment

1)1) THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS

2)2) PLEURODESISPLEURODESIS


Management of MPE is Management of MPE is palliative...palliative...

1)1) THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS

2)2) PLEURODESISPLEURODESIS


When to proceed with treatment When to proceed with treatment of Pleural Effusion?of Pleural Effusion?


When to proceed with treatment When to proceed with treatment of Pleural Effusion?of Pleural Effusion?

Patient is symptomaticPatient is symptomatic (for dyspnea or cough or chest pain), (for dyspnea or cough or chest pain), and and symptoms are considered to be caused from symptoms are considered to be caused from pleural effusion.pleural effusion. Patient is not suitable forPatient is not suitable for specific cancer specific cancer treatment (eg. chemotherapy), treatment (eg. chemotherapy), or Pleural or Pleural Effusion is resistant to specific cancer Effusion is resistant to specific cancer treatment.treatment.


Is patient symptomatic?Is patient symptomatic?


Is patient symptomatic?Is patient symptomatic? No interventionNo interventionNoNo


Is patient symptomatic?Is patient symptomatic? No interventionNo intervention

YesYes

NoNo

Therapeutic ThoracentesisTherapeutic Thoracentesis


THERAPEUTIC THERAPEUTIC THORACENTESISTHORACENTESIS Symptoms can improve after Symptoms can improve after

thoracentesisthoracentesis But But 98% to 100%98% to 100% of patients experience of patients experience

reaccumulation of fluidreaccumulation of fluid and and recurrence recurrence

of of

symptomssymptoms within 30 days within 30 days





of of


RepeatedRepeated THORACENTESESTHORACENTESES PLEURODESISPLEURODESIS





of of


RepeatedRepeated THORACENTESESTHORACENTESES PLEURODESISPLEURODESIS


PLEURODESISPLEURODESIS

Selection of patients should be based Selection of patients should be based on:on:..

Patient’s characteristicsPatient’s characteristics

Tumor’s characteristicsTumor’s characteristics

11

22




Patient characteristicsPatient characteristics

Tumor characteristicsTumor characteristics

11

22

““Does the patient’s life Does the patient’s life expectancy warrant expectancy warrant pleurodesis?” pleurodesis?” **((PSPS has the most value) has the most value)

** 32% of p. do not survive 30 days after pleurodesis32% of p. do not survive 30 days after pleurodesis




Patient characteristicsPatient characteristics

Tumor characteristicsTumor characteristics

11

22

““Does the patient’s life Does the patient’s life expectancy warrant expectancy warrant pleurodesis?” pleurodesis?” **((PSPS has the most value) has the most value)

** 32% of p. do not survive 30 days after pleurodesis32% of p. do not survive 30 days after pleurodesis



Pleural Effusion is unlikely to Pleural Effusion is unlikely to respond to pleurodesis if:respond to pleurodesis if:

There is an airway obstruction from an There is an airway obstruction from an

endobronchial tumor (the lung does not expand endobronchial tumor (the lung does not expand

to the chest wall after therapeutic to the chest wall after therapeutic

thoracentesis)thoracentesis)

Effusion is multiloculated Effusion is multiloculated

There are large tumor masses along pleural There are large tumor masses along pleural

surfacessurfaces



Chest-catheter PleurodesisChest-catheter Pleurodesis

Thoracoscopic PleurodesisThoracoscopic Pleurodesis

TALC TALC is considered a superior pleurodesis agentis considered a superior pleurodesis agent

when compared with other commonly used sclerosantwhen compared with other commonly used sclerosant

(as Bleomycin or tetracycline)(as Bleomycin or tetracycline)

Cochrane Review, 2004Cochrane Review, 2004



YesYes

NoNo




YesYes

NoNo


Improvement in symptoms?Improvement in symptoms?



YesYes

NoNo


Improvement in symptoms?Improvement in symptoms?NoNo



YesYes

NoNo



Adequate Re-expansion?Adequate Re-expansion?

YesYes



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes

PleurodesisPleurodesisYesYes



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes

PleurodesisPleurodesis

NoNo

YesYes



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes


NoNo

NoNoYesYes



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes

Repeated ThoracentesisRepeated Thoracentesis

Pleural CatheterPleural Catheter


NoNo

NoNoYesYes


RepeatedRepeated THORACENTESESTHORACENTESES

Should be reserved for patients who:Should be reserved for patients who:

(1)(1) Appear unlikely to survive Appear unlikely to survive beyond 1 to 3 monthsbeyond 1 to 3 months(2)(2) Cannot tolerateCannot tolerate other more interventional other more interventional procedures to control pleural fluid, such as procedures to control pleural fluid, such as

pleurodesispleurodesis..(3)(3) Have a PE Have a PE that does not respondthat does not respond to pleurodesis to pleurodesis


RepeatedRepeated THORACENTESESTHORACENTESES

Should be reserved for patients who:Should be reserved for patients who:

(1)(1) Appear unlikely to survive Appear unlikely to survive beyond 1 to 3 monthsbeyond 1 to 3 months(2)(2) Cannot tolerateCannot tolerate other more interventional other more interventional procedures to control pleural fluid, such as procedures to control pleural fluid, such as

pleurodesispleurodesis..(3)(3) Have a PE Have a PE that does not respondthat does not respond to pleurodesis to pleurodesis

(4)(4) Have cancers that commonly Have cancers that commonly respond to therapyrespond to therapy with resolution of the associated effusionswith resolution of the associated effusions

...OR......OR...



YesYes

NoNo




Good PS?Good PS?

YesYes

YesYes

Repeated ThoracentesisRepeated Thoracentesis

Pleural CatheterPleural Catheter


NoNo

NoNoYesYes

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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 ”