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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 ”

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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

  • Malignant Pleural Effusion (M.P.E.)An M.P.E. is defined by the presence of cancer cells in the pleural spaceUnderlying Primary Cancer Lung tumors (including malignant pleural mesothelioma) NSCLC: 14% at the time of diagnosis, 50% with advanced disease Breast cancer Ovarian cancer, gastric cancer Hodgkins and non-Hodgkins lymphoma

  • Malignant Pleural Effusion (M.P.E.)An M.P.E. is defined by the presence of cancer cells in the pleural spaceCancer cells reach the visceral pleura (through the pulmonary vasculature)or the parietal pleura (through hematogenous spread)Cancer cells in the pleural space(tumor deposit along parietal pleura) Obstruct lymphatic stromata (which drain intrapleural fluid) Release chemockines ( increasing vascular permeability)

  • Malignant Pleural Effusion (M.P.E.) Paramalignant Effusion1. Mediastinal lymph node tumor infiltration2. Bronchial obstruction/Atelectasis3. Pulmonary embolism4. Superior vena cava syndrome5. Decreased oncotic pressure (cachexia)6. Radiotherapy/Chemotherapy

  • Malignant Plural EffusionAndDiagnosis

  • M.P.E. and DiagnosisCytologic or tissue biopsy confirmation is required to establish a diagnosis of MPE

  • M.P.E. and DiagnosisCytologic or tissue biopsy confirmation is required to establish a diagnosis of MPEDiagnostic thoracentesis: Diagnostic yield of PF cytology ranging from 62 to 90% Positive results on cytology might not differentiate between adk subtypes or between pleural adk and mesothelioma Additional PF studies could complement standard cytology: Electrochetoluminescence for tumor markers, genetic analysis

  • M.P.E. and DiagnosisCytologic or tissue biopsy confirmation is required to establish a diagnosis of MPEDiagnostic thoracentesis, if cytology not diagnostic:

  • M.P.E. and DiagnosisCytologic or tissue biopsy confirmation is required to establish a diagnosis of MPEDiagnostic thoracentesis, if cytology not diagnostic:

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

    Medical thoracoscopy, orVideo Assisted Thoracoscopic Surgery (VATS)

  • M.P.E. and DiagnosisIs diagnosis with cytology or histology always requested (and useful) in our clinical practice?

  • M.P.E. and DiagnosisDoes the presence of M.P.E. add prognostic and therapeutic informations?

  • M.P.E. and DiagnosisNon Small Cell Lung CancerDoes the presence of M.P.E. add prognostic and therapeutic informations?

  • M.P.E. and DiagnosisNon Small Cell Lung Cancer Poor PS Known advanced cancer

    DIAGNOSIS NOT NECESSARY

  • M.P.E. and DiagnosisNon Small Cell Lung Cancer Poor PS Known advanced cancer

    DIAGNOSIS NOT NECESSARY Good PS multimodality treatment

    DIAGNOSIS IS CRITICAL FOR TREATMENT PLANNING

  • NSCLC with M.P.E: Prognosis Patients with M.P.E. (without other metastatic disease) had a median OS of 8 months Versus 13 months of other cT4 M0 Versus 6 months of patients with distant metastasesPostmus, JTO 2007

  • NSCLC with M.P.E: PrognosisGoldstraw, JTO 2007TNM stagingSix Edition:

    T4(Stage III B)TNM stagingSeventh Edition:

    M1 a(Stage IV)

  • NSCLC with M.P.E: PrognosisGoldstraw, JTO 2007TNM stagingSix Edition:

    T4(Stage III B)TNM stagingSeventh Edition:

    M1 a(Stage IV)If P.E. is cytologically negative. and is evaluated as not related to the tumor by clinical judgment, patient should be classified as T1, T2, T3, T4.

  • Malignant Pleural EffusionAndTreatment

  • M.P.E. and Treatment THERAPEUTIC THORACENTESIS

    PLEURODESIS

  • M.P.E. and TreatmentManagement of MPE is palliative... THERAPEUTIC THORACENTESIS

    PLEURODESIS

  • M.P.E. and TreatmentWhen to proceed with treatment of Pleural Effusion?

  • M.P.E. and TreatmentWhen to proceed with treatment of Pleural Effusion?Patient is symptomatic (for dyspnea or cough or chest pain), and symptoms are considered to be caused from pleural effusion. Patient is not suitable for specific cancer treatment (eg. chemotherapy), or Pleural Effusion is resistant to specific cancer treatment.

  • M.P.E. and TreatmentIs patient symptomatic?

  • M.P.E. and TreatmentIs patient symptomatic?No interventionNo

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic Thoracentesis

  • M.P.E. and TreatmentTHERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 days

  • M.P.E. and TreatmentTHERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 daysRepeated THORACENTESESPLEURODESIS

  • M.P.E. and TreatmentTHERAPEUTIC THORACENTESIS Symptoms can improve after thoracentesis But 98% to 100% of patients experience reaccumulation of fluid and recurrence of symptoms within 30 daysRepeated THORACENTESESPLEURODESIS

  • M.P.E. and TreatmentPLEURODESIS Selection of patients should be based on:.Patients characteristics

    Tumors characteristics12

  • M.P.E. and TreatmentPLEURODESIS Selection of patients should be based on:.Patient characteristics

    Tumor characteristics12Does the patients life expectancy warrant pleurodesis? *(PS has the most value)* 32% of p. do not survive 30 days after pleurodesis

  • M.P.E. and TreatmentPLEURODESIS Selection of patients should be based on:.Patient characteristics

    Tumor characteristics12Does the patients life expectancy warrant pleurodesis? *(PS has the most value)* 32% of p. do not survive 30 days after pleurodesis

  • M.P.E. and TreatmentPLEURODESISPleural Effusion is unlikely to respond to pleurodesis if:

    There is an airway obstruction from an endobronchial tumor (the lung does not expand to the chest wall after therapeutic thoracentesis)Effusion is multiloculated There are large tumor masses along pleural surfaces

  • M.P.E. and TreatmentPLEURODESISChest-catheter PleurodesisThoracoscopic PleurodesisTALC is considered a superior pleurodesis agentwhen compared with other commonly used sclerosant(as Bleomycin or tetracycline) Cochrane Review, 2004

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic Thoracentesis

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?No

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Yes

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYes

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYesPleurodesisYes

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYesPleurodesisNoYes

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYesPleurodesisNoNoYes

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYesRepeated ThoracentesisPleural CatheterPleurodesisNoNoYes

  • M.P.E. and TreatmentRepeated THORACENTESES Should be reserved for patients who:

    (1) Appear unlikely to survive beyond 1 to 3 months(2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis.(3) Have a PE that does not respond to pleurodesis

  • M.P.E. and TreatmentRepeated THORACENTESES Should be reserved for patients who:

    (1) Appear unlikely to survive beyond 1 to 3 months(2) Cannot tolerate other more interventional procedures to control pleural fluid, such as pleurodesis.(3) Have a PE that does not respond to pleurodesis

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

    ...OR...

  • M.P.E. and TreatmentIs patient symptomatic?No interventionYesNoTherapeutic ThoracentesisImprovement in symptoms?NoAdequate Re-expansion?Good PS?YesYesRepeated ThoracentesisPleural CatheterPleurodesisNoNoYes

    *Lung cancer, including Malignant Mesothelioma, is the most common cause of MPE. In women it is followed by breast cancer.

    *Cancer cells are absent from the pleural space*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?*Is tumor likely to respond to chemotherapy?