- Malignant pleural effusion
Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity. Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions. Other common causes include pleural mesothelioma and lymphoma.
Malignant Pleural Effusion Classification and external resources ICD-9 511.81
Investigating a malignant pleural effusion
Clinical factors predicting the diagnosis of malignant pleural effusions are symptoms lasting more than 1 month and the absence of fever.
This is needed to confirm the presence of a pleural effusion. Chest radiograph is usually performed first and may demonstrate an underlying lung cancer as well as the pleural effusion. Ultrasound has a sensitivity of 73% and specificity of 100% at distinguishing malignant pleural effusions from other causes of pleural effusion, based on the presence of visible pleural metastases, pleural thickening greater than 1 cm, pleural nodularity, diaphragmatic thickening measuring greater than 7mm and an echogenic swirling pattern visible in the pleural fluid.
Pleural fluid cytology is positive in 60% of cases. However, in the remaining cases, pleural biopsy is required. Image guided biopsy and thoracoscopy have largely replaced blind biopsy due to their greater sensitivity and safety profile. CT guided biopsy has a sensitivity of 87% compared to Abrams' needle biopsy, which has a sensitivity of 47%.
Identification of pleural fluid biomarkers to distinguish malignant pleural effusions from other causes of exudative effusions would help diagnosis. Biomarkers that have been shown to be raised in malignant pleural effusions compared to benign disease include vascular endothelial growth factor (VEGF), endostatin, matrix metalloproteinases and tumour markers such as carcinoembryonic antigen. Pleural fluid mesothelin has a sensitivity of 71%, greater than that of cytology, and a specificity of 89% for the diagnosis of malignant mesothelioma.
Treatment of malignant pleural effusions
The goal of treatment of malignant pleural effusions is relief of breathlessness. Occasionally, treatment of the underlying cancer can cause resolution of the effusion. This may be the case with types of cancer that respond well to chemotherapy, such as small cell carcinoma or lymphoma. Simple aspiration of pleural fluid can relieve breathlessness rapidly but fluid and symptoms will usually recur within a couple of weeks. For this reason, more permanent treatments are usually used to prevent fluid recurrence. Standard treatment involves chest tube insertion and pleurodesis. However, this treatment requires an inpatient stay of approximately 2–7 days, can be painful and has a significant failure rate. This has led to the development of tunneled pleural catheters (e.g., Pleurx Catheters), which allow outpatient treatment of effusions.
- Malignant pleural effusion entry in the public domain NCI Dictionary of Cancer Terms
Pathology of respiratory system (J, 460–519), respiratory diseases Upper RT
Common cold)Headvocal folds: Laryngopharyngeal reflux (LPR) · Vocal fold nodule · Vocal cord paresis · Vocal cord dysfunction
Lower RT/lung disease
(including LRTIs)acute: Acute bronchitischronic: COPD (Chronic bronchitis, Acute exacerbations of chronic bronchitis, Acute exacerbation of COPD, Emphysema) · Asthma (Status asthmaticus, Aspirin-induced, Exercise-induced) · BronchiectasisInterstitial/
restrictiveBy pathogenBy vector/routeBy distributionBroncho- · LobarOther
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- ^ Sack U, Hoffmann M, Zhao XJ et al. Vascular endothelial growth factor in pleural effusions of different origin. Eur Respir J, 25(4), 600-604 (2005)
- ^ Sumi M, Kagohashi K, Satoh H, Ishikawa H, Funayama Y, Sekizawa K. Endostatin levels in exudative pleural effusions. Lung, 181(6), 329-334 (2003)
- ^ Gaspar MJ, De Miguel J, Garcia Diaz JD, Diez M. Clinical utility of a combination of tumour markers in the diagnosis of malignant pleural effusions. Anticancer Res, 28(5B), 2947-2952 (2008)
- ^ Vatansever S, Gelisgen R, Uzun H, Yurt S, Kosar F. Potential role of matrix metalloproteinase-2,-9 and tissue inhibitors of metalloproteinase-1,-2 in exudative pleural effusions. Clin Invest Med, 32(4), E293-300 (2009)
- ^ Davies HE, Sadler RS, Bielsa S et al. Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions. Am J Respir Crit Care Med, 180(5), 437-444 (2009)
- ^ Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Thorax. 2010 Aug;65 Suppl 2:ii32-40
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