Download PDF
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)

    Permissions and Reprints

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.

KEYWORDS

Pleura - fluid - pleural effusion - malignant - interventional procedures - tunneled pleural catheter

REFERENCES

  • 1 Neragi-Miandoab S. Malignant pleural effusion, current and evolving approaches for its diagnosis and management.  Lung Cancer. 2006;  54 1-9
    CrossrefPubMedGoogle Scholar
  • 2 American Thoracic Society . Management of malignant pleural effusions.  Am J Respir Crit Care Med. 2000;  162 1987-2001
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 4 Grossi F, Pennucci M C, Tixi L, Cafferata M A, Ardizzoni A. Management of malignant pleural effusions.  Drugs. 1998;  55 47-58
    CrossrefPubMedGoogle Scholar
  • 5 Tattersall M. Management of malignant pleural effusion.  Aust N Z J Med. 1998;  28 394-396
    CrossrefPubMedGoogle Scholar
  • 6 Sears D, Hajdu S I. The cytologic diagnosis of malignant neoplasm in pleural and peritoneal effusions.  Acta Cytol. 1987;  31 85-97
    PubMedGoogle Scholar
  • 7 van de Molengraft F J, Voojis G P. Survival of patients with malignancy-associated effusions.  Acta Cytol. 1989;  33 911-916
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 9 Judson M A, Sahn S A. Pulmonary physiologic abnormalities caused by pleural disease.  Semin Respir Crit Care Med. 1995;  16 346-353
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Sahn S A. State of the art: the pleura.  Am Rev Respir Dis. 1988;  138 184-234
    CrossrefPubMedGoogle Scholar
  • 11 Lynch Jr T J. Management of malignant pleural effusions.  Chest. 1993;  103 (4 Suppl) 385S-389S
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 15 Ruckdeschel J C. Management of malignant pleural effusion: an overview.  Semin Oncol. 1988;  15 24-28
    PubMedGoogle Scholar
  • 16 Tarver R D, Broderick L S, Conces D J. Reexpansion pulmonary edema.  J Thorac Imaging. 1996;  11 198-209
    CrossrefPubMedGoogle Scholar
  • 17 Mahfood S, Hix W R, Aaron B L et al.. Reexpansion pulmonary edema.  Ann Thorac Surg. 1988;  45 340-345
    CrossrefPubMedGoogle Scholar
  • 18 Stretton F, Edmonds P, Marrinan M. Malignant pleural effusions.  Eur J Palliative Care. 1999;  6 5-9
    PubMedGoogle Scholar
  • 19 Anderson C B, Philpott G W, Ferguson T B. The treatment of malignant effusions.  Cancer. 1974;  33 916-922
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 22 Antony V B. Pathogenesis of malignant pleural effusions and talc pleurodesis.  Pneumologie. 1999;  53 493-498
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 24 Patz E F, McAdams H P, Goodman P C et al.. Ambulatory sclerotherapy for malignant pleural effusions.  Radiology. 1996;  199 133-135
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 38 Kennedy L, Rusch V W, Strange C et al.. Pleurodesis using talc slurry.  Chest. 1994;  106 342-346
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 40 Weissberg D, Ben-Zeev I. Talc pleurodesis: experience with 360 patients.  J Thorac Cardiovasc Surg. 1993;  106 689-695
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 43 Heffner J E, Standerfer R J, Torstveit J et al.. Clinical efficacy of doxycycline for pleurodesis.  Chest. 1994;  105 1743-1747
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 47 Sahn S A. Pleural diseases related to metastatic malignancies.  Eur Respir J. 1997;  10 1907-1913
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 49 Robinson L A, Fleming W H, Galbraith T A. Intrapleural doxycycline control of malignant pleural effusions.  Ann Thorac Surg. 1993;  55 1115-1121
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 64 Tremblay A, Michaud G. Single-center experience with 250 tunneled pleural catheter insertions for malignant pleural effusion.  Chest. 2006;  129 362-368
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar

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