TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3m: Module 3m: Symptoms – Malignant Pleural Effusions Symptoms – Malignant Pleural Effusions Module 3m: Module 3m: Symptoms – Malignant Pleural Effusions Symptoms – Malignant Pleural Effusions

Malignant pleural effusions... l Definition: fluid accumulation in the potential space between the visceral (inner) layer covering the lungs and the parietal (outer) layer covering the chest wall

... Malignant pleural effusions Symptoms: l Dyspnea l Cough l Chest pain l Decreased mobility and fear Symptoms: l Dyspnea l Cough l Chest pain l Decreased mobility and fear

Overview l Scope of the problem l Causes l Pathophysiology l Diagnosis l Prognosis l Management options l Treatment strategies l Scope of the problem l Causes l Pathophysiology l Diagnosis l Prognosis l Management options l Treatment strategies

Impact l More than 25% of newly diagnosed pleural effusions are due to malignancy l 50% of cancer patients will develop a pleural effusion l In US, approximately 100,000 malignant effusions/year occur l Life expectancy 4-12 months l More than 25% of newly diagnosed pleural effusions are due to malignancy l 50% of cancer patients will develop a pleural effusion l In US, approximately 100,000 malignant effusions/year occur l Life expectancy 4-12 months

Causes l Breast and lung cancer 50-65% l Lymphoma, GU, GI 25% l Unknown primary7-15% l Breast and lung cancer 50-65% l Lymphoma, GU, GI 25% l Unknown primary7-15%

Prognosis l Mortality 54% at 1 month, 84% at 6 months l Survival about 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared with positive cytology l Role of pH, Karnofsky Performance Scale? l Mortality 54% at 1 month, 84% at 6 months l Survival about 10 months where pleural effusion is first evidence of cancer l Known CA, exudate, negative cytology poor prognosis compared with positive cytology l Role of pH, Karnofsky Performance Scale?

Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

Pathophysiology l Normally pleural fluid production equals fluid resorption l Effusion: Imbalance between fluid production and resorption l Causes: o Tumor cells blocking lymphatic drainage o Changes in colloid osmotic pressure due to hypoalbuminemia l Normally pleural fluid production equals fluid resorption l Effusion: Imbalance between fluid production and resorption l Causes: o Tumor cells blocking lymphatic drainage o Changes in colloid osmotic pressure due to hypoalbuminemia

Assessment l History of dyspnea, chest pain, cough l Physical examination of decreased breath sounds, dullness to percussion l History of dyspnea, chest pain, cough l Physical examination of decreased breath sounds, dullness to percussion

... Assessment l Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance l Exam: decreased breath sounds, dullness to auscultation and percussion l Chest X-Ray PA, lateral, and decubitus films l Chest CT or Ultrasound if loculated l Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance l Exam: decreased breath sounds, dullness to auscultation and percussion l Chest X-Ray PA, lateral, and decubitus films l Chest CT or Ultrasound if loculated

Differential diagnosis l Parapneumonic effusion l Empyema l Chylothorax l Transudate l Parapneumonic effusion l Empyema l Chylothorax l Transudate

Benign vs. malignant effusions... l Light’s criteria for exudates (one or more of following): 1. Pleural fluid LDH divided by serum LDH is greater than Pleural fluid protein divided by serum protein is greater than Pleural fluid LDH is greater than two- thirds upper limit of normal (ULN) of serum LDH l Light’s criteria for exudates (one or more of following): 1. Pleural fluid LDH divided by serum LDH is greater than Pleural fluid protein divided by serum protein is greater than Pleural fluid LDH is greater than two- thirds upper limit of normal (ULN) of serum LDH

... Benign vs. malignant effusions... l Heffner meta-analysis for exudates: 1. Pleural LDH is greater than 0.45 ULN 2. Pleural cholesterol is greater than 45 mg per dl 3. Pleural protein is greater than 2.9 g per dl Heffner 1997 l Heffner meta-analysis for exudates: 1. Pleural LDH is greater than 0.45 ULN 2. Pleural cholesterol is greater than 45 mg per dl 3. Pleural protein is greater than 2.9 g per dl Heffner 1997.

... Benign vs. malignant effusions l Cytology: o Positive for cancer in approximately 55 to 65% initially o Yield up to 77% positive on three pleural fluid samples l Cytology: o Positive for cancer in approximately 55 to 65% initially o Yield up to 77% positive on three pleural fluid samples

Management options l Thoracentesis l Tube thoracostomy l Small-bore chest tubes l Pleurodesis l Thoracoscopy l Intrapleural catheters l Pleuroperitoneal shunting l Subcutaneous access ports l Thoracentesis l Tube thoracostomy l Small-bore chest tubes l Pleurodesis l Thoracoscopy l Intrapleural catheters l Pleuroperitoneal shunting l Subcutaneous access ports

Management Intrapleural catheter Doxycycline pleurodesis Initial drainage 97%68% Pleurodesis46%54% Late recurrence 13%21% Complications 13% outpt 14% inpt

Thoracentesis l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks:  Pneumothorax  Re-expansion pulmonary edema (especially if more than 1500 cc removed) l Diagnostic, therapeutic l Temporary relief l Many contraindications l Risks:  Pneumothorax  Re-expansion pulmonary edema (especially if more than 1500 cc removed)

Treatment recommendations l Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy l Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia l Thoracoscopy: life expectancy greater than 3 months, loculated effusions, biopsies l Intrapleural catheters: outpatient pleurodesis l Thoracentesis: diagnosis, palliation until more definitive procedure, medically ill, short-life expectancy l Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia l Thoracoscopy: life expectancy greater than 3 months, loculated effusions, biopsies l Intrapleural catheters: outpatient pleurodesis

Thoracoscopy benefits l Direct visualization of lung re-expansion l Identify loculated areas and drain l Administration of dry talc, chest tube placement l Confirm equal distribution of talc l Shorter hospital stay than tube thoracostomy l Diagnostic yield 90%, pleurodesis success rate 90% l Direct visualization of lung re-expansion l Identify loculated areas and drain l Administration of dry talc, chest tube placement l Confirm equal distribution of talc l Shorter hospital stay than tube thoracostomy l Diagnostic yield 90%, pleurodesis success rate 90%

Tube thoracostomy and pleurodesis... l More definitive than repeated thoracentesis for recurrent effusions l Chest tube 12 to 24 hours or until drainage is less than 250 ml per 24 hr l More definitive than repeated thoracentesis for recurrent effusions l Chest tube 12 to 24 hours or until drainage is less than 250 ml per 24 hr

... Tube thoracostomy and pleurodesis l Sclerosing agent: Use after fluid completely drained from pleural space o Talc, bleomycin, doxycycline o Tube clamping controversial o Rotation vs. nonrotation l Failure rate 10 to 40% l Most widely used and cost-effective method l Sclerosing agent: Use after fluid completely drained from pleural space o Talc, bleomycin, doxycycline o Tube clamping controversial o Rotation vs. nonrotation l Failure rate 10 to 40% l Most widely used and cost-effective method

Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.