1. Diagnosis and Management of Malignant Pleural Effusion 衛生署桃園醫院內科加護病房主任莊子儀醫師 2006 年 7 月 20 日

2. Etiology of Malignant Effusion Lung cancer: 37.5%, especially adenocarcinoma Lung cancer: 37.5%, especially adenocarcinoma Breast cancer: 16.8% Breast cancer: 16.8% Lymphoma: 11.5%, most common in young adult Lymphoma: 11.5%, most common in young adult

3. Etiology of Malignant Effusion Increasing production of effusion: Increasing production of effusion: Increasing vascular permeability: invasion of pleural vessels by tumor, cytokines, injury, infection etc. Increasing vascular permeability: invasion of pleural vessels by tumor, cytokines, injury, infection etc. Increasing vascular hydrostatic gradient: decreased pleural pressure by atelectasis, increased venous pressure by SVC syndrome, decreased plasma osmotic pressure by hypoalbuminemia Increasing vascular hydrostatic gradient: decreased pleural pressure by atelectasis, increased venous pressure by SVC syndrome, decreased plasma osmotic pressure by hypoalbuminemia Nonvascular entry by thoracic duct: chylothorax Nonvascular entry by thoracic duct: chylothorax

4. Etiology of Malignant Effusion Decreasing exit of effusion: Decreasing exit of effusion: Increasing resistance to lymphatic flow: infiltration of parietal pleura or mediastinal lymph nodes by tumor seeding Increasing resistance to lymphatic flow: infiltration of parietal pleura or mediastinal lymph nodes by tumor seeding Increasing gradient opposing lymphatic flow: decreased pleural pressure by atelectasis, increased venous pressure by SVC syndrome Increasing gradient opposing lymphatic flow: decreased pleural pressure by atelectasis, increased venous pressure by SVC syndrome

5. Clinical Presentation Dyspnea Dyspnea Cough Cough Chest pain Chest pain

6. Radiographic Evaluation Chest X-ray Chest X-ray

8. Chest X-ray Amount of pleural effusion Amount of pleural effusion More than 2/3 hemithorax or even entire hemithorax More than 2/3 hemithorax or even entire hemithorax 55% of large and massive effusions 55% of large and massive effusions Other causes: empyema and TB effusions Other causes: empyema and TB effusions Cytology diagnosis of large and small effusions: no significant difference (63% vs. 53%) Cytology diagnosis of large and small effusions: no significant difference (63% vs. 53%)

10. Chest X-ray Mediastinum position Mediastinum position Shift away from a large effusion Shift away from a large effusion Midline mediastinum in large effusion: significant lung collapse, fixed mediastinum LAP Midline mediastinum in large effusion: significant lung collapse, fixed mediastinum LAP Shift toward a large effsuion: trapped lung due to main-stem bronchial obstruction Shift toward a large effsuion: trapped lung due to main-stem bronchial obstruction

12. Radiographic Evaluation Chest X-ray Chest X-ray Chest CT Chest CT

13. Chest CT Pleural surfaces, lung parenchyma, chest wall and mediastinum Pleural surfaces, lung parenchyma, chest wall and mediastinum Malignant pleural disease: pleural thickening (>1 cm), irregularity, nodules Malignant pleural disease: pleural thickening (>1 cm), irregularity, nodules Pleural thickening: also seen in empyema Pleural thickening: also seen in empyema Pleural nodules: only 17% in malignant effusions Pleural nodules: only 17% in malignant effusions Other features: lung mass, chest wall involvement, mediastinal LAP, hepatic metastases Other features: lung mass, chest wall involvement, mediastinal LAP, hepatic metastases

16. Radiographic Evaluation Chest X-ray Chest X-ray Chest CT Chest CT Chest echo Chest echo

17. Chest Echo Pleural surfaces, lung parenchyma, chest wall and pleural effusion Pleural surfaces, lung parenchyma, chest wall and pleural effusion Pleural effusion: echo-free Pleural effusion: echo-free Pleural thickening and nodules Pleural thickening and nodules Echo-guide thoracocentesis Echo-guide thoracocentesis Echo-guide pleural biopsy Echo-guide pleural biopsy

18. Diagnosis Pleural effusion Pleural effusion Cytology Cytology Pathology Pathology

19. Pleural effusion Grossly bloody: most common cause of bloody effusion Grossly bloody: most common cause of bloody effusion Serosanguineous effusion Serosanguineous effusion Cell differentiation: lymphocytes predominant Cell differentiation: lymphocytes predominant Eosinophilia: can not exclude malignant effusion Eosinophilia: can not exclude malignant effusion

20. Pleural effusion Almost always exudate Almost always exudate Lactate dehydrogenase (LDH): increased cell turnover and lysis Lactate dehydrogenase (LDH): increased cell turnover and lysis Low glucose concentration and low pH level: possible shorter survival Low glucose concentration and low pH level: possible shorter survival pH < 7.20: easily failure of pleurodesis pH < 7.20: easily failure of pleurodesis

21. Cytology Adenocarcinoma: most likely to be positive Adenocarcinoma: most likely to be positive Low pH: greater tumor burden Low pH: greater tumor burden Cytology diagnosis of large and small effusions: no significant difference (63% vs. 53%) Cytology diagnosis of large and small effusions: no significant difference (63% vs. 53%) Body fluid + cell block Body fluid + cell block

22. Pathology Pleural biopsy Pleural biopsy Closed needle biopsy Closed needle biopsy Cope needle Cope needle Abrams needle Abrams needle Urocut needle Urocut needle

23. Cope Needle

24. Abrams Needle

25. Urocut Needle

26. Diagnostic Procedures Diagnostic thoracocentesis under echo-guide Diagnostic thoracocentesis under echo-guide Send pleural effusion for routine, BCS (LDH, protein, glucose), Gram/AFB stain, cytology, B/C, plus ABG (for pH) Send pleural effusion for routine, BCS (LDH, protein, glucose), Gram/AFB stain, cytology, B/C, plus ABG (for pH) Pleural biopsy under echo-guide Pleural biopsy under echo-guide Send pleura for pathology and TB tissue/C Send pleura for pathology and TB tissue/C Therapeutic thoracocentesis under echo-guide Therapeutic thoracocentesis under echo-guide Send pleural effusion for body fluid + cell block Send pleural effusion for body fluid + cell block

27. Primary Tumor (T) T4: T4: A tumor of any size with invasion of the mediastinum, or involving heart, great vessels, trachea, esophagus, vertebral bodies, carina, A tumor of any size with invasion of the mediastinum, or involving heart, great vessels, trachea, esophagus, vertebral bodies, carina, or with the presence of malignant pleural/pericardial effusion, or with the presence of malignant pleural/pericardial effusion, or exudative pleural effusion without evidence of obstructive pneumonitis, or exudative pleural effusion without evidence of obstructive pneumonitis, or with satellite tumor within the lobe of primary tumor at chest CT or with satellite tumor within the lobe of primary tumor at chest CT

28. Management Symptom-oriented management Symptom-oriented management Less than 1/3 hemithorax, C/T sensitive tumor Less than 1/3 hemithorax, C/T sensitive tumor C/T at first, F/U regularly C/T at first, F/U regularly Slowly recurring effusion, short life span Slowly recurring effusion, short life span Repeated therapeutic thoracocentesis Repeated therapeutic thoracocentesis More than 2/3 hemithorax, no airway obstruction More than 2/3 hemithorax, no airway obstruction Pigtail insertion for pleurodesis within 24 hours Pigtail insertion for pleurodesis within 24 hours

30. Management Before pleurodesis Before pleurodesis Daily drainage amount < 100-150 ml Daily drainage amount < 100-150 ml Confirm with chest echo Confirm with chest echo Ability of lung re-expansion Ability of lung re-expansion Chemical pleurodesis Chemical pleurodesis Mnocycline injection Mnocycline injection Beta-iodine injection Beta-iodine injection OK-432 injection OK-432 injection

31. Management Pre-medication Pre-medication 2% xylocaine 10ml in 50ml normal saline 2% xylocaine 10ml in 50ml normal saline Minocycline injection Minocycline injection After 15 minutes, 300mg Minocycline in 50ml normal saline After 15 minutes, 300mg Minocycline in 50ml normal saline Clamp catheter/tube, change position 2-6 hours Clamp catheter/tube, change position 2-6 hours Unclamp catheter/tube, low pressure suction Unclamp catheter/tube, low pressure suction

32. Management Pre-medication Pre-medication 2% xylocaine 10ml in 50ml normal saline 2% xylocaine 10ml in 50ml normal saline Beta-iodine injection Beta-iodine injection After 15 minutes, 10 ml beta-iodine in 40ml normal saline After 15 minutes, 10 ml beta-iodine in 40ml normal saline Clamp catheter/tube, change position 2-6 hours Clamp catheter/tube, change position 2-6 hours Unclamp catheter/tube, low pressure suction Unclamp catheter/tube, low pressure suction

33. Management Indwelling catheter Indwelling catheter Good outpatient situation Good outpatient situation Good for trapped lung Good for trapped lung Pigtail catheter with drainage bag Pigtail catheter with drainage bag Chest tube with Heimlich valve Chest tube with Heimlich valve

34. Management

35. Complication Re-expansion lung edema Re-expansion lung edema Empyema Empyema Restricted lung disease Restricted lung disease Trapped lung Trapped lung

39. Prognosis Medium survival Medium survival Lung cancer with malignant effusion: 3 months Lung cancer with malignant effusion: 3 months Breast cancer with malignant effusion: 5 months Breast cancer with malignant effusion: 5 months Mesothelioma with malignant effusion: 6 months Mesothelioma with malignant effusion: 6 months Lymphoma with malignant effusion: 9 months Lymphoma with malignant effusion: 9 months

40. Thank You for Attention Reference: Reference: Murray and Nadel ’ s Textbook of Respiratory Medicine, 4th edition, 2005 Murray and Nadel ’ s Textbook of Respiratory Medicine, 4th edition, 2005 Light and Lee ’ s Textbook of Pleural Disease, 1st edition, 2003 Light and Lee ’ s Textbook of Pleural Disease, 1st edition, 2003 Mathis and Lessnau ’ s Atlas of Chest Sonography, 1st edition, 2003 Mathis and Lessnau ’ s Atlas of Chest Sonography, 1st edition, 2003