The
EPEC-O
TM
Education in Palliative and End-of-life Care - Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM Project with major funding
provided by NCI, with supplemental funding provided by the Lance Armstrong
Foundation.
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EPEC – Oncology
Education in Palliative and End-of-life Care – Oncology
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Module 3m
Symptoms –
Malignant Pleural
Effusions
Malignant pleural
effusions . . .

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
Impact:

Dyspnea

Cough

Chest pain

Decreased mobility and fear
Overview

Scope of the problem

Causes

Pathophysiology

Diagnosis

Prognosis

Management options

Treatment strategies
Impact

> 25 % of newly diagnosed pleural
effusions are due to malignancy

50 % of cancer patients will develop
a pleural effusion

In US, approx. 100,000 malignant
effusions / yr

Life expectancy 4 – 12 months
Causes

Breast and lung cancer
50 – 65 %

Lymphoma, GU, GI
25 %

Unknown primary
7 – 15 %
Prognosis

Mortality 54 % at 1 month,
84% at 6 months

Survival ~ 10 months where pleural
effusion is first evidence of cancer

Known CA, exudate, negative
cytology poor prognosis compared
to positive cytology

Role of pH, Karnofsky Performance
Scale?
Key points
1. Pathophysiology
2. Assessment
3. Management
Pathophysiology

Fluid production = fluid resorption

Causes
Tumor cells blocking lymphatic drainage
Changes in colloid osmotic pressure
due to hypoalbuminemia
Assessment

History of dyspnea, chest pain,
cough

Physical examination of decreased
breath sounds, dullness to
percussion
. . . Assessment

Symptoms: dyspnea, dry cough,
pleuritic pain, chest discomfort,
limited exercise tolerance

Exam: decreased breath sounds,
dullness to auscultation and
percussion

CXR PA, lateral and decubitus films

Chest CT or U / S if loculated
Differential diagnosis

Parapneumonic effusion

Empyema

Chylothorax

Transudate
Benign vs.
malignant effusions . . .

Light’s criteria
Pleural fluid LDH > 0.6
Serum LDH
Pleural fluid protein > 0.5
Serum protein
Pleural fluid LDH > 2 / 3 ULN
serum LDH
. . . Benign vs.
malignant effusions . . .

Heffner meta-analysis:
Pleural LDH > 0.45 ULN
Pleural cholesterol > 45 mg / dl
Pleural protein > 2.9 gm / dl
Heffner 1997.
. . . Benign vs.
malignant effusions

Cytology
Positive in approximately 55 – 65 %
initially
Yield up to 77 % on three pleural fluid
samples
Management
Intrapleural
catheter
Doxycycline
pleurodesis
Initial drainage
97%
68%
Pleurodesis
46%
54%
Late recurrence
13%
21%
13% outpt
14% inpt
Complications
Putnam 1999.
Management options








Thoracentesis
Tube thoracostomy
Small-bore chest tubes
Pleurodesis
Thoracoscopy
Intrapleural catheters
Pleuroperitoneal shunting
Subcutaneous access ports
Thoracentesis

Diagnostic, therapeutic

Temporary relief

Many contraindications

Risks:
Pneumothorax
Reexpansion pulmonary edema
(especially if > 1,500 cc removed)
Treatment
recommendations

Thoracentesis: diagnosis, palliation until
more definitive procedure, medically ill,
short-life expectancy

Tube thoracostomy: free-flowing
effusions, unable to tolerate general
anesthesia

Thoracoscopy: life expectancy > 3 mos,
loculated effusions, biopsies

Intrapleural catheters: outpatient
pleurodesis
Thoracoscopy benefits

Direct visualization of lung re-expansion

Identify loculated areas and drain

Administration of dry talc, chest tube
placement

Confirm equal distribution of talc

Shorter hospital stay than tube
thoracostomy

Diagnostic yield 90 %,
pleurodesis success rate 90%
Tube thoracostomy
and pleurodesis . . .


More definitive than repeated
thoracentesis for recurrent effusions
Chest tube 12 – 24 hr or until
drainage < 250 ml / 24 hr
. . . Tube thoracostomy
and pleurodesis

Sclerosing agent when dry
Talc, bleomycin, doxycycline
Tube clamping controversial
Rotation vs. nonrotation


Failure rate 10 – 40 %
Most widely used and cost effective
method
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Summary
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Use comprehensive
assessment and
pathophysiology-based therapy
to treat the cause and improve
the cancer experience