malignant pleural effusion.pptx by remya sethu

Malignant pleural effusion by remya

1. Malignant pleural effusion Remya Sethu

2. Pleural effusion The accumulation of serous fluid within the pleural space is termed pleural effusion. The accumulation of frank pus is termed empyema that of blood is haemothorax, and that of chyle is a chylothorax.

3. Pleural fluid accumulates as a result of increased hydrostatic pressure or decreased osmotic pressure (transudative effusion, as seen in cardiac, liver or renal failure), or from increased microvascular pressure due to disease of the pleura or injury in the adjacent lung (exudative effusion)

4. Common causes Pneumonia (parapneumonic effusion) TB Pulmonary infarction Malignant disease Heart failure Sub diaphragmatic disorders (Sub phrenic abcess, pancreatitis )

5. Uncommon causes Hypoprotenemia( liver failure, nephrotic syndrome, malnutrition) Connective tissue diseases (SLE, Rheumatoid Arthritis) Post myocarial infarction syndrome ARF Meigs syndrome (ovarian tumor plus pleural effusion) Uremia

6. Malignant pleural effusion A malignant pleural effusion is defined by the accumulation of fluid in the presence of malignant cells or tumor tissue in the pleural space. The presence of a malignant pleural effusion is a hallmark of advanced-stage disease and denotes a poor overall prognosis, with a median survival ranging between 3 and 12 months depending on the primary tumor type.

7. Pleural effusion of pleura : Malignant Mesothelioma Pleural Effusions Related to Metastatic Malignancies: Lung carcinoma Breast carcinoma Lymphoma and leukemia Ovarian carcinoma Sarcoma (including melanoma) Uterine and cervical carcinoma Stomach carcinoma Colon carcinoma Pancreatic carcinoma Bladder carcinoma

8. Clinical features

9. Dyspnea, chest pain, and cough are the most common symptoms in patients presenting with a malignant pleural effusion, with dyspnea present in greater than half of all cases.Dyspnea is often debilitat- ing and can significantly impair quality of life. Since patients with a malignant pleural effusion have advanced-stage disease, systemic symptoms such fatigue, anorexia, and weight loss are often present. majority of patients will have an abnormal chest examination including decreased breath sounds and tactile fremitus, and dullness to percussion

10. Etiology

11. Although any malignancy may involve the pleura, epithelial malig- nancies account for approximately 80% of malignant pleural effu- nons, with lung and breast cancer representing the majority of cases . Lung cancer is the leading cause of a malignant pleural effusion, which is present in an estimated 15% of lung cancer patients at diagnosis and develops in up to 50% of patients during the course of their disease

12. Diagnostic Approach

13. Radilogical investigation Chest Radiograph Malignant pleural effusion is the most common cause of a unilateral effusion occupying greater than two-thirds of the hemithorax. Xray findings: presence of a pulmonary or mediastinal mass, thoracic lymphadenopathy, and lytic or sclerotic bony lesions. However, in patients with malignant tumors other than lung cancer or lymphoma, an effusion may be the only abnormality appreciated on chest radiographyal effusion occupying greater than two-thirds of the hemithorax.

14. Thoracic ultrasonography It enables the assessment of the size and depth of an effusion, the echogenicity of fluid, whether septations and loculations are present, and the presence of pleural thickening or nodules The presence of parietal pleural thickening (>10 mm), pleu- ral nodularity, and/or diaphragmatic nodularity or thickening (>7 mm) is highly suggestive of malignant disease.

15. Computed Tomography A contrast-enhanced chest CT scan may also provide valuable information in discrimi- nating benign from malignant effusions. The presence of pleural nodularity, pleural thickening ≥1 cm, circumferential parietal pleu- ral thickening, and thickening of the mediastinal pleura are strongly indicative of a malignant effusion

16. MRI MRI may have a role in the diagnostic assessment and response to therapy in malignant pleural mesothelioma (MPM). It can be particularly useful in cases of MPM when evaluating the extent of chest wall or diaphragmatic invasion by tumor, or as an alternative imaging modality in patients in whom iodinated contrast is contraindicated. However, it currently does not have a defined role in the initial evaluation of Malignant pleural effusion.

17. Positron Emission Tomography Fluorodeoxyglucose positron emission tomography (FDG-PET) scanning is a widely used imaging modality for the staging of primary malignancies; however, its role in the evaluation of malignant pleural disease remains limited.

18. Pleural Fluid Characteristics Ultrasound guided thoracentesis is the initial procedure of choice to sample pleural fluid in cases of suspected malignant effusion. Pleural fluid aspiration may be both diagnostic and therapeutic, often alleviating symptoms of dyspnea. It is reasonable to send pleural fluid for routine biochemical analysis (total protein, lactate dehydrogenase [LDH], and glucose), pH, cell count and differential, amylase, micro- biologic studies, and cytopathology in cases of suspected malignancy.

19. The majority of malignant effusions have a pleural fluid protein-to-serum ratio greater than 0.5. Malignant pleural effusions may appear serous, serosanguineous, or grossly bloody. A bloody appearance of the fluid is suggestive of malignant pleural disease. Malignant pleural effusions typically have a predominance of either lymphocytes or mononuclear cells. Malignancy and tuberculosis are the most common causes of an exudative effusion containing greater than 50% lymphocytes.

20. A pleural fluid pH less than 7.3 is seen in approximately one-third of patients and is typically associated with glucose values less than 60 mg/dL.

21. Cytology The identification of malignant cells by cytologic analysis establishes the definitive diagnosis of a malignant pleural effusion in approxi mately 55% of cases . For instance malignant tumors like lung adenocarcinoma and ovarian carcinoma often have diagnostic yields in excess of 70 % whereas lung squamous cell carcinoma and mesothelioma are postive in cytology I less than 50% cases.

22. Tumor markers number of studies have evaluated various molecular markers in pleural fluid to better distinguish benign from malignant effusions. A study evaluating the use of a combination of tumor markers measured in pleural fluid including carcinoembryonic antigen (CEA), cancer antigen 125 (CA-125), carbohydrate antigen 15-3, and cytokeratin 19 fragments (CYFRA 21-1) in 416 patients with benign and malignant effusions demonstrated a sensitivity of 54% for the diagnosis of a malignant effusion

23. Pleural biopsy Closed pleural biopsy the use of image-guided closed pleural biopsy serves as an accessible, minimally invasive, and low-cost method to evalu ate patients with undiagnosed exudative effusions, and may be par- ticularly useful in patients with pleural abnormalities and in centers where medical thoracoscopy is not readily available.

24. Medical thoracoscopy also known as pleuroscopy, is a minimally invasive procedure that involves accessing the pleural space with a rigid or semirigid thoracoscope that is typically performed with a local anesthetic and moderate sedation. The procedure enables the direct visualization of the parietal pleura in order to direct biopsies to visually abnormal areas.

25. Surgical Thoracoscopy A surgical pleural biopsy is typically performed using VATS Careful assessment of the patient's comorbidities and performance status should be performed to ensure that they can tolerate general anesthesia and single lung ventilation required for this procedure. Although VATS is still considered the gold standard for the diagnosis of malignant pleural disease, the diagnostic yield of >90% and complication rate of VATS is similar to medical thoracoscopy.

26. PROGNOSIS The prognosis for patients with a malignant pleural effusion remains poor, with median survival estimates ranging from 3 to 12 months. Survival is highly variable and depends on a number of factors including the primary tumor type, performance status, and pleural fluid markers

27. The LENT score is a prospectively validated scoring system to estimate survival in patients with a malignant effusion. The score includes the > pleural fluid LDH > performance status >serum neutrophil-to-lymphocyte ratio >Primary tumor type Resulting in a composite score that separates patients into low-, moderate, or high-risk groups, with median survival in these groups of 319, 130, and 44 days, respectively.

28. Management The primary goal of treatment is palliation of symptoms related to the effusion and improvement in overall quality of life. Clinical observation may be offered for patients with small, asymptomatic, malignant pleural effusions. For patients with symptomatic effusions, management options include >thoracenteses, drainage, and > chemical pleurodesis via either chest tube thoracostomy or thoracoscopy/pleuroscopy. > the placement of an indwelling pleural catheter.

29. In patients with respiratory symptoms potentially attributable to a malignant pleural effusion, a therapeutic thoracentesis can be performed during the initial diagnostic evaluation. A thoracentesis enables the assessment of symptomatic relief following drainage, determination of whether the lung is nonexpandable following the procedure, and assessment of the rate at which fluid reaccumulates.

30. Patients who derive symptomatic relief of dyspnea following thoracentesis should be considered for definitive pleural interventions (eg, placement of a tunneled pleural catheter, pleurodesis), Wiith persistent dyspnea despite effective fluid drainage should have further diagnostic testing to investigate alternative causes of dyspnea, such as lymphangitic carcinomatosis or a pulmonary embolism.

31. For rapidly reaccumulating effusions, a more durable solution is recommended. 1) Pleurodesis

32. pleurodesis, which involves generating inflammation within the thoracic cavity to promote adhesion of the visceral and parietal pleura. Successful pleurodesis obliterates the potential space for fluid reaccumulation, leading to sustained pleural effusion resolution

33. Pleurodesis is typically achieved chemically by the intrapleural instillation of a sclerosing agent. Many chemical sclerosants have been utilized to promote pleurodesis including talc, doxycycline, bleomycin, and povidone- iodine. Two recent studies suggest that the administration of talc is associated with fewer pleurodesis failures than other commonly used agents, Talc has a pleurodesis success rate of approximately 70% and can be delivered into the pleural space either as a slurry suspension via a chest tube or by direct aerosolized application (poudrage) via video thoracoscopy with similar efficacy.

34. Pleurodesis is contraindicated in patients who cannot achieve apposition of the visceral and parietal pleura due to lack of lung expansion Fever and pain requiring oral or parenteral analgesics are the most common adverse events associated with chemical pleurodesis. Postprocedural pain typically resolves within the first 24 h and can be mitigated by the intrapleural administration of a topical anesthetic prior to the instillation of the sclerosing agent.

35. 2) IPCs IPCs are an attractive alternative to pleurodesis. IPCs are fenestrated silicone catheters that are tunneled subcutaneously in the chest wall and subsequently inserted into the pleural space. They can be placed as an outpatient procedure, allowing immediate relief of symptoms without the need for hospitalization

36. In patients with rapidly recurring malignant effusions without lung expansion, IPCs may be a more attractive solu tion than repeat thoracenteses. Compared to talc pleurodesis, IPC placement offers better control of dyspnea at 6 months, fewer days in the hospital, and less need for another pleural procedure such as the racentesis or intercostal catheter placement. The most common complications associated with IPCs include empyema, cellulitis, and catheter blockage.