CHEST DISEASE CENTER AT A Teaching Hospital of Harvard Medical School CHEST DISEASE CENTER AT A Teaching Hospital of Harvard Medical School Management of Malignant Pleural Effusion Jefferson University Hospital 5/1/13 Erik Folch MD, MSc Division of Thoracic Surgery and Interventional Pulmonary
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CHEST DISEASE CENTER AT A Teaching Hospital of Harvard Medical School
CHEST DISEASE CENTER AT A Teaching Hospital of Harvard Medical School
Management of Malignant Pleural Effusion
Jefferson University Hospital
5/1/13
Erik Folch MD, MSc
Division of Thoracic Surgery and Interventional Pulmonary
CHEST DISEASE CENTER
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Objectives
Case in point
Epidemiology
Prognosis
Evaluation
Therapeutic Options
CHEST DISEASE CENTER
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Recurrent Pleural Effusion
73 yo man with recurrent symptomatic pleural effusion
Exudative, lymphocytic (>90%), with negative cytology.
Removal of 4.6 L
Widespread grape-like appearance in visceral and parietal pleura
– Neurogenic reflexes from lungs and chest wall Sahn SA. Semin Respir Crit Care Med 2001;22(6)
Large effusion alteration in chest wall P-V
curve Estenne M, Yernault JC, Troyer A. Mechanism of relief of dyspnea after thoracentesis in patients with large pleural effusions. Am J Med 1983;74:813-19
CHEST DISEASE CENTER
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Mechanism of malignancy-associated pleural effusion Direct metastasis Lymphatic obstruction Bronchial obstruction with atelectasis Post obstructive pneumonia Thoracic duct involvement Pericardial disease Hypoproteinemia Pulmonary embolism Radiation therapy Chemotherapy (methotrexate, procarbazine,
Pyng Lee, et al. Medical Thoracoscopy/Pleuroscopy: Manual and Atlas 2011
CHEST DISEASE CENTER
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Characteristics of Malignant Pleural Effusion
Usually exudative (5% transudates)
Mononuclear cell predominant (lymphocytes, macrophages, and mesothelial cells)
1/3 will have low pH (less than 7.3)
Sahn, SA, Clin Chest Med, 1998
Good, TJ, et al: American Review of Respiratory Disease, 1985
CHEST DISEASE CENTER
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Pleural Fluid Cytology
Very useful test
1st specimen positive in 50-60%
Very effective with adenocarcinoma
Less effective
lymphoma,
squamous cell carcinoma, mesothelioma or
Hodgkin’s disease
Pleural fluid, ThinPrep, 4x objective
Pleural fluid, ThinPrep, 40x objective
CHEST DISEASE CENTER
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Pleural Fluid Cytology vs. Thoracoscopy in Different Types of Tumors
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Anthony 2001
CHEST DISEASE CENTER
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Sensitivity of Different Diagnostic Methods for Malignant Pleural Effusion
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Loddenkemper 1983
CHEST DISEASE CENTER
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ERS & ESTS Guidelines
Conclusive dx only if
Representative material
Sufficient material for IH
Presence of clinical, radiological and/or surgical findings
Biopsy normal and abnormal pleura (1c)
No Dx should be made on frozen section
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Boutin and Rey 1983
Scherpereel A,Astolul P, Baas, P, et al. Guidelines of the ERS and the ESTS
for managmetn of MPM. Eur Respir J 2010;35:479-95
Sensitivity of Different Diagnostic Methods for Mesothelioma
CHEST DISEASE CENTER
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Diagnostic Techniques: Tumor Markers
Tumor markers
CEA,
CA 15-3
CA 19-9
enolase
All have been disappointing if used to establish diagnosis
May use to select patients for more invasive procedure if unclear exudate or need for more tissue
CHEST DISEASE CENTER
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Chest X-ray Moderate large
(500 – 2,000 cc) 75% 70% of pts with
massive effusion have underlying CA
If > 1,500 cc and no contralateral shift think: ipsilateral main stem
occlusion
fixed mediastinum (LN)
mimic of effusion due to extensive tumor involvement
Chernow, Sahn, Am J Med 1977; 63: 695
Rabin, J Mt Sinai Hosp 1957; 24: 45
Sahn, Clin Chest Med 1998; 19: 351
ATS, AJRCCM 2000; 162: 1987
CHEST DISEASE CENTER
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Survival with Malignant Pleural Effusion
Primary Total Low pH Normal pH
Breast 14 3.5 16.6
Lymphoma 7 1.7 8.8
Lung 5.3 2.4 6.8
GI 3.8 1.2 5.2
Other 6.3 1.8 17.5
Total 7.3 2.1 9.8
Sahn SA, Good JT. Pleural fluid pH in malignant effusions. Ann Intern Med
1988;108:345-9
*time in months
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Prognosis 417 patients: median survival 4.0 months
most important predictor = primary tumor • 2.3 months for GI primary • 3 months for lung CA • 5.0 months for breast CA / unknown primary • 6.0 months for mesothelioma
Karnofsky score related to prognosis
KPS < 30: median 34d KPS > 70: 395 days No relationship to:
• age • extent of pleural carcinomatosis • pH • glucose
Heffner et.al., Chest 2000; 117: 79
Burrows CM, Mathews WC, Colt HG. Predicting Survival in Pts with Recurrent Syptomatic
Incidence Of Spontaneous Pleurodesis With Indwelling Catheter
Study N % SP Time (days)
Putnam 1 91 46% 29
Putnam 2 100 21%
Pollak 31 42%
Musani 24 58% 39
Tremblay 250 43% 59
CHEST DISEASE CENTER
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Complications of Pleurx
Don’t underestimate delirium
Don’t underestimate the creativity of individuals under stress
Most complications resolve without removal
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Nassim F. Folch E., Majid E. Tunneled Pleural Catheter Dysfunction.
J Bronchology and Interventional Pulmonology 2012;19(2)
CHEST DISEASE CENTER
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Diagnostic Yield of Thoracoscopy
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Janssen JP. Why you do or do not need thoracoscopy.
Eur Respir Rev 2010;19:117:213-6
CHEST DISEASE CENTER
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Medical Thoracoscopy
Underutilized in the USA • Growing interest
• Window into the pleura
• Development of semi-rigid thoracoscope was expected to impact its use.
Integral part of Interventional Pulmonary • “art and science of medicine related to the
performance of invasive diagnostic and therapeutic procedures that require additional training and expertise beyond the required within a standard training program in respiratory medicine”
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Beamis and Mathur 1999
CHEST DISEASE CENTER
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Procedural Interest - Time
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Thoracoscopy
Percutaneous
needle biopsies
Mediastinoscopies
Open Lung Biopsies
Bronchoscopy
Number of Thoracoscopies compared to other procedures at
Lungerklinik 1948-1981. Brandt et al, 1985.
CHEST DISEASE CENTER
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Definition and Controversy
“Pleuroscopy”
“Medical Thoracoscopy”
“Thoracoscopy” • Used interchangeably
through time
• Some experts suggest pleuroscopy while others just thoracoscopy
• Not a debate in Europe
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Pyng Lee, et al. Medical Thoracoscopy/Pleuroscopy: Manual and Atlas 2011
CHEST DISEASE CENTER
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Medical vs. Surgical Thoracoscopy
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Pyng Lee, et al. Medical Thoracoscopy/Pleuroscopy: Manual and Atlas 2011
CHEST DISEASE CENTER
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Pleural Biopsies and Pleurx Placement
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CHEST DISEASE CENTER
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Pleurodesis and Chest Tube Placement
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CHEST DISEASE CENTER
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Distribution of tumor implants in:
The Pleura The Lung
Horeweg N, Van del Aalst CM, Thunnissen E, et al. Characteristics of
lung cancers detected by CT screening in the randomized NELSON
Impurity No risk of asbestos contamination Evaluated by difraction x-rays Infrared specrophotometry
DO NOT USE TALC IN RABBITS OR RATS
Ferrer et al, Chest 2001; 119: 1901 Montes et al, AJRCCM 2003; 168: 348 Fraticelli et al, Chest 2002; 122: 1737 Montes et al, AJRCCM 2003; 18: 348 Maskell et al, Am J Respir Crit Care Med 2004; 170: 377