Malignant Pleural Effusion

Malignant Pleural Effusion –General Information

Pleural effusion is a common complication in patients with malignant neoplasm, and can be defined as an abnormal accumulation of fluid in the pleural space, which is delimited by the parietal and the visceral pleura membranes. The function of the pleural liquid is to provide a frictionless zone between the parietal and visceral pleurae in response to the changing lung volume during respiration. The parietal pleurae cover the whole internal surface of the thoracic cavity, while the visceral pleurae cover the surface of the lungs.

Malignant pleural effusions are caused by carcinomas of the breast, via obstruction of mediastinal lymphatic, lung, gastrointestinal tract or ovary. Effusions may be secondary to impaired pleural lymphatic drainage from mediastinal tumor (especially in lymphomas) and not caused by direct pleural invasion. Effusions can be the first sign of cancer and they can develop after the cancer is diagnosed, but happily, only 50% of the effusions that develop in cancer during the course of the illness are malignant and half of the persons who are diagnosed with cancer develop a pleural effusion and 75% of people who have pleural effusion also have cancer of the breast, lung, ovary or lymphoma. Pleural effusions are due principally to congestive heart failure, malignancy, and infection. Patients present with the symptoms of decreased exercise tolerance and chest pain. The larger effusions can be detected on physical examination, but the small effusions may be detected only by chest radiography ultrasound and computerized tomography of the chest. There are two types of effusions exudative and transudative.

Malignant Pleural Effusion – Symptoms

• Dyspnea – meaning a shortness of breath, is the distressing symptom for the patients.  The Malignant Pleural Effusion begins with an accumulation of a small quantity of liquid that can only be seen at radiography, and can be associated with pain as the disease evolves.
• Pleuritic chest pain is a vague discomfort or a sharp pain that is unbearable in inspiration which indicates an inflammation of the parietal pleura
• They can feel their chest heavy
• Inability to make exercises and effort
• Malaise
• Cough
• Decreased breath sounds
• A pleural friction rub can appear, although it is not frequent, it is one of the classical signs of the disease
• Hiccups
• Rapid breathing

Transudative effusions are due to the combination of increased hydrostatic pressure and decreased oncotic pressure in the pulmonary or systemic circulation. Heart failure and cirrhosis are the most common causes of the Malignant Pleural Transudative Effusions.

Exudative effusions are due to local processes leading to increased capillary permeability resulting in exudation of fluid, protein, cells. The causes are various, but the most common is pneumonia, pulmonary embolism, viral infection, tuberculosis, viral infection and malignancy. The “yellow nail syndrome” is a rare disorder that causes the exudative Malignant Pleural Effusions and lymphedema and it is caused by the low lymphatic drainage.

Malignant Pleural Effusion – Treatment

If dyspnea caused by Malignant Pleural Effusion is lightened by thoracentesis and the fluid continues to reaccumulate (with dyspnea) more than once, it is recommended to perform chronic drainage or pleurodesis. The asymptomatic Pleural Effusions and the Pleural Effusions that do not respond to thoracentesis do not need additional procedures. The catheter drainage is recommended to the ambulatory patients, as the catheter can be inserted on an outpatient basis and the pleural liquid can be drained into a “vacuum” bottle. Shunting of pleural fluid to the peritoneum is recommended to patients with Malignant Effusion, that do not respond to the pleurodesis or who have a trapped lung. Pleurodesis means injecting a sclerosing agent (such as talc, doxycycline, bleomycin, tetracycline or doxycycline) in the pleural space which will make the two pleurae to fuse and the space between them to disappear. 

The Malignant Pleural Effusion is an important complication of the malignancy that can be hard to diagnose and treat, as it is associated with numerous other diseases. The pleural effusion can be an early or a late sign of cancer, but fortunately, there is an increasing number of therapeutic modalities available which, when are appropriately applied may slow down or even stop the evolution of the disease. The treatment of Malignant Pleural Effusion depends on the cause that produces it and one of the two conditions that need special consideration is the Malignant Effusion, which is usually treated relieve the patience’s shortness of breath and the chest pain and for this there are four methods:

1.Chemotherapy, which is used only if the tumor responds to the therapy and if it does the Pleural Effusion may be solved.

2. Intermittent thoracentesis it is used if the fluid reaccumulates slowly between the two pleurae and through this method the accumulated liquid is drained.

3. Pleurodesis is a method used if the Pleural Effusion reaccumulates quickly after the drainage is made and it is used to control the Malignant Pleural Effusion.

4. Pleural Peritoneal Shunt consists in placing one end of the catheter in the pleural space, the catheter is introduced under the skin, and the other end is placed in the peritoneal cavity. The fluid, which is rich in malignant cells, is pumped through the catheter from the pleural space in the peritoneal cavity, where a tumor can appear. This procedure may be used only to relieve the symptoms.