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Roberts ME, Rahman NM, Maskell NA, et al; BTS Pleural Guideline Development Group. British Thoracic Society Guideline for pleural disease. Thorax. 2023 Jul;78(Suppl 3):s1-s42. doi: 10.1136/thorax-2022-219784. PMID: 37433578.
Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018 Oct 1;198(7):839-849. doi: 10.1164/rccm.201807-1415ST. PMID: 30272503.
Hooper C, Lee YC, Maskell N; BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii4-17. doi: 10.1136/thx.2010.136978. PMID: 20696692.
Etiology and PathogenesisTop
Malignant pleural exudate may be caused by primary neoplasms (mesothelioma) and metastatic cancers, most often related to lung cancer, breast cancer, colon cancer, or lymphoma. Metastatic gastric, pancreatic, renal, bladder, or ovarian effusions are also encountered.
In patients with suspected malignant etiology where analysis of pleural fluid cytology did not establish a diagnosis, repeat pleural fluid analysis is recommended, followed by percutaneous pleural biopsy (preferably a core-needle biopsy guided by imaging studies) if the results of testing are nondiagnostic. If the diagnosis remains in doubt, consider thoracoscopy.
TreatmentTop
Treatment is most often palliative and directed towards symptom management and management of the primary disease.
1. Asymptomatic patients with small effusions should be monitored.
2. In patients with progressive effusions perform therapeutic thoracentesis. In most patients effusion recurs after ~1 week to 1 month. Repeated thoracentesis for palliative treatment of dyspnea should be considered only in patients with a very short life expectancy and long intervals between symptom recurrences.
3. In symptomatic patients with recurrent effusions and lung considered expandable, either chemical pleurodesis (pleural drainage followed by intrapleural administration of a sclerosing agent) or an indwelling intrapleural catheter can be used as the first-line definitive intervention for relieving dyspnea.
4. In symptomatic patients with unexpandable lung (see Exudative Pleural Effusion in the Course of Bacterial Pneumonia), failed pleurodesis, or loculated effusion, an indwelling intrapleural catheter is recommended.
5. Less common treatment modalities include intrapleural administration of fibrinolytic agents to facilitate drainage in patients with multiloculated pleural effusions and pleuroperitoneal shunting (in patients with lung entrapment caused by malignant infiltration).
