The

TM

EPEC-O

Education in Palliative and End-of-life Care - Oncology

Project

The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

E P E C O EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

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

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Decreased mobility and fear

Overview



Scope of the problem

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Causes

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Pathophysiology

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Diagnosis



Prognosis

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Management options

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Treatment strategies

Impact

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> 25 % of newly diagnosed pleural effusions are due to malignancy

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50 % of cancer patients will develop a pleural effusion

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In US, approx. 100,000 malignant effusions / yr

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Life expectancy 4 – 12 months

Causes

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Breast and lung cancer



Lymphoma, GU, GI

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Unknown primary 50 – 65 % 25 % 7 – 15 %

Prognosis

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Mortality 54 % at 1 month, 84% at 6 months

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Survival ~ 10 months where pleural effusion is first evidence of cancer

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Known CA, exudate, negative cytology poor prognosis compared to positive cytology

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Role of pH, Karnofsky Performance Scale?

Key points

1.

Pathophysiology 2.

Assessment 3.

Management

Pathophysiology



Fluid production

=

fluid resorption

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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

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Symptoms: dyspnea, dry cough, pleuritic pain, chest discomfort, limited exercise tolerance

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Exam: decreased breath sounds, dullness to auscultation and percussion

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CXR PA, lateral and decubitus films

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Chest CT or U / S if loculated

Differential diagnosis



Parapneumonic effusion



Empyema



Chylothorax



Transudate

Benign vs. malignant effusions . . .

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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

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Cytology Positive in approximately 55 – 65 % initially Yield up to 77 % on three pleural fluid samples

Management

Initial drainage Pleurodesis Late recurrence Complications Intrapleural catheter 97% 46% 13% 13% outpt Doxycycline pleurodesis 68% 54% 21% 14% inpt

Putnam 1999.

Management options



Thoracentesis

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Tube thoracostomy

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Small-bore chest tubes

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Pleurodesis

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Thoracoscopy

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Intrapleural catheters

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Pleuroperitoneal shunting

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Subcutaneous access ports

Thoracentesis



Diagnostic, therapeutic

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Temporary relief

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Many contraindications

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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

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Tube thoracostomy: free-flowing effusions, unable to tolerate general anesthesia

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Thoracoscopy: life expectancy > 3 mos, loculated effusions, biopsies

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Intrapleural catheters: outpatient pleurodesis

Thoracoscopy benefits

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Direct visualization of lung re-expansion

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Identify loculated areas and drain

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Administration of dry talc, chest tube placement

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Confirm equal distribution of talc

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Shorter hospital stay than tube thoracostomy

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Diagnostic yield 90 %, pleurodesis success rate 90%

Tube thoracostomy and pleurodesis . . .

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More definitive than repeated thoracentesis for recurrent effusions

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Chest tube 12 – 24 hr or until drainage < 250 ml / 24 hr

. . . Tube thoracostomy and pleurodesis

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Sclerosing agent when dry Talc, bleomycin, doxycycline Tube clamping controversial Rotation vs. nonrotation



Failure rate 10 – 40 %

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Most widely used and cost effective method

E P E C O

Summary

Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience