Transcript Practical Approach Template - Bronchoscopy International

# 12. Malignant Pleural Effusion with near
total opacification of the hemithorax
►
Objectives:
 Describe the clinical relevance of
malignant pleural effusion
 Describe the role of bronchoscopy
in patients with malignant pleural
effusions.
 Describe an appropriate choice of
palliative treatments available for
a patient with malignant pleural
effusion.
Bronch Intern; Practical Approach #12
Case Description
(practical approach # 12)
43 woman with a history of breast cancer
metastatic to the lungs presents with shortness of
breath and right sided pleuritic chest pain.
► She underwent a right sided mastectomy and
chemotherapy 3 years earlier.
► Several thoracenteses were performed, but results
of the pleural fluid analysis are not available
► The family reports a rapidly declining functional
status.
► She lives abroad, but is visiting her son in the
United States.
►
Bronch Intern; Practical Approach #12
2
The Practical Approach
Initial Evaluation
Procedural Strategies
• Examination and,
functional status
• Significant comorbidities
• Support system
• Patient preferences and
expectations
• Indications, contraindications, and
results
• Team experience
• Risk-benefits analysis and
therapeutic alternatives
• Informed Consent
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
Bronch
BI #.
Intern;
Practical
Practical
Approach
Approach
Title #12
complications
3
Initial Evaluation
► Physical








(practical approach #12)
examination reveals:
Normal vital signs
Spanish-speaking female, appears older than stated age
Mild bi-temporal wasting
Decreased right-sided breath sounds, with dullness to
percussion over entire right lung field
Normal cardiac exam
Chest wall demonstrates evidence of right breast
mastectomy
Benign abdominal exam
No extremity edema
Bronch Intern; Practical Approach #12
4
Initial Evaluation
(practical approach # 12)
► Admission
chest
radiograph: near
complete opacification
of the right hemithorax
Bronch Intern; Practical Approach #12
5
Initial Evaluation
►
(practical approach # 12 )
Chest CT: Massive
right pleural
effusion filling the
right hemi-thorax,
with leftward
mediastinal shift
and a rim of soft
tissue thickening in
the pleura
Bronch Intern; Practical Approach #12
6
Initial Evaluation
(practical approach # 12)
► Diagnostic
and therapeutic thoracentesis
reveals an exudative effusion
► Cytology demonstrates malignant cells
consistent with primary breast cancer
Bronch
BI #.
Intern;
Practical
Practical
Approach
Approach
Title #12
7
Initial Evaluation
► Our
patient’s goal: To leave the hospital,
return to her home country, and spend time
with her family.
Bronch Intern; Practical Approach #12
8
The Practical Approach
Initial Evaluation
Procedural Strategies
• Examination and,
functional status
• Significant comorbidities
• Support system
• Patient preferences and
expectations
• Indications, contraindications, and
results
• Team experience
• Risk-benefits analysis and
therapeutic alternatives
• Informed Consent
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
Bronch
BI #.
Intern;
Practical
Practical
Approach
Approach
Title #12
complications
9
Procedural Strategies
► Possible
treatment strategies for malignant
pleural effusion:







Serial therapeutic thoracenteses
Pleurodesis
Pleuroperitoneal shunting
Indwelling pleural drain
Pleurectomy
Anti-tumor therapies
End-of-life care
Bronch Intern; Practical Approach #12
10
Procedural Strategies: Thoracentesis
► Thoracentesis
is minimally invasive and can be
performed on an outpatient basis
► Can provide immediate relief of dyspnea
► The maximum amount of fluid that can be safely
removed is unknown; caution should be taken to
avoid re-expansion pulmonary edema
 Fluid can be safely removed until the pleural pressure
falls below -20 cm H2O
Light, et al. Am Rev Respir Dis 1980;121:799-804
 Chest pressure is associated with an unsafe drop in
pleural pressures and can be used as a marker for
volume that can be safely removed.
Feller-Kopman, et al. Chest 2006;129:1556-1560
Bronch Intern; Practical Approach #12
11
Procedural Strategies: Thoracentesis
► Other
potential
complications:






Pneumothorax
Bleeding
Pain
Empyema
Skin infection
Infection
Bronch Intern; Practical Approach #12
12
Procedural Strategies: Thoracentesis
► Ultrasound
guidance:
 Significantly reduces the risk of
pneumothorax
Grogan et al, Arch Int Med 1990;150:873-877
Raptopoulos et al, Am J Roentgenol 1991;156:917-920
Barnes et al, J Clin Ultrasound 2005;33:442-446
 No risk reduction if ultrasound
localization of fluid is performed
prior to the procedure (likely
due to changes in patient and
fluid positioning)
Barnes et al, J Clin Ultrasound 2005;33:442-446
Bronch Intern; Practical Approach #12
An ultrasound technician
localizes a pocket of pleural
fluid in the procedure room at
the start of the thoracentesis
13
Procedural Strategies: Thoracentesis
► Serial
thoracenteses are usually reserved for
patients who fulfill one of the following:
 Re-accumulate fluid slowly after each
thoracentesis
 Have cancers that commonly respond to
therapy with resolution of associated effusion
 Appear unlikely to survive past 1 to 3 months
 Are unable to tolerate more invasive procedures
Heffner JE, Klein JS. Mayo Clin Proc 2008;83:235-250
Bronch Intern; Practical Approach #12
14
Procedural Strategies: Pleurodesis
► Pleurodesis
involves permanent apposition
of the visceral and parietal pleura through
sclerosis of the pleural surfaces
► Can be performed using various agents:
 Chemical (doxycycline, tetracycline, bleomycin)
 Mineral (talc)
 Mechanical
► Can
be performed through a chest tube or
thoracoscopically
Bronch Intern; Practical Approach #12
15
Procedural Strategies: Pleurodesis
► Indications:
 Malignant effusion that is rapidly recurrent and
unresponsive to systemic therapy
 Symptomatic improvement after thoracentesis
and recurrence of symptoms after fluid reaccumulation
 Karnofsky score 40 or above
 Estimated survival greater than 3 months
Colt HG, Mathur PN. Manual of Pleural Procedures, Philadelphia: Lippencott Williams and Williams;199:155
Bronch Intern; Practical Approach #12
16
Procedural Strategies: Pleurodesis
► Contraindications:
 Expected survival less than 3 months
 Symptoms not attributable to the effusion
 Selected patients which may still benefit from
systemic therapy
 Patients who refuse hospitalization or refuse tube
thoracostomy
 Incomplete lung re-expansion following complete
removal of pleural fluid (i.e. trapped lung)
Colt HG, Mathur PN. Manual of Pleural Procedures, Philadelphia: Lippencott Williams and Williams;199:155
Bronch Intern; Practical Approach #12
17
Procedural Strategies: Pleurodesis
► Pleurodesis
via chest tube:
 Chest tube should be placed in a posterior and
inferior position
 After the pleural fluid is completely drained,
confirm lung re-expansion with a chest x-ray
 With the chest tube off suction, the sclerosing
agent (mixed with saline) is instilled through the
tubing into the pleural space
 The chest tube is then clamped for two hours
Bronch Intern; Practical Approach #12
18
Procedural Strategies: Pleurodesis
► Pleurodesis
via chest tube (con’t):
 Patient positioning and rotation are not likely to
improve sclerosing agent distribution or
pleurodesis success
Lorch, et al. Chest 1988;93:527-529
Dryzer, et al. Chest 1993;104:1763-1766
 Clamps are then removed and the system
placed to suction
 Chest tube may be removed when the daily
drainage is less than 100 ml
Bronch Intern; Practical Approach #12
19
Techniques and Results:
Rapid Pleurodesis
► Technique
described by Spiegler et al:
 Using local anesthesia and systemic analgesia, a small bore (14F)
chest tube is placed in the posterior axillary line directed towards
the posterior pleural gutter
 The pleural space is drained without suction into a water-seal
system
 After 15 minutes, suction at -20 cm H2O added unless drainage
exceeds an arbitrary volume of one liter
 A portable chest x-ray is obtained after two hours
 If the pleural fluid is not completely evacuated on the 2 hour x-ray,
suction is continued for a another 2 hours and the x-ray is repeated
 Pleurodesis not attempted if the chest radiograph is consistent with
trapped lung
Spiegler et al, Chest 2006;123:1895-1898
Bronch Intern; Practical Approach #12
20
Rapid pleurodesis
► Rapid
pleurodesis technique (con’t):
 When fluid is completely evacuated, pleurodesis is
performed by injecting sclerosing agent into the
chest tube
► Spiegler
et al utilized either 60 units of bleomycin or 4g of
talc slurry diluted in a 50 mL saline solution
► All patients received 10 mL of 2% lidocaine solution
instilled into the pleural space prior to the sclerosing
agent. Systemic analgesia given if needed.
 The chest tube is clamped for 90 minutes with the
patient lying in bed (no special positioning), then
unclamped and returned to suction.
 Chest tube removed after two hours.
 Minimal incidence of pain, fever, or iatrogenic
pneumothorax
Bronch Intern; Practical Approach #12
21
Thoracoscopic pleurodesis
 A rigid telescope and working instruments are
inserted through small incisions in the lateral chest
wall
 Allows for direct visualization of the pleura and lung
 Fluid drainage and pleural biopsies can be
performed under visual guidance
 Pleurodesis can be performed by utilizing a
pneumatic atomizer for talc insufflation through a
trocar
Colt HG, Mathur PN. Manual of Pleural Procedures, Lippincott Press.
Bronch Intern; Practical Approach #12
22
Preparing for video-assisted thoracoscopy using flex-rigid pleuroscope.
Bronch Intern; Practical Approach #12
23
Pleurodesis: expected outcomes
dependent on agent used
► Cochrane
Review comparing techniques in
pleurodesis for malignant pleural effusion:
 Talc is the most efficacious agent
►Relative
risk of non-recurrence was 1.34 (95% CI
1.16 to 1.55) compared to bleomycin, tetracycline,
mustine, and tube drainage alone
►Not associated with increased risk of death
Shaw P, Agarwal R. Cochrane Database of Systematic Reviews 2004, Issue 1
Bronch Intern; Practical Approach #12
24
Outcomes dependent on procedure
and agent used
► Cochrane
Database review (con’t):
 Thoracoscopic pleurodesis with talc is more
effective than tube thoracostomy pleurodesis
►RR
of non-recurrence is 1.19 (95% CI 1.04-1.36) in
comparison to tube thoracostomy using talc
►RR of non-recurrence is 1.68 (95% CI 1.35-2.10) in
comparison to tube thoracostomy using various
agents (tetracycline, bleomycin, talc, or mustine)
Shaw P, Agarwal R. Cochrane Database of Systematic Reviews 2004, Issue 1
Bronch Intern; Practical Approach #12
25
Talc vs other
► Cochrane
Database review (con’t):
 Comparison of successful pleurodesis
►Talc
(74%) more successful than tetracyclines (57%)
►Talc (79%) more successful than bleomycin (64%)
►Tetracyclines (63%) and bleomycin (62%) have
similar success rates
►Thoracoscopic talc (96%) more successful than
medical talc (81%)
Shaw P, Agarwal R. Cochrane Database of Systematic Reviews 2004, Issue 1
Note: The issue of thorascopic talc insufflation vs. medical talc slurry pleurodesis is still
controversial…!
Bronch Intern; Practical Approach #12
26
Outcomes dependent on techniques used
► Still
debated: Thoracoscopic talc insufflation
(TTI) vs. talc slurry (TS)
 Dresler et al performed a prospective
randomized trial of treatment with either TTI or
TS
►No
difference in success at 30 days in TTI (78%) vs.
TS (71%)
►Subgroup analysis of primary lung and breast cancer
patients reveals an advantage of TTI (82%) vs. TS
(67%)
Dresler et al, Chest 2005;127:909-915
Bronch Intern; Practical Approach #12
27
Thoracoscopy vs talc slurry
► Thoracoscopic
(con’t):
talc insufflation vs. talc slurry
 The authors suggest that thoracoscopic talc
insufflation:
► Allows
for direct pleural visualization and intervention for
adhesions and loculations
► May be indicated in patients with prior ipsilateral surgery,
prior attempted pleurodesis, or trapped lung
► Is equal in efficacy to talc slurry, but may be more
advantageous in primary lung or breast cancer
Dresler et al, Chest 2005;127:909-915
Bronch Intern; Practical Approach #12
28
Procedural Strategies: Pleurodesis
Reported Adverse Effects:
Shaw P, Agarwal R. Cochrane Database of Systematic Reviews 2004, Issue 1
• Respiratory failure
• Fever
• Pain
• Rigors
• GI side-effects
• Wound infections
• Cardiac arrest under
general anesthesia
•
•
•
•
•
•
•
•
Hemorrhage
Percutaneous fistula
Pulmonary emboli
Air leaks
Pulmonary edema
Leukopenia
Hypotension
subcutaneous emphysema
Bronch Intern; Practical Approach #12
29
Does talc pleurodesis cause ARDS
Case studies are contradictory.
Occurrence in some series and absence in others
appears independent of underlying disease, quantity of
talc used, or instillation method.
► Data on particle size is absent in most reports.
► Smaller particles may be able cause pneumonitis by
entering the systemic circulation through the lymphatic
stoma Ferrer et al, Chest 2001;119:1901-1905
► No cases of ARDS occurred in 558 patients who
underwent pleurodesis with 4g of large particle talc
(11% of particles <5μm) Janssen et al, Lancet 2007;369:1535-1539
►
►
Bronch Intern; Practical Approach #12
30
Pleuroperitoneal Shunting
► Involves
a drain from the pleural space into the
peritoneal cavity
► Useful in providing symptomatic relief in the
setting of trapped lung
► Requires the patient to provide digital pressure
over a valve multiple times a day to pump the
pleural fluid into the abdomen
► Has the potential risk of peritoneal seeding of
malignant cells .
► Other complications are frequent (15%): shunt
occlusion, infection, skin erosion.
Petrou et al, Cancer 1995;75:801-805
Genc et al, Eur J Cardiothorac Surg 2000;18:143-146
Bronch Intern; Practical Approach #12
31
Indwelling Pleural catheter to
external evacuation system
► Allows
the patient to intermittently drain the
effusion at home.
► Results in rapid improvement in symptoms
► General anesthesia not required for
placement
► Can be placed as an outpatient safely and
cost-effectively
► Effective as a treatment option for Trapped
Lung Syndrome
Putnam et al, Ann Thoracic Surg 2000;69:369-375
Pien et al, Chest 2001;119:1641-1646
Bronch Intern; Practical Approach #12
32
Indwelling Pleural Drain
► Tremblay
and Michaud studied 250 tunneled
pleural catheter insertions in 223 patients:
 Complete symptom control achieved at two weeks
in 38.8%, partial in 50%, and absent in 3.6%
 Spontaneous pleurodesis occurred in 42.9%
 No further ipsilateral pleural procedures (i.e.
thoracentesis, repeat catheter placement, chest
tube) required in 90.1% of successful catheter
placements
Tremblay A, Michaud G, Chest 2006;129:362-368
Bronch Intern; Practical Approach #12
33
But some complications are noted
►
Tremblay and Michaud study (con’t)- Complications:
Tremblay A, Michaud G, Chest 2006;129:362-368
Bronch Intern; Practical Approach #12
34
Procedural Strategies: Indwelling
Pleural Drain
► Warren
et al. inserted 231 pleural catheters
into 202 patients:
 Generally utilized a Seldinger technique rather than
tunneling for insertion
 No intraoperative complications
 All but 14 patients were able to care for the
catheter without nursing help
 97% of patients were compliant with the drainage
schedule (every day during the first week, then
every other day)
 The patient’s symptoms were palliated in all cases
Warren et al, Ann Thorac Surg 2008;85:1049-1055
Bronch Intern; Practical Approach #12
35
Procedural Strategies: Indwelling
Pleural Drain
► Warren
et al study (con’t):
 Spontaneous pleurodesis occurred in 58% of all patients
 Higher spontaneous pleurodesis rates occurred when
the primary site was breast or gynecologic
Warren et al, Ann Thorac Surg 2008;85:1049-1055
Bronch Intern; Practical Approach #12
36
Procedural Strategies: Indwelling
Pleural Drain
► Warren
et al study (con’t):
 The recurrence rate was lowest when the primary site
was breast or gynecologic
 Complication rates were low
Warren et al, Ann Thorac Surg 2008;1049-1055
Bronch Intern; Practical Approach #12
37
Procedural Strategies: Pleurectomy
► Pleurectomy
involves surgical stripping of
the pleura and pericardium
► Decortication may be required if tumor
hinders lung re-expansion
► Highly effective (100%), but also carries
high mortality (12.5%)
Fry WA, Khandekar JD, Annals of Surgical Oncology1995;2:160-164
► Not
generally recommended because of
high mortality
Putnam JB, Surg Clin N Am 2002;82:867-883
Bronch Intern; Practical Approach #12
38
Procedural Strategies:
Systemic Chemotherapy
► Recommended
in symptomatic malignant
pleural effusion from chemotherapy-responsive
tumors (such as breast, small cell lung, and
lymphoma)
► Can be used in combination with pleurodesis or
thoracentesis
► When contraindicated or ineffective, then local
therapy (such as pleurodesis) should be
applied
Antony et al, Am J Respir Crit Care Med 2000;162:1987
Bronch Intern; Practical Approach #12
39
Procedural Strategies:
Intrapleural Chemotherapy
► Aims
to locally treat pleural tumor without
systemic toxicities
 Trials using etoposide, fluorouracil, mitomycin-c,
doxorubicin, and cisplatin-based regimen have
not shown sufficient efficacy for use
Seto et al, Br J Cancer 2006;96:717-721
 Intrapleural chemotherapy has also been
studied in combination with intravenous
chemotherapy; more study necessary
Su et al, Oncology 2003;64:18-24
Bronch Intern; Practical Approach #12
40
Procedural Strategies:
Intrapleural Chemotherapy
►A
multi-institution phase II study of hypotonic
cisplatin treatment by Seto et al shows promise
 Instilled a mixture of cisplatin 25 mg in 500 ml of
distilled water through a chest tube
 The chest tube was clamped for one hour, then allowed
to drain and removed when the drainage was < 200 ml
per day
 Of 80 patients with malignant pleural effusion from
NSCLC, the 4 week overall response rate was 83%
► Complete
response (no effusion) noted in 34%
► Partial response (effusion < 25% of the hemithorax) noted in
49%
Seto et al, Br J Cancer 2006;95:717-721
Bronch Intern; Practical Approach #12
41
Procedural Strategies:
Intrapleural chemotherapy
► Hypotonic
cisplatin study (con’t):
 Median response time was 206 days and median
survival time was 239 days
 No hematologic toxicities or grade 4 nonhematologic toxicities were noted
 Grade 3 adverse toxicities included nausea (4%),
vomiting (1%), pyothorax (1%) and dyspnea (1%)
 Mechanism of action is believed to involve a
combination of cytotoxic effects and increased
cellular cisplatin levels due to hypotonicity
 A phase III trial is necessary
Seto et al, Br J Cancer 2006;95:717-721
Bronch Intern; Practical Approach #12
42
Procedural Strategies:
Intrapleural Immunotherapy
► Variable
success noted with instillation of active
cytokines (such as IL-2, IFN-α, IFN-β, and IFN-γ)
 The mechanism of observed responses is unclear
(sclerosing activity vs. immunologic effect)
 Results of phase II trials have been inconclusive
Antony et al, Am J Respir Crit Care Med 2000;162:1987-2001
► Combining
intrapleural chemotherapy and
intrapleural immunotherapy may be more effective
than either regimen alone
Nio et al, Br J Cancer 1999;80:775-785
► More
studies are needed
Bronch Intern; Practical Approach #12
43
Procedural Strategies:
End-of-Life Care
►
ACCP recommendations for end-of-life care
 Communication between the physicians, patients, and family
is central to the overall care
 Need for advanced directive, and the clinician should assume
responsibility for placing it in the chart
 The hospital ethics committee is underutilized and may be
effective in clarifying issues surrounding end-of-life decisions
 Palliative care should be an integral part of treatment of all
patients, including those still pursuing life-prolonging
therapies.
 The goal of palliative care should be to achieve the best
quality of life for the patients and their families.
 Terminal illness defined as expected survival less than 6
months.
Griffin et al, Chest 2003;123:312S-331S
Bronch Intern; Practical Approach #12
44
The Practical Approach
Initial Evaluation
Procedural Strategies
• Examination and,
functional status
• Significant comorbidities
• Support system
• Patient preferences and
expectations
• Indications, contraindications, and
results
• Team experience
• Risk-benefits analysis and
therapeutic alternatives
• Informed Consent
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
Bronch
BI #.
Intern;
Practical
Practical
Approach
Approach
Title #12
complications
45
Results and Long-Term Management
► Rapid
pleurodesis performed with success.
► The palliative care services consulted
► Patient discharged within two days.
► Patient returned safely to her home abroad.
► Patient expired eight months later without
evidence of recurrent effusion.
Bronch Intern; Practical Approach #12
46
Q 1: Describe the clinical relevance
of a malignant pleural effusion
Bronch Intern; Practical Approach #12
Frequency
► The
annual incidence of malignant pleural
effusion is estimated to be > 150 000
cases
► Malignancies
cause 42% to 77% of
exudative effusions
Antony et al, Am J Respir Care Med 2000;162:1987-2001
Bronch Intern; Practical Approach #12
48
Chest radiography
► Chest
radiography:
 Only 10% of malignant effusions will present as a
massive effusion (filling the entire hemithorax)
Maher GG, Berger HW, Am Rev Respir Dis 1972;105:458-460
 Malignancy causes 55% of large or massive pleural
effusions Porcel JM, Vives M, Chest 2003;124:978-983
 Absence of contralateral mediastinal shift implies:
► Fixation
of the mediastinum
►Mainstem bronchus occlusion
► Extensive pleural involvement
Antony et al, Am J Respir Care Med 2000;162:1987-2001
Bronch Intern; Practical Approach #12
49
Yield of diagnostic procedures
► Reported
yield of various diagnostic approaches:
 Pleural fluid cytology: Sensitivity 62-90%
Antony et al, Am J Respir Care Med 2000;162:1987-2001
 Closed pleural biopsy: Sensitivity 40-75%
Antony et al, Am J Respir Care Med 2000;162:1987-2001
 Blind percutaneous pleural biopsy (Abrams):
Sensitivity 43-51%
Chakrabarti et al, Chest 2006;129:1549-55
 Image-guided pleural biopsy (CT and ultrasound):
Sensitivity 76%
Benamore et al, Clin Radiol 2006;61:700-705
 Thoracoscopy: Sensitivity 80-100%
Harris et al, Chest 1995;108-828-841
Bronch Intern; Practical Approach #12
50
Etiologies
Cell type or Origin of Malignant Effusions:
► Lung 48%
 Epidermoid carcinoma 9%
 Adenocarcinoma 19%
 Large cell carcinoma 2%
 Giant cell carcinoma 2%
 Small cell carcinoma 24%
►
►
►
►
►
►
►
Breast 24%
Gastrointestinal 9%
Ovary 6%
Kidney 5%
Uterus 2%
Thyroid 1%
Unknown 14%
Sanchez-Armengol A and Rodriguez-Panadero F, Chest 1993;104:1482-1485
Bronch Intern; Practical Approach #12
51
Parietal pleural metastases. This photograph was taken during a
thoracoscopic procedure. A serous effusion is also visualized
adjacent to the lung parenchyma (arrows)
Bronch Intern; Practical Approach #12
52
Q2: Describe the role for
bronchoscopy in a patient with
malignant pleural effusion
Bronch Intern; Practical Approach #12
Role of bronchoscopy
► Routine
use of bronchoscopy may not be
warranted in patients with pleural effusion
of unknown etiology
►Not
useful in small to moderate size pleural effusions
(filling less than 75% of the hemithorax) without
other findings
Poe et al, Chest 1994;105:1663-1667
►Bronchoscopy
yield is low in evaluating undiagnosed
pleural effusions in absence of other indications
Feinsilver et al, Chest 1986;90:516-519
Bronch Intern; Practical Approach #12
54
Bronchoscopy is useful in case
►
►
►
►
Pulmonary infiltrate present on chest x-ray or CT
Hemoptysis, which increases the likelihood that a
malignancy is present
Massive pleural effusion, of which malignancy is the most
common cause (helps exclude airway obstruction by
exophytic tumor, mucosal infiltration, or extrinsic
compression).
Mediastinum is shifted toward the side of the effusion,
suggestive of an obstructing endobronchial lesion.
Light RW, Clin Chest Med 2006;27:309-319
Bronchoscopy can thus reveal causes for atelectasis and trapped lung.
Bronch Intern; Practical Approach #12
55
Q 3. Describe an appropriate
choice of palliative treatment
modalities for patients with
malignant pleural effusions
Bronch Intern; Practical Approach #12
Interactive question
►
A frail, cachetic 72 year old man lives alone and is without
family. He has a symptomatic recurrent left-sided pleural
effusion secondary to metastatic small cell lung cancer.
Thoracentesis 3 months ago relieved his symptoms. There was
full re-expansion of the lung afterwards. His functional status is
poor (Karnofsky score of 30), and the oncologist feels that he
has less than 3 months to live. Which of the following might be
the most appropriate palliative treatment strategy?
A.
B.
C.
D.
E.
Pleurectomy
Thoracoscopic talc pleurodesis
Chest tube talc pleurodesis
Serial thoracenteses
Indwelling pleural drain
Bronch Intern; Practical Approach #12
57
Answer to interactive question
D.
Some would say serial thoracenteses, others might
say indwelling pleural catheter (but he is unlikely to be
able to be able to maintain the catheter on his own
and as he becomes weaker), and still others might
suggest rapid pleurodesis (to avoid pleurodesis-related
hospitalization).
Pleurectomy has a high mortality and is generally
not recommended. Thoracoscopic pleurodesis is often
not recommended for patients with an expected
survival less than 3 months or a Karnofsky score less
than 40.
In addition to serial thoracenteses to relieve
symptoms, his physicians should discuss end-of-life
care, including advanced directives, pain control, and
hospice care.
Bronch Intern; Practical Approach #12
58
All efforts are made by Bronchoscopy International
to maintain currency of online information. All
published multimedia slide shows, streaming
videos, and essays can be cited for reference as:
Bronchoscopy International: Practical Approach, an Electronic OnLine Multimedia Slide Presentation.
http://www.Bronchoscopy.org/PracticalApproach/htm. Published
2009 (Please add “Date Accessed”).
Thank you
Bronch Intern; Practical Approach #12
59
Prepared by Steven C. Wong MD (USA)
www.bronchoscopy.org
Bronch Intern; Practical Approach #12
60