From the Guidelines
Lymphoma is a significant cause of pleural effusion, and prompt evaluation and treatment are crucial to improve morbidity, mortality, and quality of life. Lymphoma can cause pleural effusion through direct tumor invasion of the pleura or lymphatic obstruction, and it typically presents as a malignant pleural effusion characterized by exudative fluid containing malignant lymphocytes 1. Diagnosis requires thoracentesis with cytology, flow cytometry, and sometimes pleural biopsy. Management includes treating the underlying lymphoma with appropriate chemotherapy regimens such as R-CHOP for B-cell lymphomas or ABVD for Hodgkin lymphoma 1. Symptomatic effusions may require therapeutic thoracentesis, pleurodesis, or indwelling pleural catheters for palliation.
Key Considerations
- The presence of malignant cells in the effusion is associated with a poor prognosis, with an average survival time of 6 or 7 months after the first thoracentesis 1.
- Systemic chemotherapy is the treatment of choice, and pleurodesis by talc poudrage may be necessary when chemotherapy fails 1.
- Mediastinal radiation may be useful when there is mediastinal node involvement and may be effective in chylothorax 1.
- Patients with unexplained pleural effusions should be considered for lymphoma workup, especially with B symptoms (fever, night sweats, weight loss) or lymphadenopathy.
Treatment Approach
- Systemic therapy should be started if no contraindications exist, and it may be combined with therapeutic thoracentesis or pleurodesis 1.
- Neoplasms that tend to be chemotherapy responsive include breast cancer, small-cell lung cancer, and lymphoma.
- Local therapy such as pleurodesis may be applied when systemic treatment options are unavailable or contraindicated, or systemic treatment is or has become ineffective.
From the FDA Drug Label
Malignant Pleural Effusion—60 units administered as a single-dose bolus intrapleural injection When administered into the pleural cavity in the treatment of malignant pleural effusion, Bleomycin acts as a sclerosing agent
The drug bleomycin can be used to treat malignant pleural effusion. The recommended dose is 60 units administered as a single-dose bolus intrapleural injection. Bleomycin acts as a sclerosing agent when administered into the pleural cavity. 2 2
From the Research
Lymphoma and Pleural Effusion
- Lymphoma can cause pleural effusion, which is the accumulation of fluid in the pleural space of the lungs [(3,4,5,6)].
- Pleural effusion is a common finding in patients with lymphoblastic lymphoma, with one study showing that 71% of patients with lymphoblastic lymphoma had a pleural effusion at presentation 5.
- The presence of pleural effusion can be a poor prognostic factor in patients with intravascular large B-cell lymphoma 3.
- Rituximab, a monoclonal antibody, has been shown to be effective in treating malignant pleural effusions in non-Hodgkin's lymphoma 4.
- Cytological examination of pleural fluid can be used to diagnose T cell lymphoblastic leukemia/lymphoma in patients with pleural effusion as an initial clinical presentation 6.
Treatment Options
- Rituximab-containing chemotherapy has been shown to improve treatment outcomes in patients with intravascular large B-cell lymphoma 3.
- Epratuzumab, an anti-CD22 monoclonal antibody, has been combined with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) to treat patients with previously untreated diffuse large B-cell lymphoma 7.
- Intrapleural instillation of rituximab has been used to treat malignant pleural effusions in non-Hodgkin's lymphoma 4.