From the Guidelines
Metastatic cancer is strongly associated with recurrent pleural effusions, which significantly impact quality of life and are often a sign of advanced disease. The connection between metastatic cancer and recurrent pleural effusions is well-established, with up to 15% of all patients with cancer developing malignant pleural effusions (MPE) 1. When cancer metastasizes to the pleura, it can disrupt normal fluid balance, leading to fluid accumulation in the pleural space. This is particularly common in lung, breast, ovarian, and lymphatic cancers.
Management of Malignant Pleural Effusions
Management of MPE typically involves thoracentesis for immediate symptom relief, followed by more definitive approaches like pleurodesis or placement of indwelling pleural catheters for ongoing drainage. The choice of management depends on several factors, including symptoms, performance status, primary tumor, and response to systemic therapy 1.
Treatment Options
Treatment options for MPE include:
- Thoracentesis for immediate symptom relief
- Pleurodesis using agents such as talc, doxycycline, or bleomycin at standard doses to adhere the pleural surfaces together
- Placement of indwelling pleural catheters for ongoing drainage
- Tunneled pleural catheters (TPCs) for palliation of malignant effusions, which provide a less invasive means to reduce dyspnea and improve quality of life (QOL) 1
Quality of Life and Symptom Management
The presence of recurrent pleural effusions in cancer patients generally indicates advanced disease and may significantly impact QOL through symptoms like dyspnea, chest pain, and cough. Treatment decisions should consider the patient's overall condition, cancer type, response to systemic therapy, and life expectancy. According to a systematic review of 12 observational studies on TPC for palliation of malignant effusions, 96% of patients derived symptomatic relief, and the reported rate of pleurodesis was 46% 1.
Recommendation
The most effective management approach for recurrent pleural effusions in patients with metastatic cancer is the placement of indwelling pleural catheters or pleurodesis, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1. This approach provides effective symptom relief, improves QOL, and reduces the need for repeated thoracentesis and hospitalizations.
From the Research
Connection between Metastatic Cancer and Recurrent Pleural Effusions
- Metastatic cancer is a common cause of malignant pleural effusions, with approximately half of all patients with metastatic cancer developing a malignant pleural effusion at some point 2, 3, 4.
- The development of malignant pleural effusions is associated with significant symptoms, such as dyspnea and cough, and can significantly impact the quality of life of patients with metastatic cancer 2, 5.
- The management of malignant pleural effusions is controversial, and there is no universally established standard approach 2, 5, 3.
- Treatment options for malignant pleural effusions include observation, thoracentesis, indwelling pleural catheter (IPC) or chest tube placement, pleurodesis, and surgical pleurectomy 2, 5, 3.
Risk Factors for Recurrent Pleural Effusions
- Several risk factors have been identified for recurrent pleural effusions in patients with malignancy, including:
- These risk factors can help clinicians identify patients who are at high risk of recurrence and develop a treatment plan that optimizes quality of life 6.
Treatment Options for Recurrent Pleural Effusions
- Treatment options for recurrent pleural effusions include repeat thoracenteses, indwelling pleural catheter (IPC) or chest tube placement, pleurodesis, and surgical pleurectomy 2, 5, 3.
- Chemical pleurodesis is a common modality of therapy for patients with recurrent pleural effusion, with talc being the most successful pleurodesis agent 5.
- Pleur-X catheter can reduce hospital stay and add value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis 5.