What is the diagnosis and treatment for malignant pleural effusion (MPE)?

From the Guidelines

For the management of malignant pleural effusion (MPE), the most effective treatment approach is to use either an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention for management of dyspnea in patients with symptomatic MPE and expandable lung. This recommendation is based on the most recent and highest quality study available, which suggests that both IPC and chemical pleurodesis are effective options for managing MPE [ 1 ].

Diagnosis and Treatment Options

When diagnosing MPE, ultrasound imaging should be used to guide pleural interventions [ 1 ]. For patients with known or suspected MPE who are asymptomatic, therapeutic pleural interventions should not be performed [ 1 ]. However, for patients with symptomatic MPE, large-volume thoracentesis may be used to assess lung expansion and relieve symptoms [ 1 ].

Pleurodesis and IPC

Pleurodesis, typically using talc (4-5g) instilled through a chest tube, is a recommended treatment for longer-term control of MPE [ 1 ]. Chemical pleurodesis agents like bleomycin (60 units) or doxycycline (500mg) may be alternatives. Indwelling pleural catheters offer another option for recurrent effusions, allowing intermittent drainage at home [ 1 ].

Pain Management and Systemic Cancer Therapy

Pain management with NSAIDs, acetaminophen, or opioids as needed is important for patients with MPE [ 1 ]. Systemic cancer therapy (chemotherapy, immunotherapy, targeted therapy) should be pursued if the patient is a candidate, as treating the underlying malignancy may help control the effusion [ 1 ].

Multidisciplinary Care

Multidisciplinary care involving oncology, pulmonology, and palliative care provides the best outcomes for patients with MPE [ 1 ]. The prognosis for MPE is generally poor, with median survival of 3-12 months, though this varies by cancer type and patient factors [ 1 ].

Key Considerations

• Ultrasound imaging should be used to guide pleural interventions [ 1 ]
• Asymptomatic patients with MPE should not undergo therapeutic pleural interventions [ 1 ]
• IPC or chemical pleurodesis should be used as first-line definitive pleural intervention for management of dyspnea in patients with symptomatic MPE and expandable lung [ 1 ]
• Pain management and systemic cancer therapy are important components of MPE treatment [ 1 ]

From the Research

Diagnosis of Malignant Pleural Effusion (MPE)

• MPE is typically diagnosed using thoracic imaging, with computed tomography considered the gold standard 2
• Thoracic ultrasound is also useful, particularly if diaphragmatic or pleural thickening and nodularity can be identified 2
• Cytology should be obtained via pleural fluid aspiration or pleural biopsy to confirm the diagnosis 2
• Medical thoracoscopy can also be used to diagnose MPE 3

Treatment of Malignant Pleural Effusion (MPE)

• Treatment focuses on palliation and relief of symptoms 2
• Numerous interventions are available, including:
  • Drainage with thoracentesis or indwelling pleural catheter 4, 2, 3
  • Chemical pleurodesis using sclerosing agents such as talc 4, 5, 6
  • Tunneled indwelling pleural catheters 3, 5
  • Novel combined approaches 3
• The choice of intervention is guided by efficacy, local expertise, and risk, as well as patient factors and preferences 3
• Repeated thoracentesis may be used for patients with very limited life expectancy 3
• Outpatient management using a tunneled pleural catheter is a viable alternative to conventional therapy and can improve quality of life 5