Malignant Pleural Effusion GROUP PUVA AND LING GUIDED BY ROS IDAYU MAT NAWI
Introduction • A malignant pleural effusion (MPE) is the build up of fluid and cancer cells that collects between the chest wall and the lung. • Incidence of 150,000 new cases a year, have long been recognized as a cause of significant morbidity in advanced cancer patients.
• About 15% of cancer patients will occurred (MPE )due to poor prognosis. • Majority occurred in Lung cancer, breast cancer, and lymphoma. • Followed by gynecological malignancies and malignant mesothelioma. • Life expectancy of patients MPE is 3–12 months depending on tumor type and patient comorbidities. • Malignant pleural effusions must be differentiated from paramalignant pleural effusions, which are not caused by direct pleural involvement by the tumor.
What is a pleural effusion? A pleural effusion is an abnormal build-up of fluid in the pleural space
Types of pleural effusions 1.Exudative pleural effusion: (protein-rich fluid). • blocked blood vessels ,lymph vessels, inflammation, infection, lung injury or tumors. 2.Transudative effusion(watery fluid) Cause by fluid leaking in to pleural space↑ pressure in blood vessels or low blood protein count.(heart failure case)
What causes a malignant pleural effusion (MPE) to form? • MPE forms when cells from either a lung cancer or another type of cancer spread to the pleural space. • These cancer cells increase the production of pleural fluid and cause decreased absorption of the fluid.
Pathophysiology of MPE • In normal circumstances, the influx of fluids into the pleural space is balanced with its resorption. • When disturbed happen it will increase in entry rate and reduction in exit rate. • When the function of lymphatics is disrupted, such as mechanical compression of lymphatics, blockage of lymphatic stomata . • Accumulation of fluid in the pleural space. • Can be a consequence of tumor growth blocking the lymphatic drainage .
CLASSIFICATION • Primary pleural malignancy: mesothelioma • Secondary pleural malignancy: Lung, breast, ovary, hematological, GI tract, urogenital, skin(melanoma) Unknown primary.
MPE CAUSES • Congestive Heart Failure • Cancer • Pneumonia • Pulmonary Embolism
Clinical manifestation of MPE • Shortness of breath. • Dry cough. • Pain. • Feeling of chest heaviness or tightness. • Inability to lie flat. • Inability to exercise. • Generally feeling unwell.
Diagnosis • CXR • CT SCAN • MRI • Tomography • Cytology–pathology • Biomarkers CEA, CA15-3, CA125, CYFRA 21-1)
• Therapeutic pleural aspiration (pleural tapping) thoracentesis
Thoracoscopy with Pleurodesis • Use Endoscope through the chest wall for direct visualization of the pleura. • pleural fluid drainage, parietal pleural biopsy, and pleurodesis. Indwelling Pleural Catheters (IPC) • A small, soft and flexible tube. Inserted into your chest to remove fluid from around your lungs.
• Pleuroperitoneal Shunt • Pleurectomy-To prevent recurrent of effusion. • Chemotherapy- Tetracycline and bleomycin,anti VEGFBEVACIZUMAB,RITUXIMAB • immunotherapy and/or radiation. • Surgery.
Pleurodesis • A procedure that sticks your lung to your chest wall. This procedure removes the space between your lung and your chest wall (pleural space) so that fluid or air no longer builds up between the layers. • Pleurodesis collapses the pleural space. This prevents fluid buildup and can help alleviate these symptoms.
Prognosis • Medium survival rate • Lung cancer with malignant effusion 3 months • Breast cancer with malignant effusion 5 months • Mesothelioma with malignant effusion 6 months • Lymphoma with malignant effusion 9 months
Age 69 year old female. Diagnosis lung adenocarcinoma and malignant pleural effusion stage IIIB. (T3 N 2 M 0 ) Sign and symptoms shortness of breath about 2 week and become worse 3 day before enter ED. Physical examination • Conscious, B/p120/80 mmHg, p 85 per minute, resp 28 per minute, Temp 36.7, and spo2 93%. • Dyspnea, asymmetric chest movement, vocal fremitus decreases. dullness was found at the right chest and jugular venous distension. Medical history Diabetes mellitus and hypertension and routinely consumes Metformin 1x500 mg and Ramipril 1x5mg daily. Malignant Pleural Effusion in Lung Adenocarcinoma Patient: Case Report
Investigation and finding 1. Complete blood test 2. Renal function test : normal. 3. ECG :normal. 4. CT Head, abdomen and pelvis: no metastasis.
5. Chest X-ray showed: A massive right-sided pleural effusion and blunting of the left costophrenic angle. (Figure 1) 6. CT scan of the thorax showed: Pleural nodular mass with smooth margin, size 7.1x1.5x6.6 cm. In volves parietal and visceral pleural also pleural fissures. Invade the mediastinal fat (T3) with right pleural effusion , Multiple lymph node enlargement (N2).(Figure2)
7. Cytological examination showed :Atypical cells. 8. Adenosine deaminase test of pleural fluid showed within normal limit (7 U/L). 9. EGFR mutations show : PD-L1 was not detected in tumor cells.
Treatment ▪ Oxygen: 4 liters. ▪ Medication: Budesonide, salbutamol, and Ipatoprium bromide Inhalation therapy. ▪ Underwent pleural fluid evacuation by pulmonologist, around 1 liter of pleural fluid were removed. ▪ Due to rapid of pleural effusion, weekly around 500-750 pleural fluid removed. ▪ Patient was referred to oncologist consultant.
Discussion • Pleural effusion in the lung caused by the tumor. • 15% of lung cancer patients have pleural effusions. • Early-stage disease, surgery. • For advanced disease combination of surgery, chemotherapy, and radiation. • In IIIB Radiotherapy is started but very low survival, poor local control. • Radiotherapy experienced a median survival of 9-11 months, 2- year survival of 10-20% and 3-year survival of 5-10%.
Reference • https://err.ersjournals.com/content/25/140/189 • https://err.ersjournals.com/content/25/140/189#:~: text=Malignant%20pleural%20effusion%20(MPE)%20is%20defined%20as%20th e%20accumulation%20of,cachexia%20and%20reduced%20physical%20activity. • https://images.app.goo.gl/2tLT77zrWy6jariw8. • Kandasamy, P.C. et al. (2021) Malignant pleural effusions-A review of current guidelines and practices, Journal of clinical medicine. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8658426/ (Accessed: March 16, 2023). • Malignant pleural effusion - american thoracic society. Available at: https://www. thoracic.org/patients/patient-resources/resources/malignant-pleural-effusions.pdf (Accessed: March 20, 2023). • Malignant pleural effusion in lung adenocarcinoma patient: Case ... - IJSR (no date). Available at: https://www.ijsr.net/archive/v10i3/SR21301124840.pdf (Accessed: March 19, 2023).
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