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Pleural Disease
of careful handling and discarding of asbestos. However, the generate diagnostic doubt in patients with malignancy-associated
lead time between exposure and malignancy of greater than fevers. Such a low pH is associated with a poorer prognosis and an
30 years and the fact that mesothelioma risk progressively effusion that may be more difficult to control.
33
increases with time post-exposure mean that mesothelioma will
continue to be a significant cause of morbidity and mortality for Treatment
many years to come.
29
Furthermore, asbestos use continues to rise Treatment of malignant pleural effusion is primarily aimed at symptom
in developing countries.
30
control by controlling effusion size. Where possible, treatment of a
primary tumour may lead to effective effusion control (e.g. breast
carcinoma, lymphoma, small-cell lung carcinoma), and should be the
Another option for management
first therapeutic option.
of malignant pleural effusion is a Malignant mesothelioma may be treated with chemotherapy; studies
subcutaneously tunnelled indwelling
have demonstrated increased survival time (to 12.1 months), tumour
response rates and time to progression with antifolate chemotherapy
pleural catheter; such a catheter such as pemetrexed in combination with a platinum-based therapy
empowers the patient to undertake
(e.g. cisplatin).
34
domiciliary drainage. Effusion size, failure of chemotherapy or cancer progression may
mandate immediate intervention. Pleural intervention options include
thoracentesis or chest drain insertion to bring about a rapid decrease
Other forms of pleural malignancy represent spread from a primary in pleural fluid volume and symptomatic relief. It is always worth
malignancy. Any method that enables earlier detection of cancer considering factors such as a ‘drowned lung’ from a centrally
may reduce the frequency of metastatic spread to the pleura. obstructing lung carcinoma, which would make any pleural
intervention unlikely to be beneficial.
Many patients with metastatic malignancy have an asymptomatic
pleural effusion. Early intervention may prevent a subsequent A more definitive strategy is usually required to prevent fluid
problematic pleural effusion, or trapped lung, from developing. re-accumulation, most commonly pleurodesis. The aim of
Treatment of asymptomatic pleural effusions has not yet been pleurodesis is to obliterate the pleural space by creating a fibrous
evaluated in a randomised controlled trial. union between the visceral and parietal pleura. Pleurodesis can be
achieved mechanically (by surgical pleural abrasion or parietal
Diagnosis pleurectomy) or chemically (by instillation of a medicinal agent into
Diagnosis of a malignant pleural effusion should be multimodal: the pleural space); both techniques cause an inflammatory union
clinical, radiographical and pathological. A malignant pleural between the pleural layers.
effusion normally has the biochemical characteristics of an
exudative pleural effusion (although transudates have been Commonly used intrapleural agents include talc (applied as powder
described – usually in patients who have concomitant heart failure). during thoracoscopy [poudrage] or as a slurry down a chest tube),
Cytological examination should be performed, but has a sensitivity tetracycline, doxycycline or certain chemotherapeutic agents (e.g.
of only 60% in carcinomatous effusions and 30% in mesothelioma bleomycin). Several pro-inflammatory bacterial moieties are being
effusions.
31
A definitive diagnosis often requires a pleural biopsy. explored as pleurodesis agents: OK-432 (derived from Streptococcus
Blind pleural biopsies (e.g. Abrams) have a sensitivity of about 47%; pyogenes) has been used in Asia for some time;
35,36
Staphylococcus
CT-guided biopsies have a sensitivity of 87%.
31
Thoracoscopic aureus superantigen and lipoteichoic acid-T (a bacterial cell-wall
biopsies are more invasive than CT-guided biopsies, but can yield motif) have both entered early clinical trials.
37,38
larger specimens of pleura and have sensitivities of about 95%.
Medical thoracoscopy is often performed by physicians as a day- Pleurodesis with talc is a favoured option, supported above other
case under conscious sedation; this procedure also allows for agents by many randomised trials.
39
There is no clear superiority of talc
pleural fluid control. Pleural CT (acquired approximately 60 seconds poudrage over slurry (although there may be an advantage of
post-contrast injection) is the optimal radiographic imaging poudrage for metastatic breast or lung carcinoma).
40,41
Overall success
modality of the pleura; this should ideally be undertaken prior to rates with talc are approximately 70–80%.
39
complete removal of pleural fluid.
32
Ultrasound is another useful
modality, and can also be used for guided biopsies. Some units use medical thoracoscopy as a joint diagnostic and
therapeutic technique. If at thoracoscopy the pleural appearance
Diagnosis of mesothelioma often poses more challenges than clearly supports malignancy, the thoracoscopist proceeds to a talc
metastatic malignancy. Histological and cytological examination poudrage immediately.
requires immunohistochemical stains to differentiate mesothelial
malignancy from, for example, metastatic adenocarcinoma. Another option for management of malignant pleural effusion is a
Furthermore, differentiating mesothelioma from reactive mesothelial subcutaneously tunnelled indwelling pleural catheter; such a catheter
cells can be difficult. empowers the patient to undertake domiciliary drainage.
42
Some
patients with an indwelling pleural catheter will eventually develop
A low pH, traditionally associated with pleural infection, is an self-pleurodesis, associated with abolition of production of large
occasional finding in malignant effusions; this can occasionally volumes of pleural fluid. A case series demonstrated that self-
52 EUROPEAN RESPIRATORY DISEASE
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