Recommendation for the Management of Malignant Pleural Effusions
Daniel Jones, Laura Donahoe, Najib Safieddine
Malignant pleural effusions (MPE) is a common diagnosis in patients with late stage cancer. The majority of patients experience some degree of breathlessness, which has profound effects on their remaining quality of life. Indeed, life expectancy is severely reduced with an MPE diagnosis portending a median survival from 3 to 12 months. The optimal management of MPE remains controversial, with various therapeutic options available. For symptomatic patients these include repeat therapeutic thoracentesis, drainage with an indwelling pleural catheter (IPC), placement of chest tube with bedside talc pleurodesis or other sclerosing agent, and VATS pleurodesis. Ultimately, the goal of intervention is palliation of symptoms for best possible quality of life.
The most recent evidence-based guidelines for the management of MPE are the combined results of a collaboration between American Thoracic Society (ATS), Society of Thoracic Surgeons (STS), and Society of Thoracic Radiology (STR). Given the poor prognosis associated with a diagnosis of MPE, management must be guided by a patient-centered approach. This includes intervening only when patients develop symptoms (i.e. breathlessness), and with priority given to minimally invasive interventions and limited number of interventions.
For patients with known/suspected MPE, we recommend following the ATS/STS/STR clinical practice guideline (Figure 1).
Summary of Evidence
In an attempt to summarize the best recommendations for management of MPE, the ATS/STS/STR addressed 7 clinical questions. The PICO format (Population, Intervention, Comparator and Outcomes) was used to develop pertinent questions, while the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) format and Evidence to Decision framework was used to answer each question.
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