Malignant Pleural Effusions

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Recommendation for the Management of Malignant Pleural Effusions

 Daniel Jones, Laura Donahoe, Najib Safieddine

Background

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.

Recommendations

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.

PICO 1: In Patients with Known or Suspected MPE, Should Thoracic Ultrasound Be Used to Guide Pleural Interventions?

Ans: The panel recommends the use of ultrasound imaging to guide pleural interventions. (Conditional recommendation, very low confidence in estimate of effects).

PICO 2: In Patients with Known or Suspected MPE Who Are Asymptomatic, Should Pleural Drainage Be Performed?

Ans: The panel recommends withholding interventions on patients who remain asymptomatic from an MPE. (Conditional recommendation, very low confidence in estimate of effects).

PICO 3: Should the Management of Patients with Symptomatic Known or Suspected MPE Be Guided by Large-Volume Thoracentesis and Pleural Manometry?

Ans: The panel recommends performing large volume thoracentesis for a two-fold benefit: 1) to ascertain if MPE symptoms are related to effusion, and 2) to determine if lung is expandable (with the future possibility of pleurodesis as a treatment option).  (Conditional recommendation, very low confidence in estimate of effects).

PICO 4: In Patients with Symptomatic MPE with Known or Suspected Expandable Lung and No Prior Definitive Therapy, Should IPCs or Chemical Pleurodesis Be Used as First-Line Definitive Pleural Intervention for Management of Dyspnea?

Ans: The panel equally recommends the use of an indwelling pleural catheter (IPC) or chemical pleurodesis as first line for patients with symptomatic dyspnea.  (Conditional recommendation, low confidence in estimate of effects).

PICO 5: In Patients with Symptomatic MPE Undergoing Talc Pleurodesis, Should Talc Poudrage or Talc Slurry Be Used?

Ans: The panel equally recommends both Talc poudrage and Talc slurry as a therapeutic means for pleurodesis in symptomatic patients with expandable lungs. (Conditional recommendation, low confidence in estimate of effects).

PICO 6: In Patients with Symptomatic MPE with Nonexpandable Lung, Failed Pleurodesis, or Loculated Effusion, Should an IPC or Chemical Pleurodesis Be Used?

Ans: The panel recommends the use of an indwelling pleural catheter (IPC) over chemical pleurodesis in symptomatic patients with either a non-expandable lung, previous failed attempts at pleurodesis or a known loculated effusion. (Conditional recommendation, very low confidence in estimate of effects).

PICO 7: In Patients with IPC-associated Infection (Cellulitis, Tunnel Infection, or Pleural Infection), Should Medical Therapy Alone or Medical Therapy and Catheter Removal Be Used?

Ans: The panel recommends an initial trial of medical therapy (antibiotic treatment) in patients who develop IPC-associated infection. Should the initial trial of medical therapy not improve the clinical situation then the panel recommends removal of the IPC. (Conditional recommendation, very low confidence in estimate of effects).

References

  1. Li X, Ferguson M. (2014). Optimal Management of Symptomatic Malignant Pleural Effusion from: Difficult Decisions in Thoracic Surgery [electronic resource]: An Evidence-Based Approach – 3rd Edition, London
  2. Porcel JM, Gasol A, Bielsa S, Civit C, Light RW, Salud A. (2015). Clinical features and survival of lung cancer patients with pleural effusions. Respirology; 20:654–659.
  3. Clive  AO, Jones  HE, Bhatnagar  R, Preston  NJ, Maskell  N. (2016). Interventions for the management of malignant pleural effusions: a network meta‐analysis. Cochrane Database of Systematic Reviews, Issue 5
  4. Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, et al. (2018). Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med; 198(7):839-849
  5. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. (2011). GRADE guidelines: 1. Introduction—GRADE evidence profiles and summary of findings tables. J Clin Epidemiol; 64:383–394.