Contemporary best practice in the management of malignant pleural effusion

Abstract

Malignant pleural effusion (MPE) affects more than 1 million people globally. There is a dearth of evidence on the therapeutic approach to MPE, and not surprisingly a high degree of variability in the management thereof. We aimed to provide practicing clinicians with an overview of the current evidence on the management of MPE, preferentially focusing on studies that report patient-related outcomes rather than pleurodesis alone, and to provide guidance on how to approach individual cases. A pleural intervention for MPE will perforce be palliative in nature. A therapeutic thoracentesis provides immediate relief for most. It can be repeated, especially in patients with a slow rate of recurrence and a short anticipated survival. Definitive interventions, individualized according the patient's wishes, performance status, prognosis and other considerations (including the ability of the lung to expand) should be offered to the remainder of patients. Chemical pleurodesis (achieved via intercostal drain or pleuroscopy) and indwelling pleural catheter (IPC) have equal impact on patient-based outcomes, although patients treated with IPC spend less time in hospital and have less need for repeat pleural drainage interventions. Talc slurry via IPC is an attractive recently validated option for patients who do not have a nonexpandable lung.

Keywords: indwelling pleural catheter; malignant pleural effusion; pleurodesis.

Figure 1.

A suggested general approach to general management of MPEs. See text for details. IPC, indwelling pleural catheter; ICD, intercostal drain; MPE, malignant pleural effusion; NEL, nonexpandable lung; VATS, video-assisted thoracoscopic surgery. *An IPC, unless contraindicated, should be inserted in the majority patients with symptomatic MPE. Daily vacuum bottle drainage for at least 2 weeks is encouraged. If the lung fully expands, talc should be instilled via the IPC, and if successful, the IPC may be removed. Patients with symptomatic MPE presenting with a NEL and those with a failed pleurodesis are candidates for symptom-guided drainage via IPCs. **Can be combined with decortication if pleural apposition is not possible; generally reserved for fit surgical candidates.