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.

The Optimal Management of Malignant Pleural Effusion: Steady Progress Towards an Evidence-Based Approach

“…The latter has the advantage of being used to either chronically drain the pleural space, or to facilitate chemical or autopleurodesis [3], and several studies have confirmed that the improvement in QoL and other patient-related outcomes are comparable between IPC with intermittent drainage, and intercostal drainage with pleurodesis. Further, patients managed with an IPC appear to spend less time in hospital, and are less likely to require a subsequent pleural procedure [7,8].…”

“…This procedure can be repeated in patients with a slow rate of MPE recurrence, or in patients with a short anticipated survival or poor performance status [4]. However, when a longer survival is anticipated, patients should be offered a definitive intervention given the cumulative discomforts, risks and costs associated with repeated thoracentesis [4].Until recently there has been a lack of high-quality evidence to inform the optimal approach to MPE management, which has unsurprisingly resulted in large variation in clinical approaches both between institutions and between disciplines [2,3]. This lack of consensus in clinical practice has grown as more therapeutic options are developed, and is highlighted when specialities are compared.…”

“…Combining both IPC and talc pleurodesis has the potential advantage of facilitating early tube removal, and thereby reducing the inconvenience of regular drainage, the risks of infection and mechanical failure, and the cost to patient [2,3]. In the recently published IPC-Plus study, outpatients underwent regular pleural drainage via an IPC [10].…”

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Lung and breast cancers remain the most common causes of malignant pleural effusions (MPE), which, when present, generally signify incurable disease and a poor prognosis [1][2][3]. Once confirmed, the aims of the management of MPE should be to improve quality of life (QoL), limit pleural procedures and avoid the need for repeated hospital or doctor visits [2,3].

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“…Once confirmed, the aims of the management of MPE should be to improve quality of life (QoL), limit pleural procedures and avoid the need for repeated hospital or doctor visits [2,3]. In most cases, a therapeutic thoracentesis provides immediate relief, in the absence of another cause for dyspnoea.…”